WCE 2016: Retroperitoneoscopic Radical Nephrectomy With Thormbectomy From Inferior Vena Cava - Session Highlights

Cape Town, South Africa (UroToday.com) Advanced renal cell carcinoma (RCC) is associated with a tumor thrombus located in the inferior vena cava (IVC) in 3-11% of patients undergoing radical nephrectomy. Surgical treatment
of T3b RCC with IVC invasion still presents a challenge not only in endoscopic but also in open surgery.

In spite of the fact that laparoscopic radical nephrectomy is acknowledged as the gold standard of treatment of renal cell carcinoma, reports on laparoscopic thrombectomies in patients with level II-II tumor thrombi are infrequent. The transperitoneal approach was used in the vast majority of these cases, and only a few researchers have reported utilizing the retroperitoneal access. We describe our experience in performing laparoscopic retroperitoneal radical nephrectomy and IVC thrombectomy in patients with renal cell carcinoma and level II tumor thrombus.

Authors review their experience between September 2013 to August 2016. A total five patients with RCC and level II IVC tumor thrombi underwent laparoscopic radical nephrectomies with IVC thrombectomy via retroperitoneoscopic approach.

The surgical technique was described in detail and ss is the standard for reproperitoneoscopic procedures, a 1 cm long incision was made below the inferior border of the XI rib, the fibers of the external and internal oblique abdominal and transversal abdominal muscles, the abdominal fascia were consecutively drawn apart. A small cavity was created digitally and a balloon inserted. The working space was created by pumping air into the retroperitoneal dilating balloon. Authors placed a 12 mm trocar and insufflated CO2 determining 14 mm HG pressure. Two more trocars – 10 and 12 mm – were placed under endoscopic guidance at 4-5 sm distance in the direction of the iliac crest and the umbilicus respectively.

All 5 patients underwent laparoscopic procedures without conversion to open surgery. The tumor size varied from 8 to 12 cm with the mean size of 6cm. the mean thromb size 3.5 (2 to 5.5 cm). The mean duration of the procedures was 320 mins (240-450min). The blood loss did not exceed 1000 cc. No significant complications occurred intraoperatively or in the early postoperative period. The patients were discharged in satisfactory condition on the 7th - 19th postoperative day. One patient with multiple lung and bone metastases died 11 months after the surgery. With a follow-up period of 2-35 months, the two other patients have no signs of recurrence.

Authors concluded that the laparoscopic approach for T3b RCC and level II-III tumor thrombus is a challenging technique. As any other laparoscopic procedure, it is associated with a steep learning curve and requires advanced laparoscopic skills. In the hands of the experts, the procedure is relatively safe and efficacious.

Retroperitoneal approach possesses advantages over the transperitoneal one. Further introduction of retroperitoneoscopic procedures in patients of this complex category may decrease the risk of postoperative complications and possibly enhance general survival rate. However more experience and further studies are needed to elucidate the role of this approach in the routine clinical practice.

Presented by Dmitry Perlin, MD

Authors: Dmitry Perlin 1,2, V.P. Zipunnikov 1, I.N. Dymkov 1, A.O. Shmanev 2, O.N. Shevchenko
1. Volgograd State medical University, Urology Department
2. Volgograd Regional Hospital of Urology

Written By: Zhamshid Okhunov, MD, University of California, Irvine, USA, Department of Urology

34th World Congress of Endourology and SAUA meeting - November 7-12, 2016 – Cape Town, South Africa