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Faegh A, Moeinafshar A, Rezaei N. Nephrectomy and IVC thrombectomy in renal cancer: a narrative review. Clin Transl Oncol 2024; 26:574-583. [PMID: 37568007 DOI: 10.1007/s12094-023-03302-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/29/2023] [Indexed: 08/13/2023]
Abstract
Renal cell carcinoma accounts for two to three percent of adult malignancies and can lead to inferior vena cava (IVC) thrombosis. This condition can decrease the rate of 5-year survival for patients to 60%. The treatment of choice in such cases is radical nephrectomy and inferior vena cava thrombectomy. This surgery is one of the most challenging due to many perioperative complications. There are many controversial methods reported in the literature. Achieving the free of tumor IVC wall and the possibility of thrombectomy in cases of level III and level IV IVC thrombosis are two essential matters previously advocated open approaches. Nevertheless, open approaches are being replaced by minimally invasive techniques despite the difficulty of the surgical management of IVC thrombectomy. This paper aims to review recent evidence about new surgical methods and a comparison of open, laparoscopic, and robotic approaches. In this review, we present the latest surgical strategies for IVC thrombectomy and compare open and minimally invasive approaches to achieve the optimal surgical technique. Due to the different anatomy of the left and right kidneys and variable extension of venous thrombosis, we investigate surgical methods for left and right kidney cancer and each level of IVC venous thrombosis separately.
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Affiliation(s)
- Ali Faegh
- School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Aysan Moeinafshar
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Rezaei
- Network of Immunity in Infection, Malignancy, and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran.
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
- Children's Medical Center Hospital, Dr. Qarib St, Keshavarz Blvd, Tehran, 14194, Iran.
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Li KP, Chen SY, Wang CY, Li XR, Yang L. Perioperative and oncologic outcomes of minimally-invasive surgery for renal cell carcinoma with venous tumor thrombus: a systematic review and meta-analysis of comparative trials. Int J Surg 2023; 109:2762-2773. [PMID: 37526108 PMCID: PMC10498880 DOI: 10.1097/js9.0000000000000405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/06/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND The present study aimed to conduct a pooled analysis to compare the perioperative and oncologic outcomes of minimally-invasive radical nephrectomy with tumor thrombus (MI-RNTT) with open radical nephrectomy with tumor thrombus (O-RNTT). METHODS This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Four electronic databases (PubMed, Embase, Web of Science, and the Cochrane Library database) were systematically searched to identify relevant studies published in English up to December 2022. The primary outcomes were perioperative results, complications, and oncologic outcomes. Review Manager 5.4 was used for this analysis. RESULTS In total, eight retrospective trials with a total of 563 patients were included. Compared to O-RNTT, MI-RNTT had shorter hospitalization time [weighted mean difference (WMD) -3.58 days, 95% CI: -4.56 to -2.59; P <0.00001), lower volumes of blood loss (WMD -663.32 ml, 95% CI: -822.22 to -504.42; P <0.00001), fewer transfusion rates (OR 0.18, 95% CI: 0.09-0.35; P <0.00001), fewer overall complications (OR 0.33, 95% CI: 0.22-0.49; P <0.00001), and fewer major complications s (OR 0.49, 95% CI: 0.24-1.00; P =0.05). However, operative time, intraoperative complications, mortality rate (intraoperative, within 30 days, and total mortality), overall survival, recurrence-free survival, and cancer-specific survival did not significantly differ between the two groups. CONCLUSIONS MI-RNTT possesses more benefits than O-RNTT in terms of length of hospital stay, blood loss, and complications and provides comparable mortality rates and oncologic outcomes. However, more comprehensive and rigorous research is warranted to further validate the outcomes, which should include a larger sample size and comprehensive data from high-volume medical centers.
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Affiliation(s)
| | | | | | - Xiao-ran Li
- Department of Urology, The Second Hospital of Lanzhou University, Lanzhou, People’s Republic of China
| | - Li Yang
- Department of Urology, The Second Hospital of Lanzhou University, Lanzhou, People’s Republic of China
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Wang L, Li KP, Yin S, Yang L, Zhu PY. Oncologic and perioperative outcomes of laparoscopic versus open radical nephrectomy for the treatment of renal tumor (> 7 cm): a systematic review and pooled analysis of comparative outcomes. World J Surg Oncol 2023; 21:35. [PMID: 36747217 PMCID: PMC9901136 DOI: 10.1186/s12957-023-02916-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/30/2023] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE Systematic evaluation of the effectiveness and safety of laparoscopic radical nephrectomy (LRN) for renal tumor (>7 cm). METHODS The databases PubMed, Scopus, SinoMed, ScienceDirect, and Google Scholar were systematically searched for trials up to November 2022. The pooled results were evaluated by weighted mean difference (WMD), odds ratio (OR), and hazard ratio (HR). RESULTS This meta-analysis (18 trials) demonstrated that compared to open radical nephrectomy (ORN), LRN had a longer operative time (OT) (WMD=15.99, 95% CI: 6.74 to 25.24, p = 0.0007), lower estimated blood loss (EBL) (WMD = -237.07, 95% CI: -300.02 to -174.12, p < 0.00001), lower transfusion rates (OR = 0.37, 95% CI: 0.24 to 0.55, p < 0.00001), and shorter length of stay (LOS) (WMD = -2.95, 95% CI: -3.86 to -2.03, p < 0.00001). No statistically relevant differences were found in overall survival (OS) (HR = 1.04, 95% CI: 0.81 to 1.35, p = 0.76), cancer-specific survival (CSS) (HR = 1.28, 95% CI: 0.97 to 1.68, p = 0.08), progression-free survival (PFS) (HR = 1.20, 95% CI 0.97 to 1.48, p = 0.1), recurrence-free survival (RFS) (OR = 1.27, 95% CI: 0.89 to 1.81, p = 0.56), local recurrence rate (OR = 0.85, 95% CI: 0.42 to 1.71, p = 0.65), and intraoperative and postoperative complications. CONCLUSION For patients with renal tumors (> 7 cm), LRN has specific perioperative advantages over ORN (LOS, EBL, and transfusion rates). However, the OT was prolonged in the LRN group. In addition, no differences in complication or oncological outcomes (OS, CSS, PFS, RFS, and local recurrence rate) were reported. TRIAL REGISTRATION PROSPERO CRD42022367114.
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Affiliation(s)
- Li Wang
- grid.413387.a0000 0004 1758 177XDepartment of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000 China
| | - Kun-peng Li
- grid.411294.b0000 0004 1798 9345Department of Urology, The Second Hospital of Lanzhou University, Lanzhou, 730030 China
| | - Shan Yin
- grid.413387.a0000 0004 1758 177XDepartment of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000 China
| | - Lin Yang
- grid.413387.a0000 0004 1758 177XDepartment of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000 China
| | - Ping-yu Zhu
- grid.413387.a0000 0004 1758 177XDepartment of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000 China
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Gu Y, Fu Y, Pan X, Zhou Y, Ji C, Zhao T, Miao H, Lv H, Da J, Ge J, Wang L, Qu L, Ge S, Guo H, Zhou W. Prognostic value of systemic immune-inflammation index in non-metastatic clear cell renal cell carcinoma with tumor thrombus. Front Oncol 2023; 13:1117595. [PMID: 36776325 PMCID: PMC9909392 DOI: 10.3389/fonc.2023.1117595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 01/11/2023] [Indexed: 01/27/2023] Open
Abstract
This study aims to determine the prognostic value of SII for non-metastatic clear cell renal cell carcinoma (ccRCC) patients with venous tumor thrombus (VTT). We retrospectively collected and analyzed 328 non-metastatic ccRCC patients with VTT who underwent radical nephrectomy and thrombectomy from 3 tertiary centers in China between 2011 to 2021. Kaplan-Meier analyses and Cox proportional hazard analyses were used to determine its prognostic value for overall survival (OS) and disease free survival (DFS). The Harrell concordance index (C-index), receiver operating characteristic curve (ROC) analysis, and decision curve analysis (DCA) were used to evaluate its role in the improvement of prognostic accuracy of the existing models. Nomogram models containing the SII were then developed and evaluated by R. Patients were divided into low-SII and high-SII groups based on the SII optimal cut-off value 912 calculated by the Youden index in all patients. Higher SII was correlated with more symptoms, longer surgical time, higher WHO/ISUP grade, and longer tumor diameter. Kaplan-Meier analyses revealed significant differences in OS and DFS between two groups. Multivariate analyses revealed that SII was an independent prognostic factor for OS (HR:2.220, p=0.002) and DFS (HR:1.846, p=0.002). Compared with other indicators, SII had a superior accuracy (c-index=0.630 for OS and 0.595 for DFS). It also improved the performance of models for predicting OS and DFS (all p <0.01). Based on the results of LASSO Cox regression analysis, we constructed a nomogram to predict OS and it performed well on both the training cohort (AUC=0.805) and the validation cohort (AUC=0.795). Risk stratification based on nomogram can distinguish patients with different risks (all p <0.001). Preoperative SII is an independent predictive factor for OS and DFS of non-metastatic ccRCC patients with VTT. It can be used to improve the performance of current risk models.
