Robot assisted radical nephrectomy with inferior vena cava thrombectomy; feasibility and outcome for level 3 thrombus with suprahepatic clamping

Objective: To assess the feasibility and safety of robot assisted radical nephrectomy with inferior vena cava thrombectomy (RARN-IVCT) in patients with Level 3 thrombus with suprahepatic clamping. Methods: This is a retrospective analysis of the patients who underwent RARN-IVCT for locally advanced renal cell carcinoma over 6 years. The perioperative, post operative and oncological outcomes were compared between the patients who underwent level 2 vs. level 3 RARN-IVCT. Results: A total of 27 patients who underwent RARN-IVCT during the study period were included in this study. Level I, II, III and IV thrombectomy were performed in two, 14, 10 and one patients, respectively. The mean duration of follow-up was 31.6 ± 20.5 months. The thrombus length, console time, IVC clamp time, total operating time, blood loss and hospital stay were significantly less in the patients with level II IVC thrombus (7.23 ± 2.75 vs. 9.69 ± 2.82 cm, 166.78 ± 90.54 vs. 325.75 ± 105.4 min, 20.84 ± 11.5 vs. 29.6 ± 8.42 min, 337.69 ± 135.1 vs. 529.56 ± 69.45 min, 631.47 ± 321.5 vs. 980.52 ± 453.62 ml, 5.7 ± 2.7 vs. 8.34 ± 3.2 days, level II vs. level III, respectively). The tumour size, the fall of serum creatinine and the complication rates were similar. Only six patients (three patients each in level II and level III) received blood transfusion. Conclusion: RARN-IVCT with supra-hepatic clamping can be used as a safe and feasible approach in carefully selected patients. It can provide good perioperative outcomes without increasing the complications and risking survival.