Inferior Vena Cava Tumor Thrombectomy Research Articles

Neoadjuvant stereotactic ablative body radiotherapy combined with surgical treatment for renal cell carcinoma and inferior vena cava tumor thrombus: a prospective pilot study.

Surgical treatment for renal cell carcinoma (RCC) and inferior vena cava (IVC) tumor thrombus (TT) is difficult, and the postoperative complication rate is high. This study aimed to explore the safety and oncologic outcomes of neoadjuvant stereotactic ablative body radiotherapy (SABR) combined with surgical treatment for RCC and IVC-TT. Patients with RCC and IVC-TTs were enrolled in this study. All patients received neoadjuvant SABR focused on the IVC at a dose of 30Gy in 5 fractions, followed by 2 ~ 4 weeks of rest. Then, radical nephrectomy and IVC tumor thrombectomy were performed for each patient. Adverse effects, perioperative outcomes, and long-term prognoses were recorded. From June 2018 to January 2019, 8 patients were enrolled-4 with Mayo grade II TT and 4 with Mayo grade III TT. Four (50%) patients had complicated IVC wall invasion according to CT/MRI. All patients received neoadjuvant SABR as planned. Short-term local control was observed in all 8 patients. Only Grade 1-2 adverse events were reported. In total, 3 (37.5%) laparoscopic surgeries and 5 (62.5%) open surgeries were performed. The median operation time was 359 (IQR: 279-446) min, with a median intraoperative bleeding volume of 750 (IQR: 275-2175) ml. The median postoperative hospital stay was 7 (5-10) days. With a 26-month (range: 5-41) follow-up period, the estimated mean overall survival was 30.67 ± 5.38 months. This is the first preoperative radiotherapy study in Asia that focused on patients with TT. This study revealed the considerable safety of neoadjuvant SABR for RCC with IVC-TT. This study was registered in the Chinese Clinical Trials Registry on 2018-03-08 (ChiCTR1800015118). For more information, please see the direct link ( https://www.chictr.org.cn/showproj.html?proj=25747 ).

Initial experience in robot-associated radical nephrectomy with inferior vena cava tumor thrombectomy.

Renal cell carcinoma (RCC) is often locally invasive and may extend from the renal vein into the inferior vena cava (IVC) as a venous tumor thrombus (VTT). Radical nephrectomy with IVC tumor thrombectomy (IVC-TT) via an open approach has been shown to carry high morbidity and mortality. Recently, robot-associated radical nephrectomy (RARN) has been developed with the aim of improving the performance and outcomes of surgery for RCC with IVC-VTT. We here present four patients who had right RCC with IVC-VTT and underwent RARN with IVC-TT in Nagasaki University Hospital. All four patients had level II IVC-TT and underwent RARN with IVC-TT using a da Vinci Xi surgical system. The procedure comprised performing the Kocher maneuver, exposing the right renal artery in the aortocaval region dorsal to the left renal vein, exposing, mobilizing, and clipping the IVC, clamping and incising the IVC, and removing the kidney with the VTT en bloc. The mean tumor size was 83.1 (range, 50.1-115.2) mm and the mean length of the VTT within the IVC 41.6 (range, 25.3-44.3) mm. The mean console time was 290 (range, 287-367) minutes and the mean blood loss was 200 (range, 175-260) mL and no patient required blood transfusion. Our initial experience of the procedure of RARN with IVC-TT for level II IVC-VTT is that it is safe and has acceptable perioperative outcomes and complications.

MP28-20 ROBOT-ASSISTED RADICAL NEPHRECTOMY AND INFERIOR VENA CAVA LEVEL I-III THROMBECTOMY: PERIOPERATIVE AND MID-TERM ONCOLOGIC OUTCOMES

