Vena Cava Tumor Thrombectomy Research Articles

V13-07 INFERIOR VENA CAVA MANAGEMENT DURING LEFT-SIDED LEVEL III TUMOR THROMBECTOMY

You have accessJournal of UrologyCME1 May 2022V13-07 INFERIOR VENA CAVA MANAGEMENT DURING LEFT-SIDED LEVEL III TUMOR THROMBECTOMY Shawn Dason Shawn DasonShawn Dason More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002646.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: A level III vena caval tumor thrombectomy for renal cell carcinoma originating in the left kidney is an uncommon procedure. As a result, high quality video-based educational resources are not widely available. This video seeks to demonstrate the key technical considerations surrounding caval management during this procedure. METHODS: This video is a narrated compilation of several operative clips recorded during a level III vena caval tumor thrombectomy for a left-sided renal cell carcinoma. Video recording was performed with a GoPro Hero 9 camera and video editing was performed with Apple Final Cut Pro. The patient depicted in this video is a 47 year old male with a 13 cm renal left renal mass with splenic involvement, retroperitoneal lymphadenopathy, and a solitary mediastinal node. He was symptomatic and had no IMDC risk factors. Following shared decision making, resection of abdominal disease was planned. Prior to the video, the author had performed a nephrectomy, splenectomy and retroperitoneal lymphadenectomy by a chevron incision. RESULTS: This video highlights several technical aspects of the procedure, including management of the left renal vein, total isolation of the juxtarenal cava, clamp order for level III thrombectomy, and caval reconstruction. The patient sustained acute kidney injury postoperatively but otherwise has recovered well at 3-month follow-up with stable mediastinal disease. CONCLUSIONS: A left-sided level III tumor thrombectomy for renal cell carcinoma has unique technical considerations. Ongoing development of video-based educational resources for open vena caval tumor thrombectomy will increase exposure to this uncommon procedure. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e1033 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shawn Dason More articles by this author Expand All Advertisement PDF DownloadLoading ...

Robot-assisted versus open surgery for radical nephrectomy with level 1-2 vena cava tumor thrombectomy: a French monocenter experience (UroCCR study #73).

The aim of this paper was to assess the feasibility of robot-assisted radical nephrectomy (RN) with inferior vena cava thrombectomy (RRVCT) and compare perioperative and oncological outcomes of this approach to open surgery for renal tumors with level 1-2 inferior vena cava (IVC) thrombus. We performed a retrospective analysis of patients surgically treated for renal cancer with IVC level 1-2 thrombus in the Urology department of Bordeaux University Hospital between December 2015 and December 2019. Patients were stratified by surgical approach in two groups: open vs. robotic procedures. Pre-, per- and postoperative data were collected within the framework of the UroCCR project (NCT03293563). Univariate and multivariate analysis using regression models were performed. A total of 40 patients underwent RN with IVC tumor thrombus. Open and robotic surgery represented respectively 30 and 10 cases. The two groups were comparable regarding pre-operative tumor and patient characteristics. Robotic procedures were associated with lower estimated blood loss (EBL) (500 vs. 1250 mL, P=0.02), shorter Intensive Care Unit stay (2 vs. 4 days, P=0.03) and decrease of global length of stay (LOS) (7 vs. 10 days, P<0.01). Operative Time (OT) was significantly longer in the robotic group (350.5 vs. 208 min, P<0.01). No difference were observed between the two approaches regarding complications and oncological outcomes. Robotic approach induced lower bleeding and shorter LOS but required longer OT. This technique is feasible and safe for selected cases and experimented surgical teams. Complications rate and oncological outcomes are not different compared to standard open procedures.

Robot-assisted versus open surgery for radical nephrectomy with level 1-2 vena cava tumor thrombectomy: a French monocenter experience (UroCCR study #73).

