Postoperative Mortality in Renal Cell Carcinoma with Vena Cava Thrombus in the Elderly Population (uroCCR study n°192)

Postoperative Mortality in Renal Cell Carcinoma with Vena Cava Thrombus in the Elderly Population (uroCCR study n°192) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Postoperative Mortality in Renal Cell Carcinoma with Vena Cava Thrombus in the Elderly Population (uroCCR study n°192) Norbert DE BREK, Charles DARIANE, Gaëlle MARGUE, Thibaut WAECKEL, and 12 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7036412/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Oct, 2025 Read the published version in World Journal of Urology → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose : Inferior vena cava (IVC) thrombus is a severe presentation of renal cell carcinoma (RCC), traditionally treated with radical nephrectomy and thrombus extraction. However, the benefit-risk balance in elderly patients remains unclear due to limited data. This study aimed to assess surgical outcomes—particularly 90-day mortality—in patients aged ≥ 70 year and identify risk factors for postoperative mortality. Methods: We retrospectively analyzed data from the prospective French UroCCR national cohort (2007–2023), including 298 patients with RCC with IVC thrombus who underwent surgery in 13 expert centers. Patients were stratified into ≥ 70 vs. <70 year. The primary endpoint was 90-day mortality. Secondary outcomes included overall survival (OS), disease-specific survival (DSS), and predictors of postoperative 90-d death. Statistical analyses included univariate and multivariate logistic regression adjusted for sex, ASA score, and eGFR. Results: Among the 117 elderly patients, 90-d mortality was 8.5% vs. 5.5% in younger patients (p = 0.33). In those aged ≥ 80 year (n = 32), 90-d mortality reached 19% (p = 0.02). Impaired eGFR < 45 mL/min was the only significant predictor of postoperative death (OR 3.9, p = 0.04). Long-term DSS was comparable between age groups. Study limitations include its retrospective design and inclusion of only surgical candidates. Conclusions: Radical nephrectomy with thrombus extraction yields acceptable outcomes in patients aged ≥ 70 year, though ≥ 80 year face higher perioperative risk. Careful selection—including renal function evaluation—is crucial. DSS equivalence suggests age alone should not contraindicate surgery. Elderly Inferior vena cava thrombus Nephrectomy Perioperative mortality Renal cell carcinoma Surgical procedure Figures Figure 1 Figure 2 Introduction Inferior vena cava (IVC) thrombus is an extension of renal cell carcinoma (RCC), affecting approximately 4 to 10% of RCC patients. 1,2 This disease characteristic is associated with a poor prognosis. 3 Currently, the only curative and standard treatment for non-metastatic patients with IVC thrombus is radical nephrectomy (RN) combined with cavotomy and thrombus extraction, with adjuvant immunotherapy (Pembrolizumab) due to the high risk of disease recurrence. 4 The level of IVC involvement, as described in the Klein-Novick classification, serves as a key factor in disease management, even if the link between thrombus level and oncological outcomes remains uncertain 2,3 . Level III and IV thrombi may require complex surgical approaches, including thoracic intervention. The in-hospital mortality rate associated with this surgery is approximately 5% 5 . The five-year overall survival rate is low (40 to 50%) but enhanced with immunotherapy. Deciding whether to proceed with surgery for elderly patients is challenging, especially in the context of advances in systemic therapies. To date, only one study has specifically investigated perioperative morbidity and mortality associated with this procedure in elderly patients, focusing on a small cohort of 43 patients aged ≥ 70 year. 6 This study did not identify any significant differences in perioperative mortality, overall and disease-specific survival in this population, but some larger series on renal cell carcinoma with IVC extension have identified age as a risk factor for in-hospital mortality. 5 The objective of this study was to compare surgical outcomes, particularly 90-day mortality, after RN with thrombus extraction in elderly patients, and to identify prognostic factors for perioperative mortality in this population. MATERIEL AND METHODS Study design, patient population and inclusion criteria : This study is based on data from the French national prospective cohort on renal cancer (UroCCR). Eligible patients were retrospectively identified from the database between 2007 and 2023, and participating centers were asked to review and validate the data for each case. The database utilized the 2017 cTNM classification system for renal cell carcinoma. We included all patients with a confirmed diagnosis of renal cell carcinoma associated with an IVC thrombus confirmed on an abdominal CT-scan or MRI, corresponding to cT3b and cT3c disease. Patients who did not undergo surgery and centers with fewer than four cases were excluded. The analysis compared patients aged ≥ 70 year (study group) with those aged < 70 year (control group of elderly patients). Outcomes : The primary pre-specified outcome was 90-day mortality. Secondary outcomes included overall and specific-disease survival and predictive factors for perioperative mortality. We also planned a subgroup analysis for patients aged > 80 y. Additionally, we analyzed the clinical, biological, and radiological characteristics of this disease in both groups. Statistical Analysis: Population comparisons were performed using Chi-square tests or Fisher’s exact tests for categorical variables and t-test for continuous variables. Overall and disease-specific survival were analyzed using the log-rank test and Cox proportional hazards regression. Univariate analyses were conducted to identify predictive factors for perioperative mortality. A p-value < 0.05 was considered statistically significant. Ethical considerations : This study was conducted in compliance with institutional and ethical guidelines as part of the UroCCR project (NCT03293563), which has received Institutional Review Board (IRB) approval and authorization from the French Data Protection Authority (CNIL), number DR-2013-206. CNIL decision no. DT-2024-027, dated December 31, 2024, authorized the Bordeaux University Hospital Center to implement automated data processing aimed at establishing a health data warehouse named "UroCCR" (authorization request no. 2231991). All patients received oral and written information about the objectives and methodology of the UroCCR project and written consent was obtained. RESULTS Patient demographics and baseline characteristics: (Table 1) We included 298 patients with RCC and IVC thrombus treated in 13 French reference centers in uro-oncology between 2007 and 2023. A total of 117 patients were aged over 70 yr. Women were more frequently represented in the elderly group (38% vs. 24%, p = 0.016). The ASA score was significantly higher in the elderly group, whereas the ECOG score was comparable. Preoperative renal function was more impaired in the elderly group, with 23% patients presenting a GFR < 45 mL/min before surgery (vs. 10%, p < 0.01). Regarding comorbidities, hypertension, thrombotic events (excluding vena cava thrombosis), and anticoagulant treatment were more prevalent, leading to a significantly higher Charlson Comorbidity Index in the elderly group (Table 1). Disease characteristics: (Table 1) Symptoms at diagnosis were similar between groups. The renal mass was right-lateralized in 60% of patients. The size of the primary tumor was smaller in the elderly group (90 mm vs. 101 mm, p 70 group having level III or IV thrombi. Sixteen percent of patients over 70 yr were locally staged as cN+, and 20% had metastatic disease (localized in 10% to the lungs, 6% to the adrenal glands, and 3% to the brain), which was comparable to the younger group. 