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Affiliation(s)
- Yufeng Gu
- Department of Urology, Jinling Hospital, Clinical School of Medical College, Nanjing University, Nanjing, Jiangsu, China
| | - Yao Fu
- Department of Pathology, Drum Tower Hospital, Clinical School of Medical College, Nanjing University, Nanjing, Jiangsu, China
| | - Xin Pan
- Department of Urology, Jinling Hospital, Clinical School of Medical College, Nanjing University, Nanjing, Jiangsu, China
| | - Yulin Zhou
- Department of Urology, Jinling Hospital, Clinical School of Medical College, Nanjing University, Nanjing, Jiangsu, China
| | - Changwei Ji
- Department of Urology, Drum Tower Hospital, Clinical School of Medical College, Nanjing University, Nanjing, Jiangsu, China
| | - Tangliang Zhao
- Department of Urology, Jinling Hospital, Clinical School of Medical College, Nanjing University, Nanjing, Jiangsu, China
| | - He Miao
- Department of Urology, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Huichen Lv
- Department of Urology, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jianping Da
- Department of Urology, Jinling Hospital, Clinical School of Medical College, Nanjing University, Nanjing, Jiangsu, China
| | - Jingping Ge
- Department of Urology, Jinling Hospital, Clinical School of Medical College, Nanjing University, Nanjing, Jiangsu, China
| | - Linhui Wang
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Le Qu
- Department of Urology, Jinling Hospital, Clinical School of Medical College, Nanjing University, Nanjing, Jiangsu, China
| | - Silun Ge
- Department of Urology, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, Jiangsu, China,*Correspondence: Wenquan Zhou, ; Hongqian Guo, ; Silun Ge,
| | - Hongqian Guo
- Department of Urology, Drum Tower Hospital, Clinical School of Medical College, Nanjing University, Nanjing, Jiangsu, China,*Correspondence: Wenquan Zhou, ; Hongqian Guo, ; Silun Ge,
| | - Wenquan Zhou
- Department of Urology, Jinling Hospital, Clinical School of Medical College, Nanjing University, Nanjing, Jiangsu, China,*Correspondence: Wenquan Zhou, ; Hongqian Guo, ; Silun Ge,
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Zhang Y, Bi H, Yan Y, Liu Z, Wang G, Song Y, Zhang S, Liu C, Ma L. Comparative analysis of surgical and oncologic outcomes of robotic, laparoscopic and open radical nephrectomy with venous thrombectomy: a propensity-matched cohort study. Int J Clin Oncol 2023; 28:145-154. [PMID: 36380158 DOI: 10.1007/s10147-022-02265-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 11/02/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To provide insight into the surgical and oncological outcomes of robotic, laparoscopic and open radical nephrectomy with venous thrombectomy (RALRN-VT, LRN-VT, ORN-VT) in patients with renal tumor and venous thrombus. MATERIALS AND METHODS A propensity-matched retrospective cohort study containing 324 patients with renal tumor and venous thrombus from January 2014 to August 2021 was analyzed. We compared surgical outcomes and we used the Kalan-Meier method to assess the overall survival (OS), tumor-specific survival (TSS), metastasis-free survival (MFS) and local recurrence-free survival (LRFS). The Pearson chi-square test and Fisher exact test, Wilcoxon rank sum test, Cox proportional hazards regression model and log-rank test were used. RESULTS After matching, baseline characteristics were comparable in the RALRN-VT, LRN-VT and ORN-VT group. The RALRN-VT group had the least operative time (median 134 min vs 289 min vs 330 min, P < 0.001), the least blood loss (median 250 ml vs 500 ml vs 1000 ml, P < 0.001) and the fewest packed red blood cells transfusion (median 400 ml vs 800 ml vs 1200 ml, P < 0.001). The ORN-VT group had the highest complication rate (18.2 vs 22.7 vs 43.2%, P = 0.005), the highest Clavien grade (P = 0.001) and the longest postoperative hospital stay (median 7d vs 8d vs 10d, P < 0.001). No significant difference in OS, TSS and MFS between the minimally invasive procedures (MIP, including RALRN-VT and LRN-VT) group and ORN-VT group was found. The hazard ratio of LRFS for the MIP group was 0.20 (95% CI 0.06-0.70, P = 0.01) compared with ORN-VT group. CONCLUSIONS RALRN-VT can result in the best surgical outcomes compared with LRN-VT and ORN-VT. The MIP group had a better LRFS compared with ORN-VT group.
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Affiliation(s)
- Yu Zhang
- Department of Urology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, People's Republic of China
| | - Hai Bi
- Department of Urology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, People's Republic of China
| | - Ye Yan
- Department of Urology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, People's Republic of China
| | - Zhuo Liu
- Department of Urology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, People's Republic of China
| | - GuoLiang Wang
- Department of Urology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, People's Republic of China
| | - YiMeng Song
- Department of Urology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, People's Republic of China
| | - ShuDong Zhang
- Department of Urology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, People's Republic of China.
| | - Cheng Liu
- Department of Urology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, People's Republic of China.
| | - LuLin Ma
- Department of Urology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, People's Republic of China.
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Review of Robotic-Assisted Radical Nephrectomy with Inferior Vena Cava Thrombectomy in Renal Cell Carcinoma. Curr Urol Rep 2022; 23:363-370. [PMID: 36454370 DOI: 10.1007/s11934-022-01120-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE OF REVIEW Recent advances in minimally invasive technology have compelled surgeons to perform nephrectomy with inferior vena cava thrombectomy using robotic assistance. Here, we aim to review the data comparing open versus robot-assisted nephrectomy with IVC thrombectomy, as well as review operative robotic techniques for nephrectomy with IVC thrombectomy. RECENT FINDINGS Over the last decade, there have been increasing reports of successful robotic-assisted IVC thrombectomy among skilled robotic surgeons, with case series detailing operative technique, as well as operative and oncologic outcomes for levels I-IV caval thrombus. While there is immense promise in the future of robotic-assisted IVC thrombectomy, further studies with direct comparison to open surgical intervention will be needed to ensure the oncologic principles and outcomes are non-inferior.
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7
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Liu Z, Li Y, Tang S, Zhao X, Chen K, Ge L, Zhu G, Hong P, Wu B, Wu Z, Zhang S, Tian X, Wang S, Liu C, Zhang H, Ma L. Preliminary experience of oblique occlusion technique in robot-assisted infrahepatic inferior vena cava thrombectomy: step-by-step procedures and short term outcomes. BMC Surg 2022; 22:377. [PMCID: PMC9636754 DOI: 10.1186/s12893-022-01821-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Abstract
Background
We aimed to compare the oncological outcomes between the oblique occlusion technique and the traditional technique for robot-assisted radical nephrectomy (RARN) with inferior vena cava (IVC) thrombectomy, and to explore the safety and effectiveness of the oblique occlusion technique.
Methods
Overall, 21 patients with renal cell carcinoma (RCC) and IVC tumor thrombus (TT) were admitted to our hospital from August 2019 to June 2020. All the patients underwent RARN with IVC thrombectomy, of which the IVC oblique occlusion technique was used in 11 patients and traditional occlusion technique was used in 10 patients. The oblique occlusion technique refers to oblique blocking from the upper corner of the right renal vein to the lower corner of the left renal vein using a vessel tourniquet or a vessel clamp (left RCC with IVCTT as an example).
Results
Compared with patients in the traditional group, those in the oblique group had lower serum creatinine at follow-up (3 month) (95 ± 21.1 vs. 131 ± 30.7 μmol/L, P = 0.03). There was no significant difference in operation time [149 (IQR 143–245) min vs. 148 (IQR 108–261) min, p = 0.86], IVC clamping time [18 (IQR 12–20) min vs. 20 (IQR 14–23) min, p = 0.41], and estimated intraoperative blood loss [300 (IQR 100–800) mL vs. 500 (IQR 175–738) mL, p = 0.51] between both groups. During a 16-month (range, 15–23 months) follow-up period, two cases progressed in the oblique group and three cases progressed in the traditional group.
Conclusions
The modified IVC oblique occlusion technique procedure is relatively safe and effective in RARN with IVC thrombectomy. The IVC oblique occlusion technique may play a role in the protection of renal function.
