Robotic nephrectomy with IVC tumor thrombectomy: The original technique

Objectives: We present our technique for IVC tumor thrombectomy for renal malignancies invading the vena cava. The demonstrated technique was the first description of robotic IVC tumor thrombectomy originally published in 2011 and remains our preferred approach [1–5]. Methods: A 58-year-old male who presented with hematuria was found to have a 10.8 cm right renal mass with a 4.6 cm IVC tumor thrombus. Robotic nephrectomy with IVC tumor thrombectomy was performed using 4 ports, including three robotic ports and one 12 mm assistant port. Laparoscopic ultrasound is used to identify the cranial extent of the tumor thrombus. Modified Rommel tourniquets are placed on the IVC and renal veins after clipping or dividing all lumbar veins and the adrenal vein or short hepatic veins when necessary. The renal artery is clipped in the interaortocaval space. The cava is opened only after all inflow is isolated for a bloodless field. The tumor thrombus is covered with the cut end of an extraction bag to prevent intraabdominal contamination. The cava is reconstructed with permanent suture after sequential tourniquet removal. Results: The total operative time 284 min including ipsilateral retroperitoneal lymphadenectomy with estimated blood loss of 250 cc. The patient was discharged on postoperative day 1, but we now perform these procedures on an outpatient basis. There were no complications, and surveillance imaging showed no recurrence. Conclusion: Our original technique for robotic IVC tumor thrombectomy is a safe and reproducible approach and allows a minimally-invasive operation in experienced hands.