30% of patients with metastatic disease underwent surgery after initial systemic preoperative therapy. None of the non-metastatic patients received adjuvant immunotherapy. Histological subtypes were similar between groups, with 85% of cases classified as clear cell carcinoma. Therapeutics interventions: (Table 1) As an inclusion criterion, all patients underwent surgery. No statistical differences were identified in the management approach, which included: 4% undergoing preoperative biopsy, 4% of localized disease receiving neoadjuvant therapy, 30% of metastatic disease treated with 1st line systemic therapy, 20% undergoing preoperative arterial embolization, 13% undergoing robotic-assisted surgery, 40% undergoing lymph node dissection, a mean blood loss of 1.3L and an average hospital stay of 12 d. Table 1: Patient Demographics and Baseline Characteristics. (Group > 70 yr [n = 117] vs. group < 70 yr [n =181]) Patients and characteristics n (%) 70 yrs (n=117) Median age at diagnostic (IQR) 56 (21-69) 76 (70-91) Sex ratio – no (%) 138 (76) 72 (62) BMI 26 (19 - 26) 25,8 (20-28) ASA score – no (%) 1 & 2 3 & 4 98 (66) 50 (44) 49 (46) 59 (54) ECOG (%) 0 & 1 2 & 3 143 (90) 16 (10) 86 (84) 16 (16) Preoperative GFR (CKD-EPI) > 45 < 45 153 (90) 17 (10) 86 (77) 26 (23) Hypertension – no (%) 82 (45) 74 (63) Diabete – no (%) 27 (15) 21 (18) Thrombosis event – no (%) 24 (13) 16 (14) Anticoagulant – no (%) 28 (15) 37 (32) Charlson Score (mean) 4.3 6.0 Tumor and extension – n (%) Symptoms at diagnostic Local Systemic 88 (49) 49 (27) 50 (43) 30 (26) Left side – no (%) 78 (43) 47 (40) Size of tumor – mm (mean) 101 90 Level of thrombus – no (%) (Klein Novick) I & II III & IV 106 (58) 75 (41) 78 (67) 39 (34) Size of Thrombus – mm (mean) 65 48 cN+ – no (%) 49 (27) 19 (17) cM+ – no (%) 51 (28) 21 (18) Histology – no (%) Clear cell Papillary Others 153 (84) 11 (6) 17 (10) 101 (85) 12 (10) 6 (5) Surgery Neoadjuvant treatment – no (%) 10 (6) 5 (4) Robotic assistance – no (%) 15 (8) 15 (13) Lymph node dissection – no (%) 88 (48) 48 (41) Time of surgery (mn) 223 229 Blood loss (mL) 1 419 1366 Length of stay - d (mean) 10.6 12.4 Postoperative mortality at 90 days: (Table 2) At 90 d post-surgery, 22 patients had died, including 10 in the ≥70 yr group (8.5%) and 12 in the <70 yr group (5.5%), without significant difference (p = 0.33). In a subgroup analysis of patients over 80 yr (n = 32), six patients (19%) died within 90 d post-surgery, which was significantly higher than in the <80 ye group (6%, p = 0.02). These findings remained consistent in the multivariate analysis adjusted for sex ratio, eGFR group, and ASA score, with odds ratios of 1.82 (p = 0.28) and 4.30 (p = 0.018) for the ≥70 and ≥80-yr groups, respectively. The 90-day mortality across age categories (under 60, 60-70, 70-80, and over 80 yr) did not show any rising trend (p = 0.19). (Fig 1) Table 2: Postoperative Mortality Within 90 Days (univariate and multivariate analysis adjusted on sex ratio, eGFR and ASA score) Mortality at 90 d OR CI 95% p Adjusted OR CI 95% p ≥ 70 yrs 1.4 0.6 - 2.2 0.33 1.8 0.7-3.1 0.28 ≥ 80 yrs 3.9 2.4-5.1 0.02 4.3 2.7-6.2 0.018 Disease specific survival : Overall survival in the elderly group is presented in Supplementary material covering up to 10 yr post-surgery. The median survival was 85 months (7 yr). Overall survival was significantly lower in the ≥70 yr group compared to the <70 group (p < 0.01). The disease-specific survival between the elderly and younger groups, as shown in Figure 2, was not statistically different, neither in a univariate model nor after adjustment for sex ratio, eGFR, and ASA score (HR = 1,25 [95% CI 0,73-2,13], p = 0.4). Risk factor of post operative mortality in the elderly group: In the cohort of 117 elderly patients, 10 deaths occurred within 90 d postoperatively. In univariate analysis, only a mean preoperative eGFR <45 mL/min was significantly associated with mortality (OR 3.9, p = 0.04). Although other preoperative variables demonstrated elevated odds ratio, such as diabetes (OR 2.1, p = 0.3), ECOG ≥2 (OR 2.7, p = 0.18), and thrombosis events (OR 3.1, p = 0.13), these did not reach statistical significance. (Table 3) Table 3: Predictive Factors of Mortality in the Elderly Group (≥70 yr), in univariate Analyses OR CI 95% p Symptoms at diagnostic 1.02 0.24-4.2 0.97 Left side 0.55 0.15-2.05 0.38 Type of thrombus ( Level 3 & 4 vs 1 & 2) 0.47 0.23-2.34 0.36 Metastatic disease 2.1 0.5-8.1 0.31 Hypertension 1.39 0.34-5.7 0.64 Diabetes 2.11 0.5-8.9 0.3 Obesity (BMI> 30) 1.16 0.3-6 0.8 ASA score 3 & 4 (vs 1/2) 1.3 0.3-4.8 0.72 ECOG score 2 & 3 (vs 0/1) 2.7 0.61-11.8 0.18 Thrombosis event 3.1 0.7-13.5 0.13 Anticoagulant 2.34 0.6-8.6 0.2 Preoperative renal failure (eGFR< 45) 3.9 1.04-14 0.04 DISCUSSION To our knowledge, this study is the largest cohort analyzing the postoperative mortality for renal cell carcinoma surgery with IVC thrombus in the elderly population. Our study does not show a significant postoperative mortality increase in patients older than 70 year treated for RCC associated with an IVC thrombus, but a trend in patients older than 80 year. This negative result is consistent with literature. In the study by Ishiyama et al. 6 , results were similar despite the inclusion of less patients in their study. We suppose that the 70 year threshold may be too low; our secondary analysis in patients aged ≥ 80 year demonstrated a statistically significant increase in 90-day postoperative mortality. Similarly, Martin et al. 5 reported an OR of 2.14 ( p = 0.029) for in-hospital mortality in the 70–79 year group and 5.81 ( p < 0.01) in those aged ≥ 80 year compared to patients aged < 50 year, corroborating our findings. Their larger sample size of over 3,000 patients in their study provided greater statistical power. These results underscore the need for caution in surgical decision-making, particularly considering the 19% 90-days mortality rate observed in patients aged ≥ 80 year. Although this study is retrospective, the use of the prospectively included national UroCCR cohort allowed for detailed characterization of patient features with low rates of missing data. Notably, sex-ratio differed between younger and older groups, revealing a statistically higher proportion of female patients in the elderly group—a finding not previously reported. This may be explained by the longer life expectancy of women and a better ASA score, allowing for higher rate of old women eligible for surgery. Additionally, tumors were smaller in the elderly group, a result not described in prior studies 5,6 . A potential limitation is the inclusion of only operable patients, which may have excluded older individuals with larger tumors deemed unfit for surgical intervention. In addition, our study is limited to France, but it incorporates data from 13 expert centers across diverse regions, enhancing the representativeness of the cohort. However, variations in surgical expertise, perioperative management protocols, and postoperative care among centers may have influenced outcomes, such as preoperative embolization, robot-assisted approach, or neoadjuvant therapy. 