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Pahouja G, Sweigert SE, Sweigert PJ, Gorbonos A, Patel HD, Gupta GN. Does size matter? Comparing robotic versus open radical nephrectomy for very large renal masses. Urol Oncol 2022; 40:456.e1-456.e7. [PMID: 35667982 DOI: 10.1016/j.urolonc.2022.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/23/2022] [Accepted: 05/07/2022] [Indexed: 01/20/2023]
Abstract
INTRODUCTION We evaluated perioperative and mortality outcomes of robotic-assisted radical nephrectomy (RRN) vs. open radical nephrectomy (ORN) for very large renal cell carcinomas (RCC). MATERIALS AND METHODS Adult patients with non-metastatic RCC >10 cm in size (pT2b) were identified from the National Cancer Database (2010-2017). Mixed-effects multivariable logistic regression adjusting for patient, tumor, and facility characteristics were used to evaluate rates of positive margin, prolonged length of stay (LOS) (>75th percentile), 30-day readmission, and 30-day and 90-day mortality for RRN vs. ORN. Overall survival (OS) was evaluated using the Kaplan-Meier method and adjusted Cox proportional hazard modeling. RESULTS Of the 2,977 patients who underwent radical nephrectomy, 492 (16.5%) underwent RRN. Factors associated with RRN included male gender, metro or urban locations, academic facilities, Charlson-Deyo score >2, private or Medicaid insurance, and surgery in a later year (all P < 0.05). Tumors ≥15.1cm in size were associated with a higher rate of conversion to open surgery (P < 0.001). ORN was associated with increased median postoperative LOS (4d [interquartile range; IQR 3-6] vs. 3d, [IQR 2-4]; P < 0.01). RRN demonstrated no significant difference in the risk of positive margin, 30-day readmission, 30-day mortality, or 90-day mortality. RRN was associated with a decreased risk of prolonged LOS (OR 0.38; 95%CI [0.28-0.53]). There was no difference in long-term OS observed in patients treated with ORN vs. RRN. CONCLUSIONS Very large, non-metastatic RCC can be safely and effectively treated with RRN. Rates of conversion to open were higher for tumors ≥15.1 cm. RRN has comparable long-term OS and improved LOS compared to ORN.
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Affiliation(s)
- Gaurav Pahouja
- Department of Urology, Loyola University Medical Center, Maywood, IL.
| | - Sarah E Sweigert
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | | | - Alex Gorbonos
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Hiten D Patel
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Gopal N Gupta
- Department of Urology, Loyola University Medical Center, Maywood, IL; Department of Surgery, Loyola University Medical Center, Maywood, IL; Department of Radiology, Loyola University Medical Center, Maywood, IL
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Mosquera AV, Barco-Castillo C, Camacho D, Correa J, Varela R, Citarella D, Cabrera M. Radical Nephrectomy in Renal Cell Carcinoma with Venous Tumoral Thrombus: Long-term Outcomes and Overall Survival. UROLOGÍA COLOMBIANA 2022. [DOI: 10.1055/s-0042-1748871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
Objective To describe the five-year overall survival (OS) and perioperative morbidity of patients with renal cell carcinoma (RCC) with venous tumor thrombus (VTT) treated through radical nephrectomy and thrombectomy.
Materials and Methods We evaluated a cohort of 530 patients with a diagnosis of RCC from January 2009 to December 2019, and found VTT in 42 of them; these 42 patients composed the study sample. The patients were stratified according to the Neves Thrombus Classification (NTC). The baseline and perioperative characteristics, as well as the follow-up, were described. The Kaplan-Meier curve and its respective Cox regression were applied to present the 5-year OS and the OS stratified by the NTC.
Results The average age of the sample was of 63.19 ± 10.7 years, and there were no differences regarding gender. In total, VTT was present in 7.9% of the patients. According to the NTC, 30.9% of the cases corresponded to level I, 21.4%, to level II, 26.1%, to level III, and 21.4%, to level IV. The 5-year OS was of 88%. For level-I and level-II patients, the 5-year OS was of 100%, and of only 38% among level-IV patients. Complications, mostly minor, occurred in 57% of the cases.
Conclusions Radical nephrectomy with thrombectomy is a morbid procedure; however, most complications are minor, and the five-year mortality is null for patients in NTC levels I and II, and low for levels III and IV, and it may be even lower in level-III patients when standardizing transesophageal echocardiogram intraoperatively and routinary extracorporeal bypass. Thus, we recommend considering this surgery as the first-line management in patients with RCC and VTT.
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Affiliation(s)
- Aysa Vanessa Mosquera
- Department of Urology, Hospital Militar Central, Bogotá DC, Colombia and Universidad Militar Nueva Granada School of Medicine, Urology Residency Program, Bogotá DC, Colombia
| | - Catalina Barco-Castillo
- Department of Urology, Hospital Militar Central, Bogotá DC, Colombia and Universidad Militar Nueva Granada School of Medicine, Urology Residency Program, Bogotá DC, Colombia
| | - Diego Camacho
- Universidad Nacional School of Medicine, Bogotá DC, Colombia
- Department of Urology, Fundación Clínica Shaio, Bogotá DC, Colombia
| | - José Correa
- Universidad del Rosario School of Medicine, Bogotá DC, Colombia
| | - Rodolfo Varela
- Universidad Nacional School of Medicine, Bogotá DC, Colombia
- Department of Urology, Fundación Clínica Shaio, Bogotá DC, Colombia
- Facultad de Medicina, Universidad Nacional de Colombia, Bogotá DC, Colombia
| | - Danilo Citarella
- Department of Urology, Hospital Militar Central, Bogotá DC, Colombia and Universidad Militar Nueva Granada School of Medicine, Urology Residency Program, Bogotá DC, Colombia
- Department of Urology, Fundación Clínica Shaio, Bogotá DC, Colombia
| | - Marino Cabrera
- Universidad Nacional School of Medicine, Bogotá DC, Colombia
- Department of Urology, Fundación Clínica Shaio, Bogotá DC, Colombia
- Department of Urology, Fundación Clínica Shaio, Bogotá DC, Colombia
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Zhao GD, Zhang XP, Hu MG, Huang QB, Xu S, Wang BJ, Ma X, Zhang X, Zou WB, Zhang X, Zhao ZM, Tan XL, Chou S, Wang G, Liu R. Step-by-step and orderly lowering of the height of inferior vena cava tumor thrombus is the key to robot-assisted thrombectomy for Mayo III/IV tumor thrombus. BMC Cancer 2022; 22:151. [PMID: 35130848 PMCID: PMC8822687 DOI: 10.1186/s12885-022-09235-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 01/12/2022] [Indexed: 11/14/2022] Open
Abstract
Background The surgical management of Mayo III/IV tumor thrombi is difficult and risky, and robotic surgery is even more difficult. The purpose of this study was to introduce the step-by-step and orderly lowering of the height of inferior vena cava tumor thrombus, which was the core technique of robot operation for Mayo III/IV tumor thrombus. Method A total of 18 patients were included in this study. The average tumor thrombus height was 2.4 cm above the level of the second porta hepatis (SPH), and 9 patients were prepared for cardiopulmonary bypass (CPB) before surgery. During the operation, the height of the tumor thrombus was lowered orderly for 2-3 times, and the blood flow blocking method was changed sequentially. The CPB was required when tumor thrombus in the atrium; After the height of the thrombus was lowered to the atrium entrance, CPB was stopped and the blood flow was blocked in the upper- and retro-hepatic inferior vena cava (IVC); After the tumor thrombus continued to descend to the lower part of the SPH, liver blood flow could be restored, and then, the blood flow was simply blocked in the retro-hepatic IVC to complete the removal of the thrombus and the repair or resection of the IVC. Finally, the diseased kidney and renal vein were removed. Results All operations were successfully completed, and 2 cases were transferred to laparotomy. Seven cases received CPB, while the other 11 did not. 15 patients underwent two times of the lowering of the tumor thrombus, 2 patients underwent one time and 1 patient underwent three times. The mean liver/IVC dissociation and vascular suspension time was 22.0 min. All patients had less than Clavien-Dindo grade III complications, no serious complications occurred during operation, and no patient died within 90 days. Conclusions The step-by-step and orderly decline of tumor thrombus height is the key to the success of robot Mayo III / IV tumor thrombus surgery. This method can shorten FPH and CPB time and improve the success rate of surgery.
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Affiliation(s)
- Guo-Dong Zhao
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China
| | - Xiu-Ping Zhang
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China
| | - Ming-Gen Hu
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China
| | - Qing-Bao Huang
- Faculty of Urology Surgery, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Shuai Xu
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China.,School of Medicine, Nankai University, Tianjin, China
| | - Bao-Jun Wang
- Faculty of Urology Surgery, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Xin Ma
- Faculty of Urology Surgery, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Xu Zhang
- Faculty of Urology Surgery, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Wen-Bo Zou
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China
| | - Xuan Zhang
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China
| | - Zhi-Ming Zhao
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China
| | - Xiang-Long Tan
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China
| | - Sai Chou
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China
| | - Gang Wang
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China
| | - Rong Liu
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China. .,School of Medicine, Nankai University, Tianjin, China.