You have accessJournal of UrologyCME1 Apr 2023MP28-20 ROBOT-ASSISTED RADICAL NEPHRECTOMY AND INFERIOR VENA CAVA LEVEL I-III THROMBECTOMY: PERIOPERATIVE AND MID-TERM ONCOLOGIC OUTCOMES Umberto Anceschi, Aldo Brassetti, Alfredo Maria Bove, Gabriele Tuderti, Mariaconsiglia Ferriero, Leonardo Misuraca, Riccardo Mastroianni, Manuela Costantini, Salvatore Guaglianone, Giovanni Cacciamani, Mihir Desai, Monish Aron, Inderbir Singh Gill, and Giuseppe Simone Umberto AnceschiUmberto Anceschi More articles by this author , Aldo BrassettiAldo Brassetti More articles by this author , Alfredo Maria BoveAlfredo Maria Bove More articles by this author , Gabriele TudertiGabriele Tuderti More articles by this author , Mariaconsiglia FerrieroMariaconsiglia Ferriero More articles by this author , Leonardo MisuracaLeonardo Misuraca More articles by this author , Riccardo MastroianniRiccardo Mastroianni More articles by this author , Manuela CostantiniManuela Costantini More articles by this author , Salvatore GuaglianoneSalvatore Guaglianone More articles by this author , Giovanni CacciamaniGiovanni Cacciamani More articles by this author , Mihir DesaiMihir Desai More articles by this author , Monish AronMonish Aron More articles by this author , Inderbir Singh GillInderbir Singh Gill More articles by this author , and Giuseppe SimoneGiuseppe Simone More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003256.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Few series of robot-assisted radical nephrectomy (RARN) with inferior vena cava tumor thrombectomy (IVCT) for renal cell carcinoma (RCC) with venous tumor thrombus (VTT) are available in literature, all with short-term oncologic outcomes. The aim of this study is to describe perioperative and long-term oncologic outcomes of RARN and IVCT performed at a single, high-volume centre. METHODS: Between January 2014 and October 2022, 37 consecutive patients underwent RARN-IVCT for RCC and VTT at a single tertiary-care center. Baseline, demographic and perioperative data were collected. A descriptive statistical analysis was performed. Frequencies and proportions were reported for categorical variables while medians and interquartile ranges (IQRs) were reported for continuously coded variables. Overall survival (OS), disease-free survival (DFS) and metastasis-free (MFS) were computed with the Kaplan-Meier method. RESULTS: Overall 37 consecutive patients were included in the analysis, 8 with VTT Mayo level I (21.6%), 11 with level II (29.7%), and 18 with level III (48.7%), respectively. All cases were successfully completed without conversion to open surgery. Median operative time was 360 minutes (IQR 232.5-382.5). Median estimated blood loss was 550 ml (IQR 275-1500). Median hospital stay was 7 days (IQR 4-12.2). Overall, 19 patients (51.3%) had perioperative complications, 15 Clavien grade 2 (40.5%, all blood transfusions) and 4 grade 3-5 (10.8%), respectively. At a median follow-up of 32 months (IQR 17.2-62.5), MFS, DFS and OS probabilities were 37.8%, 59.4%, and 59.4%, respectively. The small series, the high rate of adjuvant targeted therapies (32.4%) as the extreme surgical complexity may affect reproducibility of outcomes. CONCLUSIONS: RARN-IVCT represents a feasible and safe surgical option in tertiary referral centers; mid-term oncologic results seem to be comparable to those reported in open surgery literature. Our results support RARN-IVCT as a feasible and safe surgical option in tertiary referral centers even in the most advanced setting. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e379 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Umberto Anceschi More articles by this author Aldo Brassetti More articles by this author Alfredo Maria Bove More articles by this author Gabriele Tuderti More articles by this author Mariaconsiglia Ferriero More articles by this author Leonardo Misuraca More articles by this author Riccardo Mastroianni More articles by this author Manuela Costantini More articles by this author Salvatore Guaglianone More articles by this author Giovanni Cacciamani More articles by this author Mihir Desai More articles by this author Monish Aron More articles by this author Inderbir Singh Gill More articles by this author Giuseppe Simone More articles by this author Expand All Advertisement PDF downloadLoading ...

V05-01 EX VIVO PARTIAL NEPHRECTOMY IN A SOLITARY KIDNEY

You have accessJournal of UrologyCME1 Apr 2023V05-01 EX VIVO PARTIAL NEPHRECTOMY IN A SOLITARY KIDNEY Martin Hofmann, Rebecca Campbell, Yi-Chia Lin, Alejandro Pita, Jesse McKenney, Mohamed Eltemamy, and Steven Campbell Martin HofmannMartin Hofmann More articles by this author , Rebecca CampbellRebecca Campbell More articles by this author , Yi-Chia LinYi-Chia Lin More articles by this author , Alejandro PitaAlejandro Pita More articles by this author , Jesse McKenneyJesse McKenney More articles by this author , Mohamed EltemamyMohamed Eltemamy More articles by this author , and Steven CampbellSteven Campbell More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003263.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nephron-sparing surgery (NSS) is common in the management of small renal masses. In locally advanced tumors, it is typically only considered in cases of a solitary kidney. Robotic and open partial nephrectomy are standard approaches with ex vivo partial nephrectomy rarely reported. This approach was abandoned at Cleveland Clinic in 1986 due to lackluster results. Since then, however, technology has improved with better vessel sealing devices, thrombogenic materials to help pack the defect and reconstruct, and better imaging. METHODS: A 44 year old woman was found to have bilateral renal masses on imaging performed during a hypertension workup. The right renal mass was large with inferior vena cava (IVC) tumor thrombus. The left sided mass was central with renal vein thrombus. After undergoing a right radical nephrectomy and IVC tumor thrombectomy, she was treated with 8 weeks of neoadjuvant axitinib on trial to downstage the remaining left renal mass. After considering all options, an ex vivo partial nephrectomy was performed. First, a laparoscopic nephrectomy was performed in similar fashion as to donor nephrectomy. The kidney was then chilled and perfused with Collins' solution before being defatted and small vascular branches ligated. The central mass was then visualized on ultrasound and a portion of parenchyma overlying it excised to allow for hilar and tumor exposure. The renal vein was opened and tumor resected. After oversewing the parenchyma, closing open vessels, and packing the defect with Surgicel Fibrillar, the outer renorrhaphy was performed with 2-0 Chromic sutures. The autotransplantation was then performed with the kidney placed into the left iliac fossa and vascular anastomoses performed to external iliac vessels and ureteral reimplantation onto the bladder dome. RESULTS: The total time in the operating room was 6 hours with 3 hours spent on the bench preparing the kidney and resecting the mass. The estimated blood loss was 500 cc. Final pathology revealed a 7 cm pT3a grade 3 clear cell renal cell carcinoma with negative margins. She experienced acute kidney injury with peak creatinine of 5.91 on post-operative day 3 which improved to 1.54 by 6 weeks. She suffered a pulmonary embolism at that time but has done well on anticoagulation. At 6 months, her creatinine was 1.32 and surveillance imaging was negative for any recurrent disease. CONCLUSIONS: The management of bilateral locally advanced renal tumors is complex and challenging. In rare circumstances, ex vivo partial nephrectomy can be considered and performed with good result. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e424 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Martin Hofmann More articles by this author Rebecca Campbell More articles by this author Yi-Chia Lin More articles by this author Alejandro Pita More articles by this author Jesse McKenney More articles by this author Mohamed Eltemamy More articles by this author Steven Campbell More articles by this author Expand All Advertisement PDF downloadLoading ...

