Clinical research on robot-assisted retroperitoneal nephrectomy with vena thrombectomy (report of 4 cases)
WU Shengpan1, PENG Cheng1, HUANG Qingbo1, DU Songliang1, FAN Yang1, GAO Yu1, GU Liangyou1, NIU Shaoxi1, WANG Hanfeng1, LIU Kan1, TANG Lu1, XU Yong1, ZHAO Hui1, Fan Zhang2, LI Hongzhao1, ZHANG Xu1, WANG Baojun1, MA Xin1
1 Department of Urology, Chinese PLA General Hospital, Beijing 100853, China; 2 Department of Urology, Affiliated Hospital of Weifang Medical University
Abstract：Objective： To investigate the safety and feasibility of robot-assisted retroperitoneal nephrectomy with vena thrombectomy. Methods： Of four enrolled patients, there were two cases of left renal cell carcinoma with tumor thrombus and the Mayo grade 0 (grade 0a in the 301 classification system); one case of right renal cell carcinoma with the Mayo grade I; and one case of right renal cell carcinoma with the Mayo gradeⅡ (The latter two cases were of grade I in the 301 classification system). All operations were performed via the retroperitoneal approach. The third arm was used to fix the kidney to create the operation space. The IVC with tumor thrombus and its branches along the psoasmuscle were exposed and dissociated then. The renal vein was blocked by the Satinsky forceps at the proximal end of the tumor for the patients with Mayo grade 0 and grade I, and the tumor thrombus was pushed back into the renal vein. Then the Endo-GIA was placed at the junction of the renal vein and the IVC to disconnect the right renal vein. There was no need to disconnect the IVC. For the patients with tumor thrombus of Mayo grade I, venous branches of the IVC, the lumbar vein and the short hepatic vein were released and disconnected. The distal end of the IVC, the left renal vein, and the IVC near the cardiac end were sequentially blocked, and the thrombus was removed. The inferior vena cava was reconstructed and the above-mentioned occlusion band was released. After the blood vessel was not oozing, the operation was performed according to the radical nephrectomy procedures. Results： All operations were completed successfully via the retroperitoneal approach without conversion to laparotomy. The average operative time was 158.75 min (range from 110 min to 210 min). The intraoperative blood loss was estimated to be 487.5 mL (ranger from 200 mL to 1 000 mL) and no blood transfusion was needed. The drainage tube was placed for 3 days. The catheter was removed after 3 days. Patients were discharged 4 days after surgery. There was no bleeding, pulmonary embolism and other complications after surgery. Conclusions： Robot-assisted retroperitoneal nephrectomy with vena thrombectomy is safe and feasible, which provides an effective minimally invasive treatment for renal cell carcinoma with tumor thrombus, and there are different surgical indications and technical characteristics for different-sided renal cell carcinoma. However, the clinical efficacy and prognosis of this procedure still need to be expanded to confirm by a larger sample.
[1] ALI AS, VASDEV N, SHANMUGANATHAN SA, et al.The surgical management and prognosis of renal cell cancer with IVC tumor thrombus: 15-Years of experience using a multi-specialty approach at a single UK referral center. Urol Oncol, 2013,31(7):1298-1304. [2] 丁玲玲,张宏,米卫东,等.机器人辅助腹腔镜下根治性肾切除联合下腔静脉瘤栓取出术的临床麻醉研究.北京医学,2016,36(6):519-522. [3] POULIOT F, SHUCH B, LAROCHELLE JC, et al.Contemporary management of renal tumors with venous tumor thrombus. J Urol, 2010,184(3):833-841. [4] GU LY, MA X, GAO Y, et al.Robotic versus Open Level I-II Inferior Vena Cava Thrombectomy: A Matched Group Comparative Analysis. J Urol, 2017,198(6):1242-1247. [5] ZHANG X, LI HZ, MA X, et al.Retroperitoneal laparoscopic nephron-sparing surgery for renal tumors: Report of 32 cases. Urology, 2005,65(6):1080-1084. [6] ABAZA R.Initial series of robotic radical nephrectomy with vena caval tumor thrombectomy. Eur Urol, 2011,59(4):652-656. [7] KUNDAVARAM C, ABREU AL, CHOPRA S, et al.Advances in robotic vena cava tumor thrombectomy: intracaval balloon occlusion, patch grafting, and vena cavoscopy. Eur Urol, 2016,70(5):884-890. [8] GILL IS, METCALFE C, ABREU A, et al.Robotic level III inferior vena cava tumor thrombectomy: initial series. J Urol, 2015,194(4):929-936. [9] RAMIREZ D, MAURICE MJ, COHEN BA, et al.Robotic level III IVC tumor thrombectomy: duplicating the open approach. Urology, 2016,90(90):204-207. [10] WANG B, LI H, HUANG Q, et al.Robot-assisted Retrohepatic Inferior Vena Cava Thrombectomy: First or Second Porta Hepatis as an Important Boundary Landmark. Eur Urol, 2017(74):512-520. [11] WANG B, LI H, MA X, et al.Robot-assisted Laparoscopic Inferior Vena Cava Thrombectomy: Different Sides Require Different Techniques. Eur Urol, 2016,69(6):1112-1119. [12] CHOI JE, YOU JH, KIM DK, et al.Comparison of perioperative outcomes between robotic and laparoscopic partial nephrectomy: a systematic review and meta-analysis. Eur Urol, 2015,67(5):891-901. [13] HUGHES-HALLETT A, PATKI P, PATEL N, et al.Robot-assisted partial nephrectomy: a comparison of the transperitoneal and retroperitoneal approaches. J Endourol, 2013,27(7):869-874. [14] GIN GE, MASCHINO AC, SPALIVIERO MA, et al.Comparison of perioperative outcomes of retroperitoneal and transperitoneal minimally invasive partial nephrectomy after adjusting for tumor complexity. Urology, 2014,84(6):1355-1360. [15] KIM EH, LARSON JA, POTRETZKE AM, et al.Retroperitoneal robot-assisted partial nephrectomy for posterior renal masses is associated with earlier hospital discharge: a single-Institution retrospective comparison. J Endourol, 2015,29(10):1137-1142. [16] 李新涛,张旭,吕香君.后腹腔入路机器人肾部分切除术:手术效果与技术现状.微创泌尿外科杂志,2016,5(2):124-128.
