AUA 2017: Robot-Assisted Radical Nephrectomy and Inferior Vena Cava Thrombectomy: Surgical Technique and Perioperative and Oncologic Outcomes
The data offered was from two tertiary referral centers over 5 years and including 35 patients. In his presentation, Dr. Simone described the surgical technique for levels 1, 2, and 3 thrombi via animated video.
The operative technique starts by ligating the renal artery. Next, the renal veins and IVC are occluded, and a small cavotomy is made to introduce a Fogarty catheter. This type of catheter is monitored via transesophageal ultrasound and is inflated above the cephalad boundary of the tumor thrombus to occlude the superior aspect of the vena cava. The renal vein is then stapled (across the thrombus) and the kidney is removed. A cavotomy is made, and the remainder of the thrombus is delivered, followed by caval closure.
The presented outcomes appear similar, if not favorable, to open approaches to IVC thrombi. Only four patients had Grade 3 or higher complications, and there were no reported deaths during the study period. Of the patients undergoing surgery, 37% had cytoreductive nephrectomy and 63% underwent surgery with curative intent. Intriguingly, cytoreductive patients experienced a 2-year survival of 92%, whereas the curative-intent group had a survival of only 77% at 2 years. Clearly, the low patient numbers and the lack of prospective controls with patient matching likely led to the survival differences seen. Nonetheless, it does appear that with appropriately selected patients in either group, robotic thrombectomies may be a reasonable surgical option.
As expected with this new technique, several audience members had questions regarding the safety and efficacy of robotic assistance versus open surgical techniques for these complex cases. As the experience with these cases grows, the data will either prove this to be a safe and effective treatment option or they will lead us to abandon this approach. As surgeons improve their experience and techniques, however, it seems more likely that robotic nephrectomy/thrombectomy is here to stay.
Presented by: Giuseppe Simone, MD, University of Southern California, Los Angeles, CA
Written By: Shreyas Joshi, MD, Fox Chase Cancer Center, Philadelphia, PA
at the 2017 AUA Annual Meeting - May 12 - 16, 2017 – Boston, Massachusetts, USA