Recent Advances in the Management of Localized and Locally Advanced Renal Cell Carcinoma: A Narrative Review.

To review the current status of surgical and procedural treatments for renal cell carcinoma (RCC), focusing on oncological and functional outcomes, and the use of techniques for advanced disease over the last 10 years. Partial nephrectomy (PN) has become the reference standard for most T1 and T2 masses. In cT2 RCC, PN exhibits oncological equivalence and improved functional outcomes compared to radical nephrectomy (RN). Additionally, emerging data suggest that PN may be used to treat cT3a RCC. The robot-assisted platform is increasingly used to treat locally advanced RCC. Studies suggest safety and feasibility of robotic RN and robotic inferior vena cava tumor thrombectomy. Additionally, single-port robot-assisted laparoscopic approaches are comparable to multiport approaches in select patients. Long-term data show that cryoablation, radiofrequency ablation, and microwave ablation are equipotent in management of small renal masses. Emerging data suggest that microwave may effectively treat cT1b masses.

Application of laparoscopic ultrasound in retroperitoneal radical nephrectomy for renal cell carcinoma with Type II inferior vena cava tumor thrombectomy.

The aim of this study was to investigate the application value of laparoscopic ultrasound (LU) in retroperitoneal radical nephrectomy for renal cell carcinoma with Type II inferior vena cava tumor thrombectomy (RRN-RCC-TII-IVCTT). The clinical data (operative time, length of tumor thrombus, tumor length, intraoperative bleeding, clinical stage, histological type, residual tumor tissue, and postoperative follow-up) of 6 patients who underwent LU-guided RRN-RCC-TII-IVCTT were retrospectively analyzed, and the intraoperative experience of LU was also summarized. All 6 patients recovered well with liver and kidney functions returning to normal, and no tumor recurrence, metastasis, or vena cava tumor thrombus. LU-guided RRN-RCC-TII-IVCTT is a feasible treatment option, which locates the tumor accurately by retroperitoneal approach and provides the additional benefit of reduced intraoperative bleeding and shortened operative time, also achieving the much sought-after goal of precision.

Management of Locally Advanced Renal Cell Carcinoma

Renal cell carcinoma (RCC) has a natural tendency to invade the venous system with formation of a venous tumor thrombus in the renal vein, which can extend proximally into the inferior vena cava (IVC) and in some cases into the right atrium. The presence of venous involvement significantly worsens prognosis. Despite recent advances in systemic therapies, surgery remains the most effective method of treatment and in the case of complete removal of all tumor, it provides satisfactory long-term survival and must be attempted whenever possible. Several surgical techniques have been proposed, but all are associated with a high rate of perioperative complications and mortality. Minimally invasive approaches are mainly applicable for less extended IVC thrombi, while open surgery remains the gold standard for this category of patients. Most IVC thrombi can be managed without use of circulatory support by using different methods of IVC control depending on the thrombus level. However, use of cardiac bypass with or without deep hypothermic cardiac arrest is indicated in some patients with bulky intraatrial tumor thombi. In select patients presenting with IVC tumor thrombus and synchronous distant metastases, cytoreductive nephrectomy with IVC tumor thrombectomy may be considered with or without neoadjuvant systemic therapy. Surgery for RCC with venous thrombus is complex and requires experienced multidisciplinary surgical, anesthesia, and critical care teams at high-volume centers to achieve the best outcomes.

