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SUO 2017

SUO 2017: Point - Counterpoint: IVC Thrombectomy for Level 2 Tumor Thrombus Versus a Robotic Approach

Washington, DC (UroToday.com) Dr. Gill provided a spirited rebuttal to Dr. Leibovich’s argument for open IVC thrombectomy by arguing that we should be doing level II IVC thrombus cases via a robotic approach. Dr. Gill notes that for skilled robotic surgeons, level II thrombi can be confidently performed robotically; there are already series describing robotic IVC thrombectomy for level III cases1. Furthermore, according to Dr. Gill, we already have the skills necessary to perform these complex procedures robotically, as well as additional minimally invasive tools including intracaval balloon occlusion, patch grafting, and vena cavoscopy2.

Dr. Gill states that prior to every case, he consults with his radiologists to assess the likelihood of requiring IVC resection. He uses the criteria from Dr. Leibovich’s group to do so, including the following pre-operative factors: AP diameter of the IVC at the renal vein ostia >24 mm (OR 4.4), complete occlusion of the IVC at the renal vein ostia (OR 4.9), and a right sided tumor (OR 3.3)3.

Predicting the probability of resection of the IVC (c-index 0.81):

  • 0 features: 2%
  • 1 feature: 8-11%
  • 2 features: 26-35%
  • 3 features: 64%
If there is a low probability of needing IVC resection, Dr. Gill feels it is feasible to perform robotic IVC thrombectomy for level 1-2 thrombi, level 2-3 thrombi, and for thrombi ≤11.6 cm in length. A recently published study from China4 assessed robotic versus open level I-II IVC thrombectomy in a matched group comparison analysis. They compared 37 open procedures (from 2006-2014) to 31 robotic procedures (from 2013-2016) and used a propensity model adjusting for age, ASA score, tumor size and thrombus length. Although robotic IVC thrombectomy was more expensive ($13,000 vs $7,300), the robotic approach was associated with shorter operative time (150 min vs 230 min, p<0.001 right sided tumors), fewer transfusions (7% vs 55%, p<0.001), shorter length of stay (5 days vs 9 days, p<0.001), and fewer complications (13% vs 33%, p=0.07) compared to the open approach. Dr. Gill subsequently presented preliminary data from his institution (USC) comparing open to robotic cases, which is being finalized for publication and will be available shortly.

To conclude, Dr. Gill notes that going forward there should be a randomized trial for level II-III IVC thrombi (open vs robotic approach), we need to further explore neoadjuvant therapies for these advanced cases, we should re-evaluate the role of peri-operative kidney embolization, and refine the use of intra-IVC balloons.

References:
  1. Gill IS, Metcalfe C, Abreu A, et al. Robotic Level III Inferior Vena Cava Tumor Thrombectomy: Initial series. J Urol 2015;194(4):929-938.
  2. Kundavaram C, Abreau AL, Chopra S, et al. Advances in robotic vena cava tumor thrombectomy: intracaval balloon occlusion, patch grafting, and vena cavoscopy. Eur Urol 2016;70(5):884-890.
  3. Psutka SP, Boorjian SA, Thompson RH, et al. Clinical and radiographic-predictors of the need for inferior vena cava resection during nephrectomy for patients with renal cell carcinoma and caval tumour thrombus. BJU Int 2015;116(3):388-396.
  4. Gu L, Ma X, Gao Y, et al. Robotic versus Open Level I-II Inferior Vena Cava Thrombectomy: A Matched Group Comparative Analysis. J Urol 2017;198(6):1241-1246.
Presented by:  Inderbir S. Gill, University of Southern California, Los Angeles, CA

Written By: Zachary Klaassen, MD, Society of Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre @zklaassen_md at the 18th Annual Meeting of the Society of Urologic Oncology, November 20-December 1, 2017 – Washington, DC