Differentiated approach in the surgical treatment of patients with venous tumor thrombus in the setting of renal cell carcinoma

Introduction. ARenal cell carcinoma (RCC) is characterized by the ability to spread intravascularly, leading to the formation of a venous tumor thrombus in the renal vein and the inferior vena cava (IVC). Radical nephrectomy with thrombectomy remains the only potentially curative treatment method for this category of patients. The development of minimally invasive technologies has made it possible to expand the indications for laparoscopic and robotic approaches, the oncological outcomes of which, according to large studies, are comparable to those of traditional open surgery; however, the search for the optimal technique for performing the intervention remains relevant.
The purpose of this study is to develop a surgical intervention strategy for patients with renal cell carcinoma complicated by a venous tumor thrombus, based on the thrombus level according to the Mayo Clinic classification and the side of the tumor lesion.
Materials and methods. The retrospective study includes hospitalization data for 29 patients who received treatment between March 2016 and April 2026 with the main diagnosis of renal cell carcinoma complicated by a venous tumor thrombus. All patients underwent a standard examination protocol, which included ultrasound of the abdominal cavity and retroperitoneal space, MSCT with intravenous contrast enhancement of the abdominal cavity and chest, echocardiography, and cavaography. In 14 patients (48,3 %), a tumor lesion was observed in the left kidney, and in 15 patients – in the right kidney (51,7 %). In 7 patients, a venous tumor thrombus of level 0 was observed, in 6 patients – of level I, in 9 patients – of level II, and in 6 patients – of level III. The clear cell histological variant predominated (91,1 %), with a grade of malignancy of G3 (51,7 %).
Research results and discussion. In group 1, 334 patients (100 %) underwent laparoscopic surgery; no conversions were performed. In group 2, 296 patients (98,3 %) were operated on using a minimally invasive approach; 5 patients (1,7 %) were treated via an open approach. The Veress needle was used in 10 patients (3 %) of the 1st group and in 3 patients (1 %) of the 2nd group, the Hasson access was used in 28 patients (8,4 %) of the 1st group and in 26 patients (8,7 %) of the 2nd group, the "direct trocar" technique – in 85 patients (25,5 %) of the 1st group and in 48 patients (16%) of the 2nd group, optical trocar – in 221 patients (63,2 %) of the 1st group and in 219 patients (72,8 %) of the 2nd group. The “stepping” trocar technique was used in 41 patients (12,3 %) in group 1 and in 91 patients (30,2 %) in group 2. The average duration of the surgical intervention in patients in group 1 was 114±13,5 minutes, and in group 2 – 139±24.6 minutes. The average blood loss during the operation in the 1st and 2nd groups was 101±33 ml and 151±25 ml, respectively.
Conclusion. A differentiated approach to surgical intervention tactics in patients with renal cell carcinoma complicated by a venous tumor thrombus, based on the Mayo Clinic thrombus level classification and the affected side, is fundamental to achieving maximum effectiveness of surgical treatment and reducing the risks of complications and distant metastases.

1. vChao C.L., Reddy N.K., Visa M., Kundu S.D., Eskandari M.K. Late survival and long‐term follow‐up after radical resection of advanced renal cell carcinoma with associated venous tumor thrombus. Journal of Surgical Oncology, 2025, no 131(5), pp. 917–924. https://doi.org/10.1002/jso.28020

2. Rose T.L., Kim W.Y. Renal cell carcinoma: a review. JAMA, 2024, no 332(12), рр. 1001–1010. https://doi.org/10.1001/jama.2024.12848

3. Horynecka Z., Jabłońska B., Kurek A. et al. Analysis of surgical outcomes in 102 patients with renal cell carcinoma with venous tumor thrombus: a retrospective observational single-center study. Medicine, 2022, no 101(40), рр. e30808. https://doi.org/10.1097/MD.0000000000030808

4. Stewart G.D., Klatte T., Cosmai L. et al. The multispeciality approach to the management of localised kidney cancer. Lancet (London, England), 2022, no 400(10351), рр. 523–534. https://doi.org/10.1016/S0140-6736(22)01059-5

5. Poirier T., Mesnard B., Roumiguie M. et al. Management of renal cancer with inferior vena cava extension over 30 years: A Bi-Centric Study. World Journal of Urology, 2025, no 43(1), рр. 544. https://doi.org/10.1007/s00345-025-05914-9

