Reframing surgical strategy for RCC with IVC tumor thrombus: From classification to integrated multimodal care

Radical nephrectomy with inferior vena cava (IVC) thrombectomy remains one of the most technically demanding procedures in urologic oncology and is associated with substantial perioperative morbidity and mortality. In this context, classification systems for IVC tumor thrombus (TT) are not merely descriptive tools; rather, they serve as the foundation for surgical planning, risk stratification, and inter-institutional communication. The widely adopted Mayo Clinic Classification, originally derived from the seminal work of Neves and Zincke and later refined by Blute et al., has historically provided a robust framework.[1,2] However, its anatomical stratification was developed in an era dominated by open surgery and therefore may not fully account for the nuances introduced by minimally invasive and robotic approaches. As highlighted in the review by Luo et al.,[3] the increasing adoption of robotic surgery represents a paradigm shift in the management of renal cell carcinoma (RCC) with IVC-TT. Robotic approaches offer enhanced visualization and dexterity and may reduce surgical morbidity in carefully selected patients, thereby necessitating reconsideration of traditional classification systems. The proposed “301 Classification” attempts to address these limitations by incorporating surgical positioning (e.g., flank position) and redefining anatomical boundaries using landmarks such as the superior mesenteric artery, first porta hepatis, and second porta hepatis. This strategy aligns the classification more closely with operative planning rather than with static anatomy, potentially improving its clinical applicability in the robotic era. Importantly, this is not the first attempt to refine the classification according to surgical anatomy. The University of Miami group previously introduced additional granularity within level 3 disease by emphasizing hepatic relationships.[4] Although these systems differ in structure and complexity, they share the common goal of improving surgical guidance. Ultimately, however, the value of any classification system should be determined by its association with clinically meaningful outcomes. Future studies should, therefore, focus on external validation, ideally using multicenter datasets, to determine whether newer systems, such as the 301 classification, provide incremental prognostic or operative advantages over established frameworks. Such investigations may be challenging because RCC with IVC-TT is relatively rare and cases are concentrated in high-volume centers; nevertheless, these efforts remain essential to establish broader generalizability. Despite growing enthusiasm for robotic surgery, the fundamental intraoperative risks associated with IVC thrombectomy remain largely unchanged. Among these, thromboembolic complications, particularly intraoperative pulmonary embolism, remain the most common. Shuch et al.[5] reported that these events occur most commonly during kidney and liver mobilization, with mortality rates approaching 60%, underscoring the importance of operative sequencing. The aforementioned review also highlighted the heterogeneity of vascular control strategies, including caudal-to-cranial and cranial-first approaches.[3] This variability likely reflects the absence of a standardized consensus in robotic surgery despite the extensive experience accumulated in open procedures. Vascular control in RCC with IVC-TT has direct implications for intraoperative safety, particularly in preventing thromboembolic events that may result in catastrophic outcomes. In this context, the concept of a “thrombus-first” approach warrants further consideration. Although only partially addressed in the review, this strategy—in which vascular control and thrombectomy are completed before kidney mobilization—has been supported by evidence from open surgery demonstrating potential advantages in operative time, estimated blood loss, and complication rates.[6] From a technical perspective, robotic surgery may further facilitate this approach by providing a stable operative field and enhanced visualization, thereby potentially improving the reproducibility of early vascular control. These considerations highlight a broader principle: the importance of translating and adapting established evidence from open surgery to the robotic era. Rather than representing an entirely distinct paradigm, robotic surgery may be better understood as an extension of established surgical principles, characterized by refinement of operative techniques rather than replacement of fundamental concepts. One aspect not extensively addressed in this review is the evolving role of systemic therapy in reshaping the surgical management for RCC with IVC-TT. Historically, the impact of neoadjuvant therapy has been limited. During the era of tyrosine kinase inhibitor monotherapy, studies reported only modest downstaging rates, generally ranging from 10% to 30%; consequently, the role of preoperative treatment remained limited.[7] The advent of immune checkpoint inhibitor–based combination therapies has changed this paradigm. Emerging evidence from recent studies suggests reductions in thrombus height and stage migration, including downstaging from level 3 to level 2 disease.[8] These changes have direct surgical implications. For example, downstaging from level 3 to level 2 could potentially eliminate the need for extensive hepatic mobilization, shorten hepatic ischemia time, and reduce intraoperative blood loss. Consequently, some patients previously considered unsuitable for minimally invasive approaches may become candidates for robotic surgery. However, several important questions remain unanswered. The optimal timing of surgery following neoadjuvant therapy remains unclear, and the biological characteristics of residual thrombi after systemic treatment have yet to be fully elucidated. These uncertainties underscore the importance of multidisciplinary decision-making and highlight the need for further studies that integrate systemic and surgical endpoints. More broadly, the management of RCC with IVC-TT appears to be evolving toward an integrated multimodal approach. Continued refinement of classification systems, greater standardization of intraoperative strategies including robotic techniques, and the incorporation of modern systemic therapies will likely shape future practice. As surgical and medical approaches continue to converge, multidisciplinary collaboration and the accumulation of robust clinical evidence will be essential for improving outcomes in this challenging disease. Acknowledgments None. Statement of ethics Not applicable. Conflict of interest statement The author declares that they have no conflicts of interest. Funding source None. Author contributions The sole author was responsible for all aspects of this work. Data availability Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.