Perioperative Outcomes for Radical Nephrectomy and Level III-IV Inferior Vena Cava Tumor Thrombectomy in Patients with Renal Cell Carcinoma

This study examined the characteristics, intraoperative, and postoperative course of patients undergoing inferior vena cava tumor thrombectomy for metastatic renal cell carcinoma. A single-center case series that reported demographic data and intraoperative and postoperative outcomes for patients with renal cell carcinoma undergoing inferior vena cava thrombectomy. This investigation was performed at a large quaternary referral center. Adult patients (age ≥18) admitted to the authors' hospital from January 1, 2005, to March 10, 2017, undergoing inferior vena cava thrombectomy for level III and IV renal cell carcinoma. No interventions were performed. Sixty-five patients who met the inclusion criteria were identified, with 31 patients diagnosed with level III and 34 with level IV renal cell carcinoma. Patients with level IV tumors were significantly more likely to have greater intraoperative blood loss, had longer surgical duration and hospital stays, and had more frequently required blood products, pressors, and cardiopulmonary bypass intraoperatively. Intraoperative transesophageal echo was more frequently used in level IV thrombectomy compared to level III (91.2% v 67.7%). Of patients with level IV thrombus, 41.2% developed postoperative atrial fibrillation compared to only 3.2% with level III thrombus. The 30-day mortality was 4.6% for both groups. Patients undergoing inferior vena cava tumor thrombectomy for renal cell carcinoma had more complex intraoperative and postoperative courses with level IV compared to level III tumor thrombus.

Molecular Characterization of Clear Cell Renal Cell Carcinoma Reveals Prognostic Significance of Epithelial-mesenchymal Transition Gene Expression Signature

BackgroundThere is an ongoing need to develop prognostic biomarkers to improve the management of clear cell renal cell carcinoma (ccRCC). ObjectiveTo leverage enriched pathways in ccRCC to improve risk-stratification. Design, setting, and participantsWe retrospectively identified two complementary discovery cohorts of patients with ccRCC who underwent (1) radical nephrectomy (RNx) with inferior vena cava tumor thrombectomy (patients = 5, samples = 24) and (2) RNx for localized disease and developed recurrence versus no recurrence (n = 36). Patients with localized ccRCC (M0) in The Cancer Genome Atlas (TCGA, n = 386) were used for validation. Outcome measurements and statistical analysisA differential expression gene (DEG) analysis was performed on targeted RNA next-generation sequencing data from both discovery cohorts. Using TCGA for validation, Kaplan-Meier survival analysis and multivariable Cox proportional hazard testing were utilized to investigate the prognostic impact of DEGs, cell cycle proliferation (CCP), and a novel epithelial-mesenchymal transition (EMT) score on progression-free (PFS) and disease-specific (DSS) survival. Results and limitationsIn the discovery cohorts, we observed overexpression of WT1 and CCP genes in the tumor thrombus versus the primary tumor, as well as in patients with recurrence versus those without recurrence. A hallmark pathway analysis demonstrated enrichment of the EMT- and CCP-related pathways in patients with high WT1 expression in the TCGA (validation) ccRCC cohort. CCP and EMT scores were derived in the validation cohort, which was stratified into four risk groups using Youden Index cut points: CCPlow/EMTlow, CCPlow/EMThigh, CCPhigh/EMTlow, and CCPhigh/EMThigh. The CCPhigh/EMThigh risk group was associated with the worst PFS and DSS (both p < 0.001). In a multivariable analysis, CCPhigh/EMThigh was independently associated with poor PFS and DSS (hazard ratio = 4.6 and 10.3, respectively; p < 0.001). ConclusionsWe demonstrate the synergistic prognostic impact of EMT in tumors with a high CCP score. Our novel EMT score has the potential to improve risk stratification and provide potential novel therapeutic targets. Patient summaryGenes involved in epithelial-mesenchymal transition provides important prognostic information for patients with clear cell renal cell carcinoma.

MP14-03 ROBOT-ASSISTED RADICAL NEPHRECTOMY AND INFERIOR VENA CAVA LEVEL I-III THROMBECTOMY: PERIOPERATIVE AND LONG-TERM ONCOLOGIC OUTCOMES

