Minimally Invasive Surgical Techniques for Renal Cell Carcinoma with Intravenous Tumor Thrombus: A Systematic Review of Laparoscopic and Robotic-Assisted Approaches

Minimally Invasive Surgical Techniques for Renal Cell Carcinoma with Intravenous Tumor Thrombus: A Systematic Review of Laparoscopic and Robotic-Assisted Approaches | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 21 March 2025 V1 Latest version Share on Minimally Invasive Surgical Techniques for Renal Cell Carcinoma with Intravenous Tumor Thrombus: A Systematic Review of Laparoscopic and Robotic-Assisted Approaches Authors : Yiting Wu 0000-0001-7997-741X , Shuyang Feng , and Ping Fu [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.174254416.64126585/v1 Published Current Oncology Version of record Peer review timeline 168 views 118 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Introduction: Locally advanced renal cell carcinoma (RCC) with intravenous tumor thrombus (IVTT) represents 4-10% of renal tumors. This review assesses the safety and outcomes of minimally invasive techniques, specifically laparoscopic (LAP) and robotic-assisted (RA) methods, for treating RCC with IVTT. Methods: A literature search across several databases identified 54 studies (42 case series, 12 cohort studies) for analysis. Perioperative outcomes, including operative time, blood loss, transfusion rates, length of stay, and complications, were compared based on IVTT levels. Results: LAP and RA techniques were feasible for low-level IVTT, showing similar perioperative results. RA outperformed LAP in high-level IVTT with shorter operative times and lower blood loss and transfusion rates, despite managing more complex cases. RA maintained stable cancer-specific mortality (CSM) and metastasis rates, whereas LAP exhibited higher rates in high-level cases. Both techniques had low local recurrence rates. Conclusion: RA may be a superior option for RCC with IVTT, especially in high-level cases, but data comes mainly from specialized centers, signaling a need for multicenter validation and standardized criteria. Long-term outcomes require further study to assess RA’s non-inferiority to LAP. Introduction Locally advanced renal cell carcinoma (RCC) with intravenous tumor thrombus (IVTT) accounts for 4-10% of renal tumor patients[1]. A recent study reported that improved treatment of advanced renal cell carcinoma appears to be responsible for survival rise, with a rate of stage III RCC of 8.3% during 2004-2015 in the National Cancer Data Center.[2] Aggressive surgical management, including radical nephrectomy (RN) and intravenous tumor thrombectomy (IVTTx), was recommended for well-selected patients with locally advanced RCC and IVTT by the latest guidelines from the European Association of Urology (EAU).[3] Although with different details, the current National Comprehensive Cancer Network (NCCN) clinical practice guidelines also preferred this surgical principle[4]. It is widely accepted that the extent of IVTT basically determines the choice of surgical approach and technique.[3, 4] Surgical management for RCC patients with tumor thrombus has always been one of the challenges in the field of urology. Once, open surgery was the only default approach for RCC with VTT.[5] Nevertheless, along with the considerable advances in laparoscopic and robotic techniques, minimally-invasive surgery has emerged as an acceptable option for complicated RCC patients due to its minimally invasive feature. Meanwhile, due to its specific ethics and paucity of control, almost all evidence on minimally-invasive techniques for these patients is rather heterogeneity and of low level, which makes the optimal patient selection criteria for minimally-invasive surgery still to be elucidated.[6] Diverse minimally-invasive techniques applied to RCC WITH IVTT emerge dramatically, and are boldly combined with technologies from other departments, including perioperative renal artery embolization, IVC filters and even cardiopulmonary bypass.[7] In addition, thanks to researchers’ pioneering techniques for laparoscopic and robotic management of renal tumor with high-level tumor thrombi, the indications of minimally-invasive surgery for these patients are expected to be further expanded. Our goal is to provide a comprehensive experience with laparoscopic (LAP) and robotic-assisted (RA) minimally invasive surgical techniques in patients with locally advanced RCC with IVTT. Meanwhile, we also performed a systematic review to compare the safety and feasibility of RA as regards the perioperative and oncological outcomes between RA and LAP, focusing on high- and low-level IVTT respectively. Search strategy To identify relevant studies for this systematic review, we performed a comprehensive search across multiple electronic databases, including MEDLINE (via PubMed), EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science (WoS). The initial search was conducted in 2020, with regular updates performed to include the latest studies up to 2024. The search strategy employed both controlled vocabulary (e.g., MeSH terms in PubMed) and free-text terms to account for variations in terminology. Boolean operators (AND, OR) were used to combine the search terms, ensuring comprehensive coverage. Key search concepts included: ”renal cell carcinoma,” ”kidney neoplasm,” ”intravenous tumor thrombus,” ”thrombosis,” ”laparoscopy,” ”hand-assisted laparoscopy,” and ”robotic surgical procedures” (Supplementary Text File). Inclusion criteria Study eligibility was assessed using a pre-specified framework based on population (P), intervention (I), comparator (C), outcome (O), and study design (S) (PICOS)[8]. Studies that did not sufficiently report these PICOS criteria were excluded from the review. The eligible study designs included case series and cohort studies. All relevant case reports were excluded due to concerns over potential publication bias. Systematic review process The systematic review followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement[9]. All identified studies (N=10,843.) were imported into EndNote (Clarivate, PA, USA) for screening and de-duplication (N=2789.). Two reviewers (Y.W., S.F.) independently screened the titles and abstracts of 2,789 records, with disagreements resolved by a third reviewer (P.F.), who oversaw the review process. After excluding book chapters, editorials, conference abstracts, preclinical studies, studies on cadaveric models, previous reviews, and articles unrelated to the primary endpoints, 84 articles were assessed for eligibility. Of these, 54 studies that met all PICOS criteria were selected for qualitative analysis. The PRISMA flowchart illustrating the review process is shown in Figure1. Data were independently extracted by two authors (Y.W. and S.F.) using a