Context Robotic surgery has significantly advanced the minimally-invasive management of kidney tumors with extension into the inferior vena cava requiring caval cross-clamping and tumor thrombectomy. Additional techniques have recently been developed to continue the evolution of this complex procedure and extend its indications. Objective To review the current state of the art as regards robotic nephrectomy with inferior vena cava thrombectomy (RNIT). Evidence acquisition A systematic review of the Medline database was performed. All literature available through October 2016 was included. Evidence synthesis RNIT has been successfully adopted at select centers, but the number of patients reported to date remains limited. Modifications in clamping and tumor thrombus management have been described allowing for multiple options in surgical technique. Early perioperative outcomes appear favorable in comparison with traditional, open surgery, but further experience is needed. Conclusions Feasibility and reproducibility of RNIT has been demonstrated, but longer-term outcomes and larger patient numbers are necessary before the role of this procedure is established. Patient summary Kidney cancers invading the largest vein in the body, the vena cava, require complex surgery for removal. Traditionally this has required a large incision, but newer techniques with robotic surgery that continue to evolve have allowed for a minimally-invasive approach.

Robotic Surgery for Renal Cell Carcinoma with Vena Caval Tumor Thrombus

Robot assistance has been rapidly adopted by urological surgeons and has become particularly popular for oncological procedures involving the retroperitoneal space. The wide dissemination of robot assistance probably reflects the limited amount of operating space available within the retroperitoneum and the advantages provided by robot-assisted approaches, including 3D imaging, wristed instrumentation and the shorter learning curve compared with that associated with the equivalent laparoscopic techniques. Surgical procedures that have traditionally been performed using an open or laparoscopic approach, such as partial nephrectomy, radical nephrectomy, retroperitoneal lymph node dissection, nephroureterectomy and adrenalectomy, are now often being performed using robot assistance. The frontiers of robot-assisted retroperitoneal oncological surgery are constantly expanding, with an emphasis on maintaining oncological and functional outcomes, while minimizing the level of surgical invasiveness.

Frontiers in robot-assisted retroperitoneal oncological surgery.

OBJECTIVE To introduce a modified sequential vascular control strategy, mimicking the open 'milking' technique principle, for the early release of the first porta hepatis (FPH) and to stop cardiopulmonary bypass (CPB) in level III-IV robot-assisted inferior vena cava (IVC) thrombectomy (RA-IVCTE). PATIENTS AND METHODS From November 2014 to June 2019, 27 patients with a level III-IV IVC tumour thrombus (IVCTT) underwent RA-IVCTE in our department. The modified sequential control strategy was used in 12 cases. Previously, we released the FPH after the thrombus was resected and the IVC was closed completely, and CPB was stopped at the end of surgery (15 patients). Presently, using our modified strategy, we place another tourniquet inferior to the second porta hepatis (SPH) once the proximal thrombus is removed from the IVC below the SPH. Then, we suture the right atrium and perform early release of the FPH, and stop CPB. Finally, tumour thrombectomy, vascular reconstruction, and radical nephrectomy are performed. RESULTS Compared with the previous strategy, the modified steps resulted in a shorter median FPH clamping (19 vs 47 min, P < 0.001) and CPB times (60 vs 87 min, P < 0.05); a lower rate of Grade II-IV perioperative complications (25% vs 60%, P < 0.05); and better postoperative hepatorenal and coagulation function, including better median serum alanine aminotransferase (172.7 vs 465.4 U/L, P < 0.001), aspartate aminotransferase (282.4 vs 759.8 U/L, P < 0.001), creatinine (113.4 vs 295 μmol/L, P < 0.01), blood urea nitrogen (7.3 vs 16.7 mmol/L, P < 0.01), and D-dimer (5.9 vs 20 mg/L, P < 0.001) levels. CONCLUSION With the early release of the FPH and stopping CPB, the modified sequential vascular control strategy in level III-IV RA-IVCTE reduced the perioperative risk for selected patients and improved the feasibility and safety of the surgery. We would recommend this approach to other centres that plan to develop robotic surgery for renal cell carcinoma with level III-IV IVCTT in the future.

A modified sequential vascular control strategy in robot-assisted level III–IV inferior vena cava thrombectomy: initial series mimicking the open ‘milking’ technique principle

Feasibility of Pure Conventional Retroperitoneal Laparoscopic Radical Nephrectomy With Level II Vena Caval Tumor Thrombectomy.

Transesophageal Echocardiography Guidance for Robot-assisted Level III Inferior Vena Cava Tumor Thrombectomy: A Novel Approach to Intraoperative Care.

Robot-assisted level 1/2 inferior vena caval (IVC) thrombectomy techniques have been recently described for clinical use. Following the IDEAL recommendations on safe surgical innovation, we here describe a robotic approach for level 3 IVC thrombectomy in fresh frozen cadavers (IDEAL stage 0). In all cadavers (n = 3), hepatic mobilization with control of short hepatic veins, contralateral renal vein, infrarenal IVC and suprahepatic-infradiaphragmatic IVC could be achieved successfully, without converting to open surgery. Clinical feasibility of our technique remains to be tested.

Robot-assisted hepatic mobilization and control of suprahepatic infradiaphragmatic inferior vena cava for level 3 vena caval thrombectomy: An IDEAL stage 0 study.

Clean intermittent catheterization (CIC) has become the gold standard for bladder management in a host of neurologic and non-neurologic disease states causing urinary retention. While CIC has been extensively studied, there has been limited research in applying CIC to the elderly population. In this review paper, we evaluate the lessons learned about the feasibility, complications, and obstacles to compliance associated with CIC and apply them to an elderly population. With the use of improved teaching methods, devices to assist with passing the catheter, and ongoing education and follow-up, we believe that CIC can be a viable option for bladder management in elderly patients with urinary retention.

Eamonn Bahnson

Papers

Robot-assisted hepatic mobilization and control of suprahepatic infradiaphragmatic inferior vena cava for level 3 vena caval thrombectomy: An IDEAL stage 0 study.

Clean Intermittent Catheterization in the Elderly