Key surgical techniques in laparoscopic nephrectomy and thrombectomy for advanced renal cell carcinoma with thrombosis

Abstract

Background: Vascular extension of Renal Cell Carcinoma (RCC) occurs in 4–10%. The most effective option is aggressive surgery, with radical nephrectomy and IVC thrombectomy, with reasonably good outcomes of 5-year survival rates ranging from 32% to 64%. Traditionally performed via open approach, newer studies have shown promising outcomes with robotic surgeries. However, laparoscopic techniques remained anecdotal. Objective: To describe our surgical technique of laparoscopic radical nephrectomy (LRN) and IVC thrombectomy and report its safety and intermediate outcomes. Design, setting and participants: We retrospectively reviewed 17 patients who underwent LRN and IVC thrombectomy between Jan 2014 to Oct 2016 across 3 tertiary institutions. Surgical procedure: Transperitoneal approach was performed in all cases. Limited IVC mobilisation is achievable in level I and mobile IVC thrombus. Higher thrombus levels required complete IVC exploration. The IVC defect is closed primarily with continuous laparoscopic stitching. Outcome measurements and statistical analysis: Intraoperative and postoperative clinical outcomes were recorded. A descriptive statistical analysis was performed. Results and limitations: Four patients had level I, 8 patients had level II and 5 had level III IVC involvement. The median operating time was 210 min (range 110–300) and median blood loss was 250 mls (range 100–550). No conversion to open surgey was required. The median length of hospital stay was 4 days (range 3–7), and only 3 patients developed Clavien Dindo Grade I complications (post-operative fever). All patients achieved negative surgical margins and histology was consistently clear cell carcinoma and Fuhrman Grade III-IV. Over a median follow-up period of 18 months, local recurrence occurred in 2 patients (11.8%). One patient had died of metastatic disease. Conclusion: Our technique of LRN with IVC thrombectomy is a safe and feasible alternative to open and robotic surgeries, with low complication rates and promising outcomes.