pre-developed extraction form encompassing all elements of the PICOS framework. Risk of bias (ROB) assessments for cohort studies and case series were conducted independently by the same authors, following the Newcastle-Ottawa Scale[10] (NOS) and the Institute of Health Economics Delphi Tool (IHE-Delphi Tool) (Supplementary Table Ⅰ). Disagreements were resolved by a third reviewer (P.F.). The overall quality of evidence was evaluated according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidelines[11] by Y.W. and S.F., with discrepancies adjudicated by P.F. (Supplementary Table Ⅱ). A narrative synthesis was employed for the qualitative data. Statistical analysis Due to the absence of fully controlled studies, we combined the effect sizes of various outcomes into high-grade and low-grade categories to compare the efficacy of the two methods. Studies with missing values were excluded. For continuous variables, both fixed-effect and random-effect models were applied, with the variance components for random effects estimated using restricted maximum likelihood (REML). For dichotomous variables, single-group proportion meta-analysis was performed to pool event proportions (e.g., complication rates) across multiple studies. Heterogeneity between studies was evaluated using the I² and Q statistics. All statistical analyses and forest plots were generated using R and RStudio. Results Characteristics of included studies The key characteristics of included studies in the review are shown in Table I, II. Table I Key characteristics of studies on laparoscopic radical nephrectomy with inferior vena cava thrombectomy. Desai, 2003[12] case series LAP 16 57.8 3.3±6.5（3-4） ccRCC, pRCC, sRCC, gRCC 0: 16; invasive: 2 T3aN0M0:13 T4N0M0:3 Kapoor, 2006[13] case series LAP/HLAP 12 62.3 8(IQR=2) 0:12 Hammond, 2007[14] case series LAP 6 55.8 9.5(7.5-11.5) ccRCC, Other RCC 0:06 T3aNxM0:4 T3aNxM0:2 Steinnerd, 2007[15] case series LAP 5 59.8 5.5(4.6-6.0) ccRCC, pRCC 0: 5; invasive: 1 T3aN0M0:5 Martin, 2008[16] case series LAP/HLAP 14 65 7.3±2.2 ccRCC 0: 10; I: 3; II: 1 T3bNx Guzzo,2009[17] case series LAP 37 65 6(3.5-12) ccRCC, pRCC, sRCC 0:37 T3aN0M0:32 T3aN1+T3aNxM1:5 Liss, 2013[18] case series LAP 26 60.8 7.9±2.2 ccRCC, Other RCC 0:26 T3aNxM0 Bansal, 2014[19] case series LAP 41 64.4 9.3(4-22) ccRCC, pRCC, Other RCC 0: 39; I: 3 T3aNxM0:34 T3aNxM1:5 T3bNxM1:2 Wang(left), 2014[20] case series LAP 10 64 6.3(5.0-8.5) ccRCC(9), chRCC(1) 0:10 T3aN0M0:8 T3aN0M1:2 Wang(right), 2014[21] case series LAP 2 64.5 8.8±0.7(8.1-9.5) 0:02 T3bN0M0 Xu, 2014[22] cohort study LAP 17 50.1 7.9±2.6 0: 5; I: 12 T3aNxM0:5 T3bNxM0:12 Castillo, 2014[23] case series LAP/HLAP 11 66.8 10.5±2.5 ccRCC(10), ccRCC+sRCC(1) 0:11 T3aN0M0 Shao, 2015[24] case series LAP 11 53.5 7.8(6.5-9.3) ccRCC(10), pRCC(1) II: 6; IV: 5 T3bN0M0:9 T3bN1M0:2 Wang M, 2016[25] case series LAP 5 57 6.9(3.5-9) ccRCC II: 5 T3bN0M0 Crisan, 2018[26] case series LAP 9 61 7.6(5.5-10.5) ccRCC(8), sRCC(1) 0: 3; I: 3; II: 3 T3bN0M0:3 T3bN1M0:6 Cinar, 2019[27] case series LAP 13 61.6 9.5x7.3(5-14) ccRCC(11). pRCC(2) 0/I:11 ; II:2; invasive: 4 T3bN0M0:6 T3bN1M0:2 T3bN0M1:5 Tohi, 2019[28] case series LAP/HLAP 5 63 7.3(3.5-11) ccRCC I: 1; II: 3; III:1 T3aN0M0:1 T3bN0M0:1 T3cN0M0:3 Tian, 2020[29] case series LAP 78 59 8.3(IQR: 6.9-9.5) ccRCC(70), pRCC(7), chRCC(1) 0: 28; I: 27; II: 23 T3aNxM0+T3aNxM1:28 T3bN0M0+T3bNxM1:50 Zhao, 2020[30] cohort study LAP 58 61.2 7.9±2.3 ccRCC(52), Other RCC(6) 0: 22; I:23; II: 10; III: 3 T3a:22 T3b:33 T3c:3 Keranmu, 2021[31] case series LAP 3 56 ccRCC(3) 0: 1; I: 2 T3aN0M1; T3aN1M1; T4N0M0 Liu, 2021[32] cohort study LAP 17 52.2 8.1±3.4(3.5-11) ccRCC(12), pRCC(1), chRCC(1), other(3) II: 13; III:4 T3bNxMx=13; T3cNxMx=4 Liu, 2021[33] cohort study LAP 41 60.2 7.98±2.16 ccRCC(37), other(4) I: 26; II: 15 T3aN0M0+T3aN1M0:32 T3bN0M1+T3bN1M1:9 Ma,2021[34] case series LAP 11 57 7.20(IQR:6.00-10.50) ccRCC I: 6; II: 5 T3bN0M0=9; T3bN0M1=2 Chen, 2023[35] cohort study LAP 57 61 8.0 (M; IQR=6.1-9.9) ccRCC(48), pRCC(4), chRCC(1), other(4) I: 25; II: 29; III:3 T3bN0Mx=56; T3bNxM0=45 Scherñuk, 2023[36] cohort study LAP 15 61.9 9.00(M; IQR=6.50-11.90) ccRCC(13), pRCC(1), other(1) I: 7; II: 27; III:6 T3bNxMx=15; T3bN1Mx=3; T3bNxM1=4 Zhang, 2023[37] cohort study LAP 88 60 6.4(M; IQR=5.8-9.8) ccRCC(78), pRCC(9), chRCC(1), other(6) I: 20; II: 61; III:7; invasive: 21 T3a=15; T3b=39; T3c=36; T4=4; N1=54; M1=21 Varkarakis, 2004[38] case series HLAP 4 56 9(6-13) II: 4 T3bNx Henderson, 2008[39] case series HLAP 13 68.8 8.1(4.5-12) 0:13 T3aN0M0:12 T3aN1M0:1 Hoang, 2010[40] case series HLAP 7 66 9.1(5.7-12.8) II: 6; III: 1 T3bNxM0:5 T3bNxM1:1 T3cNxM0:1 Table II Key characteristics of studies on robotic radical nephrectomy with inferior vena cava thrombectomy . Ronney Abaza, 2010[41] case series ROB 5 64 10.4(7.8-15.5) I: 2, II: 3, T3bN1M0:4 T3bN1M1:1 Gill, 2015[42] case series ROB 16 66.2 9.7(6.5-19.5) II: 7, III: 9, invasive: 2 T3bN0M0: 28 T3bN1M0: 4 T3bN0M1: 4 Wang, 2015[43] case series ROB 17 61 M=5.8(4-10) I: 4, II: 3 T3bN0M0:16 T3bN1M0:2 T3bN0M1:1 Abaza, 2016[44] case series ROB 32 63 9.6(5.4-20) I/II: 30, III: 2 Kundavaram, 2016[45] case series ROB 5 59.3 8.0(5.5-9.5) ccRCC(3),pRCC(1)Collecting duct CA(1) II: 1, III: 3, invasive: 1 T3cN1Mx:1 T3cN0Mx:2 T4N2M0 T3cN0Mx Chopra, 2016[46] case series ROB 24 64 8.5（5.3-19.5） ccRCC(23),pRCC(1) II: 13, IV: 1 T3b:19 T3c:3 T4:3 TxN1Mx:3 TxNxM1:5 Davila, 2016[47] case series ROB 10 55.6 1.9-11 Gu, 2017[48] cohort study ROB 31 55.7 7.3(SD=3.0) ccRCC(26),pRCC(3),Other(2) I: 10, II: 21 T3bN0Mx:29 T3bN1Mx:2 Wang, 2017[49] case series ROB 22 58.5 7.8(2.5-15.0) ccRCC(16),pRCC(2),Other(4) II: 20, III: 2, invasive: 3 T3bN0M0:17 T3bN0M1:4 T3cN0M1:1 Ke, 2018[50] case series ROB 6 57 7.2(3.2-8.4) ccRCC(4),pRCC(1),Other(1) 0: 3, I: 1, II: 2, T3aN0M0:3 T3bN0M0:1 T3bN1M0:1 T3bN0M1:1 Fan, 2019[51] case series ROB 15 62 M=8.1(3-10) ccRCC(4),pRCC(1),Collecting duct CA(1) 0:15 T3aN0M0:5 T3aN1Mx:1 T4NxM0:2 T3aNxM1:2 T3aN0M0:4 T3aN1M0:1 Rose, 2019[52] cohort study ROB 24 ccRCC(20),Other(4) I: 2, II: 22 T3bNxM0:19 T3bNxM1:5 Du, 2020[53] case series ROB 7 58 9.2(6.0-15.0) ccRCC(5),pRCC(2) II: 5, III: 2, invasive: 5 T3bN0M0:2 T3cN0M0:5 Kishore, 2020[54] case series ROB 13 56.5 9.25 ccRCC(12),pRCC(1) I: 5, II: 7, III: 1, T3aN0M0:1 T3bN0M0:8 T3bN1M0:2 T3bN0M1:2 Shen, 2020[55] case series ROB 27 60.3 III: 14, IV: 13 T3bNxMx:4 T3cNxMx:7 T4NxMx:1 T3bNxMx:5 T3cNxMx:8 T4NxMx:2 Shen, 2020[56] case series ROB 120 54.1 7.9(SD=3.1) ccRCC(81),pRCC(14),Other(25) I: 30, II: 74, III: 14, IV: 2 T3b:93 T3c:23 T4:4 Nx:70 N0:35 N1:15 M0:107 M1:13 Shi, 2020[57] case series ROB 90 54 8.6(2.5-19.0) ccRCC(77), pRCC(13) II: 90, invasive: 18 T3b+T3c:14 T4:17 TxN1Mx:4 TxNxM1:6 T3b+T3c:59 T4:1 TxN1Mx:8 TxNxM1:6 Wang, 2020[58] case series ROB 13 57.5 8.2(SD=4.3) ccRCC III: 7, IV: 6 T3bN0M0:4 T3bN1M0:1 T3cN0M0:7 T4N0M1:1 Ma, 2021[59] case series ROB 20 59 67 cm2 (IQR: 40-91 cm2) ccRCC(9), other(11) 0: 2, I: 3, II: 12, III: 3, invasive: 1 T3aNxM0:2; T3bNxM0:13; T3cNxM0:3; T4NxM0: 2 Wu, 2021[60] cohort study ROB 35 58 6.9 (IQR:3.