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11
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Liu Z, Li Y, Zhao X, Ge L, Zhu G, Hong P, Tang S, Zhang S, Tian X, Wang S, Liu C, Zhang H, Ma L. Renal cell carcinoma with tumor thrombus growing against the direction of venous return: an indicator of complicated surgery and poor prognosis. BMC Surg 2021; 21:443. [PMID: 34963464 PMCID: PMC8713414 DOI: 10.1186/s12893-021-01448-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 12/20/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To explore the effect of tumor thrombus growing against the direction of venous return (GADVR) tumor thrombus on the choice of surgical approach, the impact on the complexity of the surgery and the prognosis. METHODS We retrospectively analyzed the clinicopathological data of 213 patients, who underwent surgery in a single center of Peking University Third Hospital between January 2016 and June 2020. For right renal cell carcinoma (RCC) and venous tumor thrombus (VTT), imaging revealed a filling defect in the left renal vein, which was significantly enhanced in enhanced imaging, suggesting that the tumor thrombus grew against the direction of venous return into the left renal vein. For left RCC and VTT, at least one of the left renal vein branches has tumor thrombus. The branches include the left adrenal vein, the left gonadal vein (testicular vein or ovarian vein), and the left ascending lumbar vein. The patients were divided into two groups according to whether they were GADVR tumor thrombus, and we compare the clinicopathological characteristics of GADVR tumor thrombus and non-GADVR tumor thrombus. Univariate and multivariate Cox regression analyses were performed to explore the risk factors that affect the prognosis of patients with RCC and VTT. Kaplan-Meier plots were conducted to evaluate the effect of GADVR on progression-free survival (PFS). RESULTS Compared with non-GADVR tumor thrombus, patients with GADVR tumor thrombus had a higher proportion of open surgery (76.2% vs. 52.1%, P = 0.035), a higher proportion of tumor thrombus adhering to the inferior vena cava (IVC) vessel wall (81% vs. 45.8%, P = 0.002), a higher proportion of segmental resection of the IVC vessel wall (61.9% vs. 15.6%, P < 0.001); higher preoperative serum creatinine value (110.0 μmol/L vs. 91.0 μmol/L, P = 0.015), a higher proportion of tumor thrombus combined with bland thrombus (non-tumor thrombus) (57.1% vs. 19.8%, P < 0.001). In terms of surgical complexity, patients with GADVR tumor thrombus had a longer median operation time (379 min vs. 308 min, P = 0.038), more median surgical blood loss (1400 mL vs. 600 mL, P = 0.018), and more postoperative complications (52.4% vs. 30.7%, P = 0.045). Multivariate Cox regression analysis showed that GADVR tumor thrombus, symptoms, postoperative serum creatinine, distant metastasis, sarcomatoid feature, pathological type, lymph node dissection were independent risk factors for PFS. Patients with GADVR tumor thrombus's median survival time was 14.0 months, while patients with non-GADVR tumor thrombus were 32.0 months (P = 0.016). GADVR tumor thrombus is an independent risk factor for PFS in patients with RCC and VTT. CONCLUSION GADVR tumor thrombus is a characteristic feature of tumor thrombus, with an incidence of 9.9%. It has a higher proportion of open surgery and higher surgical complexity, which is an independent risk factor for PFS.
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Affiliation(s)
- Zhuo Liu
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Yuxuan Li
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Xun Zhao
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Liyuan Ge
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Guodong Zhu
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Peng Hong
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Shiying Tang
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Shudong Zhang
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Xiaojun Tian
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Shumin Wang
- Department of Ultrasound, Peking University Third Hospital, Haidian District, Beijing, 100191, People's Republic of China
| | - Cheng Liu
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Hongxian Zhang
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian, Beijing, 100191, People's Republic of China.
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12
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Keranmu A, Wang M, Li Y, Yang F, Wahafu W, Chen D, Liang J, Guan K, Xing N. Feasibility of single position laparoscopic radical nephrectomy and tumor thrombectomy for left renal cell carcinoma with high-risk Mayo grade 0 and 1 tumor thrombus. BMC Urol 2021; 21:181. [PMID: 34937546 PMCID: PMC8693484 DOI: 10.1186/s12894-021-00924-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/08/2021] [Indexed: 11/17/2022] Open
Abstract
Background To explore the feasibility of single-position laparoscopic radical nephrectomy (LRN) and tumor thrombectomy for left renal cell carcinoma with high-risk Mayo 0 and 1 tumor thrombus (TT). Methods All patients with left renal cell carcinoma and venous TT (high-risk Mayo grade 0 and 1) who were performed single-position LRN and tumor thrombectomy were involved. After the renal artery was controlled by Hem-o-lok, the left renal vein was dissected through descending colon mesentery. The left renal vein was divided by EndoGIA for high-risk Mayo grade 0 TT. For Mayo grade 1 TT, part of the inferior vena cava was blocked by a bulldog clamp after milking the TT into the left renal vein and the inferior vena cava was sutured after complete excision of the TT. Results 3 patients were involved and operations were performed successfully without conversion to open surgery. The mean operation time was 136 min and the mean estimated blood loss was 60 mL. No postoperative complications occurred. Conclusions It is feasible to control left renal vein and partial inferior vena cava through descending colon mesentery in a single position during LRN and tumor thrombectomy for the treatment of high-risk Mayo grade 0 and 1 TT.
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13
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Crocerossa F, Carbonara U, Cantiello F, Marchioni M, Ditonno P, Mir MC, Porpiglia F, Derweesh I, Hampton LJ, Damiano R, Autorino R. Robot-assisted Radical Nephrectomy: A Systematic Review and Meta-analysis of Comparative Studies. Eur Urol 2021; 80:428-439. [DOI: 10.1016/j.eururo.2020.10.034] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/23/2020] [Indexed: 12/21/2022]
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14
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Campi R, Marchioni M, Bertolo R, Erdem S, Kara O, Pavan N, Amparore D. Robotic surgery for renal cell carcinoma with inferior vena cava thrombosis: balancing feasibility and safety toward individualized decision-making. Minerva Urol Nephrol 2021; 73:544-548. [PMID: 34494415 DOI: 10.23736/s2724-6051.21.04606-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Riccardo Campi
- Unit of Urological Robotic Surgery and Renal Transplantation, University of Florence, Careggi Hospital, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Michele Marchioni
- Department of Medical, Oral and Biotechnological Sciences, Laboratory of Biostatistics, University "G. D'Annunzio" Chieti-Pescara, Chieti, Italy.,Department of Urology, SS Annunziata Hospital, "G. D'Annunzio" University of Chieti, Chieti, Italy
| | | | - Selcuk Erdem
- Division of Urologic Oncology, Department of Urology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Onder Kara
- School of Medicine, Department of Urology, University of Kocaeli, Kocaeli, Turkey
| | - Nicola Pavan
- Clinic of Urology, Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - Daniele Amparore
- School of Medicine, Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy -
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15
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Ljungberg B, Bex A. Radical Nephrectomy: The Widening Gap Between Evolution of Technique and Evidence. Eur Urol 2021; 80:440-441. [PMID: 33994217 DOI: 10.1016/j.eururo.2021.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 04/28/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Börje Ljungberg
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden.
| | - Axel Bex
- Department of Urology, The Royal Free London NHS Foundation Trust, London, UK; Division of Surgery and Interventional Science, University College London, London, UK
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16
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Abstract
Minimally invasive renal surgery has revolutionized the surgical management of renal cancer since the initial report of laparoscopic nephrectomy in 1991. Laparoscopic nephrectomy became the mainstay of management in surgically resectable renal masses since the 1990s. The growing body of literature supporting nephron-sparing surgery over the last two decades has meant that minimally invasive radical nephrectomy (MI-RN) is now the preferred treatment for renal tumors not amenable to partial nephrectomy. While there is a well-described experience with complex radical nephrectomy using standard laparoscopy, robot-assisted surgery has shortened the learning curve and facilitated greater uptake of minimally invasive surgery in difficult surgical scenarios traditionally performed open surgically. Increased experience and expertise with robot-assisted renal surgery has led to expansion of the indications for MI-RN to include larger masses, locally advanced renal masses invading adjacent tissues or regional hilar/retroperitoneal lymph nodes, cytoreductive nephrectomy (CN) in metastatic disease, and concurrent venous tumor thrombectomy for renal vein or inferior vena cava (IVC) involvement. In this article, we review the various surgical techniques and adjunctive procedures associated with MI-RN.
