Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China.
Department of Interventional Radiology, Chinese PLA General Hospital, Beijing, China.
Eur Urol. 2020 Oct;78(4):592-602. doi: 10.1016/j.eururo.2020.03.020. Epub 2020 Apr 15.
Robot-assisted thrombectomy (RAT) for inferior vena cava (IVC) thrombus (RAT-IVCT) is being increasingly reported. However, the techniques and indications for robot-assisted cavectomy (RAC) for IVC thrombus are not well described.
To develop a decision-making program and analyze multi-institutional outcomes of RAC-IVCT versus RAT-IVCT.
DESIGN, SETTING, AND PARTICIPANTS: Ninety patients with renal cell carcinoma (RCC) with level II IVCT were included from eight Chinese urological centers, and underwent RAC-IVCT (30 patients) or RAT-IVCT (60 patients) from June 2013 to January 2019.
The surgical strategy was based on IVCT imaging characteristics. RAT-IVCT was performed with standardized cavotomy, thrombectomy, and IVC reconstruction. RAC-IVCT was mainly performed in patients with extensive IVC wall invasion when the collateral blood vessels were well-established. For right-sided RCC, the IVC from the infrarenal vein to the infrahepatic veins was stapled. For left-sided RCC, the IVC from the suprarenal vein to the infrahepatic veins was removed and caudal IVC reconstruction was performed to ensure the right renal vein returned through the IVC collaterals.
Clinicopathological, operative, and survival outcomes were collected and analyzed.
All procedures were successfully performed without open conversion. The median operation time (268 vs 190 min) and estimated blood loss (1500 vs 400 ml) were significantly greater for RAC-IVCT versus RAT-IVCT (both p < 0.001). IVC invasion was a risk factor for progression-free and overall survival at midterm follow-up. Large-volume and long-term follow-up studies are needed.
RAC-IVCT or RAT-IVCT represents an alternative minimally invasive approach for selected RCC patients with level II IVCT. Selection of RAC-IVCT or RAT-IVCT is mainly based on preoperative IVCT imaging characteristics, including the presence of IVC wall invasion, the affected kidney, and establishment of the collateral circulation.
In this study we found that robotic surgeries for level II inferior vena cava thrombus were feasible and safe. Preoperative imaging played an important role in establishing an appropriate surgical plan.
机器人辅助下腔静脉（IVC）血栓切除术（RAT）治疗下腔静脉血栓（IVCT）的应用越来越多。然而，机器人辅助下腔静脉切开术（RAC）治疗 IVC 血栓的技术和适应证尚不清楚。
制定决策程序并分析 RAC-IVCT 与 RAT-IVCT 的多中心结果。
设计、地点和参与者：本研究纳入了来自中国 8 家泌尿外科中心的 90 例肾细胞癌（RCC）合并 II 级 IVCT 患者，于 2013 年 6 月至 2019 年 1 月期间分别行 RAC-IVCT（30 例）或 RAT-IVCT（60 例）。
根据 IVCT 影像学特征制定手术策略。RAT-IVCT 采用标准的腔切开术、血栓切除术和 IVC 重建。RAC-IVCT 主要用于 IVC 壁广泛侵犯且侧支循环良好的患者。对于右侧 RCC，将肾下静脉至肝下静脉的 IVC 用吻合器吻合。对于左侧 RCC，切除肾静脉至肝下静脉的 IVC，并进行尾侧 IVC 重建，以确保右肾静脉通过 IVC 侧支回流。
收集并分析了临床病理、手术和生存结果。
所有手术均成功完成，无中转开放。RAC-IVCT 组的中位手术时间（268 分钟 vs 190 分钟）和估计失血量（1500 毫升 vs 400 毫升）明显长于 RAT-IVCT 组（均 p < 0.001）。IVC 侵犯是中期随访时无进展生存和总生存的危险因素。需要进行大样本量和长期随访研究。
对于合并 II 级 IVCT 的特定 RCC 患者，RAC-IVCT 或 RAT-IVCT 是一种替代的微创方法。RAC-IVCT 或 RAT-IVCT 的选择主要基于术前 IVCT 影像学特征，包括 IVC 壁侵犯、受累肾脏和侧支循环建立情况。
在这项研究中，我们发现机器人手术治疗 II 级下腔静脉血栓是可行和安全的。术前影像学在制定合适的手术计划中起着重要作用。