-7.2) ccRCC(28), other(7) 0:, I: 10, II: 25 T3bN0M0=14; T3bN1M0=2 T3bN0M0=15; T3bN1M0=3; T3bN0M1=1 Miyake et, 2022[61] case series ROB 2 67.5 3.8(range=3-4.6; SD=0.8) ccRCC(2) 0:02 T3aN0M0=2 Morgan, 2022[62] case series ROB 45 64.9 4.3(range=NA; SD=1.3) ccRCC(41); pRCC(2); other(2) 0:45 T3aN0M0=45 Zhao, 2022[63] cohort study ROB 18 55.3 8.9(range=NA; SD=2.9) ccRCC(15); pRCC(1); other(2) III: 10, IV: 8 T3bNxMx=10; T4NxMx=1 or T3NxM1=1 T3cNxMx=7 Zhang, 2023[37] case series ROB 30 60 7.3（M; range=NA; IQR=6.1-8.7) ccRCC (23), pRCC(3), other(4) II: 28, III: 2, invasive: 13 T3bNxMx=8; T3cNxMx=7; T3N1Mx=3; T3NxM1=4 T3bNxMx=8; T3cNxMx=7; T3N1Mx=3; T3NxM1=7 Zhang, 2023[64] cohort study ROB 22 58 6.5(M; range=NA; IQR=5.8-9.6) ccRCC(21), pRCC(1) I: 5, II: 15, III: 2, IV:, invasive: 4 T3a=5; T3b=10; T3c=7; N1=13; M1=6 In total, 54 studies were included, either as case series (N.=42) or retrospective cohort studies (N.=12). No case reports were included in the review due to potential publication bias and low quality of evidence. 29 studies including 632 patients who underwent laparoscopic radical nephrectomy and IVTT thrombectomy were included in the LAP group as per Table 1. Most of them were case series (N.=22). Pure laparoscopic surgeries were performed in most studies, only a few studies (N.=7) involved hand-assisted laparoscopic techniques. The number of patients included in the studies ranged from 3 to 88. Most included patients were with right-sided renal tumor (63.9%, 404/632). Most patients had a low-level tumor thrombus (95.3%, 602/632) counting 244, 170 and 188 patients with level 0, 1 and 2 tumor thrombi respectively. Histology was clear cell RCC (ccRCC) in most cases, of which papillary renal carcinoma (pRCC) contributed to the second most common histology. T3b was most common tumor pathological stage in included studies. 25 studies including 673 patients who underwent robotic-assisted radical nephrectomy and IVTT thrombectomy were included in the RA group as per Table 2. Most of them were case series (N.=20). The number of patients included in the studies ranged from 2 to 120. Patients with right-sided renal tumor (72.1%, 485/673) prevailed in them. Most patients had a low-level tumor thrombus (83.2%, 560/673), patients with level 2, 1 and 3 tumor thrombi ranked the top three among them (58.5%/13.2%/12.5%, 394/89/84). Histology was ccRCC in most cases, pRCC also ranked the second most common histology, while the histopathological analysis was not reported in 8 studies. pT3b was the main pathological stage in most studies, whereas more advanced stages like pT3c or pT4 were also reported in 20 of them. Overall, a hand-assisted laparoscopic approach was used in 7 studies in LAP group. In LAP studies, transperitoneal approach was performed in most series whilst retroperitoneal approach was also reported in 12 latest studies, of which two studies revealed combined approaches for complex cases. In RA studies, transperitoneal approach was performed in most, and 1 study reported a combined approach. Most studies in LAP series focused on the management of right-sided tumor with low-level IVTT, especially level 0. Pure laparoscopic technique performed in high-level IVTT was reported in only 7 studies, notably, 3 studies included left-sided tumors with IVTT. Robotic-assisted management performed in patients with high-level IVTT was reported in 14 studies, in which four studies tried to extend the indication to level Ⅳ thrombi. Twenty-one studies in RA group included left-sided tumors with IVTT. Figure 2 depicts the number of studies on minimally invasive treatment of RCC with IVTT according to tumor side and the level of intravenous tumor thrombi. Comparison of RA and LAP across different levels of IVTT In accordance with the levels of IVTT involved, the studies in LAP and RA were categorized into High Level (level 0-Ⅱ thrombi) and Low Level (level Ⅲ-Ⅳ thrombi) groups, respectively. The perioperative outcomes we extracted for combination include estimated blood loss (EBL), operative time (OR time), transfusion rate, conversion, length of stay (LOS), perioperative complications, cancer specific mortality (CSM), distant metastasis and local recurrence. In the LAP, 8 eligible studies were categorized into the High Level, and 23 into the Low Level, with the aforementioned data extracted for pooled analysis. In two of the studies, data were repeatedly classified into two separate categories because they included two distinct cohorts, each of which could be independently assigned to a different category. Similarly, in the RA, 14 and 9 eligible studies were categorized into the High Level and Low Level groups, respectively, and the same data were extracted. It is worth noting that not all eligible studies were applicable or clearly reported all perioperative outcomes. Thus, the number of eligible studies may vary across different pooled analyses. Operative time Of the 33 eligible studies, 10 and 5 studies from the RA group were categorized as High Level and Low Level, respectively, while 5 and 13 studies from the LAP group were categorized as High Level and Low Level, respectively. (Figure3A) Combined median operative time was 154.89 minutes (range: 108.30-256.00 minutes; weight range: 0.4-43.4%; I² = 45%) for the Low Level LAP group compared to 201.25 minutes (range: 130.00-268.00 minutes; weight range: 4.0-43.1%; I² = 34%) for the RA group, based on a common effect model. Combined median operative time was 280.48 vs 225.29 minutes for the High Level from LAP vs RA (range: 249.00-345.90 vs 134.00-540.00 minutes; weight range: 2.1-35.8% vs 0.9-33.8%; I 2 = 56% vs 27%). Estimated blood loss Of the 31 eligible studies, 10 studies were categorized as High Level and 5 as Low Level in the RA group, while in the LAP group, 3 studies were categorized as High and 13 as Low Level. (Figure3B) Combined median EBL was 140.15 vs 155.67 mL for the Low Level from LAP vs RA based on common effect model (range: 83.00-400.00 vs 31.50-1500.00 mL; weight range: 0.2-34.4% vs 0.4-35.0%; I 2 = 19% vs 26%). While for High Level, combined median EBL was 353.25 vs 408.71 mL for LAP vs RA (range: 200.00-500.00 vs 250.00-2750.00 mL; weight range: 21.6-46.5% vs 0.1-35.3%; I 2 = 58% vs 39%). Transfusion rate Of the 51 eligible studies, 14 studies were categorized as High Level and 8 as Low Level in the RA group, while in the LAP group, 8 studies were categorized as High and 23 as Low Level. Notably, 2 studies from LAP group were classified in both categories with distinct cohorts. (Figure6A) Combined proportion of perioperative transfusion of blood