6. Martínez-Salamanca J.I., Huang W.C., Millán I. et al. Prognostic Impact of the 2009 UICC/AJCC TNM staging system for renal cell carcinoma with venous extension. European Urology, 2011, no 59(1), рр. 120–127. https://doi.org/10.1016/j.eururo.2010.10.001

7. Tang Q., Song Y., Li X. et al. Prognostic outcomes and risk factors for patients with renal cell carcinoma and venous tumor thrombus after radical nephrectomy and thrombectomy: the prognostic significance of venous tumor thrombus level. BioMed Research International, 2015, 163423. https://doi.org/10.1155/2015/163423

8. Haddad A.Q., Wood C.G., Abel E.J. et al. Oncologic outcomes following surgical resection of renal cell carcinoma with inferior vena caval thrombus extending above the hepatic veins: a contemporary multicenter cohort. The Journal of Urology, 2014, no 192(4), рр. 1050–1056. https://doi.org/10.1016/j.juro.2014.03.111

9. Kidney Cancer. National Comprehensive Cancer Network. Updated 2026-07-01.

10. Korbecka Z., Jabłońska B., Król R. Venous tumor thrombus level in renal cell carcinoma: impact on surgical and oncologic outcomes. Cancers, 2026, no 18(11), рр. 1801. https://doi.org/10.3390/cancers18111801

11. Roberson D.S., Basourakos S.P., Cheville J.C. et al. A simplified prediction tool for metastasis after nephrectomy with venous tumor thrombectomy for RCC. Urology, 2026, no 210, рр. 91–96. https://doi.org/10.1016/j.urology.2026.01.043

12. Novacescu D., Baloi A., Latcu S. et al. Open surgical management of renal cell carcinoma with infradiaphragmatic venous tumor thrombus (Mayo Levels 0–III): the epitome of surgical self-reliance in urology. Cancers, 2026, no 18(7), рр. 1080. https://doi.org/10.3390/cancers18071080

13. Yuan S.M. Surgical treatment of renal cell carcinoma with inferior vena cava tumor thrombus. Surgery Today, 2022, no 52(8), рр. 1125–1133. https://doi.org/10.1007/s00595-021-02429-9

14. Berry B., Pavithran N., Mumtaz F., Bex A. Modern management of locally advanced renal cancers with inferior vena cava thrombus. World Journal of Urology, 2026, no 44(1), рр. 421. https://doi.org/10.1007/s00345-026-06523-w

15. Zhang Y., Bi H., Yan Y. et al. Comparative analysis of surgical and oncologic outcomes of robotic, laparoscopic and open radical nephrectomy with venous thrombectomy: a propensity-matched cohort study. International Journal of Clinical Oncology, 2023, no 28(1), рр. 145–154. https://doi.org/10.1007/s10147-022-02265-y

16. Rose K.M., Navaratnam A.K., Faraj K.S. et al. Comparison of open and robot assisted radical nephrectomy with level I and II inferior vena cava tumor thrombus: the mayo clinic experience. Urology, 2020, no 136, рр. 152–157. https://doi.org/10.1016/j.urology.2019.11.002

17. Hoang A.N., Vaporcyian A.A., Matin S.F. Laparoscopy-assisted radical nephrectomy with inferior vena caval thrombectomy for level II to III tumor thrombus: a single-institution experience and review of the literature. Journal of Endourology, 2010, no 24(6), рр. 1005–1012. https://doi.org/10.1089/end.2009.0532

18. Tang Q., Wang T., Li X. et al. Renal cell carcinoma with infrahepatic vena caval tumor thrombus treated with a novel combined retroperitoneal and transperitoneal pure laparoscopic procedure. Urology, 2014, no 83(5), рр. e9-10. https://doi.org/10.1016/j.urology.2014.01.025

19. Shao P., Li J., Qin C. et al. Laparoscopic radical nephrectomy and inferior vena cava thrombectomy in the treatment of renal cell carcinoma. European Urology, 2015, no 68(1), рр. 115–122. https://doi.org/10.1016/j.eururo.2014.12.011

20. Garg H., Psutka S.P., Hakimi A.A. et al. A decade of roboticassisted radical nephrectomy with inferior vena cava thrombectomy: a systematic review and meta-analysis of perioperative outcomes. The Journal of Urology, 2022, no 208(3), рр. 542–560. https://doi.org/10.1097/JU.0000000000002829