Removal of Complex Renal Tumors Performed Safely by Robotic Surgery in Selected Patients
- None of the operations was converted to open surgery and all but two patients were ambulatory on the day of or day after surgery.
- Twenty-one patients resumed regular diets the day after surgery.
- Eight patients had node-positive disease and seven patients had distant recurrence 15 months later, including four of those with node-positive disease.
Renal cell carcinoma can sometimes spread to the inferior vena cava, posing a threat to the heart and brain. Robotic nephrectomy for inferior vena cava tumor thrombus has favorable outcomes in selected patients compared with open surgery, which can have a high rate of complications, reported Abaza et al in The Journal of Urology.
Renal vein surgery can often be managed with minimally invasive laparoscopic techniques, but this is not typically advisable for an inferior vena cava thrombus, which is surgically far more complex with potentially fatal complications that can occur in the course of removing the thrombus and reconstructing the inferior vena cava.
The first known procedure using robotic surgery of renal tumors with inferior vena cava tumor thrombi was performed in 2008.
Experts from nine leading U.S. medical centers reported on their combined experience of 32 cases since 2008. Each surgeon performed between 1 and 10 procedures for inferior vena cava tumor thrombi, which ranged from 1 to 11 cm in length on preoperative imaging. Patient age ranged from 43 to 80 years.
The inferior vena cava required cross-clamping in 24 cases. One patient had two renal veins with two caval thrombi, and one patient required a synthetic patch. Surgeries lasted from 3 to 7 hours. None of the operations was converted to open surgery, and all but two patients were ambulatory on the day of or day after surgery. Twenty-one patients resumed regular diets the day after surgery. Eight patients had node-positive disease and seven patients had distant recurrence 15 months later, including four of those with node-positive disease.
Favorable Outcomes and Reproducibility
“This is a complex condition, and the complication rate with open surgery is 12% to 47%, depending on the thrombus level, with a mortality rate of 5% to 10%,” explained Ronney Abaza, MD, Robotic Surgery Director at OhioHealth Dublin Methodist Hospital. “Using robotic nephrectomy, our complication rate and lack of mortalities compare reasonably with open series with no grade III to V complications, according to the Clavien system, in any patient, including no deaths.”
Dr. Abaza added, “While complications were relatively minor in our series, it is evident that complications are not entirely avoidable. Even with a minimally invasive approach, the surgical management of severe cancers in mostly elderly patients will likely involve complications. However, despite the complex and critical nature of these procedures, our series demonstrates favorable outcomes and reproducibility by surgeons with adequate robotic experience.”