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Affiliation(s)
- Akbar N Ashrafi
- USC Institute of Urology and Catherine & Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.,Division of Surgery, North Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia.,Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Inderbir S Gill
- USC Institute of Urology and Catherine & Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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17
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Vuong NS, Ferriere JM, Michiels C, Calen L, Tesi L, Capon G, Bensadoun H, Alezra E, Estrade V, Robert G, Bladou F, Bernhard JC. Robot-assisted versus open surgery for radical nephrectomy with level 1-2 vena cava tumor thrombectomy: a French monocenter experience (UroCCR study #73). Minerva Urol Nephrol 2020; 73:498-508. [PMID: 33200900 DOI: 10.23736/s2724-6051.20.04052-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of this paper was to assess the feasibility of robot-assisted radical nephrectomy (RN) with inferior vena cava thrombectomy (RRVCT) and compare perioperative and oncological outcomes of this approach to open surgery for renal tumors with level 1-2 inferior vena cava (IVC) thrombus. METHODS We performed a retrospective analysis of patients surgically treated for renal cancer with IVC level 1-2 thrombus in the Urology department of Bordeaux University Hospital between December 2015 and December 2019. Patients were stratified by surgical approach in two groups: open vs. robotic procedures. Pre-, per- and postoperative data were collected within the framework of the UroCCR project (NCT03293563). Univariate and multivariate analysis using regression models were performed. RESULTS A total of 40 patients underwent RN with IVC tumor thrombus. Open and robotic surgery represented respectively 30 and 10 cases. The two groups were comparable regarding pre-operative tumor and patient characteristics. Robotic procedures were associated with lower estimated blood loss (EBL) (500 vs. 1250 mL, P=0.02), shorter Intensive Care Unit stay (2 vs. 4 days, P=0.03) and decrease of global length of stay (LOS) (7 vs. 10 days, P<0.01). Operative Time (OT) was significantly longer in the robotic group (350.5 vs. 208 min, P<0.01). No difference were observed between the two approaches regarding complications and oncological outcomes. CONCLUSIONS Robotic approach induced lower bleeding and shorter LOS but required longer OT. This technique is feasible and safe for selected cases and experimented surgical teams. Complications rate and oncological outcomes are not different compared to standard open procedures.
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Affiliation(s)
- Nam-Son Vuong
- Department of Urology, Bordeaux University Hospital, Bordeaux, France -
| | | | - Clément Michiels
- Department of Urology, Bordeaux University Hospital, Bordeaux, France
| | - Laura Calen
- Department of Urology, Bordeaux University Hospital, Bordeaux, France
| | - Lorenso Tesi
- Department of Urology, Bordeaux University Hospital, Bordeaux, France
| | - Grégoire Capon
- Department of Urology, Bordeaux University Hospital, Bordeaux, France
| | - Henri Bensadoun
- Department of Urology, Bordeaux University Hospital, Bordeaux, France
| | - Eric Alezra
- Department of Urology, Bordeaux University Hospital, Bordeaux, France
| | - Vincent Estrade
- Department of Urology, Bordeaux University Hospital, Bordeaux, France
| | - Grégoire Robert
- Department of Urology, Bordeaux University Hospital, Bordeaux, France
| | - Franck Bladou
- Department of Urology, Bordeaux University Hospital, Bordeaux, France
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18
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Ghoreifi A, Djaladat H. Surgical Tips for Inferior Vena Cava Thrombectomy. Curr Urol Rep 2020; 21:51. [PMID: 33090290 DOI: 10.1007/s11934-020-01007-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to describe the preoperative evaluation, surgical techniques, and postoperative management of patients with renal cell carcinoma (RCC) undergoing radical nephrectomy (RN) and inferior vena cava (IVC) thrombectomy. RECENT FINDINGS RN and IVC thrombectomy remains the standard management option in non-metastatic RCC patients with IVC thrombus. A comprehensive preoperative workup, including high-quality imaging, blood works, and appropriate consultations are required for all patients. The aim of the surgery is complete resection of all tumor burden, which requires a skillful surgical team for such a challenging procedure and is inherently associated with a high rate of perioperative morbidity and mortality. Preoperative CT or MRI is essential for surgical planning. The surgical approach is mainly determined by the level of the tumor thrombus. The open approach has been the standard, though minimally invasive and robotic techniques are emerging in selected cases by experienced surgeons.
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Affiliation(s)
- Alireza Ghoreifi
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Ave. Suite 7416, Los Angeles, CA, 90089, USA
| | - Hooman Djaladat
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Ave. Suite 7416, Los Angeles, CA, 90089, USA.
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19
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Complex robotic nephrectomy and inferior vena cava tumor thrombectomy: an evolving landscape. Curr Opin Urol 2020; 30:83-89. [PMID: 31725003 DOI: 10.1097/mou.0000000000000690] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Robotic nephrectomy for complex renal masses and in the setting of inferior vena cava (IVC) tumor thrombus has been shown to be a well tolerated and reproducible surgical option. Recent developments in such procedures will be discussed as they continue to evolve. RECENT FINDINGS Multiple case series have demonstrated the application of robotic surgery in the management of the most complex renal tumors and for IVC thrombi with acceptable oncologic and perioperative outcomes. Prior to the advent of robotic surgery, massive tumors, contiguous organ invasion, need for lymphadenectomy, and IVC tumor thrombus were thought by many to require open surgery. Since 2011, several studies have reported robotic nephrectomy for complex tumors with recent comparisons of robotic and open approaches finding similar oncologic and survival outcomes but with shorter length of stay (LOS) and less blood loss with robotic surgery. SUMMARY Robotic surgery is a feasible and well tolerated alternative to open surgery for the management of complex renal tumors and IVC thrombi. The potential benefits of shorter LOS, less blood loss, and earlier convalescence suggest this approach should continue to be evaluated. Patient selection and surgeon experience are of paramount importance.
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20
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Wang B, Huang Q, Liu K, Fan Y, Peng C, Gu L, Shi T, Zhang P, Chen W, Du S, Niu S, Liu R, Zhao G, Li Q, Xiao C, Wang R, Li S, Wang M, Liu F, Wang H, Li H, Ma X, Zhang X. Robot-assisted Level III-IV Inferior Vena Cava Thrombectomy: Initial Series with Step-by-step Procedures and 1-yr Outcomes. Eur Urol 2020; 78:77-86. [DOI: 10.1016/j.eururo.2019.04.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 04/12/2019] [Indexed: 11/15/2022]
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21
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Seetharam Bhat KR, Moschovas MC, Onol FF, Rogers T, Roof S, Patel VR, Schatloff O. Robotic renal and adrenal oncologic surgery: A contemporary review. Asian J Urol 2020; 8:89-99. [PMID: 33569275 PMCID: PMC7859360 DOI: 10.1016/j.ajur.2020.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 03/30/2020] [Accepted: 04/22/2020] [Indexed: 01/20/2023] Open
Abstract
Robot-assisted surgery has evolved over time. Radical nephrectomy with inferior vena cava thrombectomy is feasible and safe for level I, II and III thrombus in high volume centers. Though it is feasible for level IV thrombus, this procedure needs a multi-departmental co-operation. However, the safety of robot-assisted procedures in this subset is still unknown. Robot-assisted partial nephrectomy has been universally approved and found oncologically safe. Robotic adrenalectomy has been increasingly utilized for select cases, especially in bilateral tumors and for retroperitoneal adrenalectomy.
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Affiliation(s)
| | | | - Fikret Fatih Onol
- Global Robotics Institute, AdventHealth Celebration Health, Celebration, FL, USA
| | - Travis Rogers
- Global Robotics Institute, AdventHealth Celebration Health, Celebration, FL, USA
| | - Shannon Roof
- Global Robotics Institute, AdventHealth Celebration Health, Celebration, FL, USA
| | - Vipul R Patel
- Global Robotics Institute, AdventHealth Celebration Health, Celebration, FL, USA
| | - Oscar Schatloff
- Global Robotics Institute, AdventHealth Celebration Health, Celebration, FL, USA.,Sudmedica Health, Chile
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22
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Falagario U, Veccia A, Weprin S, Albuquerque EV, Nahas WC, Carrieri G, Pansadoro V, Hampton LJ, Porpiglia F, Autorino R. Robotic-assisted surgery for the treatment of urologic cancers: recent advances. Expert Rev Med Devices 2020; 17:579-590. [PMID: 32342705 DOI: 10.1080/17434440.2020.1762487] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION As the medical field is moving toward personalized and tailored approaches, we entered the era of precision surgery for the management of genitourinary cancers1. This is facilitated by the implementation of new technologies, among which robotic surgery stands out for the significant impact in the surgical field over the last two decades. AREAS COVERED This article reviews the latest evidence on robotic surgery for the treatment of urologic cancers, including prostate, kidney, bladder, testis, and penile cancer. Functional and oncologic outcomes, new surgical techniques, new imaging modalities, and new robotic platforms are discussed. EXPERT OPINION Robotic surgery had a growing role in the management of genitourinary cancers over the past 10 years. Despite a lack of high-quality evidence comparing the effectiveness of robotic to open surgery, the robotic approach allowed a larger adoption of a minimally invasive surgical approach, translating into lower surgical morbidity and shorter hospital stay. New robotic platforms might allow to explore novel surgical approaches, and new technologies might facilitate surgical navigation and intraoperative identification of anatomical structures, allowing a more tailored and precise surgery. It is an exciting time for robotic surgery, and upcoming technological advances will offer better outcomes to urologic cancer patients.
