JU INSIGHT: Robotic Level IV Inferior Vena Cava Thrombectomy Using an Intrapericardial Control Technique

By: Qingbo Huang, MD; Guodong Zhao, MD; Yonghui Chen, MD; Peng Wu, MD; Shuanglei Li, MD; Cheng Peng, MD; Kan Liu, MD; Hongkai Yu, MD; Yubo Gao, MD; Cangsong Xiao, MD; Qiang Fu, MD; Hao Shen, MD; Qiuyang Li, MD; Nan Li, MD; Haiyi Wang, MD; Xeng Inn Fam, MD; Baojun Wang, MD; Rong Liu, MD, PhD; Xu Zhang, MD, PhD; Xin Ma, MD, PhD | Posted on: 17 Jan 2023

Huang Q, Zhao G, Chen Y, et al. Robotic level IV inferior vena cava thrombectomy using an intrapericardial control technique: is it safe without cardiopulmonary bypass?. J Urol. 2023;209(1):99-110.

Figure. A diagram illustrating transabdominal-transdiaphragmatic robot-assisted (RA) level IV inferior vena cava (IVC) thrombectomy (intrapericardial control technique, right-sided) with cardiopulmonary bypass backup. The key procedure was the incision of the central tendon of the diaphragm and the pericardium to achieve intrapericardial IVC control with cardiopulmonary bypass backup. The key steps were as follows: (1) after clamping the first porta hepatis (FPH) and (2) tightening the cephalic intrapericardial IVC, the suprahepatic IVC was incised and the thrombus was removed. Subsequently, nephrectomy and cavectomy were performed through the transection of the (3) caudal IVC, (4) right renal artery (RRA), and (5) left renal vein (LRV), in that order. RCC indicates renal cell carcinoma.

Study Need and Importance

Level IV inferior vena cava (IVC) thrombectomy is one of the most challenging procedures that frequently requires cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA), which causes additional morbidities. In this study, we were to introduce an intrapericardial control technique via robotic approach, obviating CPB and DHCA for level IV IVC thrombus not entering the right atrium (level IVa; see Figure).

What We Found

The initial experience indicated that this technique is safe for level IVa thrombi with CPB backup. The median operation time and first porta hepatis occlusion time were shorter, and estimated blood loss was lower in the CPB-free group as compared to the CPB group. Severe complications (level IV-V) were also lower in the CPB-free group than in the CPB and CPB/DHCA groups. Oncologic outcomes were comparable among the 3 groups in short-term follow-up.


Due to the small sample size and selection bias, we should be more tempered in this conclusion. A prospective, randomized, controlled study with more cases is required to further validate this new technique.

Interpretation for Patient Care

If technically feasible, we encourage avoidance of CPB and DHCA for level IV IVC thrombus not entering the right atrium.