7 Furthermore, our study presents long-term oncological outcomes, with a median overall survival of 85 months in the elderly group, which appears slightly longer than previously reported series 6,8–10 . This favorable outcome may be explained by recent advances in systemic therapies, as well as the involvement of expert centers. The retrospective nature of our study may have introduced attrition bias; however, the low rate of losses to follow-up strengthens the reliability of our findings. Additionally, contrary to overall survival, disease-specific mortality appears comparable between age groups, consistent with the results reported by Ishiyama et al 6 . These results may encourage the consideration of interventional therapies in elderly patients, provided that the critical 90-day postoperative period is safely managed, as the disease does not appear to exhibit more aggressive behavior compared to younger individuals. Neo-adjuvant systemic therapy has also to be evaluated in clinical trials, in order to allow for lower IVC thrombus level, leading to less complex surgery. 11 Further prospective studies are needed to better stratify surgical candidates among the elderly, incorporating comprehensive geriatric assessments, patient preferences, and alternative treatment modalities. Ultimately, multidisciplinary discussions should be encouraged to optimize individualized treatment strategies, particularly for patients over 80 year. CONCLUSION In conclusion, radical nephrectomy with vena cava thrombus extraction in elderly patients demonstrates acceptable perioperative and oncological outcomes, comparable to those observed in younger patients. While postoperative mortality does not significantly increase in patients aged ≥ 70 year, a markedly higher 90-day mortality rate is noted in individuals aged ≥ 80 year, underscoring the importance of careful patient selection. Our findings highlight the need to incorporate preoperative renal function and comorbidities, notably impaired eGFR, into the surgical decision-making process. Given the comparable long-term disease specific survival in elderly patients, surgical intervention may remain a valuable option, provided perioperative risks are properly assessed. Declarations Competing interests: All authors declare that they have no relevant financial or nonfinancial interests to disclose. Funding: The authors did not receive support from any organization for the submitted work. Author Contribution N.D.B., A.I. and C.D. wrote the main manuscript text.M.G, W.T., P.B, L.S., M.O.T, F.A, F.B, R.B, J.C.B. participated to the data collection.All authors reviewed the manuscript. Acknowledgement To the UroCCR team for their support, and in particular Mr. Guillaume Herman for his commitment and enthusiasm throughout this project. On behalf of the CCAFU – Kidney Cancer Committee of the French Association of Urology References Almatari AL, Sathe A, Wideman L, et al. Renal cell carcinoma with tumor thrombus: A review of relevant anatomy and surgical techniques for the general urologist. Urol Oncol . 2023;41(4):153-165. doi:10.1016/j.urolonc.2022.11.021 Klatte T, Pantuck AJ, Riggs SB, et al. Prognostic factors for renal cell carcinoma with tumor thrombus extension. J Urol . 2007;178(4 Pt 1):1189-1195; discussion 1195. doi:10.1016/j.juro.2007.05.134 Wagner B, Patard JJ, Méjean A, et al. Prognostic value of renal vein and inferior vena cava involvement in renal cell carcinoma. Eur Urol . 2009;55(2):452-459. doi:10.1016/j.eururo.2008.07.053 EAU Guidelines 2024 renal carcinoma cancer. Martin T, Huber J, Koch R, et al. Defining a threshold for safe surgical management of vena cava thrombus in renal cell carcinoma patients: evidence from German total population data with 3,700 cases from 2006 to 2020. World J Urol . 2024;43(1):1. doi:10.1007/s00345-024-05360-z Ishiyama Y, Kondo T, Tachibana H, et al. Surgical outcomes for older patients with renal cell carcinoma and inferior vena cava thrombus. Urol Oncol . 2022;40(3):110.e11-110.e18. doi:10.1016/j.urolonc.2021.12.013 Suzuki K, Okamura Y, Bando Y, et al. Impact of presurgical systemic therapy on perioperative outcomes of renal cell carcinoma with inferior vena cava tumor thrombus. Int J Clin Oncol . 2025;30(3):532-538. doi:10.1007/s10147-024-02680-3 Pieretti AC, Ozambela M, Westerman ME, et al. Predictors of Survival in Patients Undergoing Surgery for Renal Cell Carcinoma and Inferior Vena Cava Tumor Thrombus. Clin Genitourin Cancer . 2022;20(4):e330-e338. doi:10.1016/j.clgc.2022.02.001 Poirier T, Karam G, Bouchot O, et al. [Results of the management of kidney cancer with extension into the inferior vena cava: A retrospective, single-center, observational study]. Progres En Urol J Assoc Francaise Urol Soc Francaise Urol . 2023;33(6):333-343. doi:10.1016/j.purol.2023.03.004 Gamboa-Hoil SI, Martínez-Cornelio A, Hernández-Toríz N, Riera-Kinkel C. Outcomes in Renal Cell Carcinoma with Inferior Vena Cava Thrombus Treated with Surgery. Curr Health Sci J . 2021;47(1):96-100. doi:10.12865/CHSJ.47.01.15 Gu L, Peng C, Li H, et al. Neoadjuvant therapy in renal cell carcinoma with tumor thrombus: A systematic review and meta-analysis. Crit Rev Oncol Hematol . 2024;196:104316. doi:10.1016/j.critrevonc.2024.104316. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 Oct, 2025 Read the published version in World Journal of Urology → Version 1 posted Editorial decision: Revision requested 21 Aug, 2025 Reviews received at journal 17 Aug, 2025 Reviewers agreed at journal 17 Aug, 2025 Reviews received at journal 06 Aug, 2025 Reviewers agreed at journal 21 Jul, 2025 Reviewers invited by journal 17 Jul, 2025 Editor assigned by journal 05 Jul, 2025 Submission checks completed at journal 05 Jul, 2025 First submitted to journal 03 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7036412","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":488761841,"identity":"e73b6b96-d4e6-4944-9dec-9c3d4147e60e","order_by":0,"name":"Norbert DE 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Conception","correspondingAuthor":false,"prefix":"","firstName":"Romain","middleName":"","lastName":"BOISSIER","suffix":""},{"id":488761857,"identity":"d5e13833-7f9c-4308-98a4-8d39c99ae723","order_by":14,"name":"Jean-Christophe BERNHARD","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Bordeaux","correspondingAuthor":false,"prefix":"","firstName":"Jean-Christophe","middleName":"","lastName":"BERNHARD","suffix":""},{"id":488761858,"identity":"750f7eec-7cb0-45ef-a454-37a5a42520b4","order_by":15,"name":"Alexandre