Contemporary outcomes of nephrectomy with IVC thrombectomy: Analysis from a large multi-institutional database.

Abstract

469 Background: Nephrectomy with IVC thrombectomy for renal cell carcinoma remains one of the most technically demanding procedures in urologic oncology. Despite advances in surgical technique and perioperative management, these operations carry substantial morbidity. Existing literature includes predominantly single-institution series with variable sample sizes, limiting comprehensive risk stratification for patient counseling. We present perioperative outcomes from the largest contemporary multi-institutional analysis to provide evidence-based benchmarks for this high-risk population. Methods: We analyzed the 2019-2023 ACS-NSQIP database for patients undergoing radical nephrectomy with IVC thrombectomy, identified using appropriate CPT codes. Pathologic staging determined thrombus level, with T3b correlating with level II-III thrombi and T3c with level IV thrombi. Demographics, comorbidities, and 30-day perioperative outcomes including major and minor complications, operative time, length of stay (LOS), readmissions, and mortality were analyzed. Results: Among 439 patients 362 had level II-III (T3b) thrombi and 77 had level IV (T3c) thrombi. Robotic surgery was utilized in 20.1% of level II-III cases and 9.6% of level IV. Demographics were similar across groups, though level IV patients had higher ASA class and lower preoperative hematocrit. Complication rates increased with advancing thrombus level: minor complications occurred in 58.5% of level II-III and 74.4% of level IV patients. Major complications occurred in 18.8% of level II-III and 29.9% of level IV patients, with level IV cases experiencing high rates of pulmonary embolism (9.1%), deep vein thrombosis (5.2%), myocardial infarction (2.6%), and cardiac arrest (3.9%). Bleeding requiring transfusion was the most frequent overall complication, affecting 51.9% of level II-III and 64.9% of level IV patients. LOS increased: level II-III 6.9±5.3 days, level IV 10.5±6.9 days. 30-day mortality rates were 1.9% for level II-III and 10.4% for level IV. Conclusions: This analysis demonstrates the significant morbidity associated with IVC thrombectomy. Level II-III operations carry significant complication rates, while level IV procedures involve even greater morbidity, with particularly high rates of bleeding, cardiovascular complications, and mortality. These outcome data provide evidence-based benchmarks for patient counseling and informed consent discussions. IVC thrombectomy patient outcomes. T3bN = 362 T3cN = 77 Minor Complications 213 (58.52%) 58 (74.36%) Other Bleeding 188 (51.93%) 50 (64.94%) Major Complications 68 (18.78%) 23 (29.87%) PE 15 (4.14%) 7 (9.09%) Operative Time (minutes) 291 ± 89 354.18 ± 145.02 Length of Total Hospital Stay (days) 6.88 ±5.27 10.48 ± 6.92 Return to operating room 7 (1.93%) 7 (9.09%) Readmission 34 (9.39%) 3 (3.9%) Death 7 (1.93%) 8 (10.39%)