Abstract
This is a case of a 55 year old female with an incidentally discovered right renal mass. CT scan showed a 4 cm low density lesion extending from the renal cortex into the renal vein and inferior vena cava (IVC) (level 1 thrombus) with fat content, suggestive of possible angiomyolipoma.
To demonstrate the surgical steps of robotic partial nephrectomy with IVC thrombectomy.
After trocar placement, the da Vinci Xi system is docked in the standard manner for right robotic partial nephrectomy. The procedure is initiated with mobilization of the colon followed by identification of the right ureter and gonadal vein. The gonadal vein is followed proximally to its insertion into the IVC. The renal vein and artery are subsequently identified and dissected. A vessel loop is passed around the renal vein to ensure proximal control of the tumor thrombus during excision of the mass. Intraoperative ultrasound is used to identify the location and depth of the mass prior to excision. Bulldog clamps are placed sequentially over the renal artery and renal vein. Traction is applied with a vessel loop and suction irrigator to ensure proximal control of the tumor thrombus. Excision of the mass is accomplished utilizing a combination of sharp and blunt dissection. An incision is made into the branch of the renal vein containing the tumor thrombus. The incision is extended circumferentially to facilitate mobilization and complete en bloc removal of the renal mass and thrombus. The renal vein defect is then closed in 2 layers with 4–0 Prolene suture. The tumor bed defect is closed in 2 layers in a continuous manner with 3–0 barbed suture. A sliding clip technique is then performed with 3–0 barbed suture in an interrupted manner to re-approximate the edges of the kidney and complete the reconstruction.
Estimated blood loss was 70 cc with a warm ischemia time of 45 min. The patient was discharged from the hospital on postoperative day number 1 without complications. Final pathology demonstrated a 2.1 cm angiomyolipoma with negative margins.
Robotic partial nephrectomy with IVC thrombectomy is a feasible and safe surgical option for patients with suspected benign renal masses with extension of tumor thrombus into the IVC.