was 0.19 vs 0.12 for the Low Level from LAP vs RA based on a random effects model (range: 0.00-0.38 vs 0.00-0.77; weight range: 1.3-17.2% vs 8.1-15.2%; I 2 = 0.1% vs 0.84%). For High Level, it was 0.27 vs 0.39 for LAP vs RA (range: 0.00-1.00 vs 0.00-1.00; weight range: 7.7-17.8% vs 3.4-10.3%; I 2 = 0.72% vs 0.72%). Conversion rate Of the 51 eligible studies, 14 studies were categorized as High Level and 8 as Low Level in the RA group, while in the LAP group, 8 studies were categorized as High and 23 as Low Level, with duplication due to the aforementioned reason. (Figure5B) Combined proportion of conversion to open surgery was 0.10 vs 0.02 for the Low Level from LAP vs RA based on a random effects model (range: 0.00-0.65 vs 0.00-0.00; weight range: 2.8-10.2% vs 10.6-11.4%; I 2 = 0.42% vs 0.00%). For High Level, it was 0.09 vs 0.04 for LAP vs RA (range: 0.00-1.00 vs 0.00-0.11; weight range: 3.1-59.7% vs 3.9-24.6%; I 2 = 0.4% vs 0.0%). Length of stay Of the 30 eligible studies, 10 studies were categorized as High Level and 2 as Low Level in the RA group, while in the LAP group, 5 studies were categorized as High and 13 as Low Level. (Figure7A) Combined median LOS was 4.98 vs 4.98 days for the Low Level from LAP vs RA based on a common effect model (range: 1.90-8.00 vs 4.57-5.20; weight range: 0.0-98.5% vs 7.6-50.0%; I 2 = 67vs 56%). For High Level, it was 7.94 vs 7.32 for LAP vs RA (range: 5.00-10.90 vs 3.30-15.00; weight range: 0.1-89.9% vs 0.7-32.7%; I 2 =68% vs 34%). Minor perioperative complications rate (Clavien-Dindo Grade Ⅰ and Ⅱ) Of the 39 eligible studies, 8 studies were categorized as High Level and 8 as Low Level in the RA group, while in the LAP group, 5 studies were categorized as High and 20 as Low Level, with duplication due to the aforementioned reason. (Figure4A) Combined proportion of minor perioperative complications was 0.17 vs 0.13 for the Low Level from LAP vs RA based on a random effects model (range: 0.00-0.67 vs 0.00-0.50; weight range: 2.2-13.3% vs 6.4-17.0%; I 2 = 0.26% vs 0.71%). For High Level, it was 0.21 vs 0.32 for LAP vs RA (range: 0.00-0.80 vs 0.00-0.63; weight range: 12.5-33.6% vs 4.5-17.0%; I 2 = 0.55% vs 0.64%). Major perioperative complications rate (Clavien-Dindo Grade≥Ⅲ) Of the 39 eligible studies, 8 studies were categorized as High Level and 8 as Low Level in the RA group, while in the LAP group, 5 studies were categorized as High and 20 as Low Level, with duplication due to the aforementioned reason. (Figure4B) Combined proportion of major perioperative complications was 0.06 vs 0.06 for the Low Level from LAP vs RA based on a random effects model (range: 0.00-0.25 vs 0.00-0.43; weight range: 2.9-19.3% vs 8.5-18.9%; I 2 = 0.26% vs 0.74%). For High Level, it was 0.13 vs 0.15 for LAP vs RA (range: 0.00-0.43 vs 0.00-0.31; weight range: 10.1-30.2% vs 6.1-24.50%; I 2 = 0.58% vs 0.38%). Cancer specific mortality Of the 39 eligible studies, 8 studies were categorized as High Level and 8 as Low Level in the RA group, while in the LAP group, 5 studies were categorized as High and 20 as Low Level, with duplication due to the aforementioned reason. (Figure5A) Combined proportion of CSM was 0.08 vs 0.08 for the Low Level from LAP vs RA based on a random effects model (range: 0.00-0.17 vs 0.00-0.43; weight range: 2.7-21.6% vs 7.8-18.8%; I 2 = 0% vs 0.72%). For High Level, it was 0.23 vs 0.05 for LAP vs RA (range: 0.00-0.27 vs 0.00-0.09; weight range: 2.9-72.2% vs 7.7-44.6%; I 2 = 0% vs 0 %). Distant metastasis and local recurrence Of the 41 eligible studies, 8 studies were categorized as High Level and 8 as Low Level in the RA group, while in the LAP group, 5 studies were categorized as High and 20 as Low Level, with duplication due to the aforementioned reason. (Figure6B) Combined proportion of distant metastasis was 0.14 vs 0.18 for the Low Level from LAP vs RA based on a random effects model (range: 0.00-0.38 vs 0.00-0.63; weight range: 1.6-22.5% vs 0.0-17.4%; I 2 = 0% vs 0.8%). For High Level, it was 0.27 vs 0.15 for LAP vs RA (range: 0.00-0.38 vs 0.00-0.22; weight range: 4.7-53.9% vs 3.0-34.7%; I 2 = 0% vs 0%). Of the 41 eligible studies, 8 studies were categorized as High Level and 8 as Low Level in the RA group, while in the LAP group, 5 studies were categorized as High and 20 as Low Level, with duplication due to the aforementioned reason. (Figure6B) Combined proportion of local recurrence was 0.06 vs 0.06 for the Low Level from LAP vs RA based on a random effects model (range: 0.00-0.11 vs 0.00-0.35; weight range: 3.1-20.5% vs 8.8-20.4%; I 2 = 0% vs 0.69%). For High Level, it was 0.04 vs 0.03 for LAP vs RA (range: 0.00-0.01 vs 0.00-0.05; weight range: 14.0-34.0% vs 11.0-22.0%; I 2 = 0% vs 0%). Zhang et al conducted a comparative analysis of perioperative outcomes between 22 patients undergoing RA management and 148 patients undergoing LAP management, using a propensity-matched approach. Without stratification by IVTT level, they observed that patients managed with RA had significantly shorter operative times (median 134 min vs 289 min, P <0.001), less estimated blood loss (median 250 mL vs 500 mL, P <0.001), and a reduced rate of perioperative transfusion (36.4% vs 43.2%, P <0.001). However, no significant differences were found between the groups regarding perioperative complications or postoperative length of stay. Techniques for laparoscopic management Experience with Laparoscopy for Level 0-Ⅱ Thrombi The use of laparoscopy for managing level 0-Ⅱ inferior vena cava tumor thrombi (IVTT) has evolved significantly since the first hand-assisted laparoscopic surgery for right-sided renal cell carcinoma (RCC) with level I IVTT was reported by Sundaram et al. in 2002[65]. Desai et al. [12] introduced the ”thrombus milking” technique using an endoscopic stapler to remove intraluminal thrombi, while Varkarakis et al.[38] demonstrated the feasibility of hand-assisted laparoscopic surgery with Satinsky clamps for en bloc thrombus removal. Kapoor et al. [13] utilized intraoperative ultrasound to define thrombus margins, addressing the limited tactile feedback of laparoscopy. Early renal artery ligation, as described by Martin et al. [16], facilitated thrombus retraction and control in both pure and hand-assisted techniques. Guzzo et al. [66] emphasized the use of DeBakey graspers or Satinsky clamps to ensure thrombus-free renal vein transection. Liss et al. [67] pioneered laparoendoscopic single-site surgery for selected patients, while Bansal et al. [68] highlighted the benefits of early renal artery ligation in reducing tumor vascularity and thrombus retraction. Castillo et al. [23] employed a GelPort device for enhanced tactile feedback in complex cases. Wang et al. [20] introduced the pure retroperitoneal approach for left-sided RCC, enabling early renal hilar control and minimizing thrombus contact. For incomplete thrombus milking, Wang et al.