Physicians at Upstate Medical University in Syracuse describe in the December issue of Urology the first case ever in which doctors used minimally invasive robotic surgery to perform a radical nephrectomy (removal of entire kidney) with a level III inferior vena cava thrombectomy (removal of a tumor from the largest vein that carries blood to the heart).
The procedure also included the removal of numerous lymph nodes. The surgery was performed in 2013 and is featured on the cover of the current issue of Urology.
Of special note in this case was the size of the tumor thrombus—11 centimeters. Prior to this operation the largest inferior vena cava (IVC) tumor removed by robotic surgery has been reported in literature as five centimeters (level II).
In about 10 percent of kidney cancer cases, tumors grow and enter IVC. Eventually, this tumor can reach the patient’s heart with deadly consequences. Surgery to remove this tumor can be complicated depending on its proximity to the heart. In the case performed at Upstate, doctors say the tumor came within two inches of the patient’s heart.
Previously, removal of this type of tumor was done by making large incisions that often required patients to remain in the hospital for many days or even weeks. Recently, with the introduction of the robotic-assisted surgery, a few centers have performed this tumor removal without large incisions allowing patients to go home earlier than after traditional open approach.
The Upstate case is important in that it expands the surgical limits of minimally invasive laparoscopic and robotic surgery, said Gennady Bratslavsky, MD, chief of Urology at Upstate Medical University, who authored the case report with Jed-Sian Cheng, MD MPH.
Robotic surgery for this complex case provided the benefit of three-dimensional vision, articulating instruments and precise instrument control, and was able to handle challenging and delicate procedures, Bratslavsky said.
Bratslavsky suggests that for minimally invasive surgery to be a realistic option, the procedure should not be prohibitively long. The procedure at Upstate ran about 6 hours (366 minutes) well within the reported rangers of 240 to 411 minutes for smaller IVC thrombus.
The successful use of robotic surgery in this complex case also can be seen by the relatively short hospital stay for the patient. In this case, the patient was discharged to home after 36 hours with no postoperative complications.
While this reports offers encouraging progress for using robotic-assisted surgery in a complex IVC thrombus case, Bratslavsky warns that maximum caution should be exercised when using this approach and that centers providing this surgical option have the appropriate infrastructure for management of these complex patients.