Minimally invasive options for the management of localized RCC (without tumor thrombus) have become established alternatives to open surgery. However, MIS options for patients with tumor thrombus are only now being explored – indeed, the boundaries are being pushed in selected patients, with reports of Level 3 thrombi being treated robotically. However, the data to support the safety of MIS in patients with tumor thrombus is not yet there.
In this study, utilizing the established, largest multi-institutional database of tumor thrombus patients (the International Renal Cell Carcinoma-Venous Thrombus Consortium database), which includes 2552 patients. Of these, 120 had a MIS approach (0.5%), emphasizing its rarity. The authors report oncologic and surgical outcomes.
Of the 110 were laparoscopic and only 10 were robotic, highlighting the older era of the study population. Mean age and BMI of the entire cohort was 66.48 ±11.24 years and 27.9 ±5.27 respectively. Most were healthy, representing a selected population (51% with ASA score ≤2). Charlson comorbidity index score was 4.02±3.26. Mean pre-operative eGFR was 77.93 ±30.6mL/min. Mean tumor size was 6.8 ±2.57cm; 7.89% and 13.33% were N+ or M+ respectively. Follow-up was 935 days ± 862 days, so very variable.
Thrombus level was confined to the renal vein or to its segmental branches (level≤I) in 94.53% - which again highlights the extremely selected nature of this cohort; most were technically similar to a nephrectomy.
Mean operating time was 197.05 ±88.35min with a mean blood loss of 682.37 ±2156.61mL. Both of these represent a very wide range of results, indicating the highly variable and nonstandardized nature of the procedure.
Overall 14.42%, 1.11% and 6.73% underwent lymphadenectomy, cardiopulmonary bypass and cavotomy respectively.
In terms of post-operative outcomes, major complications (Clavien ≥3) occurred in almost 1 on 4 patients (24.8%) with no intraoperative deaths. Mean hospital stay was 7.97 ±8.50days. After a mean follow up of 935.33 ±862.14days, mean eGFR variation was -2.04 ±47.26 mL/min.
As for oncologic outcomes, CSS and OS were 75.85% and 72.65% respectively with 80.26% of the patients being free of recurrence, 7.89% having disease progression and 11.84% stable disease.
As the authors note, while MIS may be feasible yielding acceptable oncological and functional outcomes, the blood loss, hospital stay and high grade (>= 3) complications remain relatively high.
Further large prospective studies are needed to evaluate the role of MI surgery for KC + VT. Particularly, as most of these patients were in the pre-robotic era, further evaluation of this technology would be useful.
Speaker: G. Marra
Co-Author(s): Brattoli M., Filippini C., Linares Espinos E., Martinez Salamanca J., Spahn M., Scherr D., Delgado-Oliva F., Vera-Donoso C., Lorentz A., Viraj M., McKiernan J., Libertino J, Huang W., Evans C., Capitanio U., Montorsi F., Hutterer G., Zigeuner R., Gontero P.
Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, Twitter: @tchandra_uromd at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark