Minimally-Invasive Radical Nephrectomy and Left-Sided Level II Caval Thrombectomy: A New Combined Technique

Objective: To present a combined multiport robotic and open approach for left radical nephrectomy and inferior vena cava thrombectomy in patients with a primary left renal mass and level II inferior vena cava (IVC) tumor thrombus. Methods: A 69-year-old female was diagnosed with an 8.9cm left renal neoplasm with level II IVC thrombus. She was placed in the left-side-up flank position. The descending colon was mobilized and the left gonadal vein was identified. The left renal vein was identified and fully dissected. The left renal artery was dissected and stapled. The kidney was dissected and left detached with exception of the renal vein. The robot was undocked and the patient was positioned supine. Through a supra-umbilical midline incision, the ascending colon and duodenum were mobilized medially. The right renal vein and IVC were identified and dissected to the level of hepatic veins. The IVC was clamped using a Satinsky clamp. The right renal artery and vein remained patent during thrombectomy. The IVC was opened, the thrombus was evacuated, and IVC was closed. Clamps were removed and the kidney was removed. Results: Operative time was 405 minutes. IVC clamp time was 14 minutes. Estimated blood loss was 500cc. Recovery was uncomplicated. Length of stay was 4 days. Pathology showed clear cell carcinoma with negative margins. Conclusion: IVC thrombectomy is challenging on left sided tumors. Combining a robotic and open technique together is feasible and allows a smaller supra-umbilical midline incision compared to standard open incision.