BACKGROUND The aim of this paper was to assess the feasibility of robot-assisted radical nephrectomy (RN) with inferior vena cava thrombectomy (RRVCT) and compare perioperative and oncological outcomes of this approach to open surgery for renal tumors with level 1-2 inferior vena cava (IVC) thrombus. METHODS We performed a retrospective analysis of patients surgically treated for renal cancer with IVC level 1-2 thrombus in the Urology department of Bordeaux University Hospital between December 2015 and December 2019. Patients were stratified by surgical approach in two groups: open vs. robotic procedures. Pre-, per- and postoperative data were collected within the framework of the UroCCR project (NCT03293563). Univariate and multivariate analysis using regression models were performed. RESULTS A total of 40 patients underwent RN with IVC tumor thrombus. Open and robotic surgery represented respectively 30 and 10 cases. The two groups were comparable regarding pre-operative tumor and patient characteristics. Robotic procedures were associated with lower estimated blood loss (EBL) (500 vs. 1250 mL, P=0.02), shorter Intensive Care Unit stay (2 vs. 4 days, P=0.03) and decrease of global length of stay (LOS) (7 vs. 10 days, P<0.01). Operative Time (OT) was significantly longer in the robotic group (350.5 vs. 208 min, P<0.01). No difference were observed between the two approaches regarding complications and oncological outcomes. CONCLUSIONS Robotic approach induced lower bleeding and shorter LOS but required longer OT. This technique is feasible and safe for selected cases and experimented surgical teams. Complications rate and oncological outcomes are not different compared to standard open procedures.

Robotic-assisted Radical Nephrectomy With Retrohepatic Vena Caval Tumor Thrombectomy (Level III) Combined With Extended Retroperitoneal Lymph Node Dissection

To describe a case of robotic-assisted radical nephrectomy (RARN) with level III retrohepatic vena caval tumor thrombectomy (11cm) and extended retroperitoneal lymph node dissection (RPLND) for renal cell carcinoma (RCC). A 52-year-old woman with a large right renal mass, 11-cm (level III) inferior vena cava (IVC) thrombus, with a negative metastatic workup presented to our clinic and was consented to undergo RARN. Intraoperative ultrasound confirmed the presence of tumor thrombus. After the division of the renal artery, control of the vena cava above and below the tumor thrombus as well as contralateral renal vein was obtained. A cavotomy was performed, the thrombus was removed, and the cavotomy was repaired. Additionally, an extended RPLND was performed with robotic assistance. Total operative time was 6hours and 6minutes. Estimated blood loss was 1200cc. The final pathology demonstrated an 8.5-cm, Fuhrman grade 3, clear cell RCC with sarcomatoid features and negative surgical margins. All 44 lymph nodes removed (hilar, paracaval, precaval, retrocaval, interaortocaval, and preaortic) were negative. Final staging was pT3b, N0, M0. The patient was discharged to home 36hours postoperatively and experienced no perioperative or postoperative complications. RARN with retrohepatic (level III) vena caval tumor thrombectomy and extended RPLND is technically feasible and has potential benefits. Robotic assistance may allow for improved intracorporal repair of the IVC and shortened recovery time, while maintaining oncologic principles.

Level III-IV Inferior Vena Caval Thrombectomy Without Cardiopulmonary Bypass: Long-Term Experience with Intrapericardial Control

Inferior vena cava tumor thrombectomy requires experienced surgical teams due to complex hemodynamic considerations. The teams often use vascular bypass techniques that introduce additional risk. Inferior vena caval control in the pericardium obviates the need for cardiopulmonary bypass. We reviewed our experience with intrapericardial control during inferior vena caval tumor thrombectomy to evaluate perioperative outcomes and determine factors associated with overall survival. We retrospectively reviewed the records of 87 patients who underwent nephrectomy with inferior vena caval tumor thrombectomy using intrapericardial inferior vena caval control from 1978 to 2012. This technique was performed in all 43 and 35 cases of intrahepatic and supradiaphragmatic thrombi, respectively, and in 9 select cases of intra-atrial thrombi. Patient demographics, operative variables and postoperative outcomes were examined. Multivariate regression analysis was used to determine associations between clinical variables and overall survival. Mortality 30 days perioperatively was 9.2% and the incidence of high grade complications was 19.5%. Median survival was 3.1 and 2.5 years in patients with pT3bN0 and pT3cN0, respectively. Extended regional lymphadenectomy, which was performed in all cases, revealed nodal metastasis in 38%. Onmultivariate analysis ECOG greater than 2 and pT3c stage were associated with worse survival. Histological grade, perinephric fat invasion and lymph nodeinvolvement were not associated with worse survival. Intrapericardial control of the inferior vena cava enables a single surgical team to safely perform tumor thrombectomy for intrahepatic and supradiaphragmatic thrombi, eliminating the risk and morbidity related to cardiopulmonary bypass. Although supradiaphragmatic extent and ECOG greater than 2 are associated with worse survival, complete resection with lymphadenectomy can allow for long-term survival in patients with locally advanced disease.