INGELS","email":"","orcid":"","institution":"Hôpitaux Universitaires Henri-Mondor","correspondingAuthor":false,"prefix":"","firstName":"Alexandre","middleName":"","lastName":"INGELS","suffix":""}],"badges":[],"createdAt":"2025-07-03 09:38:41","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7036412/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7036412/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00345-025-05998-3","type":"published","date":"2025-10-11T15:58:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87379655,"identity":"47b265b7-1841-48f9-a327-3bc635f8d669","added_by":"auto","created_at":"2025-07-23 08:31:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":93273,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of Ninety-Days Postoperative Mortality According to Age Categories\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e*Cochrane-Armitage test for trend (p = 0.15)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7036412/v1/8e8075d1c46a83ada68219b4.png"},{"id":87378301,"identity":"9c875172-3696-4c81-8288-17968099097d","added_by":"auto","created_at":"2025-07-23 08:23:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":219850,"visible":true,"origin":"","legend":"\u003cp\u003eDisease-Specific Survival Multivariate Analyses\u003cstrong\u003e (\u003c/strong\u003eAdjusted model on eGFR, sexe ratio and ASA score)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMultivariate analysis performed using Cox proportional hazards regression.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHR = 1,25 [95% CI 0,73-2,13], p = 0.4\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7036412/v1/1ceec690fe5ce6c80adb86f7.png"},{"id":93419772,"identity":"17eb9f7b-5dd2-4fff-93e5-6bae6cdebb4e","added_by":"auto","created_at":"2025-10-13 16:07:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1027866,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7036412/v1/7bfde078-2558-41f2-815b-2223dc7f5fe8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Postoperative Mortality in Renal Cell Carcinoma with Vena Cava Thrombus in the Elderly Population (uroCCR study n°192)","fulltext":[{"header":"Introduction","content":"\u003cp\u003eInferior vena cava (IVC) thrombus is an extension of renal cell carcinoma (RCC), affecting approximately 4 to 10% of RCC patients. \u003csup\u003e1,2\u003c/sup\u003e This disease characteristic is associated with a poor prognosis.\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eCurrently, the only curative and standard treatment for non-metastatic patients with IVC thrombus is radical nephrectomy (RN) combined with cavotomy and thrombus extraction, with adjuvant immunotherapy (Pembrolizumab) due to the high risk of disease recurrence. \u003csup\u003e4\u003c/sup\u003e The level of IVC involvement, as described in the Klein-Novick classification, serves as a key factor in disease management, even if the link between thrombus level and oncological outcomes remains uncertain \u003csup\u003e2,3\u003c/sup\u003e. Level III and IV thrombi may require complex surgical approaches, including thoracic intervention. The in-hospital mortality rate associated with this surgery is approximately 5% \u003csup\u003e5\u003c/sup\u003e. The five-year overall survival rate is low (40 to 50%) but enhanced with immunotherapy. Deciding whether to proceed with surgery for elderly patients is challenging, especially in the context of advances in systemic therapies.\u003c/p\u003e\u003cp\u003eTo date, only one study has specifically investigated perioperative morbidity and mortality associated with this procedure in elderly patients, focusing on a small cohort of 43 patients aged\u0026thinsp;\u0026ge;\u0026thinsp;70\u0026nbsp;year. \u003csup\u003e6\u003c/sup\u003e This study did not identify any significant differences in perioperative mortality, overall and disease-specific survival in this population, but some larger series on renal cell carcinoma with IVC extension have identified age as a risk factor for in-hospital mortality. \u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe objective of this study was to compare surgical outcomes, particularly 90-day mortality, after RN with thrombus extraction in elderly patients, and to identify prognostic factors for perioperative mortality in this population.\u003c/p\u003e"},{"header":"MATERIEL AND METHODS","content":"\u003cp\u003e\u003cb\u003eStudy design, patient population and inclusion criteria\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eThis study is based on data from the French national prospective cohort on renal cancer (UroCCR).\u003c/p\u003e\u003cp\u003eEligible patients were retrospectively identified from the database between 2007 and 2023, and participating centers were asked to review and validate the data for each case.\u003c/p\u003e\u003cp\u003eThe database utilized the 2017 cTNM classification system for renal cell carcinoma.\u003c/p\u003e\u003cp\u003eWe included all patients with a confirmed diagnosis of renal cell carcinoma associated with an IVC thrombus confirmed on an abdominal CT-scan or MRI, corresponding to cT3b and cT3c disease. Patients who did not undergo surgery and centers with fewer than four cases were excluded. The analysis compared patients aged\u0026thinsp;\u0026ge;\u0026thinsp;70\u0026nbsp;year (study group) with those aged\u0026thinsp;\u0026lt;\u0026thinsp;70\u0026nbsp;year (control group of elderly patients).\u003c/p\u003e\u003cp\u003e\u003cb\u003eOutcomes\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eThe primary pre-specified outcome was 90-day mortality. Secondary outcomes included overall and specific-disease survival and predictive factors for perioperative mortality. We also planned a subgroup analysis for patients aged\u0026thinsp;\u0026gt;\u0026thinsp;80 y. Additionally, we analyzed the clinical, biological, and radiological characteristics of this disease in both groups.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis:\u003c/h2\u003e\u003cp\u003ePopulation comparisons were performed using Chi-square tests or Fisher\u0026rsquo;s exact tests for categorical variables and t-test for continuous variables. Overall and disease-specific survival were analyzed using the log-rank test and Cox proportional hazards regression. Univariate analyses were conducted to identify predictive factors for perioperative mortality. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEthical considerations\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e This study was conducted in compliance with institutional and ethical guidelines as part of the UroCCR project (NCT03293563), which has received Institutional Review Board (IRB) approval and authorization from the French Data Protection Authority (CNIL), number DR-2013-206. CNIL decision no. DT-2024-027, dated December 31, 2024, authorized the Bordeaux University Hospital Center to implement automated data processing aimed at establishing a health data warehouse named \"UroCCR\" (authorization request no. 2231991).\u003c/p\u003e\u003cp\u003e All patients received oral and written information about the objectives and methodology of the UroCCR project and written consent was obtained.