1. Volume 70, Issue 5, Pages 884-890 (November 2016)
Advances in Robotic Vena Cava Tumor Thrombectomy: Intracaval Balloon Occlusion, Patch Grafting, and Vena Cavoscopy 
Chandan Kundavaram, Andre Luis de Castro Abreu, Sameer Chopra, Giuseppe Simone, Rene Sotelo, Monish Aron, Mihir M. Desai, Michele Gallucci, Inderbir S. Gill 
European Urology 
Volume 70, Issue 5, Pages (November 2016)
DOI: /j.eururo
Copyright © 2016 European Association of Urology Terms and Conditions

2. Fig. 1
Schematics with corresponding intraoperative photos of Rummel tourniquet placement (a, b) at the infrarenal inferior vena cava, (c, d) at the left renal vein, and (e, f) at the right renal vein. Schematics and photos of (g) the Fogarty balloon catheter (9F; Coda LP, Cook Medical, Bloomington, IN, USA); (h, i) Fogarty balloon catheter with balloon inflated with a predetermined volume of saline.
European Urology  , DOI: ( /j.eururo )
Copyright © 2016 European Association of Urology Terms and Conditions

3. Fig. 2
Schematics and photos of achieving suprarenal inferior vena cava (IVC) control using an intracaval Fogarty balloon. (a, b) Fogarty balloon catheter insertion through cavotomy. There are three technical caveats in this regard: (1) The 5-mm laparoscopic port for introducing the Fogarty into the abdomen should be located low in the pelvis to allow a gentle curve of the catheter shaft parallel to the IVC, (2) the cavotomy for catheter insertion should be made on the caval wall contralateral to the thrombus to allow smooth atraumatic catheter insertion without rubbing against the thrombus, and (3) test inflation of the balloon prior to insertion should be avoided because after the balloon is deflated it does not regain either its exact preinflation size or its smooth contour; this necessitates a larger cavotomy incision for balloon insertion and may increase the chances of the now-corrugated balloon surface rubbing against the thrombus. The first and only time we inflate the balloon is after we have positioned it at its desired intracaval location. (c, d) Fogarty catheter positioned in the suprarenal IVC cephalad to the thrombus. Note that the Fogarty balloon is 5.5cm long with a maximal diameter of 3.2cm, which is achieved by injecting 30ml of water. The length of catheter insertion into the IVC and the volume of water injected to inflate the balloon are predetermined, based on the individual patient's computed tomography (CT) scan data. In patient 1, for example, the CT-measured thrombus length was 3.5cm and suprarenal IVC diameter was 2.2cm. As such, the catheter was inserted into the IVC for 9.3cm (thrombus length 3.5cm, balloon length 5.5cm, safety margin 3mm; total 9.3cm), and the balloon was inflated with only 17ml of water to reach the predetermined 2.2cm diameter, at which point resistance was felt, indicating the balloon was snug within the IVC. (e, f): Inflated Fogarty balloon proximal to thrombus with confirmation of cessation of IVC flow on intraoperative Doppler ultrasound. (g) Transesophageal echocardiography localizing the IVC thrombus (arrow).
European Urology  , DOI: ( /j.eururo )
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4. Fig. 3
Thrombus extraction. (a) Extraction of caval thrombus with demonstration of inflated intracaval balloon providing secure proximal hemostatic control (arrow). (b) Following caval suture repair, demonstration of restored IVC flow on intraoperative color Doppler ultrasound.
European Urology  , DOI: ( /j.eururo )
Copyright © 2016 European Association of Urology Terms and Conditions

5. Fig. 4
Robotic cavoscopy. (a) Robot-directed insertion of flexible cystoscope into cavotomy; (b) cavoscopic inspection of caval lumen demonstrating no residual or skip thrombi.
European Urology  , DOI: ( /j.eururo )
Copyright © 2016 European Association of Urology Terms and Conditions

6. Fig. 5
Intraoperative phototographs of biologic patch cavoplasty. (a) After thrombus extraction, inspection of the caval lumen revealed possible malignant invasion (*) of a segment of the inferior vena cava (IVC) wall. (b) Sharp excision of diseased IVC wall (*), creating caval luminal narrowing. (c) A precisely measured bovine pericardial patch graft, marked on its nonluminal surface with a blue dot (*) (SJM, EncapTechnologies, St. Jude Medical, St. Paul, MN, USA) is inserted into the abdomen through a laparoscopic port and oriented appropriately. (d, e) Suturing the patch graft (*) cavoplasty using 4-0 Gore-Tex suture (W.L. Gore & Associates, Inc., Newark, DE, USA). (f) Completed cavoplasty (*) with restoration of IVC flow after release of Rummel tourniquets.
European Urology  , DOI: ( /j.eururo )
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7. European Urology 2016 70, 884-890DOI: (10.1016/j.eururo.2016.06.024)
Copyright © 2016 European Association of Urology Terms and Conditions