Surgical Outcomes of Radical Nephrectomy and Inferior Vena Cava Thrombectomy Following Preoperative Systemic Immunotherapy: A Propensity Score Analysis

Introduction: The impact of neoadjuvant immune checkpoint inhibitors (ICIs) on perioperative outcomes of radical nephrectomy (RN) with inferior vena cava (IVC) thrombectomy for renal cell carcinoma (RCC) remains unclear. This study aimed to assess the safety of preoperative immunotherapy prior to surgical resection of RCC with IVC tumor thrombus. Patients and Methods: A retrospective review identified patients with RCC and IVC tumor thrombus who underwent concomitant nephrectomy and IVC thrombectomy. Patients were stratified based on preoperative ICI use. Inverse probability of treatment weighting (IPTW) was used to balance baseline characteristics. Intraoperative, postoperative, and oncological outcomes were evaluated using logistic, linear, and Cox proportional hazards regression models. Results: A total of 101 patients were included in the study: 39 (39%) received preoperative ICI and 62 (61%) underwent upfront surgery. After IPTW adjustment, propensity score variables were well-balanced. Preoperative ICI was associated with longer operative time (+99.7 minutes, 95% CI: 38-172, P = .001), but no significant differences in intraoperative incidents, postoperative complications, or postoperative renal function (all p > 0.05). With a median 19-month follow-up, exploratory analyses stratified by metastatic status revealed no significant differences in disease-free or overall survival between groups in both unweighted and IPTW-adjusted analyses (p > 0.05). Conclusions: Preoperative immunotherapy appears safe and feasible for patients with RCC and IVC thrombus undergoing RN and thrombectomy, with no significant increase in postoperative morbidity despite longer operative times. Larger prospective studies with extended follow-up are needed to confirm these findings.