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003ePatient demographics and baseline characteristics:\u0026nbsp;\u003c/strong\u003e(Table 1)\u003c/p\u003e\n\u003cp\u003eWe included 298 patients with RCC and IVC thrombus treated in 13 French reference centers in uro-oncology between 2007 and 2023. A total of 117 patients were aged over 70 yr. Women were more frequently represented in the elderly group (38% vs. 24%, p = 0.016).\u003c/p\u003e\n\u003cp\u003eThe ASA score was significantly higher in the elderly group, whereas the ECOG score was comparable. Preoperative renal function was more impaired in the elderly group, with 23% patients presenting a GFR \u0026lt; 45 mL/min before surgery (vs. 10%, p \u0026lt; 0.01).\u003c/p\u003e\n\u003cp\u003eRegarding comorbidities, hypertension, thrombotic events (excluding vena cava thrombosis), and anticoagulant treatment were more prevalent, leading to a significantly higher Charlson Comorbidity Index in the elderly group (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisease characteristics:\u0026nbsp;\u003c/strong\u003e(Table 1)\u003c/p\u003e\n\u003cp\u003eSymptoms at diagnosis were similar between groups. The renal mass was right-lateralized in 60% of patients. The size of the primary tumor was smaller in the elderly group (90 mm vs. 101 mm, p \u0026lt; 0.01).\u003c/p\u003e\n\u003cp\u003eThe thrombus level, classified according to the Klein-Novick classification, was comparable between groups, with 34% of patients in the \u0026gt;70 group having level III or IV thrombi.\u003c/p\u003e\n\u003cp\u003eSixteen percent of patients over 70 yr were locally staged as cN+, and 20% had metastatic disease (localized in 10% to the lungs, 6% to the adrenal glands, and 3% to the brain), which was comparable to the younger group. 30% of patients with metastatic disease underwent surgery after initial systemic preoperative therapy. None of the non-metastatic patients received adjuvant immunotherapy.\u003c/p\u003e\n\u003cp\u003eHistological subtypes were similar between groups, with 85% of cases classified as clear cell carcinoma.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTherapeutics interventions:\u0026nbsp;\u003c/strong\u003e(Table 1)\u003c/p\u003e\n\u003cp\u003eAs an inclusion criterion, all patients underwent surgery. No statistical differences were identified in the management approach, which included: 4% undergoing preoperative biopsy, 4% of localized disease receiving neoadjuvant therapy, 30% of metastatic disease treated with 1st line systemic therapy, 20% undergoing preoperative arterial embolization, 13% undergoing robotic-assisted surgery, 40% undergoing lymph node dissection, a mean blood loss of 1.3L and an average hospital stay of 12 d.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e Patient Demographics and Baseline Characteristics. \u0026nbsp;(Group \u0026gt; 70 yr [n = 117] vs. group \u0026lt; 70 yr [n =181])\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"633\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 633px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePatients and characteristics n (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026lt; 70 yrs (n = 181)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026gt; 70 yrs (n=117)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003eMedian age at diagnostic (IQR)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e56 (21-69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e76 (70-91)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003eSex ratio \u0026ndash; no (%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e138 (76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e72 (62)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003eBMI\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e26 (19 - 26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e25,8 (20-28)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003eASA score\u003c/em\u003e \u0026ndash; no \u003cem\u003e(%)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e1 \u0026amp; 2\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e3 \u0026amp; 4\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e98 (66)\u003c/p\u003e\n \u003cp\u003e50 (44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e49 (46)\u003c/p\u003e\n \u003cp\u003e59 (54)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003eECOG (%)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e0 \u0026amp; 1\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e2 \u0026amp; 3\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e143 (90)\u003c/p\u003e\n \u003cp\u003e16 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e86 (84)\u003c/p\u003e\n \u003cp\u003e16 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003ePreoperative GFR (CKD-EPI)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026gt; 45\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lt; 45\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e153 (90)\u003c/p\u003e\n \u003cp\u003e17 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e86 (77)\u003c/p\u003e\n \u003cp\u003e26 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003eHypertension\u003c/em\u003e\u0026ndash; no \u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e82 (45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e74 (63)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003eDiabete\u0026nbsp;\u003c/em\u003e\u0026ndash; no \u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e27 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e21 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003eThrombosis event\u0026nbsp;\u003c/em\u003e\u0026ndash; no \u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e24 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e16 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003eAnticoagulant\u0026nbsp;\u003c/em\u003e\u0026ndash; no \u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e28 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e37 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003eCharlson Score (mean)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 633px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTumor and extension \u0026ndash; n (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eSymptoms at diagnostic\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eLocal\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSystemic\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e88 (49)\u003c/p\u003e\n \u003cp\u003e49 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e50 (43)\u003c/p\u003e\n \u003cp\u003e30 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eLeft side \u0026ndash; no \u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e78 (43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e47 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eSize of tumor\u003cem\u003e\u0026nbsp;\u003cstrong\u003e\u0026ndash;\u0026nbsp;\u003c/strong\u003emm (mean)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eLevel of thrombus \u0026ndash; no \u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e(Klein Novick)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eI \u0026amp; II\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIII \u0026amp; IV\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e106 (58)\u003c/p\u003e\n \u003cp\u003e75 (41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e78 (67)\u003c/p\u003e\n \u003cp\u003e39 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003eSize of Thrombus \u003cstrong\u003e\u0026ndash;\u0026nbsp;\u003c/strong\u003emm (mean)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003ecN+\u0026nbsp;\u003c/em\u003e\u0026ndash; no \u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e49 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e19 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003ecM+\u0026nbsp;\u003c/em\u003e\u0026ndash; no \u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e51 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e21 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eHistology \u0026ndash; no \u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eClear cell\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ePapillary\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eOthers\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e153 (84)\u003c/p\u003e\n \u003cp\u003e11 (6)\u003c/p\u003e\n \u003cp\u003e17 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e101 (85)\u003c/p\u003e\n \u003cp\u003e12 (10)\u003c/p\u003e\n \u003cp\u003e6 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 633px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSurgery\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003eNeoadjuvant treatment\u0026nbsp;\u003c/em\u003e\u0026ndash; no \u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e10 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e5 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003eRobotic assistance\u0026nbsp;\u003c/em\u003e\u0026ndash; no \u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e15 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e15 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003eLymph node dissection\u0026nbsp;\u003c/em\u003e\u0026ndash; no \u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e88 (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e48 (41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003eTime of surgery (mn)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e223\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e229\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003eBlood loss (mL)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1 419\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e1366\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003eLength of stay - d (mean)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e10.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e12.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative mortality at 90 days:\u0026nbsp;\u003c/strong\u003e(Table 2)\u003c/p\u003e\n\u003cp\u003eAt 90 d post-surgery, 22 patients had died, including 10 in the \u0026ge;70 yr group (8.5%) and 12 in the \u0026lt;70 yr group (5.5%), without significant difference (p = 0.33).\u003c/p\u003e\n\u003cp\u003eIn a subgroup analysis of patients over 80 yr (n = 32), six patients (19%) died within 90 d post-surgery, which was significantly higher than in the \u0026lt;80 ye group (6%, p = 0.02).\u003c/p\u003e\n\u003cp\u003eThese findings remained consistent in the multivariate analysis adjusted for sex ratio, eGFR group, and ASA score, with odds ratios of 1.82 (p = 0.28) and 4.30 (p = 0.018) for the \u0026ge;70 and \u0026ge;80-yr groups, respectively.\u003c/p\u003e\n\u003cp\u003eThe 90-day mortality across age categories (under 60, 60-70, 70-80, and over 80 yr) did not show any rising trend (p = 0.19). (Fig 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2:\u0026nbsp;\u003c/strong\u003ePostoperative Mortality Within 90 Days (univariate and multivariate analysis adjusted on sex ratio, eGFR and ASA score)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eMortality at 90 d\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eCI 95%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003eAdjusted OR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003eCI 95%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ge; 70 yrs\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.6 - 2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.7-3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ge; 80 yrs\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2.4-5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e2.7-6.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eDisease specific survival\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eOverall survival in the elderly group is presented in Supplementary material covering up to 10 yr post-surgery. The median survival was 85 months (7 yr). Overall survival was significantly lower in the \u0026ge;70 yr group compared to the \u0026lt;70 group (p \u0026lt; 0.01).\u003c/p\u003e\n\u003cp\u003eThe disease-specific survival between the elderly and younger groups, as shown in Figure 2, was not statistically different, neither in a univariate model nor after adjustment for sex ratio, eGFR, and ASA score (HR = 1,25 [95% CI 0,73-2,13], p = 0.4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRisk factor of post operative mortality in the elderly group:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the cohort of 117 elderly patients, 10 deaths occurred within 90 d postoperatively. In univariate analysis, only a mean preoperative eGFR \u0026lt;45 mL/min was significantly associated with mortality (OR 3.9, p = 0.04). Although other preoperative variables demonstrated elevated odds ratio, such as diabetes (OR 2.1, p = 0.3), ECOG \u0026ge;2 (OR 2.7, p = 0.18), and thrombosis events (OR 3.1, p = 0.13), these did not reach statistical significance. (Table 3)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3:\u003c/strong\u003e Predictive Factors of Mortality in the Elderly Group (\u0026ge;70 yr), in univariate Analyses\u0026nbsp;\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"557\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCI 95%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eSymptoms at diagnostic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.24-4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eLeft side\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.15-2.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eType of thrombus \u003cem\u003e(\u003c/em\u003eLevel 3 \u0026amp; 4 vs 1 \u0026amp; 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.23-2.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eMetastatic disease\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.5-8.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e1.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.34-5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.5-8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eObesity (BMI\u0026gt; 30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e1.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.3-6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eASA score\u003cem\u003e\u0026nbsp;\u003c/em\u003e3 \u0026amp; 4 \u003cem\u003e(vs 1/2)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.3-4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eECOG score\u003cem\u003e\u0026nbsp;\u003c/em\u003e2 \u0026amp; 3 \u003cem\u003e(vs 0/1)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.61-11.