Robotic renal surgery or renal cell carcinoma with inferior vena cava thrombus

Surgical management of renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombus is inherently complex, posing challenges for even the most experienced urologists. Until the mid-2000s, nephrectomy with IVC thrombectomy was exclusively performed using variations of the open technique initially described decades earlier, but since then several institutions have reported their robotic experiences. Robotic IVC thrombectomy was initially reported for level I and II thrombi, and more recently in higher-lever III thrombi. In general, the robotic approach is associated with less blood loss and shorter hospital stays compared to the open approach, low rates of open conversion in reported cases, relatively low rates of high-grade complications, and favorable overall survival on short-term follow-up in limited cohorts. Operative times are longer, costs are significantly higher, and left-sided tumors always require intraoperative repositioning and usually require preoperative embolization. To date, criteria for patient selection or open conversion have not been defined, and long-term oncologic outcomes are lacking. While the early published robotic experience demonstrates feasibility and safety in carefully selected patients, longer-term follow-up remains necessary. Patient selection, indications for open conversion, logistics of conversion particularly in emergent settings, necessity and safety of preoperative embolization, the value proposition, and long-term oncologic outcomes must all be clearly defined before this approach is widely adopted.