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Affiliation(s)
- Ugo Falagario
- Division of Urology, VCU Health System , Richmond, Virginia, USA.,Urology and Renal Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia , Foggia, Italy
| | - Alessandro Veccia
- Division of Urology, VCU Health System , Richmond, Virginia, USA.,Urology Unit, ASST Spedali Civili Hospital , Brescia, Italy.,Department of Medical and Surgical Specialties, Radiological Science, and Public Health, University of Brescia , Italy
| | - Samuel Weprin
- Division of Urology, VCU Health System , Richmond, Virginia, USA
| | - Emanuel V Albuquerque
- Divisão De Urologia, Faculdade De Medicina Da Universidade De São Paulo, Instituto Do Câncer De Estado De São Paulo , São Paulo, Brazil
| | - William C Nahas
- Divisão De Urologia, Faculdade De Medicina Da Universidade De São Paulo, Instituto Do Câncer De Estado De São Paulo , São Paulo, Brazil
| | - Giuseppe Carrieri
- Urology and Renal Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia , Foggia, Italy
| | - Vito Pansadoro
- Department of Urology, Vincenzo Pansadoro Foundation , Rome, Italy
| | - Lance J Hampton
- Division of Urology, VCU Health System , Richmond, Virginia, USA
| | - Francesco Porpiglia
- Division of Urology, University of Turin, San Luigi Gonzaga Hospital , Orbassano, Italy
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23
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Du S, Huang Q, Yu H, Shen D, Gu L, Yan F, Liu F, Zhang X, Ma X, Wang B. Initial Series of Robotic Segmental Inferior Vena Cava Resection in Left Renal Cell Carcinoma With Caval Tumor Thrombus. Urology 2020; 142:125-132. [PMID: 32339559 DOI: 10.1016/j.urology.2020.03.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 03/18/2020] [Accepted: 03/24/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To present our preliminary experience of robotic left radical nephrectomy (LRN) and segmental inferior vena cava (IVC) resection without caval replacement for left renal cell carcinoma (RCC) with inferior vena cava tumor thrombus. MATERIALS AND METHODS Between 2017 and 2018, 7 patients underwent segmental IVC resection and LRN robotically. All patients underwent preoperative cavography, demonstrating complete IVC occlusion. Computed tomography-based 3-dimensional reconstruction revealed sufficient collateralization of the IVC and right renal vein (RRV). The cephalic IVC was circumferentially resected and ligated just below the second porta hepatis. The caudal IVC was circumferentially resected above the RRV with preservation of the major collaterals. The RRV was not dissected during the procedure to avoid compromising its neocollaterals. The IVC portion between the RRV and the second porta hepatis was removed en bloc with the tumor thrombus, and the LRN was performed. RESULTS All cases were successfully performed by robotic surgery without conversion. Median operative time was 420 minutes. Median intensive care unit stay was 3 days. Four grade Ⅱ complications occurred in 2 patients. One patient had mild LEE postoperatively and recovered without special medication. Median preoperative and 3-6 months follow-up serum creatinine was 118.7 μmol/L and 135.2 μmol/L, respectively. No patient needed dialysis postoperatively. One case occurred disease progression. No patient died during the follow-up period. CONCLUSION Robotic segmental IVC resection for left RCC with inferior vena cava tumor thrombus is feasible in well-selected cases. Three-dimensional reconstruction and cavography are helpful in the preoperative evaluation of neocollaterals in patients with suprarenal IVC occlusion.
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Affiliation(s)
- Songliang Du
- School of Medicine, Nankai University, Tianjin, China; Department of Urology/ State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
| | - Qingbo Huang
- Department of Urology/ State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
| | - Hongkai Yu
- Department of Urology/ State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
| | - Donglai Shen
- Department of Urology/ State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
| | - Liangyou Gu
- Department of Urology/ State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
| | - Fei Yan
- Department of Radiology, Chinese PLA General Hospital, Beijing, China
| | - Fengyong Liu
- Department of Interventional Radiology, Chinese PLA General Hospital, Beijing, China
| | - Xu Zhang
- School of Medicine, Nankai University, Tianjin, China; Department of Urology/ State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
| | - Xin Ma
- School of Medicine, Nankai University, Tianjin, China; Department of Urology/ State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
| | - Baojun Wang
- School of Medicine, Nankai University, Tianjin, China; Department of Urology/ State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing, China.
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Huang Q, Gu L, Zhu J, Peng C, Du S, Liu Q, Chen J, Wang B, Fan Y, Gao Y, Fam X, Wang H, Liu F, Guo A, Li H, Zhang X, Ma X. A three-dimensional, anatomy-based nephrometry score to guide nephron-sparing surgery for renal sinus tumors. Cancer 2020; 126 Suppl 9:2062-2072. [PMID: 32293724 DOI: 10.1002/cncr.32748] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/28/2019] [Accepted: 01/10/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND A quantitative nephrometry scoring system specifically for renal sinus tumors will assist in classifying surgical complexity and treatment planning. METHODS By using preoperative computed tomography, magnetic resonance imaging, and 3-dimensional image reconstruction, 5 critical components were assessed: the ratio of the sinus area occupied by the tumor in relation to the whole sinus area (R), the compression of the renal segmental vessels or collection system by the tumor (O), the anteroposterior relation of the tumor relative to the segmental vessels or collection system (A), the tumor diameter (D), and whether the tumor affects a solitary kidney (S) ("ROADS"). The ROADS score, indicating low, moderate, or high surgical complexity, was then used to guide surgical strategy planning, including cooling techniques, surgical approaches, and parenchyma incision techniques. A cohort of 134 patients with renal sinus tumors was treated based on their ROADS score and was retrospectively analyzed. RESULTS The authors successfully performed 113 nephron-sparing surgeries and 21 radical nephrectomies with a complication rate of 7.9%. During follow-up, 3 cases were classified according to surgical margin status because they lacked an intact tumor capsule. There was only 1 case of local recurrence, and there were no cases of metastasis. A high ROADS score was correlated with greater operative complexity, such as longer operation and ischemia times and higher estimated blood loss and complication rates. However, renal function and short-term oncologic outcomes were not related to the score. CONCLUSIONS The ROADS scoring system provides a standardized, quantitative, 3-dimensional anatomic classification to guide surgical strategy in renal sinus tumors.
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Affiliation(s)
- Qingbo Huang
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital/PLA Medical School, Beijing, China
| | - Liangyou Gu
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital/PLA Medical School, Beijing, China
| | - Jie Zhu
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital/PLA Medical School, Beijing, China
| | - Cheng Peng
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital/PLA Medical School, Beijing, China
| | - Songliang Du
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital/PLA Medical School, Beijing, China
| | - Qiming Liu
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital/PLA Medical School, Beijing, China
| | - Jianwen Chen
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital/PLA Medical School, Beijing, China
| | - Baojun Wang
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital/PLA Medical School, Beijing, China
| | - Yang Fan
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital/PLA Medical School, Beijing, China
| | - Yu Gao
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital/PLA Medical School, Beijing, China
| | - Xenginn Fam
- Urology Unit, Department of Surgery, Kebangsaan Malaysia University Medical Center, Kuala Lumpur, Malaysia
| | - Haiyi Wang
- Department of Radiology, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Fengyong Liu
- Department of Interventional Radiology, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Aitao Guo
- Department of Pathology, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Hongzhao Li
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital/PLA Medical School, Beijing, China
| | - Xu Zhang
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital/PLA Medical School, Beijing, China
| | - Xin Ma
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital/PLA Medical School, Beijing, China
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Kishore TA, Pathrose G, Raveendran V, Ganpule A, Gautam G, Laddha A, Pooleri GK, Desai M. Robot-assisted laparoscopic radical nephrectomy and inferior vena cava thrombectomy: A multicentre Indian experience. Arab J Urol 2020; 18:124-128. [PMID: 33029418 PMCID: PMC7473165 DOI: 10.1080/2090598x.2020.1738104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective To assess feasibility of robot-assisted laparoscopic radical nephrectomy (RALRN) and inferior vena cava thrombectomy (IVCT) in treating renal tumours with level I–III IVC thrombi and to assess their outcomes. Patients and methods We conducted a retrospective analysis of RALRN-IVCTs, involving four centres across India, from September 2015 to June 2019. We analysed patients who underwent RALRN-IVCT for level I–III thrombi according to the Mayo classification. The total operative duration with console time, length of hospital stay, preoperative and postoperative creatinine, IVC clamp time and intraoperative blood loss were recorded. Results Of the 13 patients that underwent RALRN-IVCT, five had a level I thrombus, seven had level II, and one had a level III thrombus. In all, 11 of the patients had right-sided tumours and the remaining two had left-sided tumours. The mean (SD) age of the patients was 56.5 (12.3) years, the mean (SD) operative time was 329.5 (97.22) min, the mean (SD) console time was 222.5 (70) min, the mean (SD) blood loss was 395 (170) mL, and the mean (SD) IVC clamp time was 19.14 (9.5) min. The mean (SD) length of hospital stay was 7.8 (3.27) days. Of the 13 patients, 12 had clear cell renal cell carcinoma (RCC) and one had papillary RCC. The mean (range) follow-up was 19 (4–50) months. One patient had upfront metastasis and two patients developed metastasis, while 10 patients remained disease-free during the follow-up. Conclusion With appropriate patient selection, surgical planning and robotic experience, completely intracorporeal robotic level I–III IVCT is feasible and can be performed efficiently. Larger experiences, with longer follow-ups and comparisons with open surgery are needed to confirm these initial outcomes. Abbreviations ECOG: Eastern Cooperative Oncology Group; IVC: inferior vena cava; IVCT: inferior vena cava thrombectomy; (RAL)RN: (robot-assisted laparoscopic) radical nephrectomy
