Introduction: Robotic nephrectomy with level I-III inferior vena cava (IVC) tumour thrombectomy is feasible and safe in highly experienced surgeons for well-selected patients. Herein, we present the video of a complete minimally-invasive surgery for renal cancer with level IV intracardiac tumour thrombus.
Methods: An 83-year-old woman presented to the Emergency department with flank pain. Laboratory investigations showed haemoglobin concentration of 11g/dl, normal coagulation panel, serum creatinine concentration of 0.98mg/dl. CT-scan showed a 5.8 cm right renal mass with an 8.0 cm IVC tumour thrombus extending 1.5 cm into the right atrium. No metastases and suspect of infiltration of IVC wall at preoperative imaging were identified. Standard surgery (i.e.: laparotomy combined with sternotomy and extracorporeal circulation) was contraindicated since the high mortality risk. A less invasive approach was performed, consisting of a robotic radical nephrectomy and cavo-atrial thrombectomy with SI system combined with AngioVac system. First, cannulas for ECMO were placed into the right jugular and femoral veins and the left femoral artery. Second, the kidney tumour was isolated, the liver was rotated, the right renal artery clipped and the IVC was isolated. Finally, ECMO was started and AngioVac catheter was inserted through the jugular vein under transoesophageal ultrasound guidance. The device was used to aspirate and push the thrombus into the retro-hepatic IVC, while a robotic drop-in ultrasound probe was used to identify the upper end of the thrombus. After clamping the infra-renal IVC, the left renal vein and the retro-hepatic IVC above the thrombus, IVC was opened and the thrombus was entirely removed alongside the kidney.
Results: Total operative time and estimated blood loss were respectively 9 hours and 2000 ml. Final pathology showed clear cell RCC pT3cN0. At the end of the surgery, the patient had two cardiac arrests. After a prolonged ICU hospitalization due to pleural effusion and cerebral hypoxia, the patient gradually recovered. Post-operative CT scan found no residual tumour or thrombus. The patient was discharged after 90 days, including rehabilitation. At 6 months of follow up, the patient is alive, disease free and without neurological impairments.
Conclusions: Complete minimally-invasive surgery for renal cancer with level IV intracardiac tumour thrombus is a feasible highly-challenging procedure that requires multidisciplinary cooperation. Future studies are needed to confirm these findings and its extensions to fitter patients.