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eThrombosis event\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.7-13.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eAnticoagulant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.6-8.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003ePreoperative renal failure\u003cem\u003e\u0026nbsp;(eGFR\u0026lt; 45)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1.04-14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.04\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eTo our knowledge, this study is the largest cohort analyzing the postoperative mortality for renal cell carcinoma surgery with IVC thrombus in the elderly population. Our study does not show a significant postoperative mortality increase in patients older than 70\u0026nbsp;year treated for RCC associated with an IVC thrombus, but a trend in patients older than 80\u0026nbsp;year.\u003c/p\u003e\u003cp\u003eThis negative result is consistent with literature. In the study by Ishiyama \u003cem\u003eet al.\u003c/em\u003e \u003csup\u003e6\u003c/sup\u003e, results were similar despite the inclusion of less patients in their study. We suppose that the 70\u0026nbsp;year threshold may be too low; our secondary analysis in patients aged\u0026thinsp;\u0026ge;\u0026thinsp;80\u0026nbsp;year demonstrated a statistically significant increase in 90-day postoperative mortality. Similarly, Martin \u003cem\u003eet al.\u003c/em\u003e \u003csup\u003e5\u003c/sup\u003e reported an OR of 2.14 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.029) for in-hospital mortality in the 70\u0026ndash;79\u0026nbsp;year group and 5.81 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) in those aged\u0026thinsp;\u0026ge;\u0026thinsp;80\u0026nbsp;year compared to patients aged\u0026thinsp;\u0026lt;\u0026thinsp;50\u0026nbsp;year, corroborating our findings. Their larger sample size of over 3,000 patients in their study provided greater statistical power. These results underscore the need for caution in surgical decision-making, particularly considering the 19% 90-days mortality rate observed in patients aged\u0026thinsp;\u0026ge;\u0026thinsp;80\u0026nbsp;year.\u003c/p\u003e\u003cp\u003eAlthough this study is retrospective, the use of the prospectively included national UroCCR cohort allowed for detailed characterization of patient features with low rates of missing data. Notably, sex-ratio differed between younger and older groups, revealing a statistically higher proportion of female patients in the elderly group\u0026mdash;a finding not previously reported. This may be explained by the longer life expectancy of women and a better ASA score, allowing for higher rate of old women eligible for surgery. Additionally, tumors were smaller in the elderly group, a result not described in prior studies \u003csup\u003e5,6\u003c/sup\u003e. A potential limitation is the inclusion of only operable patients, which may have excluded older individuals with larger tumors deemed unfit for surgical intervention.\u003c/p\u003e\u003cp\u003eIn addition, our study is limited to France, but it incorporates data from 13 expert centers across diverse regions, enhancing the representativeness of the cohort. However, variations in surgical expertise, perioperative management protocols, and postoperative care among centers may have influenced outcomes, such as preoperative embolization, robot-assisted approach, or neoadjuvant therapy.\u003csup\u003e7\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eFurthermore, our study presents long-term oncological outcomes, with a median overall survival of 85 months in the elderly group, which appears slightly longer than previously reported series \u003csup\u003e6,8\u0026ndash;10\u003c/sup\u003e. This favorable outcome may be explained by recent advances in systemic therapies, as well as the involvement of expert centers. The retrospective nature of our study may have introduced attrition bias; however, the low rate of losses to follow-up strengthens the reliability of our findings. Additionally, contrary to overall survival, disease-specific mortality appears comparable between age groups, consistent with the results reported by Ishiyama \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e6\u003c/sup\u003e. These results may encourage the consideration of interventional therapies in elderly patients, provided that the critical 90-day postoperative period is safely managed, as the disease does not appear to exhibit more aggressive behavior compared to younger individuals. Neo-adjuvant systemic therapy has also to be evaluated in clinical trials, in order to allow for lower IVC thrombus level, leading to less complex surgery. \u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eFurther prospective studies are needed to better stratify surgical candidates among the elderly, incorporating comprehensive geriatric assessments, patient preferences, and alternative treatment modalities. Ultimately, multidisciplinary discussions should be encouraged to optimize individualized treatment strategies, particularly for patients over 80\u0026nbsp;year.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn conclusion, radical nephrectomy with vena cava thrombus extraction in elderly patients demonstrates acceptable perioperative and oncological outcomes, comparable to those observed in younger patients. While postoperative mortality does not significantly increase in patients aged\u0026thinsp;\u0026ge;\u0026thinsp;70\u0026nbsp;year, a markedly higher 90-day mortality rate is noted in individuals aged\u0026thinsp;\u0026ge;\u0026thinsp;80\u0026nbsp;year, underscoring the importance of careful patient selection. Our findings highlight the need to incorporate preoperative renal function and comorbidities, notably impaired eGFR, into the surgical decision-making process. Given the comparable long-term disease specific survival in elderly patients, surgical intervention may remain a valuable option, provided perioperative risks are properly assessed.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eCompeting interests:\u003c/h2\u003e\u003cp\u003eAll authors declare that they have no relevant financial or nonfinancial interests to disclose.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThe authors did not receive support from any organization for the submitted work.