Robotic Radical Nephrectomy with Vena Caval Tumor Thrombectomy: Experience of Novice Robotic Surgeons

The introduction of robot-assisted laparoscopic surgery has facilitated the application of minimally invasive surgical techniques to many complex reconstructive and extirpative procedures. Even early on in their learning experience, robotic surgeons have been able to complete procedures using a minimally invasive approach, but would not have been able to do so using a purely laparoscopic technique. Although the open surgical approach remains the standard of care in the management of large renal tumors presenting with a thrombus within the vena cava, robot-assisted surgery may provide the precision and dexterity necessary to allow for the safe application of minimally invasive techniques to such complex clinical scenarios, perhaps even by relatively novice robotic surgeons. We describe the management of a large renal mass with vena caval thrombus (cT3b), which required complete cross-clamping of the vena cava, with the use of a purely robot-assisted laparoscopic approach.

Simplified perfusion strategy for removing retroperitoneal tumors with extensive cavoatrial involvement

Our objective was to compare effectiveness and safety of a simplified approach for removing retroperitoneal tumors with extensive cavoatrial involvement using beating-heart cardiopulmonary bypass (CPB) versus hypothermic circulatory arrest (HCA). From January 1984 to January 2009, 144 patients underwent radical nephrectomy and inferior vena caval tumor thrombectomy, 56 (39%) using CPB and 88 (61%) HCA. Compared with HCA patients, CPB patients were of similar age (62 ± 10 vs 60 ± 11 years, P = .4) and gender (39% vs 39% female, P > .9), with similar stroke history (3.6% vs 2.3%, P =.6), but had less pulmonary disease (18% vs 33%, P = .06) and lower preoperative creatinine concentration (1.3 ± 0.72 vs 1.5 ± 0.86 mg · dL(-1), P = .04). Complete tumor removal was achieved in all patients by both strategies. Compared with HCA procedures, CPB times were shorter (50 ± 33 vs 94 ± 40 minutes, P < .0001). CPB patients required fewer blood transfusions (36% no transfusion vs 17%, and 45% ≥4 units vs 72%; P = .003) and had no statistical difference in morbidity, including reoperation for bleeding (3.8% vs 8.0%, P = .3), renal failure requiring dialysis (3.6% vs 10%, P = .14), respiratory insufficiency (21% vs 19%, P = .8), sepsis (5.4% vs 10%, P = .3), stroke (5.4% vs 1.1%, P = .13), and in-hospital mortality (7.1% vs 13%, P = .3). Ten-year survival (22% vs 22%, P > .9) and freedom from cancer recurrence (24% vs 28%, P = .8) were similar. Radical nephrectomy and removal of inferior vena caval tumor-thrombus can be simply, effectively, and safely performed with beating-heart CPB, avoiding the deleterious effects of HCA and providing clinical benefit without increasing morbidity or mortality.