[69] used partial IVC clamping and cold laparoscopic scissors for en bloc excision, preserving over 50% of the IVC lumen. Shao et al. [24] and Wang et al. [25] further refined techniques with bulldog clamps and modified Rummel tourniquets for precise IVC control and partial wall resection. Crisan et al. [26] combined retroperitoneal and transperitoneal approaches for complex cases, while Cinar et al. [70]used suction irrigation cannulas for thrombus milking. Tohi et al. [71] introduced an IVC semi-occlusion technique to minimize thrombus fragmentation risks. Tian et al. [72] reported successful outcomes in 58 patients using a pure retroperitoneal approach. Keranmu et al. [73] employed a transmesocolic approach for left-sided RCC, and Ma et al.[59] developed a modified vein clamping technique for level I-II thrombi. Liu et al. [32] introduced the Delayed Occlusion of the Proximal Inferior Vena Cava (DOPI) technique, utilizing pneumoperitoneum pressure to delay IVC clamping. Chen et al. [35] recently described the Pure Retroperitoneal Laparoscopic Peritoneum Incision Technique (PREP-IT) for improved IVC access in right-sided RCC. Experience with Laparoscopy for Level Ⅲ-Ⅳ Thrombi For high-level IVTT (Ⅲ-Ⅳ), Hoang et al. pioneered hand-assisted laparoscopic nephrectomy and thrombectomy for level Ⅲ thrombi, using intraoperative ultrasonography and extensive liver mobilization with IVC clamping[24]. Shao et al.[24] documented the first thoracoscope-assisted open atriotomy under cardiopulmonary bypass for level Ⅳ thrombi, involving femoral and jugular cannulation and intercostal port guidance. Tohi et al. [28] described liver rotation and the Pringle maneuver for level Ⅲ thrombi, while Liu et al.[32] applied the DOPI technique to avoid immediate IVC clamping. Chen et al.[35] extended the PREP-IT technique to level Ⅲ thrombi, and Scherñuk et al.[36] reported an adjustable IVC and hepatic vein control technique for cases without hepatic vein involvement. These advancements highlight the growing role of laparoscopy and robotic-assisted techniques in managing IVTT, with innovations in vascular control, thrombus extraction, and minimally invasive approaches improving surgical outcomes. Experience with Robot-Assisted Laparoscopy for Level 0-Ⅱ Thrombi Robot-assisted laparoscopy has become a significant advancement in managing level 0-Ⅱ IVTT. In 2010, Abaza[74] reported the first case series of robotic radical nephrectomy (RN) and IVC thrombectomy (IVTTx) for right-sided RCC with level I-II thrombi, utilizing a modified Rummel tourniquet for IVC cross-clamping and a percutaneous Satinsky clamp for tangential control. The robotic fourth arm was employed to retract the kidney, reducing thrombus length within the IVC. Gill et al.[42] introduced a ”minimal-touch” technique for level II thrombi, emphasizing a ”midline-first, lateral-last” strategy to minimize peri-caval tissue manipulation. Wang et al.[43] described side-specific techniques for left- and right-sided RCC, with preoperative renal artery embolization for left-sided cases to facilitate exposure and reduce blood loss. For right-sided RCC, clamping the left renal vein preserved venous return, while left-sided cases required right renal artery and vein clamping for full IVC control. Abaza et al.[44] further refined techniques using Satinsky clamps for low-level thrombi, while Kundavaram et al.[45] employed Fogarty balloon catheters for proximal IVC occlusion, avoiding liver mobilization. Gu et al.[48] managed IVC tributaries extensively in 31 cases, using Hem-o-lok clips and sutures for secure vascular control. Fan et al.[51] reported dual-positioning strategies for left-sided RCC with thrombi extending beyond the SMA, while Rose et al.[52] highlighted pure robotic RN and IVTTx in 24 cases. Du et al.[53] utilized 3D reconstruction for precise IVC resection in left-sided RCC with level II thrombi, preserving major collaterals. Shi et al.[57] reported selective robotic cavectomy or thrombectomy based on IVC wall invasion, employing tailored vascular stapling techniques. Zhang et al.[64] introduced the cephalic IVC non-clamping technique, using increased pneumoperitoneum pressure to control blood flow and minimize thrombus dislodgement. Experience with Robot-Assisted Laparoscopy for Level Ⅲ-Ⅳ Thrombi For high-level thrombi (Ⅲ-Ⅳ), Gill et al.[42] pioneered an ”IVC-first, kidney-last” strategy in 9 cases, prioritizing thrombus extraction and IVC repair before renal manipulation. Kundavaram et al.[45] described intracaval balloon occlusion and robotic biologic patch cavoplasty for complex level III thrombi, while Wang et al.[49] emphasized liver mobilization and short hepatic vein (SHV) ligation based on thrombus location relative to the first and second porta hepatis (FPH and SPH). Du et al.[53] and Wang et al.[58] extended these techniques to level III and IV thrombi, with cardiopulmonary bypass (CPB) for level IV cases and thoracoscopy-assisted thrombectomy for intra-atrial thrombi. Shen et al.[55] introduced a modified sequential vascular control strategy to enable early CPB cessation, while Ma et al.[59] used rubber vascular bands for sequential IVC clamping. Zhao et al.[63] reported a stepwise thrombus-lowering technique, reducing CPB duration by transitioning vascular control from CPB to suprahepatic and retrohepatic IVC control. These advancements demonstrate the efficacy and versatility of robot-assisted laparoscopy in managing complex IVTT, with innovations in vascular control, thrombus extraction, and minimally invasive approaches improving surgical outcomes. LAP: hand-assisted value still exsist? Kalra et al.[75] even suggested that hand-assisted management could be a viable option for complex cases like large renal masses or significant perirenal inflammation and demonstrated its feasibility as a bridge between pure laparoscopic and open surgery in early stages. Both Henderson et al .[76] and Martin et al .