Robot-assisted Cavectomy Versus Thrombectomy for Level II Inferior Vena Cava Thrombus: Decision-making Scheme and Multi-institutional Analysis

Shi T 1 , Huang Q 1 , Liu K 1 , Du S 1 , Fan Y 1 , Yang L 1 Show all authors , Peng C 1 , Shen D 1 , Wang Z 1 , Gao Y 1 , Gu L 1 , Niu S 1 , Ai Q 1 , Li H 1 , Liu F 2 , Li Q 3 , Wang H 4 , Guo A 5 , Fu B 6 , Yang X 7 , Zhang X 8 , Wang D 9 , Wang D 10 , Guo H 11 , Li H 12 , Olivero A 13 , Fam XI 14 , Ma X 15 , Wang B 16 , Zhang X 17

Affiliations 

  • 1 Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China
  • 2 Department of Interventional Radiology, Chinese PLA General Hospital, Beijing, China
  • 3 Department of Ultrasound, Chinese PLA General Hospital, Beijing, China
  • 4 Department of Radiology, Chinese PLA General Hospital, Beijing, China
  • 5 Department of Pathology, Chinese PLA General Hospital, Beijing, China
  • 6 Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, China
  • 7 Department of Urology, Xijing Hospital of Chinese PLA Air Force Medical University, Xi'an, China
  • 8 Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
  • 9 Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
  • 10 Department of Urology, First Hospital of Shanxi Medical University, Taiyuan, China
  • 11 Department of Urology, Nanjing Drum Tower Hospital of Nanjing Medical school, Nanjing, China
  • 12 Department of Urology, Gansu Provincial Hospital, Lanzhou, China
  • 13 Department of Urology, San Martino Policlinico Hospital, University of Genova, Genoa, Italy
  • 14 Urology Unit, Surgery Department, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
  • 15 Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China. Electronic address: urologist@foxmail.com
  • 16 Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China. Electronic address: baojun40009@126.com
  • 17 Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China. Electronic address: xzhang@foxmail.com
Eur Urol, 2020 10;78(4):592-602.
PMID: 32305170 DOI: 10.1016/j.eururo.2020.03.020

Abstract

BACKGROUND: Robot-assisted thrombectomy (RAT) for inferior vena cava (IVC) thrombus (RAT-IVCT) is being increasingly reported. However, the techniques and indications for robot-assisted cavectomy (RAC) for IVC thrombus are not well described.

OBJECTIVE: To develop a decision-making program and analyze multi-institutional outcomes of RAC-IVCT versus RAT-IVCT.

DESIGN, SETTING, AND PARTICIPANTS: Ninety patients with renal cell carcinoma (RCC) with level II IVCT were included from eight Chinese urological centers, and underwent RAC-IVCT (30 patients) or RAT-IVCT (60 patients) from June 2013 to January 2019.

SURGICAL PROCEDURE: The surgical strategy was based on IVCT imaging characteristics. RAT-IVCT was performed with standardized cavotomy, thrombectomy, and IVC reconstruction. RAC-IVCT was mainly performed in patients with extensive IVC wall invasion when the collateral blood vessels were well-established. For right-sided RCC, the IVC from the infrarenal vein to the infrahepatic veins was stapled. For left-sided RCC, the IVC from the suprarenal vein to the infrahepatic veins was removed and caudal IVC reconstruction was performed to ensure the right renal vein returned through the IVC collaterals.

MEASUREMENTS: Clinicopathological, operative, and survival outcomes were collected and analyzed.

RESULTS AND LIMITATIONS: All procedures were successfully performed without open conversion. The median operation time (268 vs 190 min) and estimated blood loss (1500 vs 400 ml) were significantly greater for RAC-IVCT versus RAT-IVCT (both p < 0.001). IVC invasion was a risk factor for progression-free and overall survival at midterm follow-up. Large-volume and long-term follow-up studies are needed.

CONCLUSIONS: RAC-IVCT or RAT-IVCT represents an alternative minimally invasive approach for selected RCC patients with level II IVCT. Selection of RAC-IVCT or RAT-IVCT is mainly based on preoperative IVCT imaging characteristics, including the presence of IVC wall invasion, the affected kidney, and establishment of the collateral circulation.

PATIENT SUMMARY: In this study we found that robotic surgeries for level II inferior vena cava thrombus were feasible and safe. Preoperative imaging played an important role in establishing an appropriate surgical plan.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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