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eN.D.B., A.I. and C.D. wrote the main manuscript text.M.G, W.T., P.B, L.S., M.O.T, F.A, F.B, R.B, J.C.B. participated to the data collection.All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eTo the UroCCR team for their support, and in particular Mr. Guillaume Herman for his commitment and enthusiasm throughout this project. On behalf of the CCAFU \u0026ndash; Kidney Cancer Committee of the French Association of Urology\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAlmatari AL, Sathe A, Wideman L, et al. Renal cell carcinoma with tumor thrombus: A review of relevant anatomy and surgical techniques for the general urologist. \u003cem\u003eUrol Oncol\u003c/em\u003e. 2023;41(4):153-165. doi:10.1016/j.urolonc.2022.11.021\u003c/li\u003e\n\u003cli\u003eKlatte T, Pantuck AJ, Riggs SB, et al. Prognostic factors for renal cell carcinoma with tumor thrombus extension. \u003cem\u003eJ Urol\u003c/em\u003e. 2007;178(4 Pt 1):1189-1195; discussion 1195. doi:10.1016/j.juro.2007.05.134\u003c/li\u003e\n\u003cli\u003eWagner B, Patard JJ, M\u0026eacute;jean A, et al. Prognostic value of renal vein and inferior vena cava involvement in renal cell carcinoma. \u003cem\u003eEur Urol\u003c/em\u003e. 2009;55(2):452-459. doi:10.1016/j.eururo.2008.07.053\u003c/li\u003e\n\u003cli\u003eEAU Guidelines 2024 renal carcinoma cancer.\u003c/li\u003e\n\u003cli\u003eMartin T, Huber J, Koch R, et al. Defining a threshold for safe surgical management of vena cava thrombus in renal cell carcinoma patients: evidence from German total population data with 3,700 cases from 2006 to 2020. \u003cem\u003eWorld J Urol\u003c/em\u003e. 2024;43(1):1. doi:10.1007/s00345-024-05360-z\u003c/li\u003e\n\u003cli\u003eIshiyama Y, Kondo T, Tachibana H, et al. Surgical outcomes for older patients with renal cell carcinoma and inferior vena cava thrombus. \u003cem\u003eUrol Oncol\u003c/em\u003e. 2022;40(3):110.e11-110.e18. doi:10.1016/j.urolonc.2021.12.013\u003c/li\u003e\n\u003cli\u003eSuzuki K, Okamura Y, Bando Y, et al. Impact of presurgical systemic therapy on perioperative outcomes of renal cell carcinoma with inferior vena cava tumor thrombus. \u003cem\u003eInt J Clin Oncol\u003c/em\u003e. 2025;30(3):532-538. doi:10.1007/s10147-024-02680-3\u003c/li\u003e\n\u003cli\u003ePieretti AC, Ozambela M, Westerman ME, et al. Predictors of Survival in Patients Undergoing Surgery for Renal Cell Carcinoma and Inferior Vena Cava Tumor Thrombus. \u003cem\u003eClin Genitourin Cancer\u003c/em\u003e. 2022;20(4):e330-e338. doi:10.1016/j.clgc.2022.02.001\u003c/li\u003e\n\u003cli\u003ePoirier T, Karam G, Bouchot O, et al. [Results of the management of kidney cancer with extension into the inferior vena cava: A retrospective, single-center, observational study]. \u003cem\u003eProgres En Urol J Assoc Francaise Urol Soc Francaise Urol\u003c/em\u003e. 2023;33(6):333-343. doi:10.1016/j.purol.2023.03.004\u003c/li\u003e\n\u003cli\u003eGamboa-Hoil SI, Mart\u0026iacute;nez-Cornelio A, Hern\u0026aacute;ndez-Tor\u0026iacute;z N, Riera-Kinkel C. Outcomes in Renal Cell Carcinoma with Inferior Vena Cava Thrombus Treated with Surgery. \u003cem\u003eCurr Health Sci J\u003c/em\u003e. 2021;47(1):96-100. doi:10.12865/CHSJ.47.01.15\u003c/li\u003e\n\u003cli\u003eGu L, Peng C, Li H, et al. Neoadjuvant therapy in renal cell carcinoma with tumor thrombus: A systematic review and meta-analysis. \u003cem\u003eCrit Rev Oncol Hematol\u003c/em\u003e. 2024;196:104316. doi:10.1016/j.critrevonc.2024.104316.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Elderly, Inferior vena cava thrombus, Nephrectomy, Perioperative mortality, Renal cell carcinoma, Surgical procedure","lastPublishedDoi":"10.21203/rs.3.rs-7036412/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7036412/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose :\u003c/h2\u003e\u003cp\u003eInferior vena cava (IVC) thrombus is a severe presentation of renal cell carcinoma (RCC), traditionally treated with radical nephrectomy and thrombus extraction. However, the benefit-risk balance in elderly patients remains unclear due to limited data. This study aimed to assess surgical outcomes\u0026mdash;particularly 90-day mortality\u0026mdash;in patients aged\u0026thinsp;\u0026ge;\u0026thinsp;70\u0026nbsp;year and identify risk factors for postoperative mortality.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eWe retrospectively analyzed data from the prospective French UroCCR national cohort (2007\u0026ndash;2023), including 298 patients with RCC with IVC thrombus who underwent surgery in 13 expert centers. Patients were stratified into \u0026ge;\u0026thinsp;70 vs. \u0026lt;70\u0026nbsp;year. The primary endpoint was 90-day mortality. Secondary outcomes included overall survival (OS), disease-specific survival (DSS), and predictors of postoperative 90-d death. Statistical analyses included univariate and multivariate logistic regression adjusted for sex, ASA score, and eGFR.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eAmong the 117 elderly patients, 90-d mortality was 8.5% vs. 5.5% in younger patients (p\u0026thinsp;=\u0026thinsp;0.33). In those aged\u0026thinsp;\u0026ge;\u0026thinsp;80\u0026nbsp;year (n\u0026thinsp;=\u0026thinsp;32), 90-d mortality reached 19% (p\u0026thinsp;=\u0026thinsp;0.02). Impaired eGFR\u0026thinsp;\u0026lt;\u0026thinsp;45 mL/min was the only significant predictor of postoperative death (OR 3.9, p\u0026thinsp;=\u0026thinsp;0.04). Long-term DSS was comparable between age groups. Study limitations include its retrospective design and inclusion of only surgical candidates.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eRadical nephrectomy with thrombus extraction yields acceptable outcomes in patients aged\u0026thinsp;\u0026ge;\u0026thinsp;70\u0026nbsp;year, though \u0026ge;\u0026thinsp;80\u0026nbsp;year face higher perioperative risk. Careful selection\u0026mdash;including renal function evaluation\u0026mdash;is crucial. DSS equivalence suggests age alone should not contraindicate surgery.\u003c/p\u003e","manuscriptTitle":"Postoperative Mortality in Renal Cell Carcinoma with Vena Cava Thrombus in the Elderly Population (uroCCR study n°192)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-23 08:22:58","doi":"10.21203/rs.3.rs-7036412/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-21T10:32:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-17T16:12:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"58018654886128585455858021707083633881","date":"2025-08-17T14:35:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-06T13:41:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"19308236212737008690239205955293184870","date":"2025-07-21T18:44:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-17T08:52:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-05T06:21:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-05T06:12:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Urology","date":"2025-07-03T09:32:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"ccf70dd7-f573-44cc-be6e-efcd8379bdff","owner":[],"postedDate":"July 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-13T16:02:19+00:00","versionOfRecord":{"articleIdentity":"rs-7036412","link":"https://doi.org/10.1007/s00345-025-05998-3","journal":{"identity":"world-journal-of-urology","isVorOnly":false,"title":"World Journal of Urology"},"publishedOn":"2025-10-11 15:58:06","publishedOnDateReadable":"October 11th, 2025"},"versionCreatedAt":"2025-07-23 08:22:58","video":"","vorDoi":"10.1007/s00345-025-05998-3","vorDoiUrl":"https://doi.org/10.1007/s00345-025-05998-3","workflowStages":[]},"version":"v1","identity":"rs-7036412","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7036412","identity":"rs-7036412","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}