Comparative Efficacy of Robot Assisted Radical Nephrectomy and Open Surgery for IVC ThrombusRobot assisted surgery shows fewer complications for certain kidney cancers

For patients with renal cell carcinoma (RCC) complicated by inferior vena cava (IVC) tumor thrombus, radical nephrectomy combined with thrombectomy remains a key surgical option. Open radical nephrectomy with IVC thrombectomy (O-RNTT) has long been regarded as the traditional operative strategy, whereas robot-assisted radical nephrectomy with IVC thrombectomy (R-RNTT) is now being used more frequently in high-experience centers. Direct comparative data, however, remain limited. This study aimed to compare perioperative outcomes and available short-term pathological and oncologic findings between R-RNTT and O-RNTT in patients with RCC and IVC tumor thrombus. A PRISMA-guided systematic review and meta-analysis was performed. Embase, PubMed, Web of Science, and the Cochrane Library were searched up to January 2026. Eligible studies directly compared R-RNTT with O-RNTT and reported at least one relevant clinical outcome. Mean differences (MDs) were calculated for continuous variables, while odds ratios (ORs) were used for categorical variables, each with corresponding 95% confidence intervals (CIs). Prespecified subgroup analyses were conducted according to thrombus level. Six comparative studies including 1210 patients were analyzed, with 194 undergoing R-RNTT and 1016 receiving O-RNTT. Operative duration was similar between the two surgical approaches (MD = 29.64 min, 95% CI - 75.97 to 135.26, P = 0.58). R-RNTT resulted in less estimated blood loss than O-RNTT (MD = - 703.11 mL, 95% CI - 1052.49 to - 353.73, P < 0.0001), a lower need for transfusion (OR = 0.19, 95% CI 0.06 to 0.54, P = 0.002), and reduced postoperative hospitalization (MD = - 3.48 days, 95% CI - 4.61 to - 2.34, P < 0.00001). Conversion to open surgery after attempted R-RNTT occurred in 6% of cases (95% CI 2% to 10%). The rate of minor postoperative complications did not significantly differ between groups (OR = 0.69, 95% CI 0.42 to 1.16, P = 0.16). By contrast, major postoperative complications were less frequent after R-RNTT (OR = 0.46, 95% CI 0.23 to 0.90, P = 0.02). A lower positive surgical margin rate was also observed with R-RNTT (OR = 0.20, 95% CI 0.07-0.58, P = 0.003). An exploratory analysis of crude all-cause mortality events favored R-RNTT (OR = 0.33, 95% CI 0.16-0.68, P = 0.002). The available thrombus-level analyses suggested that favorable perioperative associations may be more evident in lower-level thrombi, although evidence for higher-level thrombi was limited to individual studies. R-RNTT may represent a feasible minimally invasive option for appropriately selected RCC patients with IVC tumor thrombus. Compared with O-RNTT, it was linked to reduced blood loss, fewer transfusions, fewer major complications, and shorter hospitalization, without evidence of compromised short-term oncologic safety. The benefit was more apparent in lower-level thrombi. For more advanced thrombus extension, careful case selection, extensive surgical experience, and multidisciplinary support remain essential. Further prospective multicenter studies with standardized outcome reporting and longer follow-up are warranted.