Robot-assisted radical nephrectomy with thrombectomy using fluorescence guidance

Background. Radical nephrectomy with thrombectomy for renal cell carcinoma complicated by inferior vena cava (IVC) tumor thrombus requires precise intraoperative identification of the thrombus borders. Indocyanine green (ICG) fluorescence-guided navigation may facilitate localization of the thrombus tip during surgery and help determine the required extent of cavotomy. Aim. To assess the feasibility of ICG fluorescence imaging during robot-assisted radical nephrectomy with thrombectomy and to describe the key steps of the surgical technique. Materials and methods. The study included five patients with cT3b renal cell carcinoma and IVC tumor thrombus. All patients underwent robotassisted surgery with intravenous ICG administration for thrombus visualization in near-infrared range. The ability to identify the thrombus tip, operative time, blood loss, postoperative length of stay, and surgical margin status were analyzed. The surgical technique is described in detail using an example of a patient with right-sided renal tumor and a Mayo level I tumor thrombus. Results. The tip of the tumor thrombus was successfully visualized in all five patients. The mean operative time was 266.20 ± 74.56 min, median blood loss was 30 mL (Q 1 –Q 3 : 10–100 mL), and the mean postoperative length of stay was 10.80 ± 6.30 days. No positive surgical margins were observed. The obtained results were comparable to scientific literature data. ICG fluorescence imaging allowed to clarify thrombus extent and the required length of cavotomy; for a short tumor thrombus, kidney traction resulted in displacement of the thrombus into the renal vein, which allowed to avoid cavotomy. Repeat ICG administration was also used to further assess the integrity of the vascular suture line. Conclusion. The use of indocyanine green fluorescence-guided navigation during robot-assisted radical nephrectomy with thrombectomy is technically feasible. This approach enables real-time delineation of the cranial margin and extent of the tumor thrombus, optimization of the required cavotomy, and, in selected cases, avoidance of cavotomy altogether. The proposed technique may therefore represent a promising direction for further refinement of surgical management of renal cell carcinoma complicated by tumor thrombus.