(UroToday.com) The 2025 South Central AUA annual meeting included a session on kidney cancer, featuring a presentation from Ryan Packham discussing contemporary outcomes for radical nephrectomy with inferior vena cava thrombectomy in the era of pre-operative immunotherapy. Renal cell carcinoma (RCC) often presents with venous tumor thrombus, requiring complex IVC thrombectomy, which carries significant morbidity and mortality.
Phase I and II studies have shown RCC venous tumor thrombus downstaging and acceptable outcomes post-immunotherapy, and many patients present with metastatic disease for cytoreductive nephrectomy and IVC thrombectomy after treatment with systemic therapy. Few studies to date have compared surgical outcomes between pre-treated and non-treated patients. The goal of this study was to report contemporary outcomes among patients undergoing radical nephrectomy and IVC thrombectomy and compare outcomes between patients exposed to systemic pre-treatment and those undergoing upfront surgery.
Patient demographic, clinical, pathological, and perioperative data were collected retrospectively for consecutive patients undergoing radical nephrectomy and IVC thrombectomy from January 1, 2023, to September 30, 2024. Therapy regimens, adverse events, and tumor downstaging rates were noted for pre-treated patients.
Twenty-six patients, of whom 12 (46.2%) were female and 16 (61.5%) were Hispanic, with a median age of 64 years (IQR 57, 69), were identified. Eight (30.8%) patients were pre-treated with immunotherapy, with 7 (85.5%) undergoing deferred cytoreductive nephrectomy. Regimens included pembrolizumab alone (n = 1), pembrolizumab + axitinib (n = 2), lenvatinib + pembrolizumab (n = 2), nivolumab + ipilimumab (n = 2), cabozantinib alone (n = 1), and nivolumab + cabozantinib (n = 1).
Dose reductions occurred in 5 (62.5%) patients, though none discontinued therapy. Venous tumor thrombus downstaging occurred in 5 (62.5%) patients, with 3 (37.5%) achieving complete pathologic response in the primary tumor. A primary tumor size reduction (mean 3.1 cm) was observed in 5 (62.5%) patients. Pre-treated patients had a higher median Charlson comorbidity index (8 versus 5, p = 0.005), likely due to cytoreductive nephrectomy. No significant differences were found in intraoperative blood loss, transfusions, ICU admissions, Clavien-Dindo grade >3 complications, length of hospital stay, or 30-day mortality.
Ryan Packham concluded his presentation discussing contemporary outcomes for radical nephrectomy with inferior vena cava thrombectomy in the era of pre-operative immunotherapy by noting that preoperative systemic therapy downstaged venous tumor thrombus in most patients and was safe, with similar intraoperative and early postoperative outcomes compared to upfront nephrectomy patients.
Presented by: Ryan Packham, Long School of Medicine, UT Health San Antonio, San Antonio, TX
Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Associate Professor of Urology, Georgia Cancer Center, Wellstar MCG Health, @zklaassen_md on Twitter during the 2025 South Central American Urological Association (AUA) Annual Meeting, Orlando, FL, Wed, Sept 10 – Sat, Sept 13, 2025.