Radical robot-assisted laparoscopic nephrectomy with thrombectomy in the vena cava

Renal cell carcinoma has a natural tendency to extend through the renal vein. When the thrombus reaches the vena cava, thrombectomy and the necessary reconstruction of the vena cava are typically performed by open pathway. Robot-assisted technology provides advantages for performing this complex technique, using a minimally invasive access. We present the technique we employed in the first case performed in our department. After performing renal artery embolisation, we conducted the surgery with the Vinci S robotic system. The main steps of the surgery are as follows: detachment and Kocher manoeuvre; release of the lower renal pole; clamping and sectioning of the renal artery; endocavitary ultrasound to locate the thrombus; placement of tourniquets in the vena cava below and above the renal veins and in the left renal vein; closure of the 3 tourniquets; opening of the vena cava; resection and extraction of the thrombus; suture of the vena cava; opening of the tourniquets; complete release of the kidney; bagging and extraction of the specimen. The surgery was performed without complications. The patient required a transfusion of 2 units of packed red blood cells and was discharged with modest renal failure (creatinine level of 1.60mg/dl). Radical nephrectomy with thrombectomy in the vena cava is a technique susceptible to severe complications and has, to date, been performed in few centres. We believe that the technique is reproducible and has clear advantages for our patients.