Background:
Renal cell carcinoma (RCC) is associated with a propensity for vascular invasion with extension of tumor to the renal vein, infradiaphragmatic inferior vena cava (IVC) (Level I-III) or supradiaphragamatic IVC (Level IV) till the right atrium.
Resection of both renal tumor and vascular thrombus is considered the optimal therapy when no distant metastases are present. Overall, tumor thrombectomy is among the most challenging urologic procedures and it is traditionally performed by open approach.
Objectives:
To describe our technique in a step-by-step fashion for robot-assisted thrombectomy for level IV intraatrial thrombus and report on preliminary outcomes.
Surgical procedure:
Our technique include a simultaneous antegrade-retrograde robot-assisted approach by using a dual da Vinci Surgical System. The thrombus is extracted after opening both the right atrium and infradiaphragmatic inferior vena cava.
Design, setting, and participants:
Patients with a renal mass and a level IV intraatrial tumor thrombus and good performance status (ECOG performance status 0 or 1) will be enrolled. Exclusion criteria comprise Level I-III thrombi and widespread metastatic disease. Included patients will receive our new anatomic-based technique of robot-assisted thrombectomy focusing on minimizing mainly the chances of intraoperative tumor thromboembolism and hemorrhage.
Outcome measurements and statistical analysis:
Primary end-point of the study is the intra- and post-operative morbidity. Secondary end-points include perioperative outcomes, time to recovery after surgery and oncological results (recurrence-free, cancer-specific and overall survival at last follow-up) with a minimum 1-yr follow-up.
Categorical variables are reported as frequency and percentage, and continuous variables as median and interquartile range (IQR) or mean and standard deviation. Kaplan-Meier methods are used to estimate tumour recurrence and survival after tumor thrombectomy.
Robot-assisted IVC tumor thrombectomy is certainly an innovative procedure, from both surgeon's and patient's perspectives.
This study can significantly contribute to body of knowledge. Indeed, radical surgery in patients with level IV thrombus extension is associated with high perioperative mortality, even if long-term survival is possible.
In this study, we describe a novel technique of combined antegrade-retrograde robot-assisted vena caval and intraatrial tumor thrombectomy.
First, we aim at demonstrating the safety of this novel robot-assisted approach (particularly, in terms of intraoperative tumor thromboembolism and major hemorrhage occurrence, the two major complications of IVC thrombectomy surgery). In addition, the reduced invasiveness (smaller incisions and scarring, faster recovery times, reduced pain) of robot-assisted thrombectomy might turn into a higher adherence to enhanced recovery after surgery (early bowel recovery and reduced need for painkillers) and consequently to shorter hospital stay and to faster return to daily activities. Perioperative and oncological outcomes (recurrence-free, cancer-specific and overall survival) are considered as secondary endpoints.