Techniques for Robotic Nephrectomy with Vena Caval Tumor Thrombectomy

Objectives: Laparoscopy has become the standard of care for most renal tumors but not yet for renal cell carcinoma involving the vena cava (IVC). Robotic technology may facilitate such complex procedures. Methods: Two techniques for totally intracorporeal robotic nephrectomy for renal tumors with IVC tumor thrombus are described with video illustration.1,2 The first technique for smaller tumor thrombi involves tangential clamping of the IVC for preserved flow, whereas larger tumor thrombi are managed with IVC cross-clamping using modified Rummel tourniquets. In all cases, the IVC is circumferentially mobilized with all lumbar veins controlled. Laparoscopic ultrasonography is used selectively to evaluate extent of larger thrombi and to confirm lack of caval invasion. These techniques have been performed in five patients with one patient having two renal veins each with an IVC thrombus. Results: Robotic surgery has been applied safely for renal cell carcinoma with IVC tumor thrombus with the two described techniques in five patients with tumor sizes of 6 to 15.5 cm and thrombi protruding 1 to 5 cm into the IVC. Mean estimated blood loss was 170 mL (range, 50–400 mL). Mean operative time from incision to dressing including robotic full retroperitoneal lymphadenectomy in four patients was 327 minutes (range, 240–411 minutes). The largest incision used for extraction was 6 cm and as small as 4 cm. Four patients were discharged on postoperative day 1 and the other patient on day 2. There were no complications, transfusions, or readmissions. Conclusions: Further experience is necessary to validate this promising application of robotic surgery and to determine whether more extensive thrombi can treated in minimally-invasive fashion. The author has no disclosures to report relevant to this publication. No competing financial interests exist. Runtime of video: 6 mins 54 secs

Initial Series of Robotic Radical Nephrectomy with Vena Caval Tumor Thrombectomy

Initial Series of Robotic Radical Nephrectomy with Vena Caval Tumor Thrombectomy

Initial Series of Robotic Radical Nephrectomy with Vena Caval Tumor Thrombectomy

Laparoscopy has become a standard modality for most renal tumors but not as yet for renal cell carcinoma (RCC) involving the inferior vena cava (IVC). Robotic technology may facilitate such complex procedures. We report the first series of robotic nephrectomy with IVC tumor thrombectomy including the first cases requiring cross-clamping of the IVC in a minimally invasive fashion. Five patients underwent robotic nephrectomy with IVC tumor thrombectomy including one patient having two renal veins, each with an IVC thrombus, for a total of six IVC thrombi. The IVC was opened in all patients, and tumor thrombi were delivered intact, followed by sutured closure. The mean patient age was 64 yr (53–70 yr) with a mean body mass index of 36.6kg/m2 (22–43kg/m2). Thrombi protruded 1cm, 2cm, 4cm, and 5cm into the IVC in five patients and 3cm and 2cm in the patient with two thrombi. The mean estimated blood loss was 170ml (50–400ml). Mean operative time was 327min (240–411min). Mean length of stay was 1.2 d. There were no complications, transfusions, or readmissions. This early series represents a limited experience by a single surgeon with a new procedure and may not be reproducible in larger numbers or by all surgeons. Further experience is necessary to validate this application.

894 INITIAL SERIES OF ROBOTIC RADICAL NEPHRECTOMY WITH VENA CAVAL TUMOR THROMBECTOMY

You have accessJournal of UrologyTechnology & Instruments: Robotics/Laparoscopy/Ureteroscopy II1 Apr 2010894 INITIAL SERIES OF ROBOTIC RADICAL NEPHRECTOMY WITH VENA CAVAL TUMOR THROMBECTOMY Ronney Abaza Ronney AbazaRonney Abaza More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1650AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Laparoscopy has become the standard of care for most renal tumors but not yet for renal cell carcinoma (RCC) involving the vena cava (IVC). Despite advances in laparoscopy, there are only two reports in the literature regarding laparoscopy and IVC thrombi including one hand-assisted case report for a small thrombus and four lap-assisted cases where the IVC was managed open. Robotic technology may facilitate such complex procedures. The first cases of completely intracorporeal robotic management are presented. METHODS One female and three male patients presented with right renal masses consistent with RCC. Robotic nephrectomy with IVC thrombectomy and retroperitoneal lymphadenectomy was performed in all four with one patient having two renal veins each with an IVC thrombus for a total of five IVC thrombi. The IVC and left renal vein were dissected circumferentially. The IVC was clamped with a curved laparoscopic Satinsky clamp tangentially across its lumen excluding the tumor thrombi in four of five thrombi, while the IVC was cross-clamped using modified Rommel tourniquets for one thrombus. The IVC was then incised and the tumor thrombi delivered intact after which the IVC was closed with permanent suture in all cases. RESULTS Mean patient age was 66yrs (range 60-70) with mean BMI of 35 kg/m2 (22-42). All had RCC on pathology with a mean size of 9cm (6-11cm). Thrombi protruded 1cm, 2cm and 4cm beyond the renal vein and into the IVC and 3cm and 2cm in the patient with two thrombi. Mean estimated blood loss was 113cc (range 50cc-150cc). Mean operative time from incision to dressing including lymphadenectomy was 306min (range, 240-396min). The IVC was cross clamped for 14 minutes in the case requiring it. Mean yield of the lymphadenectomy was 12.5 nodes (range 7-24) with one patient found to have a positive node. The largest incision used for extraction was 6cm and as small as 4cm. Three patients were discharged on postoperative day one and the other patient on day two. There were no complications, transfusions, or readmissions. CONCLUSIONS Robotic surgery was applied safely for RCC with IVC tumor thrombus. Further experience is necessary to validate this promising application and to determine whether more extensive thrombi can treated in minimally-invasive fashion. Columbus, OH© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e349 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ronney Abaza More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Intraoperative transesophageal echocardiography for inferior vena caval tumor thrombus in renal cell carcinoma.

