Robotic Left-sided Level II Caval Thrombectomy and Nephrectomy Using a Novel Supine, Single-dock Approach: Primary Description

Objective: To demonstrate a novel supine, single-dock approach for robotic nephrectomy and inferior vena cava (IVC) thrombectomy for a left-sided renal cell carcinoma with level II IVC thrombus. Methods: We perform robotic nephrectomy and IVC thrombectomy in a 79-year-old man with a 6-cm left renal mass and level II IVC thrombus. For this approach, the patient is placed in steep Trendelenburg, and a 6-port transperitoneal technique is used, with the robot docked such that the arms are oriented in a cephalad direction. We describe key steps, including (1) exposure of the retroperitoneum, (2) IVC exposure and control, (3) left renal hilar control, (4) cavotomy, thrombectomy, and reconstruction, (5) nephrectomy and lymph node dissection. Perioperative outcomes are reported. Results: Robotic left nephrectomy and level II IVC thrombectomy were successfully completed using this novel, single-dock approach. Total operative time was 7 hours with IVC clamp time of 27 minutes. Estimated blood loss was 500 cc without perioperative transfusion. There were no intraoperative or major perioperative complications. The patient was discharged on postoperative day 5. This approach allows rapid caval control, bilateral renal hilar access, and obviates the need for preoperative renal artery embolization or intraoperative redocking or repositioning steps, as has been previously described for other approaches. Conclusion: We demonstrate the first description of robotic left-sided level II IVC thrombectomy and radical nephrectomy using a supine, single-dock approach. This novel, versatile approach adds to the armamentarium for minimally invasive surgical management of renal cell carcinoma with IVC thrombus.