Robotic surgery and minimally invasive management of renal tumors with vena caval extension

PURPOSE OF REVIEW: Although laparoscopic nephrectomy for renal cell carcinoma (RCC) has become a widely accepted option for most renal tumors, open surgery remains the standard in managing tumors with extension into the inferior vena cava (IVC). Robotic technology has been applied to increasingly complex laparoscopic procedures and may facilitate minimally invasive procedures previously felt unfeasible with standard laparoscopy. The evolution to completely intracorporeal techniques for IVC tumor thrombectomy from incremental advancements in laparoscopic and hybrid techniques is reviewed. RECENT FINDINGS: Laparoscopic management of IVC tumor thrombi has been demonstrated in animal models and more recently in the form of individual case reports. Hybrid laparoscopic techniques have been developed to allow hand-assisted thrombus retraction out of the IVC or open incisions for IVC management after laparoscopic dissection. Robotic surgery only recently has been described to allow a completely minimally invasive technique for tumor thrombectomy even when cross-clamping of the cava is required. Such techniques have yet to gain popular acceptance but have been reproduced to a limited degree by other investigators. SUMMARY: Robotic technology applied to complex laparoscopic procedures may extend the limits of what can be performed successfully in minimally invasive fashion. The early reported experiences of robotic nephrectomy with IVC tumor thrombectomy, thus far, demonstrate feasibility but require further investigation. Discrimination of ideal candidates and reproducibility by other surgeons will be necessary before widespread adoption and acceptance.