We investigated the advantages of intraoperative transesophageal echocardiography (TEE) during inferior vena caval tumor thrombectomy in renal cell carcinoma (RCC). Five patients with RCC that extended into the inferior vena cava (IVC) underwent radical nephrectomy. To remove the tumor thrombus in the IVC, an inflated Fogarty balloon catheter was used to pull the thrombus below the level of the hepatic veins with real-time TEE monitoring. In all cases, TEE monitoring during surgery provided an accurate and excellent view of the IVC thrombus. TEE was particularly helpful for the thrombectomy to minimize hepatic mobilization by using occlusion balloon catheter in two patients whose thrombus extended to the intrahepatic IVC. Intraoperative real-time TEE monitoring is a safe, minimally invasive technique that can provide accurate information regarding the presence and extent of IVC involvement, guidance for placement of a vena caval clamp, confirmation of complete removal of the IVC thrombus and intervention using catheters to assist in thrombectomy.

COMPLETE RADICAL NEPHRECTOMY AND VENA CAVAL THROMBECTOMY DURING CIRCULATORY ARREST

A modification of radical nephrectomy for renal carcinoma and vena caval tumor thrombectomy for supradiaphragmatic tumor extension under hypothermic circulatory arrest is presented. Nephrectomy was performed during the circulatory arrest time in 16 consecutive patients during the last 4 years. Average hypothermic circulatory arrest time increased by 6 minutes. By elimination of manipulation of tumor and thrombus before circulatory arrest potential thrombus fragmentation and embolization were minimized. There were no significant differences in blood loss or complications compared to a prior series of 10 patients undergoing the procedure using conventional techniques. Performance of complete radical nephrectomy along with venal caval embolectomy during circulatory arrest increases the safety of the procedure without significant morbidity.

Resection of the Inferior Vena Cava or Intraluminal Vena Caval Tumor Thrombectomy During Retroperitoneal Lymph Node Dissection for Metastatic Germ Cell Cancer: Indications and Results

A total of 42 patients underwent inferior vena caval resection (40) or intraluminal tumor thrombectomy (2) during retroperitoneal lymph node dissection for bulky abdominal metastatic nonseminomatous germ cell cancer (7% of all post-chemotherapy retroperitoneal lymph node dissection cases). The 3 indications for vena caval resection included tumor clearance (38%), vena caval scar occlusion (14%) and vena caval tumor thrombus (48%). En bloc vena caval resection to achieve tumor clearance was justified by subsequent nodal pathology (cancer in 63% of the specimens and teratoma in 31%). Vena caval resection in the presence of scar occlusion was de facto required by virtue of its incorporation in the specimen. Vena caval resection or thrombectomy is indicated for intraluminal tumor thrombus because thrombus pathology (cancer 35%, teratoma 45% and fibrosis 20%) reflected nodal pathology in 71% of the patients with cancer, 78% with teratoma and 100% with fibrosis. The complications of vena caval resection were generally transitory. The 71% survival rate justifies this intensive surgical approach because these patients had exhausted all chemotherapy options.