Renal cell carcinoma (RCC) is the most common type of kidney cancer, accounting for about 90% of kidney cancer incidence. In about 10% of RCC cases, a blot clot known as inferior vena cava (IVC) thrombus occurs. In these cases, surgical resection is the only curative treatment. The procedure, known as open radical nephrectomy with inferior vena cava thrombectomy (O-CT), remains a technically complex surgery.
In 2011, robotic-assisted radical nephrectomy with IVC thrombectomy (R-CT) was described in a small study of patients with RCC with IVC. In this study, one surgeon performed R-CT on five patients. To date, most other studies consist of single-center analyses resulting in an incomplete understanding of the potential benefits, or potential safety concerns, of R-CT.
To better understand the current research landscape, a group of researchers performed a systemic review to assess the safety and feasibility of R-CT using data from various studies published over the past decade. The manuscript, recently published in the Journal of Urology, compared the outcomes of R-CT and O-CT.
The authors found four studies that directly compared O-CT to R-CT—combining data from these studies resulted in 1,046 patients (110 R-CT and 936 O-CT). Patients who underwent R-CT also experienced a lower risk of complications; only 14.5% of R-CT patients experienced a complication compared to 36.7% in the O-CT group. Of note, the rate of severe complications (grade 3 or higher) was not different between the groups. The thirty-day postoperative mortality rate was also similar (less than 2%) between the groups.
All four direct comparison studies found a lower rate of blood loss for patients undergoing R-CT compared to O-CT, leading to a lower blood transfusion rate in the R-CT patients. Patients receiving robotic surgery had a consistently shorter hospital stay (range = 2 – 4 days) than those receiving open surgery. The studies reported similar survival outcomes between O-CT and R-CT, including progression-free survival and overall survival.
Based on the lower blood transfusion rate, reduced complications, and shorter hospitalization time, the authors conclude that, when performed by an experienced robotic surgeon, R-CT is a feasible and safe technique for treating some RCC patients with IVC thrombus. In addition to the surgeon's experience, patient- and tumor-related factors strongly affect the outcomes and must be considered when determining which patients are best suited for R-CT. While the available literature suggests this is feasible, the authors acknowledge the need for a large-scale randomized control trial to compare overall safety and efficacy between O-CT and R-CT before a definitive change in the standard procedure should be updated.
Sources: Cancer Imag, Eu Urol, J Urol