Robot-assisted Single-docking Approach for Level III Inferior Vena Cava Tumor Thrombectomy: Surgical Technique and Outcomes

BACKGROUND AND OBJECTIVE: Robot-assisted tumor thrombectomy (RATT) for level III inferior vena cava (IVC) tumor thrombus is an emerging but complex approach with limited reports. Variability in docking strategies, renal artery management, surgical exposure, and vascular control complicates adoption. We evaluated the safety, feasibility, and outcomes of RATT for level III IVC using a single-docking technique. METHODS: This retrospective study included 15 patients who underwent RATT for level III IVC tumor thrombus at a tertiary center between 2019 and 2023. A novel strategy, including early division of the renal artery, IVC control, and tumor thrombectomy, was completed robotically without redocking. Distal repositioning of the IVC clamp was carried out when indicated. Median follow-up was 24 mo. Exclusion criteria were unresectable metastasis and severe comorbidities. KEY FINDINGS AND LIMITATIONS: All surgeries were successfully completed using a single-docking technique. The median operative time was 225 min (range 140-375), and median blood loss was 400 ml (range: 200-2000). Twelve patients (80%) required intraoperative transfusions. The median IVC occlusion time was 14 min (range 8-25). Segmental IVC resection was performed in seven patients, with angioplasty reconstruction in two cases. Complications occurred in 73.3% (11/15), including three Clavien-Dindo grade IIIb events. At median follow-up of 24 mo, five patients had died and one had developed liver metastasis. Limitations include the small cohort size and the single-surgeon experience. CONCLUSIONS AND CLINICAL IMPLICATIONS: Single-docking RATT for level III IVC tumor thrombus is a feasible and reproducible technique. Standardization of key surgical steps enhances procedural efficiency and addresses challenges in vascular control. This technique offers a viable alternative to multistage procedures in selected cases. Further validation with extended follow-up in multicenter studies is required.