Right radical nephrectomy with level IV thrombus by combined 3D laparoscopic and mini-thoracotomy approach.

OBJECTIVE: To report our step-by-step technique for 3D laparoscopic radical nephrectomy and thrombectomy for a right renal tumour with level IV venous thrombus.Worldwide experience in minimally-invasive approach for such complex cases is limited.

MATERIALS AND METHODS: A 66-year-old male was incidentally diagnosed with a right renal tumour. He had a medical history of hypertension and benign prostatic hyperplasia. Blood test analysis showed a haemoglobin of 11.2 g/dl, creatinine of 0.92 mg/dl. Liver function and bilirubin were within normal limits. Contrast-enhanced abdominal CT scan showed an 90/77/85 mm right renal mass with a level IV inferior vena cava (IVC) tumour thrombus. Cardiac MRI showed that the tumour thrombus was extending into the right atrium, through the tricuspid valve and into the right ventricle. There was no evidence of distant metastases. After a multidisciplinary team reviewed the case the patient was scheduled for 3D laparoscopic radical nephrectomy and thrombectomy by mini-thoracotomy approach RESULTS: Retroperitoneal laparoscopic approach was used to ensure rapid access on the renal artery, with minimal mobilisation of the renal vein, and to better isolate the posterior wall of the IVC. Surgery continued with the transperitoneal approach and the isolation of the infrarenal and infrahepatic IVC and left renal vein. Meanwhile the right femoral artery and vein and right jugular vein were cannulated. Mini-thoracotomy was performed and cardiopulmonary by-pass was started. Blood flow through the IVC and left renal vein was stopped, and the right atrium was opened to control the thrombus. Cavotomy was performed at the level of right renal hilum and the tumour thrombus was identified and sectioned. There were no signs of thrombus adherence to the IVC wall. The thoracic segment of the thrombus was completely extracted by the cardiovascular surgeons. Pringle manoeuvre was not necessary, as there was no retrograde bleeding. No intraoperative adverse events occurred, according to the ICARUS Criteria. The operative time was 7 hours. Blood loss was minimal, with no need of intra- or postoperative transfusions. Hospital length of stay was 8 days. Pathology revealed renal cell carcinoma, ISUP 3, with negative surgical margins. At 9 months follow-up, the patient is doing well, without signs of local or distant recurrence.

CONCLUSION: 3D laparoscopy is a feasible alternative to open surgery for the most complex cases, enabling very precise dissection and suturing. We have shown a case of successful 3D laparoscopic radical nephrectomy with IVC thrombectomy combined with minithoracotomy achieving complete intracardiac thrombus removal.