A Modified Sequential Vascular Control Strategy in Robot-assisted Level III-IV Inferior Vena Cava Thrombectomy: Initial Series Mimicking the "Open Milk Technique" Principle.

Robot-assisted level III-IV inferior vena cava (IVC) thrombectomy requires occlusion of the first porta hepatis (FPH) and establishment of cardiopulmonary bypass (CPB), which bring additional risks. We aimed to introduce a modified sequential vascular control strategy, mimicking the "open milk technique" principle, for the early release of the FPH and to stop CPB in robot-assisted level III-IV IVC thrombectomy (RA-IVCTE).

From November 2014 to June 2019, 27 patients with a level III-IV IVC tumour thrombus (IVCTT) underwent RA-IVCTE in our department. The modified sequential control strategy was applied in twelve cases. Previously, we released the FPH after the thrombus was resected and the IVC was closed completely and stopped CPB at the end of surgery. Presently, we placed another tourniquet inferior to the second porta hepatis (SPH) once the proximal thrombus was removed from the IVC below the SPH. Then, we sutured the right atrium and performed early release of the FPH and stopped CPB. Finally, tumour thrombectomy, vascular reconstruction, and radical nephrectomy were performed.

Compared with the previous strategy, the modified steps resulted in a shorter median FPH clamping time (19 vs 47 min, p<0.001) and CPB time (60 vs 87 min, p<0.05), a lower rate of grade II-IV perioperative complications (25% vs 60%, p<0.05), and a better postoperative hepatorenal and coagulation function, including better median serum ALT (172.7 vs 465.4 U/l, p<0.001), AST (282.4 vs 759.8 U/l, p<0.001), Cr (113.4 vs 295 μmol/l, p<0.01), BUN (7.3 vs 16.7 mmol/l, p<0.01), and D-dimer (5.9 vs 20 mg/l, p<0.001) levels.

With the early release of the FPH and stopping CPB, the modified sequential control strategy in level III-IV RA-IVCTE reduced the perioperative risk for selected patients and improved the feasibility and safety of the surgery, which might be recommended in the future.

BJU international. 2020 Apr 24 [Epub ahead of print]

Donglai Shen, Songliang Du, Qingbo Huang, Yu Gao, Yang Fan, Liangyou Gu, Kan Liu, Cheng Peng, Yundong Xuan, Pin Li, Hongzhao Li, Xin Ma, Xu Zhang, Baojun Wang

Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/PLA Medical School, Beijing, 100853, China., Department of Urology, The Seventh Medical Center of Chinese, PLA General Hospital, Beijing, 100007, China., Department of Pediatric Urology, Bayi Children's Hospital Affiliated to The Seventh Medical Center of Chinese PLA General Hospital, Beijing, 100007, China.