Robotic-assisted laparoscopic nephrectomy(right)combined with inferior vena caval thrombectomy for level II tumor thrombus:the first clinical case in China

Objective To report the first clinical case of robotic-assisted laparoscopic nephrectomy(right)combined with inferior vena caval thrombectomy for levelⅡtumor thrombus in China.Methods A 73-year-old female patient presented with"gross hematuria and flank discomfort for 4 months"was admitted to our hospital.Preoperative CT scans revealed a 4.9cm×4.7cm right renal cancer,grossly extending into the inferior vena cava(IVC,length of the IVC tumor thrombus:4.6cm).After three months of neoadjuvant targeted molecular therapies(TKIs),the tumor size reduced to 4.3cm×4.4cm on CT and the IVC tumor thrombus length reduced to 3.3cm.IVC filter was placed cephalad 2 days before surgery under DSA intervention.The patient was placed in recumbent position during the operation;a 12-mm optical port was placed to the right of the rectus abdominis at 2cm above the umbilicus.Two 8-mm robotic ports and three 12-mm assistant ports were placed percutaneously under direct visualization through a stab incision.The robotic system was then docked,with the colon reflected medially and the duodenum kocherized.The IVC sheath was opened,and the IVC was dissected circumferentially above and below the insertion of the right renal vein to the extent dictated by the length of the thrombus.With the right renal artery dissected and transected,the vessel loops were used to create modified-Rummel tourniquets.The vena cava below and above tumor thrombus,and the left renal vein were cross-clamped.With the vessel loops cinched down completely and secured by hem-o-lok clips,the wall of the IVC was then incised longitudinally for approximately 5cm.The tumor thrombus was delivered intact along with the invaded IVC wall.The IVC was closed and tourniquet was loosened.After adequate hemostasis was achieved,the specimen was placed into an entrapment sac and incisions were closed by layers.Results The procedure was smoothly completed.The total operating time was 363min and the total IVC cross-clamp time was 47min.The estimated blood loss was 1 200mL.The amount of intraoperative transfusion was 1 200mL and 1 000mL postoperative blood transfusion was required for a low level of hemoglobin.The bowel function recovered at day 3 after operation and drainage was maintained for 3 days.The patient was discharged 16 days after operation.Conclusion We successfully completed the first clinical case of robotic-assisted laparoscopic nephrectomy combined with inferior vena caval thrombectomy for levelⅡ tumor thrombus in China;it is a safe and feasible procedure,but has great technical difficulty,so the patients should be chosen with great care.