Inferior vena cava control for which individualized surgical planning is necessary, including locations of many blood vessels to be clamped and indicators of the extent of Levels I, II and III thrombi, and the relative sizes of the obstructions.

Inferior vena cava control for which individualized surgical planning is necessary, including locations of many blood vessels to be clamped and indicators of the extent of Levels I, II and III thrombi, and the relative sizes of the obstructions.

A new article published by the Journal of Urology details a pioneering robotic surgical procedure developed at the USC Institute of Urology for treatment of a particularly challenging type of kidney cancer.

The new surgical method was first performed in 2014 by a team led by Inderbir S. Gill, MD, founding executive director of the USC Institute of Urology, for treatment of a type of cancer of the kidney that causes a Level III thrombus, or clot, to develop in the major vein leading back to the heart.

Previously, the standard treatment involved a complicated procedure — inferior vena cava (IVC) thrombectomy — that was performed using a large open incision, primarily because the vein is often difficult to reach. In the Journal of Urology article published online in advance of the October 2015 edition, surgeons from Keck Medicine of USC describe the first cases in which this procedure was successfully performed robotically, using only seven small incisions and four robotic tools.

Gill, chairman and professor, Catherine and Joseph Aresty Department of Urology at the Keck School of Medicine of USC, said, “Level III IVC tumor thrombectomy for renal cancer is one of the most challenging open urologic oncologic surgeries. While IVC tumor thrombus occurs in only 4 to 10 percent of all patients with otherwise organ-confined kidney cancer, surgery is the only cure. The ability to do this complicated procedure in a minimally invasive way represents a major advancement.”

In the article, the authors report on nine patients with renal cancer and Level III thrombi treated with robotic IVC thrombectomy. After about seven months of follow-up, all have survived and eight show no evidence of disease. One patient had a spinal tumor and has since undergone further surgery.

The report also details seven additional robotic surgeries on patients with smaller thrombi (Level II), and compares tumor sizes, operating room times, blood losses, length of hospital stays, and other details for Level III and Level II cases.

Because the surgery involves removal of the thrombus as well as removal of the diseased kidney, the surgeon must remove the clot first to prevent it from breaking off and causing a potentially fatal embolism. This requires many blood vessels to be clamped.

“All necessary surgical maneuvers could be performed completely robotically without open conversion or mortality,” according to the article.

“This demonstration of efficient robotic performance of the challenging vascular, oncologic and reconstructive procedures inherent herein opens the door for major renal, caval and hepatic robotic surgeries in the future,” writes Gill and his colleagues. “Although our experience is yet initial, we believe that robotic IVC thrombus surgery has considerable potential for the future.”

The authors of the article, titled “Robotic Level III Inferior Vena Cava Tumor Thrombectomy: The Initial Series,” include Gill and fellow Keck Medicine of USC physicians Charles Metcalfe, Andre Abreu, Vinay Duddalwar, Sameer Chopra, Mark J. Cunningham, Duraiyah Thangathurai, Osamu Ukimura, Raj Satkunasivam, Andrew Hung, Rocco Papilla, Monish Aron, Mihir Desai and Michele Gallucci.