Renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombus is an uncommon disease presentation, although most urologic oncologists will encounter it at some point in their careers. The standard of care for patients with nonmetastatic RCC with thrombus into the IVC has been radical nephrectomy with IVC thrombectomy. Despite the rapid advances in laparoscopic and robotic approaches to localized RCC surgery, open radical nephrectomy with IVC thrombectomy (O-CT) has long been considered the only surgical choice available to patient and surgeon.1 Thus, there have been few articles in the literature of pure laparoscopic radical nephrectomy and IVC thrombectomy, with the first case reported in 2011 by Abaza et al.2
In the decade since, there continue to be single-institution reports of the feasibility of robot-assisted laparoscopic radical nephrectomy with IVC thrombectomy (R-CT), with limited high-quality evidence such as a randomized multi-institutional study. Therefore, the multi-institutional group headed by Garg et al sought to assess the safety and feasibility of R-CT and provide an accumulated understanding of the first decade of its use in a systematic review published in the Journal of Urology.3
The authors conducted a retrospective review of appropriate studies in the PubMed database to compare the perioperative outcomes with R-CT and O-CT. They separated their findings into single-arm studies reporting on R-CT (n=21), as well as comparative studies comparing R-CT with O-CT (n=7). Only 4 of the comparative studies evaluated R-CT versus O-CT, while 3 studies compared various robotic techniques.
R-CT Study Results
Of the 21 single-arm studies, only 9 (43%) included a cohort of >10 patients. A total of 329 patients from the single-arm studies were analyzed: 75% had right-sided tumors, of whom 61% had level II tumor thrombi extending into the IVC >2 cm above the renal vein.4 A level I, tumor thrombus <2 cm above the renal vein occurred was found in ~15% of the patients, while level III tumor thrombi above the hepatic veins but below the diaphragm was documented in 20% of the cohort. Only 2.5% of the R-CT cohort had a level IV tumor thrombus extending above the diaphragm. Notably, 12% of the cohort had metastatic disease at the time of surgery.
Most of the single-arm studies reporting outcomes data described surgery performed by highly experienced robotic surgeons using a multidisciplinary approach. Almost one-third of all patients underwent angioembolization before surgery to try to reduce the tumor burden before starting the planned intervention. The weighted mean operative time for R-CT was 282 minutes. Mean estimated blood loss ranged from 150 to 2000 mL, and 38% of patients required a perioperative blood transfusion. It is worth noting that only 1.2% of cases (n=4) were converted to open surgery. A total of 6 cases (1.8%) reported an intraoperative complication, including 3 vascular injuries, 2 bowel injuries, and 1 liver laceration. The overall perioperative complication rate was 30%, with a major complication rate (Clavien-Dindo grade ≥III) of 8.5%.
In perhaps the most, meaningful analysis of their study, Garg et al identified 4 studies comparing R-CT to O-CT.5,6,7,8 In these studies, 110 patients underwent R-CT and 936 patients underwent O-CT. No definitive statement could be made about the operative time of R-CT versus O-CT. One study used a matched cohort analysis to match 31 patient pairs by age, ASA score, and tumor characteristics, and found median operative time was significantly shorter for patients undergoing R-CT than O-CT. However, 2 other studies found median operative time for R-CT to be significantly longer than for O-CT, while the fourth study did not demonstrate a significant difference.
A New Understanding of R-CT
However, all 4 studies reported significantly less median blood loss and a significantly lower transfusion rate in patients undergoing R-CT compared with O-CT. Notably, the overall complication rate was significantly lower in the R-CT group than in the O-CT group, but there was no significant difference between the groups regarding serious complications (Clavien-Dindo grade ≥III). There also was no difference identified between the groups in 30-day mortality, unplanned readmission, progression-free survival, or overall survival. The median follow-up time was 27 months for patients receiving R-CT and 44.8 months for those receiving O-CT.
At more than 10 years since the first reports on R-CT, the findings of Garg et al help provide a contemporary understanding of the safety and feasibility of using R-CT, compared with standard O-CT, in patients with RCC and tumor extension into the IVC. Their systematic analysis of the relevant literature establishes that R-CT’s safety and perioperative outcomes are acceptable compared with O-CT. Moreover, some aspects of R-CT are potentially safer, with patients experiencing significantly less blood loss after robot-assisted versus open surgery.
However, the authors acknowledged the frequent use of perioperative angioembolization with R-CT to help decompress venous collaterals and assist in robotic efficacy compared with the rare (given a lack of evidence) use of the procedure for O-CT as a primary difference between the approaches. They also noted that despite using the best available evidence in the current literature, the data collected may be skewed by selection bias, as well as by the varied methodologies for of reporting complications. While they commented that their promising data appear to support the use of R-CT in patients who have RCC with an IVC tumor thrombus, a prospective randomized clinical trial is needed make a thorough assessment of the 2 procedures.
Daniel Tennenbaum is a urology resident at Maimonides Medical Center in Brooklyn, NY. His interests include surgical education and GU oncology with a focus on pediatric malignancies.
- Jurado A, Romeo A, Gueglio G, Marchiñena PG. Current trends in management of renal cell carcinoma with venous thrombus extension. Curr Urol Rep. 2021;22(4):23. doi: 10.1007/s11934-021-01036-y
- Abaza R. Initial series of robotic radical nephrectomy with vena caval tumor thrombectomy. Eur Urol. 2011;59(4):652-656. doi: 10.1016/j.eururo.2010.08.038
- Garg H, Psutka SP, Hakimi AA, et al. A decade of robotic-assisted radical nephrectomy with inferior vena cava thrombectomy: a systematic review and meta-analysis of perioperative outcomes. J Urol. 2022;208(3):542-560. doi: 10.1097/JU.0000000000002829
- Psutka SP, Leibovich BC. Management of inferior vena cava tumor thrombus in locally advanced renal cell carcinoma. Ther Adv Urol. 2015;7(4):216-229. doi: 10.1177/1756287215576443
- Gu L, Ma X, Gao Y, et al. Robotic versus open level I-II inferior vena cava thrombectomy: a matched group comparative analysis. J Urol. 2017;198(6):1241-1246. doi: 10.1016/j. juro.2017.06.094
- Beksac AT, Shah QN, Paulucci DJ, et al. Trends and outcomes in contemporary management renal cell carcinoma and vena cava thrombus. Urol Oncol. 2019;37(9):576. e17-576.e23. doi: 10.1016/j.urolonc.2019.05.010
- Rose KM, Navaratnam AK, Faraj KS, et al. 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
- Vuong NS, Ferriere JM, Michiels C, et al. 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. 2021;73(4):498-508. doi: 10.23736/S2724-6051.20.04052-7