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Affiliation(s)
| | | | | | - Arvind Ganpule
- Department of Urology, Muljibhai Patel Urology Hospital, Nadiad, India
| | - Gagan Gautam
- Department of Urology, Max Hospital Saket, New Delhi, India
| | - Abhishek Laddha
- Department of Urology, Amrita Institute of Medical Sciences, Kochi, India
| | | | - Mahesh Desai
- Department of Urology, Muljibhai Patel Urology Hospital, Nadiad, India
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Li Q, Li N, Luo Y, Yu H, Ma X, Zhang X, Tang J. Role of intraoperative ultrasound in robotic-assisted radical nephrectomy with inferior vena cava thrombectomy in renal cell carcinoma. World J Urol 2020; 38:3191-3198. [PMID: 32133570 DOI: 10.1007/s00345-020-03141-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 02/19/2020] [Indexed: 10/24/2022] Open
Abstract
PURPOSE To determine the impact of intraoperative ultrasound on robotic-assisted radical nephrectomy with inferior vena cava (IVC) tumor thrombectomy in renal cell carcinoma (RCC). METHODS We retrospectively analyzed intraoperative records of 27 patients with RCC and invasion of the IVC who underwent robotic-assisted nephrectomy with tumor thrombectomy at our center between December 2017 and July 2018. Diagnostic utility and impact of intraoperative transesophageal echocardiography (TEE), intraoperative robotic-assisted ultrasonography, and intraoperative contrast-enhanced ultrasound (CEUS) on surgical management were extracted from the surgical notes and intraoperative ultrasound reports. RESULTS Twenty-seven patients with thrombus had intraoperative ultrasound. Complete tumor removal was achieved in 22 patients, IVC transection in 5 patients, and no residual tumor was observed in all patients. Intraoperative TEE changed the robotic surgical strategy in three patients by monitoring thrombus-level regression. Downstaging of the thrombus level occurred in three patients: Levels IV to III in one and Levels III to II in two. Intraoperative robotic-assisted ultrasonography has facilitated safe VC clamp placement and identification and protection of collateral vessels during IVC transection in five patients. Intraoperative CEUS helped to differentiate the boundary between tumor thrombus (enhancement and small vessel pulsation) and bland thrombus (hypoechoic or no enhancement) in eight (29.6%) patients with bland thrombus. CONCLUSIONS Intraoperative ultrasound is a safe, minimally invasive technique that can provide accurate real-time information regarding the presence and extent of IVC involvement and guidance for placement of a vena cava clamp, confirming the character of the thrombus to plan an optimal surgical approach.
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Affiliation(s)
- Qiuyang Li
- Department of Ultrasound, Chinese PLA General Hospital, Beijing, 100853, China
| | - Nan Li
- Department of Ultrasound, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yukun Luo
- Department of Ultrasound, Chinese PLA General Hospital, Beijing, 100853, China.
| | - Hongkai Yu
- Department of Urology, Chinese PLA General Hospital, Beijing, 100853, China
| | - Xin Ma
- Department of Urology, Chinese PLA General Hospital, Beijing, 100853, China
| | - Xu Zhang
- Department of Urology, Chinese PLA General Hospital, Beijing, 100853, China
| | - Jie Tang
- Department of Ultrasound, Chinese PLA General Hospital, Beijing, 100853, China.
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Shen D, Wang H, Wang C, Huang Q, Li S, Wu S, Xuan Y, Gong H, Li H, Ma X, Wang B, Zhang X. Cumulative Sum Analysis of the Operator Learning Curve for Robot-Assisted Mayo Clinic Level I-IV Inferior Vena Cava Thrombectomy Associated with Renal Carcinoma: A Study of 120 Cases at a Single Center. Med Sci Monit 2020; 26:e922987. [PMID: 32107362 PMCID: PMC7063847 DOI: 10.12659/msm.922987] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background This study aimed to use cumulative sum analysis of the operator learning curve for robot-assisted Mayo Clinic level I–IV inferior vena cava (IVC) thrombectomy associated with renal carcinoma, and describes the development of an optimized operative procedure at a single center. Material/Methods A retrospective study included 120 patients with Mayo Clinic level I–IV IVC thrombus who underwent robotic surgery between 2013 and 2018. Points in the learning curve were identified using cumulative sum analysis, and their impact was assessed by multiple regression analysis. Perioperative indicators analyzed included operative time, estimated blood loss, early complications, and the 90-day progression rate. Results Cumulative sum analysis identified three phases in the learning curve of robot-assisted IVC thrombectomy. The median operative time decreased from 265 min (range, 212–401 min) to 207 min (range, 146–276 min) (p=0.003), the median estimated blood loss decreased from 775 ml (range, 413–1500 ml) to 300 ml (range, 163–813 ml) (p=0.006), and the early complication rate decreased from 52.5% to 15.0% (p<0.001). Multivariate analysis showed that for an initial 40 cases and a further 80 cases, the learning phase, the affected side, the Mayo Clinic level, and the surgical method were independent factors that affected operative time, estimated blood loss, and the rate of early complications. Conclusions Experience from an initial 40 cases and a further 80 cases of Mayo Clinic level I–IV IVC thrombectomy associated with renal carcinoma were found to provide acceptable surgical and clinical outcomes.
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Affiliation(s)
- Donglai Shen
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Hanfeng Wang
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Chenfeng Wang
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Qingbo Huang
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Shichao Li
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Shengpan Wu
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Yundong Xuan
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Huijie Gong
- Department of Urology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China (mainland)
| | - Hongzhao Li
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Xin Ma
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Baojun Wang
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Xu Zhang
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
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Rose KM, Navaratnam AK, Faraj KS, Abdul-Muhsin HM, Syal A, Elias L, Moss AA, Eversman WG, Stone WM, Money SR, Davila VJ, Tyson MD, Castle EP. Comparison of Open and Robot Assisted Radical Nephrectomy With Level I and II Inferior Vena Cava Tumor Thrombus: The Mayo Clinic Experience. Urology 2020; 136:152-157. [DOI: 10.1016/j.urology.2019.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/24/2019] [Accepted: 11/02/2019] [Indexed: 10/25/2022]
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29
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Li QY, Li N, Huang QB, Luo YK, Wang BJ, Guo AT, Ma X, Zhang X, Tang J. Contrast-enhanced ultrasound in detecting wall invasion and differentiating bland from tumor thrombus during robot-assisted inferior vena cava thrombectomy for renal cell carcinoma. Cancer Imaging 2019; 19:79. [PMID: 31791422 PMCID: PMC6889486 DOI: 10.1186/s40644-019-0265-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 11/11/2019] [Indexed: 12/13/2022] Open
Abstract
Background Vena cava thrombus is one of the main clinical manifestations of locally aggressive renal cell carcinoma (RCC). Inferior vena cava (IVC) wall invasion and presence of bland thrombus could affect the surgical outcome. This study aims to assess the value of contrast-enhanced ultrasound (CEUS) in detecting wall invasion and differentiating bland thrombus from tumor thrombus during robot-assisted IVC thrombectomy for RCC. Methods The intraoperative CEUS findings of 60 patients with RCC accompanied by IVC tumor thrombus were retrospectively analyzed. The CEUS features were compared with the intra- and post-operative pathological findings. CEUS in patients with wall invasion showed that the tumor thrombus was enhanced synchronously with the IVC wall, and the continuity of the IVC wall was lost. In contrast, in patients without wall invasion, CEUS showed that the contrast agent could pass between the tumor thrombus and the IVC wall, and the continuity of IVC wall was good. Typically, contrast-enhanced perfusion was seen in tumor thrombus but not in bland thrombus. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CEUS were statistically analyzed. Results The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of the typical enhancement mode of CEUS were 93.1, 93.5, 93.3, 93.1, and 93.5% in identifying wall invasion and 100, 96, 96.7, 83.3, and 100% in differentiating bland thrombus from tumor thrombus, respectively. There were excellent inter-observer agreements for identifying IVC wall invasion and differentiating bland thrombus from tumor thrombus with kappa coefficients of 0.90 and 0.97. Conclusions The present study indicates that intraoperative CEUS plays an important role in robot-assisted IVC thrombectomy for RCC. It can detect wall invasion and differentiate bland thrombus from tumor thrombus, thus offering real-time information to the operator during surgery.