You have accessJournal of UrologyKidney Cancer: Advanced (including Drug Therapy) I (MP14)1 Sep 2021MP14-03 ROBOT-ASSISTED RADICAL NEPHRECTOMY AND INFERIOR VENA CAVA LEVEL I-III THROMBECTOMY: PERIOPERATIVE AND LONG-TERM ONCOLOGIC OUTCOMES Umberto Anceschi, Aldo Brassetti, Maria Consiglia Ferriero, Gabriele Tuderti, Leonardo Misuraca, Alfredo Maria Bove, Riccardo Mastroianni, Alfredo Maria Bove, Salvatore Guaglianone, Monish Aron, Mihir Desai, Inderbir Gill, Michele Gallucci, and Giuseppe Simone Umberto AnceschiUmberto Anceschi More articles by this author , Aldo BrassettiAldo Brassetti More articles by this author , Maria Consiglia FerrieroMaria Consiglia Ferriero More articles by this author , Gabriele TudertiGabriele Tuderti More articles by this author , Leonardo MisuracaLeonardo Misuraca More articles by this author , Alfredo Maria BoveAlfredo Maria Bove More articles by this author , Riccardo MastroianniRiccardo Mastroianni More articles by this author , Alfredo Maria BoveAlfredo Maria Bove More articles by this author , Salvatore GuaglianoneSalvatore Guaglianone More articles by this author , Monish AronMonish Aron More articles by this author , Mihir DesaiMihir Desai More articles by this author , Inderbir GillInderbir Gill More articles by this author , Michele GallucciMichele Gallucci More articles by this author , and Giuseppe SimoneGiuseppe Simone More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001995.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The aim of this study is to describe long-term oncologic outcomes of robot-assisted radical nephrectomy (RARN) with inferior vena cava tumor thrombectomy (IVCT) performed at a single-institution. METHODS: Between January 2014 and October 2018, 30 consecutive patients underwent RARN-IVCT for RCC and VTT for either curative (n=19) or cytoreductive intent (n=11) at a single tertiary-care center. Baseline, demographic and perioperative data were collected. A descriptive statistical analysis was performed. Frequencies and proportions were reported for categorical variables while medians and interquartile ranges (IQRs) were reported for continuously coded variables. Overall survival (OS), cancer-specific survival (CSS), local recurrence-free survival (LRFS) and metastasis-free (MFS) were computed by Kaplan-Meier curves for the entire cohort and compared by surgical indication with the log-rank test. RESULTS: All cases were succesfully completed without any conversion to open surgery. Median operative time was 360 minutes (IQR 240-390). Median estimated blood loss was 550 ml (IQR 225-1500). Fifteen patients (50%) required blood transfusions. Median hospital stay was 7 days (IQR 4-12.2). Overall, nineteen patients (63.3%) had perioperative complications, 15 Clavien grade 1-2 (50%) and 4 grade 3-5 (13.3%) complications, respectively. At a median follow-up of 31.1 months (IQR 18-52.9), LRFS, MFS, CSS and OS were 93.3%, 40%, 46.7% and 40%, respectively. No significant survival differences were noted according to surgical indication (each p>0.1). The small cohort, high rate of adjuvant targeted-therapies (46.7%) and extreme surgical complexity may affect reproducibility of outcomes. CONCLUSIONS: RARN-IVCT represents a feasible and safe surgical option in tertiary referral centers; long-term oncologic results seem to be comparable to those reported in open surgery literature. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e252-e253 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Umberto Anceschi More articles by this author Aldo Brassetti More articles by this author Maria Consiglia Ferriero More articles by this author Gabriele Tuderti More articles by this author Leonardo Misuraca More articles by this author Alfredo Maria Bove More articles by this author Riccardo Mastroianni More articles by this author Alfredo Maria Bove More articles by this author Salvatore Guaglianone More articles by this author Monish Aron More articles by this author Mihir Desai More articles by this author Inderbir Gill More articles by this author Michele Gallucci More articles by this author Giuseppe Simone More articles by this author Expand All Advertisement Loading ...

Case reports of robot-assisted laparoscopic radical nephrectomy and inferior vena cava tumor thrombectomy: A retrospective analysis.

Renal cell carcinoma is one common type of urologic cancers. It has tendencies to invade into the inferior vena cava (IVC) and usually requires an open surgery procedure. High rates of operative complications and mortality are usually associated with an open surgery procedure. The recently emerged robot-assisted laparoscopic radical nephrectomy (RAL-RN) and IVC tumor thrombectomy have shown to reduce operative related complications in patients with renal cell carcinoma.This case series study aimed to summarize technical utilization, perioperative outcomes, and efficacies of RAL-RN and IVC tumor thrombectomy in our hospital. A retrospective analysis was performed on clinical data from 20 patients who underwent RAL-RN and IVC tumor thrombectomy from January 2017 to December 2019 in our department.Patients had a median age of 59 years (interquartile range [IQR], 46–68). Four patients had renal neoplasm on left side and 16 on right side. Nineteen patients underwent RAL-RN (level 0: n = 2) or RAL-RN with IVC thrombectomy (n = 17) (level I: n = 3; level II: n = 12; and level III: n = 3) and 1 patient was converted into an open surgery. The median operative time was 328 minutes (IQR, 221–453). The estimated median blood loss was 500 mL (IQR, 200–1200). The median size of removed renal carcinoma was 67 cm2 (IQR, 40–91); the length of IVC tumor thrombus was 5 cm (IQR, 3–7). The postsurgery hospital length of stay was 6 days (IQR, 5–7). The complications included intestinal obstruction (n = 1), lymphatic fistula (n = 1), heart failure (n = 1), and low hemoglobin level (n = 1). The outcomes for patients after 16 months (IQR, 11–21) follow-up were tumor-free (n = 10), tumor progression (n = 4), loss of contact (n = 1), and death (n = 5).We concluded that RAL-RN and IVC thrombectomy renders good safety profiles including minimal invasiveness, low estimated median blood loss, short hospitalization, low morbidity, and quick renal function recovery. The long-term efficacy needs a further investigation.

Renal Primitive Neuroectodermal Tumor With Inferior Vena Cava Thrombus: Case Series and Literature Review of a Rare but Challenging Entity.

