Comparative outcomes of robot-assisted and open radical nephrectomy with inferior vena cava thrombectomy for renal cell carcinoma: a systematic review and meta-analysis.

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.