Category: Robotic Surgery: UpperTract - Malignant

VS7-4 - Indocyanine green guided Robot assisted radical nephrectomy and level III Inferior Vena Cava tumor thrombectomy

Sat, Sep 22
10:00 AM - 12:00 PM

Introduction & Objective :

Radical nephrectomy with Inferior vena cava (IVC) thrombectomy for renal cancer is one of the most challenging urologic surgical procedures. A crucial step is the control of the cranial edge of the thrombus, which can be made with the assistance of indocyanine green (ICG) guidance.


Methods :

In this video we highlighted surgical steps of a right radical nephrectomy and level III IVC thrombectomy using ICG guidance.
Preoperative embolization of the two right renal arteries was performed. Liver was mobilized with an extensive incision of triangular ligament to expose the retrohepatic IVC. IVC was meticulously prepared, cranially and distally to the neoplastic thrombus. All lumbar veins and right gonadal vein were secured, while left renal vein was isolated for tourniquet encircling.
Once completed the infrarenal IVC dissection, the retrohepatic IVC was progressively prepared, taking care of all visible short hepatic veins and posterior lumbar veins.
Right renal arteries were transected with Ligasure and previously applied tourniquets were synched down after confirming with near infrared fluorescence the proper control of cranial thrombus edge.
Cavotomy was performed and the thrombus delivered and secured into an endo catch bag.
IVC lumen was copiously irrigated with heparin saline solution and IVC suture performed with 3-0 monocryl running suture.
After tourniquets removal, near infrared fluorescence was used to inspect IVC lumen and to confirm proper restoration of IVC flow. Finally, nephrectomy was completed.


Results :

Operative time was 300 minutes. Estimated blood loss was 350 ml. Patients was discharged on 7th postoperative day. Postoperative course was uneventful.


Conclusions :

Near infrared fluorescence imaging represents a significant technical advancement in management of level III IVC tumor thrombi, to improve control of cranial thrombus edge and to confirm proper restoration of IVC flow after cava suture.

Giuseppe Simone

Consultant
“Regina Elena” National Cancer Institute, Dept. of Urology
Roma, Lazio, Italy

Leonardo Misuraca

Fellow
"Regina Elena" National Cancer Institute, Dept. of Urology
Rome, Lazio, Italy

Gabriele Tuderti

Fellow
"Regina Elena" National Cancer Institute, Dept. of Urology
Roma, Lazio, Italy

Mariaconsiglia Ferriero

MD, PhD
"Regina Elena" National Cancer Institute, Dept. of Urology
Rome, Lazio, Italy

Francesco Minisola

"Regina Elena" National Cancer Institute, Dept. of Urology
Roma, Lazio, Italy

Salvatore Guaglianone

"Regina Elena" National Cancer Institute, Dept. of Urology
Roma, Lazio, Italy

Michele Gallucci

Roma, Lazio, Italy