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Affiliation(s)
- Qiu-Yang Li
- Department of Ultrasound, Chinese PLA General Hospital, Beijing, 100853, China
| | - Nan Li
- Department of Ultrasound, Chinese PLA General Hospital, Beijing, 100853, China
| | - Qing-Bo Huang
- Department of Urology, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yu-Kun Luo
- Department of Ultrasound, Chinese PLA General Hospital, Beijing, 100853, China.
| | - Bao-Jun Wang
- Department of Urology, Chinese PLA General Hospital, Beijing, 100853, China
| | - Ai-Tao Guo
- Department of Pathology, Chinese PLA General Hospital, Beijing, 100853, China
| | - Xin Ma
- Department of Urology, Chinese PLA General Hospital, Beijing, 100853, China
| | - Xu Zhang
- Department of Urology, Chinese PLA General Hospital, Beijing, 100853, China
| | - Jie Tang
- Department of Ultrasound, Chinese PLA General Hospital, Beijing, 100853, China.
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30
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Rose KM, Navaratnam AK, Abdul-Muhsin HM, Faraj KS, Eversman SA, Moss AA, Eversman WG, Stone WM, Money SR, Davila VJ, Castle EP. Robot Assisted Surgery of the Vena Cava: Perioperative Outcomes, Technique, and Lessons Learned at The Mayo Clinic. J Endourol 2019; 33:1009-1016. [DOI: 10.1089/end.2019.0429] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Affiliation(s)
- Kyle M. Rose
- Department of Urology, Mayo Clinic Arizona, Phoenix, Arizona
| | | | | | - Kassem S. Faraj
- Department of Urology, Mayo Clinic Arizona, Phoenix, Arizona
| | | | - Adyr A. Moss
- Division of Transplant, Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | | | - William M. Stone
- Department of Vascular Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Samuel R. Money
- Department of Vascular Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Victor J. Davila
- Department of Vascular Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Erik P. Castle
- Department of Urology, Mayo Clinic Arizona, Phoenix, Arizona
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Trends and outcomes in contemporary management renal cell carcinoma and vena cava thrombus. Urol Oncol 2019; 37:576.e17-576.e23. [DOI: 10.1016/j.urolonc.2019.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 04/12/2019] [Accepted: 05/13/2019] [Indexed: 11/22/2022]
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Campi R, Tellini R, Sessa F, Mari A, Cocci A, Greco F, Crestani A, Gomez Rivas J, Fiori C, Lapini A, Gallucci M, Capitanio U, Roupret M, Abaza R, Carini M, Serni S, Ficarra V, Porpiglia F, Esperto F, Minervini A. Techniques and outcomes of minimally-invasive surgery for nonmetastatic renal cell carcinoma with inferior vena cava thrombosis: a systematic review of the literature. MINERVA UROL NEFROL 2019; 71:339-358. [PMID: 30957477 DOI: 10.23736/s0393-2249.19.03396-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Current guidelines recommend considering surgical excision of non-metastatic renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombosis in patients with acceptable performance status. Of note, several authors have pioneered specific techniques for laparoscopic and robotic management of renal cancer with level I-IV IVC thrombosis. EVIDENCE ACQUISITION A systematic review of the English-language literature on surgical techniques and perioperative outcomes of minimally-invasive radical nephrectomy (RN) and IVC thrombectomy for nonmetastatic RCC was performed without time filters using the MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials and Web of Science (WoS) databases in September 2018 according to the PRISMA statement recommendations. EVIDENCE SYNTHESIS Overall, 28 studies were selected for qualitative analysis (N.=13 on laparoscopic surgery, N.=15 on robotic surgery). The quality of evidence according to GRADE was low. Laparoscopic techniques included hand-assisted, hybrid and pure laparoscopic approaches. Most of these series included right-sided tumors with predominantly level I or II IVC thrombi. Similarly, most robotic series reported right-sided RCC with level I-II IVC thrombosis; yet, few authors extended the indication to level III thrombi and to left-sided RCC. Surgical techniques for minimally-invasive IVC thrombectomy evolved over the years, with specific technical nuances aiming to tailor surgical strategy according to both tumor side and thrombus extent. Among the included studies, perioperative outcomes were promising. CONCLUSIONS Minimally-invasive surgery is technically feasible and has been shown to achieve acceptable perioperative outcomes in selected patients with renal cancer and IVC thrombosis. The evidence is premature to draw conclusions on intermediate-long term oncologic outcomes. Robotic surgery allowed to extend surgical indications to more challenging cases with more extensive tumor thrombosis. Nonetheless, global experience on minimally-invasive IVC thrombectomy is limited to high-volume surgeons at high-volume Centers. Future research is needed to prove its non-inferiority as compared to open surgery and to define its benefits and limits.
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Affiliation(s)
- Riccardo Campi
- Department of Urology, Careggi University Hospital, Florence, Italy - .,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy -
| | - Riccardo Tellini
- Department of Urology, Careggi University Hospital, Florence, Italy
| | - Francesco Sessa
- Department of Urology, Careggi University Hospital, Florence, Italy
| | - Andrea Mari
- Department of Urology, Careggi University Hospital, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Andrea Cocci
- Department of Urology, Careggi University Hospital, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | - Alessandro Crestani
- Unit of Urology, Santa Maria della Misericordia Academic Medical Center Hospital, Udine, Italy
| | - Juan Gomez Rivas
- Department of Urology, La Paz University Hospital, Madrid, Spain
| | - Cristian Fiori
- Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Alberto Lapini
- Department of Urology, Careggi University Hospital, Florence, Italy
| | - Michele Gallucci
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - Umberto Capitanio
- Unit of Urology, San Raffaele Hospital IRCCS, Vita-Salute San Raffaele University, Milan, Italy.,Unit of Renal Cancer, Division of Oncology, Urological Research Institute (URI), San Raffaele Hospital IRCCS, Milan, Italy
| | - Morgan Roupret
- Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Ronney Abaza
- Unit of Robotic Urologic Surgery, Ohio Health Dublin Methodist Hospital, Columbus, OH, USA
| | - Marco Carini
- Department of Urology, Careggi University Hospital, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Sergio Serni
- Department of Urology, Careggi University Hospital, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Vincenzo Ficarra
- Department of Human Pathology of Adult and Evolutive Age, University of Messina, Messina, Italy
| | - Francesco Porpiglia
- Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | | | - Andrea Minervini
- Department of Urology, Careggi University Hospital, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Robot-assisted Retrohepatic Inferior Vena Cava Thrombectomy: First or Second Porta Hepatis as an Important Boundary Landmark. Eur Urol 2017; 74:512-520. [PMID: 29223604 DOI: 10.1016/j.eururo.2017.11.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 11/17/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Robot-assisted retrohepatic inferior vena cava (IVC) thrombectomy (RA-R-IVCTE) has been reported only for limited series. OBJECTIVE To describe in detail the techniques for RA-R-IVCTE with regard to the relationship of a proximal thrombus to either the first porta hepatis (FPH) or second porta hepatis (SPH). DESIGN, SETTING, AND PARTICIPANTS From May 2013 to July 2016, 22 patients with R-IVC tumor thrombi were admitted to our hospital. SURGICAL PROCEDURE RA-R-IVCTE was performed using the Rummel tourniquet technique. For a proximal thrombus inferior to the FPH, we ligated some short hepatic veins (SHVs; typically 1-3). For a thrombus between the FPH and SPH, we mobilized the right lobe of the liver from the IVC by ligating additional SHVs. For a thrombus near or above the SPH but below the diaphragm, we mobilized both the right and left lobes of the liver to obtain high proximal control of the suprahepatic and infradiaphragmatic IVC, and simultaneously clamped the FPH. MEASUREMENTS Detailed techniques were described for various scenarios and perioperative outcomes were recorded. RESULTS AND LIMITATIONS The median operation time was 285min (interquartile range [IQR] 191-390). Intraoperative estimated blood loss was 1350ml (IQR 1000-2075ml). Some 63.6% of patients required an intraoperative blood transfusion and 68% were transferred to the intensive care unit after surgery. Grade IV complications developed in five cases. Vascular injuries (4 cases) were treated with intraoperative endoscopic sutures. An intestinal fistula was found on postoperative day 7 in one case; treatment with gastrointestinal decompression and drainage resolved the condition by 1 mo. CONCLUSIONS Even though the risks involved are high, RA-R-IVCTE is feasible for selected patients. The FPH/SPH is an important boundary landmark for RA-R-IVCTE. The location of proximal IVC tumor thrombi in relation to the FPH or SPH should determine the technique used. PATIENT SUMMARY Robot-assisted thrombectomy for retrohepatic inferior vena cava tumor thrombus is feasible in selected patients.
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This Month in Adult Urology. J Urol 2017. [DOI: 10.1016/j.juro.2017.08.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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