To investigate the clinicopathological characteristics, treatments, and prognosis of patients with renal primitive neuroectodermal ectodermal tumors (rPNETs) with inferior vena cava (IVC) tumor thrombus. We retrospectively reviewed 6 patients with rPNETs and IVC tumor thrombus between January 2005 and December 2019, and identified 39 published cases through a literature review. The clinicopathological characteristics, treatments, and survival data were analyzed. The median patient age patients was 26 years, and the male to female ratio was approximately 1:1. The average tumor diameter was 12.5 cm. Seventeen patients (37.8%) showed metastasis at diagnosis. Forty-three cases (95.6%) were managed with surgical resection, and 35 (77.8%) received adjuvant chemotherapy after surgery. Follow-up data were available for 41 patients (median follow-up, 10 months; range, 4.5-13.0). The median overall survival (OS) and median progression-free survival (PFS) were both 30.0 months. Patients who received adjuvant chemotherapy had better PFS than those who underwent surgery only (30.0 months [95% confidence interval [CI], 4.3-55.7] vs 5.0 months [95% CI, 1.0-9.0]; P=.036). In terms of OS, however, the difference between the 2 groups was not significant (30.0 months [95% CI, 8.4-52.6] vs 7.0 months [95% CI, 4.5-9.5]; P=.244). rPNET with IVCTT is an extremely rare entity that mostly occurs in young adults. Although multidisciplinary treatment is used, the prognosis of this disease remains unclear. RN with IVC tumor thrombectomy is a challenging procedure requiring vascular management techniques and experience. Adjuvant chemotherapy contributes to improved PFS, but not OS. Thus, early diagnosis and treatment play a key role in improving prognosis.

Imaging predictors for assessment of inferior vena cava wall invasion in patients with renal cell carcinoma and inferior vena cava tumor thrombus: a retrospective study.

BackgroundRenal cell carcinoma (RCC) has the propensity to lead to venous tumor thrombus (VTT). Nephrectomy with tumor thrombectomy is an effective treatment option but is a technically challenging surgical procedure that is accompanied by a high rate of complications. The aims of this study were to investigate pre-operative imaging parameters for the assessment of inferior vena cava (IVC) wall invasion due to a tumor thrombus in patients with RCC and to identify predictors from the intra-operative findings.MethodsClinical and imaging data were collected from 110 patients who underwent nephrectomy with IVC tumor thrombectomy (levels I–IV) for RCC and IVC tumor thrombus at the Peking University Third Hospital between May 2015 and March 2018. Univariable and multivariable logistic regression and receiver operating characteristic curves were used to assess the correlations between pre-operative imaging features and intra-operative macroscopic invasions of the IVC wall by tumor thrombus.ResultsAmong the 110 patients, 41 underwent partial or segmental resection of IVC. There were univariate associations of pre-operative imaging parameters that could be used to predict the need for IVC resection, including those of the Mayo classification, maximum anterior-posterior (AP) diameter of the renal vein at the renal vein ostium (RVo), maximum AP diameter of the VTT at the RVo and IVC occlusion. For the multivariable analysis, the AP diameter of the VTT at the RVo and IVC occlusion were associated with a significantly increased risk of invasion of the IVC wall by tumor thrombus. The optimum imaging thresholds included an AP diameter of the VTT at the RVo larger than 17.0 mm and the presence of IVC occlusion, with which we predicted invasions of the IVC wall requiring IVC resection. The probabilities of intra-operative IVC resection for patients without both independent factors, with an AP diameter of the VTT at the RVo larger than 17.0 mm, with IVC occlusion, and with both concurrent factors were 5%, 23%, 56%, and 66%, respectively.ConclusionAn increase in the AP VTT diameter at the RVo and the presence of complete occlusion of the IVC are independent risk factors for a high probability of IVC wall invasion by tumor thrombus.

Pure Robotic-assisted Level IV Inferior Vena Cava Thrombectomy for Angiomyolipoma Without Cardiopulmonary Bypass: A First Report

ObjectiveTo report the initial case of robotic-assisted level IV inferior vena cava (IVC) tumor thrombectomy, with the supra- and infradiaphragmatic caval segments managed purely by a robotic-assisted technique. MethodsA 67-year-old female presented with a 5.3 × 2.4 cm right renal tumor and a level IV IVC tumor thrombus, 16.5 cm in length, extending 1.5 cm into the right atrium. Through a robotic trans-abdominal approach, the infrarenal and retrohepatic IVC, left renal vein and right kidney were secured. Using a robotic transthoracic approach, the thrombus was milked out of the right atrium. The intrapericardial caval segment was secured and the right atrium was excluded. No cardiopulmonary bypass was used. A cavotomy was made at the right renal vein os and the tumor thrombus was extracted en bloc in a retrograde manner under transesophageal echocardiographic visualization. ResultsTotal operative time was 211 minutes, including robotic docking, with 90 minutes spent on taking down intraabdominal adhesions. Caval clamp time was 13 minutes. Estimated blood loss was 100 mL. Postoperatively, the patient developed atrial fibrillation with rapid ventricular rate (RVR) requiring diltiazem infusion (Clavien Grade II). Hospital stay was 5 days. There were no further complications. Pathology revealed an Angiomyolipoma and negative surgical margins. ConclusionThis is the initial report of a purely robotic-assisted level IV IVC tumor thrombectomy. We used this technique for an angiomyolipoma with tumor thrombus extending 1.5cm into the right atrium, managing both the supra- and infradiaphragmatic caval segments robotically. This report further extends the field of robotic surgery.

