Surgical Management of Nonmetastatic Renal Cell Carcinoma with Inferior Vena Cava Thrombus: A Systematic Review and...

Inferior vena cava (IVC) tumor thrombus can impact the surgical management of locally advanced renal cell carcinoma (RCC). While open surgery remains the standard for complex thrombi, minimally invasive surgery (MIS) is increasingly adopted. The aim of this review was to compare perioperative outcomes across the different surgical approaches for IVC thrombectomy in nonmetastatic RCC.

We systematically searched the PubMed, Embase, Scopus, and Web of Science databases from inception to January 10, 2025 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The review protocol was registered on PROSPERO (CRD42022330114). Retrospective and prospective studies reporting operative time (OT), estimated blood loss (EBL), complication rates, or length of stay (LOS) after IVC thrombectomy were included. A meta-analysis of proportions and a network meta-analysis (NMA) of comparative studies were performed using random-effects models.

Sixty-six studies (3241 patients) were included. Conventional meta-analysis revealed that mean OT was similar across approaches (p = 0.07), while mean EBL was significantly lower with MIS (robotic: 918.2 ml; laparoscopic: 253.7 ml) than with open surgery (1488.4 ml; p < 0.001). Overall complication rates were 28.5% with robotic, 12.6% with laparoscopic, and 28.9% with open surgery (p = 0.05), with corresponding major complication rates of 5.1%, 2.8%, and 12.9% (p = 0.02). NMA revealed shorter mean OT for robotic (-58.7 min; p < 0.001) and laparoscopic (-43.3 min; p = 0.01) approaches versus open surgery, and lower odds ratios for overall complications (robotic 0.37, p = 0.01; laparoscopic 0.24, p < 0.001) with MIS. Mean LOS was also shorter with MIS (robotic: -3.8 d; laparoscopic: -4.8 d; p < 0.05). Differences in major complication rates were not significant on NMA. Limitations include the retrospective design of the studies included, selection bias favoring open surgery for advanced thrombi, and under-reporting of oncological outcomes.

High-quality comparative evidence on MIS for IVC thrombectomy is limited and affected by substantial selection bias, which restricts robust comparisons to open surgery. Our findings suggest that MIS is associated with favorable perioperative outcomes in carefully selected patients, mainly with Mayo I-II thrombi in experienced centers, but no definitive conclusions on their comparative effectiveness versus open surgery can be drawn.