Surgical strategy and outcomes in renal cell carcinoma with inferior vena cava tumor extension: A tertiary center experience

Background: Renal cell carcinoma (RCC) may extend into the inferior vena cava (IVC) and, in advanced cases, into the right atrium. Radical nephrectomy with IVC thrombectomy remains the mainstay of treatment; however, the role of cardiopulmonary bypass (CPB) in advanced tumor thrombus remains controversial. This study aimed to evaluate the surgical and early oncologic outcomes of patients with RCC and IVC tumor thrombus and to assess the impact of CPB on perioperative outcomes while cautiously interpreting the findings because of the limited sample size. Methods: We retrospectively analyzed 22 consecutive patients who underwent synchronous radical nephrectomy and IVC thrombectomy between 2009 and 2025 at a tertiary referral center. Patients were divided into two groups: Group I (n=8), who underwent surgery with CPB (± total circulatory arrest), and Group II (n=14), who underwent surgery without CPB. Tumor thrombus level was classified according to the Mayo clinic classification system. Operative variables, perioperative complications, recurrence rates, and survival outcomes were compared. Results: Level II thrombus was the most common presentation, whereas all Level IV cases required CPB. Operative time was significantly longer in the CPB group (267.5±121.4 vs. 190.4±38.7 minutes, p=0.038). Postoperative bleeding was significantly greater in Group I (p=0.001), whereas transfusion requirements, intensive care unit stay, and total hospital stay did not differ significantly between the groups. Perioperative mortality occurred in two patients (25%) in the CPB group and in none in Group II (p=0.16). The overall recurrence rate was 45% and was significantly higher in Group I (p=0.002). The overall 1-year survival rate was 77.2%, with no significant difference between the groups (p=0.12). Conclusion: Radical nephrectomy with IVC thrombectomy may provide acceptable perioperative and early survival outcomes in patients with RCC and venous tumor extension. In this limited series, the use of CPB in patients with advanced tumor thrombus did not appear to significantly increase overall morbidity and may improve operative safety in technically demanding cases. Nevertheless, the interpretation of these findings is limited by the unequal distribution of disease stage between the two groups.