Role of intraoperative ultrasound in robotic-assisted radical nephrectomy with inferior vena cava thrombectomy in renal cell carcinoma.

To determine the impact of intraoperative ultrasound on robotic-assisted radical nephrectomy with inferior vena cava (IVC) tumor thrombectomy in renal cell carcinoma (RCC). We retrospectively analyzed intraoperative records of 27 patients with RCC and invasion of the IVC who underwent robotic-assisted nephrectomy with tumor thrombectomy at our center between December 2017 and July 2018. Diagnostic utility and impact of intraoperative transesophageal echocardiography (TEE), intraoperative robotic-assisted ultrasonography, and intraoperative contrast-enhanced ultrasound (CEUS) on surgical management were extracted from the surgical notes and intraoperative ultrasound reports. Twenty-seven patients with thrombus had intraoperative ultrasound. Complete tumor removal was achieved in 22 patients, IVC transection in 5 patients, and no residual tumor was observed in all patients. Intraoperative TEE changed the robotic surgical strategy in three patients by monitoring thrombus-level regression. Downstaging of the thrombus level occurred in three patients: Levels IV to III in one and Levels III to II in two. Intraoperative robotic-assisted ultrasonography has facilitated safe VC clamp placement and identification and protection of collateral vessels during IVC transection in five patients. Intraoperative CEUS helped to differentiate the boundary between tumor thrombus (enhancement and small vessel pulsation) and bland thrombus (hypoechoic or no enhancement) in eight (29.6%) patients with bland thrombus. Intraoperative ultrasound is a safe, minimally invasive technique that can provide accurate real-time information regarding the presence and extent of IVC involvement and guidance for placement of a vena cava clamp, confirming the character of the thrombus to plan an optimal surgical approach.

Complex robotic nephrectomy and inferior vena cava tumor thrombectomy: an evolving landscape.

Robotic nephrectomy for complex renal masses and in the setting of inferior vena cava (IVC) tumor thrombus has been shown to be a well tolerated and reproducible surgical option. Recent developments in such procedures will be discussed as they continue to evolve. Multiple case series have demonstrated the application of robotic surgery in the management of the most complex renal tumors and for IVC thrombi with acceptable oncologic and perioperative outcomes. Prior to the advent of robotic surgery, massive tumors, contiguous organ invasion, need for lymphadenectomy, and IVC tumor thrombus were thought by many to require open surgery. Since 2011, several studies have reported robotic nephrectomy for complex tumors with recent comparisons of robotic and open approaches finding similar oncologic and survival outcomes but with shorter length of stay (LOS) and less blood loss with robotic surgery. Robotic surgery is a feasible and well tolerated alternative to open surgery for the management of complex renal tumors and IVC thrombi. The potential benefits of shorter LOS, less blood loss, and earlier convalescence suggest this approach should continue to be evaluated. Patient selection and surgeon experience are of paramount importance.

Fairly rare small-diameter hepatocellular carcinoma with right adrenal gland metastasis having an inferior vena cava tumor thrombus: a case report

BackgroundHepatocellular carcinoma (HCC) may lead to extrahepatic metastasis (EHM). Most patients with EHM had either intrahepatic stage III or IVA tumor at the site of metastases. Herein, we present the case of a fairly rare 1.5-cm small-diameter HCC with right adrenal gland tumor having an inferior vena cava (IVC) tumor thrombus.Case presentationA 75-year-old man had a 1.5-cm hepatocellular carcinoma (HCC) in segment 8 of the liver and a 3.0-cm right adrenal gland tumor with inferior vena cava (IVC) tumor thrombus. He underwent partial hepatectomy, right adrenalectomy, and IVC tumor thrombectomy. Tumor resection was successful, but the tumor progressed rapidly, and the patient died 8 months after the operation. Immunohistochemical staining revealed that both HCC cells and adrenal tumor cells were positive for HCC markers Glypican-3 and alpha-fetoprotein. In terms of adrenal carcinoma markers vimentin and Melan-A, vimentin was negative in the HCC and adrenal tumor, and Melan-A was negative in the HCC. In adrenal tumor, slight positivity of Melan-A was observed, but the intensity of staining was clearly weak compared with that in normal adrenal glands. CD133, one of the stem cell markers, was positive in both HCC and adrenal tumor cells. Next-generation amplicon sequencing analyses were performed using DNA derived from the HCC, adrenal tumor, and normal liver tissue. After exome data analyses for representative HCC-related genes as TERT, CTNNB1, TP53, and ARID2, TP53 mutation (exon3: c.G351 T: p.R117S) was found in both HCC cells and adrenal tumor cells. Conversely, no significant mutations in other genes were observed. These pathological findings and sequencing results showed that the adrenal tumor might be an adrenal metastasis of HCC in spite of small primary tumor size.ConclusionsThis case suggests that the right adrenal tumor was a metastasis of HCC. Immunohistochemical staining and gene mutation analyses using NGS are very useful in differentiating the tumor origin.

