title: Robotic Level III Inferior Vena Cava Tumor Thrombectomy: Initial Series.
abstract: OBJECTIVE
  Level III inferior vena cava tumor thrombectomy for renal cancer is one of the most challenging open urologic oncology surgeries. We present the initial series of completely intracorporeal robotic level III inferior vena cava tumor thrombectomy.
  
  
  METHODS
  Nine patients underwent robotic level III inferior vena cava thrombectomy and 7 patients underwent level II thrombectomy. The entire operation (high intrahepatic inferior vena cava control, caval exclusion, tumor thrombectomy, inferior vena cava repair, radical nephrectomy, retroperitoneal lymphadenectomy) was performed exclusively robotically. To minimize the chances of intraoperative inferior vena cava thrombus embolization, an "inferior vena cava-first, kidney-last" robotic technique was developed. Data were accrued prospectively.
  
  
  RESULTS
  All 16 robotic procedures were successful, without open conversion or mortality. For level III cases (9), median primary kidney (right 6, left 3) cancer size was 8.5 cm (range 5.3 to 10.8) and inferior vena cava thrombus length was 5.7 cm (range 4 to 7). Median operative time was 4.9 hours (range 4.5 to 6.3), estimated blood loss was 375 cc (range 200 to 7,000) and hospital stay was 4.5 days. All surgical margins were negative. There were no intraoperative complications and 1 postoperative complication (Clavien 3b). At a median 7 months of followup (range 1 to 18) all patients are alive. Compared to level II thrombi the level III cohort trended toward greater inferior vena cava thrombus length (3.3 vs 5.7 cm), operative time (4.5 vs 4.9 hours) and blood loss (290 vs 375 cc).
  
  
  CONCLUSIONS
  With appropriate patient selection, surgical planning and robotic experience, completely intracorporeal robotic level III inferior vena cava thrombectomy is feasible and can be performed efficiently. Larger experience, longer followup and comparison with open surgery are needed to confirm these initial outcomes.
authors: USC Institute of Urology, Departments of Urology, Radiology, Anesthesia & Cardiac Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Urology, Regena Elena Cancer Center, Rome, Italy. Electronic address: gillindy@gmail.com.
authors: Inderbir S
authors: IS
authors: Gill
authors: USC Institute of Urology, Departments of Urology, Radiology, Anesthesia & Cardiac Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Urology, Regena Elena Cancer Center, Rome, Italy.
authors: Charles
authors: C
authors: Metcalfe
authors: USC Institute of Urology, Departments of Urology, Radiology, Anesthesia & Cardiac Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Urology, Regena Elena Cancer Center, Rome, Italy.
authors: Andre
authors: A
authors: Abreu
authors: USC Institute of Urology, Departments of Urology, Radiology, Anesthesia & Cardiac Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Urology, Regena Elena Cancer Center, Rome, Italy.
authors: Vinay
authors: V
authors: Duddalwar
authors: USC Institute of Urology, Departments of Urology, Radiology, Anesthesia & Cardiac Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Urology, Regena Elena Cancer Center, Rome, Italy.
authors: Sameer
authors: S
authors: Chopra
authors: USC Institute of Urology, Departments of Urology, Radiology, Anesthesia & Cardiac Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Urology, Regena Elena Cancer Center, Rome, Italy.
authors: Mark
authors: M
authors: Cunningham
authors: USC Institute of Urology, Departments of Urology, Radiology, Anesthesia & Cardiac Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Urology, Regena Elena Cancer Center, Rome, Italy.
authors: Duraiyah
authors: D
authors: Thangathurai
authors: USC Institute of Urology, Departments of Urology, Radiology, Anesthesia & Cardiac Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Urology, Regena Elena Cancer Center, Rome, Italy.
authors: Osamu
authors: O
authors: Ukimura
authors: USC Institute of Urology, Departments of Urology, Radiology, Anesthesia & Cardiac Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Urology, Regena Elena Cancer Center, Rome, Italy.
authors: Raj
authors: R
authors: Satkunasivam
authors: USC Institute of Urology, Departments of Urology, Radiology, Anesthesia & Cardiac Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Urology, Regena Elena Cancer Center, Rome, Italy.
authors: Andrew
authors: A
authors: Hung
authors: USC Institute of Urology, Departments of Urology, Radiology, Anesthesia & Cardiac Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Urology, Regena Elena Cancer Center, Rome, Italy.
authors: Rocco
authors: R
authors: Papalia
authors: USC Institute of Urology, Departments of Urology, Radiology, Anesthesia & Cardiac Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Urology, Regena Elena Cancer Center, Rome, Italy.
authors: Monish
authors: M
authors: Aron
authors: USC Institute of Urology, Departments of Urology, Radiology, Anesthesia & Cardiac Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Urology, Regena Elena Cancer Center, Rome, Italy.
authors: Mihir
authors: M
authors: Desai
authors: USC Institute of Urology, Departments of Urology, Radiology, Anesthesia & Cardiac Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Urology, Regena Elena Cancer Center, Rome, Italy.
authors: Michele
authors: M
authors: Gallucci
mesh_terms: D000328:Adult; D000368:Aged; D002292:Carcinoma, Renal Cell / Q000556:secondary* / Q000601:surgery*; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000473:pathology; D008297:Male; D008875:Middle Aged; D009360:Neoplastic Cells, Circulating; D065287:Robotic Surgical Procedures; D017131:Thrombectomy / Q000379:methods*; D014682:Vena Cava, Inferior
keywords: inferior; robotics; thrombectomy; vena cava