[77] emphasized that hand-assisted laparoscopic management provided superior tactile feedback compared to pure laparoscopic techniques, which facilitates achieving negative margins and better control of major hemorrhage without conversion to open surgery. Discussion Minimally invasive techniques, including laparoscopic and robot-assisted approaches, have become feasible for managing RCC with IVC tumor thrombi, offering superior perioperative outcomes and maintaining oncological safety [78, 79]. Over the past two decades, these techniques have evolved, but variability in outcomes highlights the need for comparative evaluation [49]. This review synthesizes perioperative data and surgical innovations to assess the relative advantages and limitations of laparoscopic and robot-assisted techniques. Perioperative Outcomes Operative Time : Laparoscopic techniques showed shorter times for low-level thrombi, while robot-assisted approaches had shorter times for high-level cases. Blood Loss and Transfusion : Minimal differences were observed for low-level thrombi, but robot-assisted techniques had higher transfusion rates for high-level cases, likely due to more level IV thrombi requiring cardiopulmonary bypass (CPB). Complications : Robot-assisted techniques had lower minor complication rates for low-level thrombi but increased rates for high-level cases. Major complications were similar across both approaches. Oncological Outcomes : Robot-assisted techniques showed stable cancer-specific mortality (CSM) and distant metastasis rates across thrombus levels, while laparoscopic techniques exhibited increased CSM and metastasis rates for high-level thrombi. Technical Advancements Laparoscopy : Hand-assisted techniques provided early tactile feedback, while innovations like DOPI IVC management and PREP-IT expanded capabilities for high-level thrombi. However, experience remains limited. Robot-Assisted Surgery : Replicating laparoscopic techniques, robotic surgery introduced innovations like intracaval balloon occlusion and detailed IVC control. For high-level thrombi, it often requires liver mobilization, CPB, and multidisciplinary collaboration, with growing experience in complex cases like double-thrombi and IVC reconstruction. Imaging and Expertise Preoperative and intraoperative imaging, such as intraluminal ultrasound and 3D reconstruction, play a critical role in surgical planning and decision-making. However, most studies originate from highly experienced single-center teams, raising questions about broader applicability and underscoring the need for multicenter studies. Limitations: Exclusion of case reports to reduce bias. Limited to English-language publications. Heterogeneity in data prevents direct comparisons, necessitating descriptive interpretation. Long-term oncological safety of robotic techniques remains understudied. Conclusions: The perioperative results and oncological outcomes of robotic surgery in all grades of IVTT were not inferior to those of laparoscopic surgery and were within an acceptable range. Robotic surgery is technically feasible for patients with RCC and IVC tumor thrombus and may be superior to laparoscopic surgery However, most of these robotic surgery cases come from a few senior surgeons. Therefore, there is still a long way to go in the training and promotion of robotic surgery for RCC patients with IVC tumor thrombus in urology. The evidence is currently insufficient to draw reliable conclusions about the long-term oncologic outcomes of this technique. Future research is needed to establish the non-inferiority of this strategy compared to laparoscopic surgery and to develop robust selection criteria as an initial step in assessing the reproducibility of robotic surgery beyond expert surgical teams. Contributions: Experimental design and investigation: Yiting Wu, Shuyang Feng；Execution of literature search and data collection: Shuyang Feng；Data analysis and interpretation: Yiting Wu, Shuyang Feng；Preparation of manuscript and editing: Yiting Wu, Shuyang Feng, Ping Fu. Conflict(s) of interest: The authors declare that there are no conflicts of interest regarding the publication of this systematic review. References: 1. Mathew, G., et al., STROCSS 2021: Strengthening the reporting of cohort, cross-sectional and case-control studies in surgery. Int J Surg, 2021. 96 : p. 106165.2. Patel, H.D., et al., Clinical Stage Migration and Survival for Renal Cell Carcinoma in the United States. Eur Urol Oncol, 2019. 2 (4): p. 343-348.3. B. Ljungberg (Chair), L.A., J. Bedke, A. Bex (Vice-chair), U. Capitanio, R.H. Giles (Patient Advocate), M. Hora, T. Klatte, T. Lam, L. Marconi, T. Powles, A. Volpe, EAU guidelines on renal cell carcinoma 2021. 2021.4. Motzer, R.J., et al., NCCN Guidelines® Insights: Kidney Cancer, Version 2.2024. J Natl Compr Canc Netw, 2024. 22 (1): p. 4-16.5. Lardas, M., et al., Systematic Review of Surgical Management of Nonmetastatic Renal Cell Carcinoma with Vena Caval Thrombus. Eur Urol, 2016. 70 (2): p. 265-80.6. Garg, H., et al., A Decade of Robotic-Assisted Radical Nephrectomy with Inferior Vena Cava Thrombectomy: A Systematic Review and Meta-Analysis of Perioperative Outcomes. J Urol, 2022. 208 (3): p. 542-560.7. Campi, R., et al., Techniques and outcomes of minimally-invasive surgery for nonmetastatic renal cell carcinoma with inferior vena cava thrombosis: a systematic review of the literature. Minerva Urol Nefrol, 2019. 71 (4): p. 339-358.8. Moher, D., et al., Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med, 2009. 6 (7): p. e1000097.9. Moher, D., et al., Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev, 2015. 4 (1): p. 1.10. Lo, C.K., D. Mertz, and M. Loeb, Newcastle-Ottawa Scale: comparing reviewers’ to authors’ assessments. BMC Med Res Methodol, 2014. 14 : p. 45.11. Guyatt, G., et al., GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol, 2011. 64 (4): p. 383-94.12. Desai, M.M., et al., Laparoscopic radical nephrectomy for cancer with level I renal vein involvement. J Urol, 2003. 169 (2): p. 487-91.13. Kapoor, A., et al., Laparoscopic management of advanced renal cell carcinoma with level I renal vein thrombus. Journal of Urology, 2006. 175 (4): p. 544-544.14. Hammond, L., T.M. Powell, and B.F. Schwartz, Pure laparoscopic radical nephrectomy for stage T(3b) renal-cell carcinoma: more than 2-year follow-up. J Endourol, 2007. 21 (4): p. 408-10.15. Steinnerd, L.E., I.Y. Vardi, and S.B. Bhayani, Laparoscopic radical nephrectomy for renal carcinoma with known level I renal vein tumor thrombus. Urology, 2007. 69 (4): p. 662-5.16. Martin, G.L., et al., Outcomes of laparoscopic radical nephrectomy in the setting of vena caval and renal vein thrombus: seven-year experience. J Endourol, 2008. 22 (8): p. 1681-5.17. Guzzo, T.J., et al., Laparoscopic radical nephrectomy for patients with pathologic T3b renal-cell carcinoma: the Johns Hopkins experience. J Endourol, 2009. 23 (1): p. 63-7.18. Liss, M.A., et al., Is laparoendoscopic single-site surgery a viable approach for radical nephrectomy with renal vein thrombus? Comparison with multiport laparoscopy. Urology, 2013. 82 (1): p. 105-10.19. Bansal, R.K., et al., Laparoscopic management of advanced renal cell carcinoma with renal vein and inferior vena cava thrombus. Urology, 2014. 83 (4): p. 812-6.20. Wang, W., et al., Pure retroperitoneal laparoscopic radical nephrectomy for left renal cell carcinoma with differential extensions of level I renal vein tumor thrombus. J Endourol, 2014. 28 (3): p. 312-7.21. Wang, W., et al., Pure retroperitoneal laparoscopic radical nephrectomy for right renal masses with renal vein and inferior vena cava thrombus. J Endourol, 2014. 