Surgical treatment of renal angiomyolipoma with inferior vena cava tumor thrombus: case report and literature review

Objective To explore the clinical characteristics of renal angiomyolipoma (AML) with inferior vena cava (IVC) tumor thrombus and to improve the diagnosis and treatment of the disease. Methods The clinical data of 3 patients with renal AML and inferior vena cava tumor thrombus was retrospectively reviewed. The patients were all female, aged 19 to 70 years. Among them, 2 patients presented with lumbago on the right side, and the other one was diagnosed by physical examination. The body mass index ranged from 18.4 to 24.6 kg/m2, with a median value of 20.4 kg/m2. According to the American Society of Anesthesiologists (ASA), they were classified as grade Ⅱ. Color doppler ultrasound examination of the kidney and IVC was performed in all the 3 patients, all of which showed hyperechoic solid mass in the right kidney. Color doppler ultrasound of IVC showed hyperechoic band in the IVC, indicating blood flow signals and the tumor thrombus. All the 3 cases showed irregular fat density or mixed density in the right kidney and multiple irregular fat density were observed in the right renal vein and inferior vena cava on CT. Two of them received MRI examination of IVC, which showed irregular lesions in the right kidney, short T1 and long T2 signals, low lipids, and no definite limited diffusion on DWI. Irregular fat signal were seen in the right renal vein and inferior vena cava. All 3 patients were diagnosed with right renal mass with IVC tumor thrombus, with 1 patient of Mayo grade Ⅲ tumor thrombus and the other 2 of Mayo gradeⅡtumor thrombus. One underwent laparoscopic radical nephrectomy and inferior vena cava tumor thrombectomy, another one underwent open right partial nephrectomy and tumor thrombectomy, and the third one suffered preoperative AML rupture, undergoing open radical nephrectomy and tumor thrombectomy. Results The operation time was 168 to 659 min, with median of 220 min. Intraoperative blood loss ranged from 50 to 300 ml, with the median of 50 ml. Postoperative indwelling time of drainage tube was 5 to 11 days, with the median of 6 days. Postoperative hospital stay ranged from 7 to 14 days, with a median of 8 days. Postoperative follow-up ranged from 12 to 16 months, with a median follow-up of 13 months. All the three patients underwent operation without postoperative complications. Postoperative pathology proved to be right renal angiomyolipoma. After 3 months of follow-up, the patients showed no tumor recurrence or metastasis. Conclusions Renal AML is a benign lesion, which is rarely concurrent with inferior vena cava cancer thrombus. Enhanced CT examination is the main diagnostic method, surgical resection of the lesion is the preferred treatment, partial nephrectomy combined with thrombectomy can be performed in patients with AML, if permitted, and postoperative prognosis turns out to be propitious. Key words: Inferior vena cava; Renal angiomyolipoma; Tumor thrombus

Robot Assisted Surgery of the Vena Cava: Perioperative Outcomes, Technique, and Lessons Learned at The Mayo Clinic.

Introduction: This study aims to describe robot assisted surgery of the inferior vena cava (IVC) by assessing techniques utilized, perioperative outcomes, complications, and long-term patency of the IVC. Methods: A retrospective review was performed on all robotic surgeries involving dissection and repair of the IVC at our institution. Patient characteristics, operative reports, and follow-up visits were analyzed. Preoperative and postoperative imaging was independently reviewed by a single radiologist to determine changes in IVC diameter. Complications were analyzed according to early (<30 days) vs late (>30 days). Results: Thirty-four patients underwent robot assisted surgery of the vena cava from 2008 to 2018. Twenty-six cases were performed for urologic malignancy, four were performed for IVC filter explantation, and four renal vein transpositions were performed for nutcracker syndrome. Twenty-four of the 26 patients with urologic malignancy underwent radical nephrectomy with IVC tumor thrombectomy. Three cases were converted to open. Median length of stay was two nights, and mean estimated blood loss (EBL) was 375 mL. There were five complications, ranging from Clavien-Dindo grade II-IIIa, four of which were early complications. No patients required return to the operating room, and there were no perioperative mortalities. IVC diameter was reduced by 41% on axial diameter, with no patients experiencing compromised venous return. Conclusion: Robot assisted surgery offers the advantage of minimally invasive surgery with the ability to apply open surgical principles. In our series, an experienced multidisciplinary team approach yielded low EBL, short length of stay, and low complication rates.

V26 - Indocyanine green guided robot assisted radical nephrectomy and level III inferior vena cava tumor thrombectomy

V26 - Indocyanine green guided robot assisted radical nephrectomy and level III inferior vena cava tumor thrombectomy