Introduction

Inferior vena cava (IVC) tumor thrombectomy for kidney cancer is one of the most challenging urologic oncologic operations, routinely performed open. After reporting the initial series of level III robotic IVC thrombectomy (J Urol. 2015; 194, 929), we have standardized our technique across 3 institutions. Herein, we report the largest series to date (n=64) and identify clinical parameters that predict intraoperative efficiency and success._x000D_ _x000D_

Methods

This is an IRB-approved, 3-center, retrospective analysis of prospectively-collected data. 64 consecutive patients with level I-III IVC tumor thrombus underwent robotic IVC thrombectomy (01/2011 to 10/2016): Level I (2, 3.1%), Level II (52, 81.2%), Level III (10, 15.6%). Patient demographics, imaging data, intraoperative parameters, pathology data, complications, and oncologic outcomes were collected.

Results

Robotic IVC thrombectomy was successful in 63 patients (98%); 1 patient was electively converted to open surgery for failure to progress. Median BMI was 25 kg/m2 (21-42) and ASA score was 2 (1-4). Primary kidney tumor was left-sided in 14 patients (21%). Median IVC thrombus length was 4 cm (1.5-12). Median operative time was 4 hrs (1-8), estimated blood loss (EBL) 260cc (20-7,000), peri-operative transfusion rate 21.5% (median/mean units transfused/patient = 0/1.2) and hospital stay 6 days (1-32). Complications occurred in 8 patients (12%): Clavien 3a (2), Clavien 3b (2), Clavien 4 (4). Pathology revealed renal cell carcinoma (n=63) and adult Wilms&[prime] tumor (n=1). One-year cancer-specific and overall survival rates were 100% and 97.9%._x000D_ _x000D_ &[prime]Trifecta&[prime] of operative efficiency was defined as realization of the following 3 parameters: OR time < 4 hrs, no transfusions and no complications. Trifecta outcome was achieved in 24 patients (38%). Characteristics of patients in whom trifecta was achieved were: thrombus level II (100%), thrombus characteristics: no arterialization, no caval wall involvement, no projection into contralateral renal vein (92-96%), right-sided primary renal tumor (92%), no bland tumor thrombus (88%) and complete occlusion of IVC (0%). In the trifecta group, median thrombus length and diameter were 4 cm and 2.4 cm, respectively, median EBL was 165cc. With increasing experience, there were no discernible trends regarding operative time, EBL, or complications._x000D_

Conclusions

This is the largest series to date of robotic IVC thrombectomy surgery. This is a safe and feasible procedure when performed by experienced surgeons. Additional follow up is needed to determine long-term oncologic outcomes._x000D_

Funding

none