Renal cell carcinoma (RCC) may invade the venous system, extending into the inferior vena cava (IVC), posing significant surgical challenges. Traditional open surgery for IVC thrombus carries high risks, including substantial blood loss and prolonged recovery. Recently, robotic-assisted surgery has emerged as a minimally invasive alternative, offering enhanced visualization, precision, and dexterity. While still complex and requiring expert planning and skill, this approach shows promise, especially for lower-level thrombi. We present a rare case of cytoreductive left robotic-assisted nephrectomy with IVC thrombectomy in an 81-year-old male.

An 81-year-old male with a history of spinal stenosis post-laminectomy and type 2 diabetes on insulin and OHA presented with painless gross hematuria. Imaging revealed a left renal mass with renal vein thrombus distal to the adrenal vein and bilateral lung metastases, suggesting metastatic RCC. After shared decision-making, cytoreductive robotic-assisted nephrectomy with IVC thrombectomy was performed. The patient was positioned in left-lateral decubitus with five ports placed: one 8 mm camera port at the left paraumbilical site, three 8 mm robotic ports, and one 12 mm assistant port. After docking, the descending colon was mobilized to identify the ureter and renal hilum. The kidney was dissected, the renal artery ligated with hem-o-lok clips, and thrombus level confirmed via laparoscopic ultrasound. The left renal vein was clamped, and the kidney with thrombus was carefully removed. A drain was placed in the renal fossa following hemostasis.

The pathology reported Papillary renal cell carcinoma, type II, WHO/ISUP nucleolar grade 3 with focal sarcomatoid feature (5%). Tumor also extended into pelvicaliceal system, and hilar vessel with metastasized to adrenal gland and hilar lymph nodes (4/7). The pathological TNM stage was pT3aN1M1. The patient recovery smoothly in the post-operative period. Further immunotherapy (nivolumab) was scheduled as systemic therapy for the goal of improving survival outcome.

Robotic-assisted nephrectomy with IVC thrombectomy is a highly specialized procedure that merges the advantages of minimally invasive techniques with the precision of robotic technology. It offers a valuable alternative to open surgery for appropriately selected patients. We recommend robotic surgery primarily for level I IVC thrombi, where precise and controlled thrombus removal can be more reliably achieved. Cytoreductive surgery remains a key treatment option in selected cases of metastatic RCC, particularly when integrated with systemic therapies. Treatment decisions should be individualized, based on patient health, tumor features, and response to systemic treatment.