28 (7): p. 819-24.22. Xu, B., et al., Laparoscopic versus open surgery for renal masses with infrahepatic tumor thrombus: the largest series of retroperitoneal experience from China. J Endourol, 2014. 28 (2): p. 201-7.23. Castillo, O., A. Silva, and E. Alemán, Laparoscopic management of renal tumors with macroscopic level 1 renal vein involvement. Urol Int, 2015. 94 (1): p. 88-92.24. Shao, P., et al., Laparoscopic Radical Nephrectomy and Inferior Vena Cava Thrombectomy in the Treatment of Renal Cell Carcinoma. Eur Urol, 2015. 68 (1): p. 115-22.25. Wang, M., et al., Feasibility of Pure Conventional Retroperitoneal Laparoscopic Radical Nephrectomy With Level II Vena Caval Tumor Thrombectomy. Urology, 2016. 90 : p. 101-4.26. Crisan, N., et al., Dual Combined Laparoscopic Approach for Renal-Cell Carcinoma with Renal Vein and Level I-II Inferior Vena Cava Thrombus: Our Technique and Initial Results. J Endourol, 2018. 32 (9): p. 837-842.27. Cinar, O., et al., Laparoscopic Transperitoneal Radical Nephrectomy for Renal Masses with Level I and II Thrombus. J Laparoendosc Adv Surg Tech A, 2019. 29 (1): p. 35-39.28. Tohi, Y., et al., En bloc laparoscopic radical nephrectomy with inferior vena cava thrombectomy: A single-institution experience. Int J Urol, 2019. 26 (3): p. 363-368.29. Tian, X., et al., En bloc retroperitoneal laparoscopic radical nephrectomy with inferior vena cava thrombectomy for renal cell carcinoma with level 0 to II venous tumor thrombus: A single-center experience. Cancer, 2020. 126 Suppl 9 : p. 2073-2078.30. Zhao, X., et al., PKUTHLP score: A comprehensive system to predict surgical approach in radical nephrectomy and thrombectomy. Oncol Lett, 2020. 20 (1): p. 201-208.31. Keranmu, A., et al., Feasibility of single position laparoscopic radical nephrectomy and tumor thrombectomy for left renal cell carcinoma with high-risk Mayo grade 0 and 1 tumor thrombus. BMC Urol, 2021. 21 (1): p. 181.32. Liu, Z., et al., Pure retroperitoneal laparoscopic radical nephrectomy and thrombectomy with delayed occlusion of the proximal inferior vena cava (DOPI) technique for renal tumor with level II-III venous tumor thrombus. BMC Cancer, 2021. 21 (1): p. 627.33. Liu, Z., et al., Completely laparoscopic versus open radical nephrectomy and infrahepatic tumor thrombectomy: Comparison of surgical complexity and prognosis. Asian J Surg, 2021. 44 (4): p. 641-648.34. Ma, J., et al., Modified vein clamping technique for renal cell carcinoma complicated with level I-II IVC thrombi: a study at a single centre. BMC Urol, 2021. 21 (1): p. 179.35. Chen, J., et al., Pure Retroperitoneal Laparoscopic Peritoneum Incision Technique in Right Nephrectomy and Inferior Vena Cava Tumor Thrombectomy: A Novel Surgical Technique and Long-Term Outcomes from a Large Chinese Center. J Endourol, 2023. 37 (9): p. 986-994.36. Scherñuk, J., et al., Renal Cell Carcinoma with Venous Extension: Safety of Laparoscopic Surgery for Thrombus Levels I-IIIa. J Endourol, 2023. 37 (7): p. 786-792.37. Zhang, Y., et al., Cephalic inferior vena cava non-clamping technique versus standard procedure for robot-assisted laparoscopic level II-III thrombectomy: a prospective cohort study. Int J Surg, 2023. 109 (6): p. 1594-1602.38. Varkarakis, I.M., et al., Laparoscopic-assisted nephrectomy with inferior vena cava tumor thrombectomy: preliminary results. Urology, 2004. 64 (5): p. 925-9.39. Henderson, A., et al., Hand-assisted laparoscopic nephrectomy for renal cell cancer with renal vein tumor thrombus. Urology, 2008. 72 (2): p. 268-72.40. Hoang, A.N., A.A. Vaporcyian, and S.F. Matin, Laparoscopy-assisted radical nephrectomy with inferior vena caval thrombectomy for level II to III tumor thrombus: a single-institution experience and review of the literature. J Endourol, 2010. 24 (6): p. 1005-12.41. Abaza, R., Initial series of robotic radical nephrectomy with vena caval tumor thrombectomy. Journal of Urology, 2010. 183 (4): p. e349.42. Gill, I.S., et al., Robotic Level III Inferior Vena Cava Tumor Thrombectomy: Initial Series. J Urol, 2015. 194 (4): p. 929-38.43. Wang, B., et al., Robot-assisted Laparoscopic Inferior Vena Cava Thrombectomy: Different Sides Require Different Techniques. Eur Urol, 2016. 69 (6): p. 1112-9.44. Abaza, R., et al., Multi-Institutional Experience with Robotic Nephrectomy with Inferior Vena Cava Tumor Thrombectomy. J Urol, 2016. 195 (4 Pt 1): p. 865-71.45. Kundavaram, C., et al., Advances in Robotic Vena Cava Tumor Thrombectomy: Intracaval Balloon Occlusion, Patch Grafting, and Vena Cavoscopy. Eur Urol, 2016. 70 (5): p. 884-890.46. Chopra, S., et al., Robot-assisted Level II-III Inferior Vena Cava Tumor Thrombectomy: Step-by-Step Technique and 1-Year Outcomes. Eur Urol, 2017. 72 (2): p. 267-274.47. Davila, V.J., et al., Robotic inferior vena cava surgery. J Vasc Surg Venous Lymphat Disord, 2017. 5 (2): p. 194-199.48. Gu, L., et al., Robotic versus Open Level I-II Inferior Vena Cava Thrombectomy: A Matched Group Comparative Analysis. J Urol, 2017. 198 (6): p. 1241-1246.49. Wang, B., et al., Robot-assisted Retrohepatic Inferior Vena Cava Thrombectomy: First or Second Porta Hepatis as an Important Boundary Landmark. Eur Urol, 2018. 74 (4): p. 512-520.50. Ke, X.W., et al., Robotic-assisted Laparoscopic Nephrectomy with Vein Thrombectomy: Initial Experience and Outcomes from a Single Surgeon. Curr Med Sci, 2018. 38 (5): p. 834-839.51. Fan, Y., et al., Robotic Radical Nephrectomy and Thrombectomy for Left Renal Cell Carcinoma with Renal Vein Tumor Thrombus: Superior Mesenteric Artery as an Important Strategic Dividing Landmark. J Endourol, 2019. 33 (7): p. 557-563.52. Rose, K.M., et al., Robot Assisted Surgery of the Vena Cava: Perioperative Outcomes, Technique, and Lessons Learned at The Mayo Clinic. J Endourol, 2019. 33 (12): p. 1009-1016.53. Du, S., et al., Initial Series of Robotic Segmental Inferior Vena Cava Resection in Left Renal Cell Carcinoma With Caval Tumor Thrombus. Urology, 2020. 142 : p. 125-132.54. Kishore, T.A., et al., Robot-assisted laparoscopic radical nephrectomy and inferior vena cava thrombectomy: A multicentre Indian experience. Arab Journal of Urology, 2020. 18 (2): p. 124-128.55. Shen, D., et al., A modified sequential vascular control strategy in robot-assisted level III-IV inferior vena cava thrombectomy: initial series mimicking the open ’milking’ technique principle. BJU Int, 2020. 126 (4): p. 447-456.56. Shen, D., et al., Cumulative Sum Analysis of the Operator Learning Curve for Robot-Assisted Mayo Clinic Level I-IV Inferior Vena Cava Thrombectomy Associated with Renal Carcinoma: A Study of 120 Cases at a Single Center. Med Sci Monit, 2020. 26 : p. e922987.57. Shi, T., et al., Robot-assisted Cavectomy Versus Thrombectomy for Level II Inferior Vena Cava Thrombus: Decision-making Scheme and Multi-institutional Analysis. Eur Urol, 2020. 78 (4): p. 592-602.58. Wang, B., et al., Robot-assisted Level III-IV Inferior Vena Cava Thrombectomy: Initial Series with Step-by-step Procedures and 1-yr Outcomes. Eur Urol, 2020. 78 (1): p. 77-86.59. Ma, S., et al., Case reports of robot-assisted laparoscopic radical nephrectomy and inferior vena cava tumor thrombectomy: A retrospective analysis. Medicine (Baltimore), 2021. 100 (33): p. e26886.60. Wu, S., et al., Robotic Retroperitoneal Versus Transperitoneal Inferior Vena Cava Thrombectomy: Right-Sided Cases with Level I-II Tumor Thrombus. J Endourol, 2021. 35 (10): p. 1498-1503.61. Miyake, H., et al., Initial experience of robot-assisted radical nephrectomy in Japan: Single institutional study of 12 cases. Asian J Endosc Surg, 2022. 15 (1): p. 162-167.62. Morgan, T.N., et al., Clinical Outcomes of Robotic Assisted Partial Nephrectomy for Pathologic T3a Renal Masses With Venous Tumor Thrombus. Urology, 2022. 159 : p. 120-126.63. Zhao, G.D., et al., Step-by-step and orderly lowering of the height of inferior vena cava tumor thrombus is the key to robot-assisted thrombectomy for Mayo III/IV tumor thrombus. BMC Cancer, 2022. 22 (1): p. 151.64. Zhang, Y., et al., Comparative analysis of surgical and oncologic outcomes of robotic, laparoscopic and open radical nephrectomy with venous thrombectomy: a propensity-matched cohort study. Int J Clin Oncol, 2023. 28 (1): p. 145-154.65. Sundaram, C.P., et al., Hand assisted laparoscopic radical nephrectomy for renal cell carcinoma with inferior vena caval thrombus. J Urol, 2002. 168 (1): p. 176-9.66. Guzzo, T.J., et al., Laparoscopic Radical Nephrectomy for Patients with Pathologic T-3b Renal-Cell Carcinoma: The Johns Hopkins Experience. Journal of Endourology, 2009. 23 (1): p. 63-67.67. Liss, M.A., et al., Is Laparoendoscopic Single-site Surgery a Viable Approach for Radical Nephrectomy With Renal Vein Thrombus? Comparison With Multiport Laparoscopy. Urology, 2013. 82 (1): p. 105-110.68. Bansal, R.K., et al., Laparoscopic Management of Advanced Renal Cell Carcinoma With Renal Vein and Inferior Vena Cava Thrombus. Urology, 2014. 83 (4): p. 812-816.69. Wang, L.H., et al., Robotic-assisted laparoscopic nephrectomy (right) combined with inferior vena caval thrombectomy for level II tumor thrombus: The first clinical case in China. Academic Journal of Second Military Medical University, 2014. 35 (7): p. 763-768.70. Cinar, O., et al., Laparoscopic transperitoneal radical nephrectomy for renal masses with level i and ii thrombus. Journal of Laparoendoscopic and Advanced Surgical Techniques, 2018. 29 (1): p. 35-39.71. Tohi, Y., et al., En bloc laparoscopic radical nephrectomy with inferior vena cava thrombectomy: A single-institution experience. International Journal of Urology, 2019. 26 (3): p. 363-368.72. Tian, X.J., et al., [Single-center study of laparoscopic radical nephrectomy with Mayo 0-2 level inferior vena cava thrombectomy]. Beijing Da Xue Xue Bao Yi Xue Ban, 2018. 50 (6): p. 1053-1056.73. Keranmu, A., et al., Single Position Laparoscopic Radical Nephrectomy and Tumor Thrombectomy for Left Renal Cell Carcinoma With High-Risk Mayo 0 Thrombus. Urology, 2022. 160 : p. 225-226.74. Abaza, R., Techniques for robotic nephrectomy with vena caval tumor thrombectomy. Journal of Endourology, 2010. 24 : p. A342.75. Kalra, P., et al., Outcomes of hand-assisted laparoscopic nephrectomy in technically challenging cases. Urology, 2006. 67 (1): p. 45-9.76. Henderson, A., et al., Hand-Assisted Laparoscopic Nephrectomy for Renal Cell Cancer with Renal Vein Tumor Thrombus. Urology, 2008. 72 (2): p. 268-272.77. Martin, G.L., et al., Outcomes of laparoscopic radical nephrectomy in the setting of vena caval and renal vein thrombus: Seven-year experience. Journal of Endourology, 2008. 22 (8): p. 1681-1685. Figure Legends: Figure 1. Flowchart illustrating the systematic literature search and study selection process for the review. The process followed the PRISMA guidelines and included four main stages: Identification: A total of 219 records (168 from database searches and 51 from additional sources) were identified. Screening: After removing duplicates, 2,789 records were screened based on titles and abstracts, resulting in 84 articles for full-text assessment. Eligibility: Of the 84 articles, 28 met the predefined PICOS criteria and were selected for qualitative analysis. Included: Ultimately, 58 studies (46 case series and 12 cohort studies) were included in the systematic review. The flowchart provides a detailed visual representation of the study selection process, highlighting the exclusion criteria and the final number of studies included for analysis. Figure 2. Schematic Illustration of Renal Cell Carcinoma (RCC) with Intravenous Tumor Thrombus (IVTT) Classification. Schematic representation of the Mayo classification for renal cell carcinoma (RCC) with intravenous tumor thrombus (IVTT). The illustration depicts the anatomical levels of tumor thrombus extension within the venous system, as follows: Level 0: Thrombus limited to the renal vein. Level I: Thrombus extending into the inferior vena cava (IVC) but ≤ 2 cm above the renal vein ostium. Level II: Thrombus extending into the IVC > 2 cm above the renal vein ostium but below the hepatic veins. Level III: Thrombus extending into the IVC above the hepatic veins but below the diaphragm. Level IV: Thrombus extending into the IVC above the diaphragm or into the right atrium. Figure 3. Forest plots summarizing the pooled effect sizes for perioperative outcomes, stratified A) Forest plot for operative time, comparing laparoscopic (LAP) and robotic-assisted (RA) approaches. The plot displays median operative times (in minutes) with 95% confidence intervals for low-grade and high-grade tumor thrombi. B) Forest plot for estimated blood loss (EBL), comparing LAP and RA approaches. The plot shows median EBL (in milliliters) with 95% confidence intervals for low-grade and high-grade tumor thrombi. Each plot includes heterogeneity statistics (I²) to assess variability across studies. Figure 4. Forest Plots of Pooled Effect Sizes for Perioperative Complications Stratified by Tumor Thrombus Level A) Forest plot for Clavien-Dindo Grade I-II (minor) complications, comparing laparoscopic (LAP) and robotic-assisted (RA) approaches. The plot displays the proportion of minor complications with 95% confidence intervals for low-grade and high-grade tumor thrombi. B) Forest plot for Clavien-Dindo Grade ≥ III (major) complications, comparing LAP and RA approaches. The plot shows the proportion of major complications with 95% confidence intervals for low-grade and high-grade tumor thrombi. Each plot includes heterogeneity statistics (I²) to assess variability across studies. Figure 5. Forest Plots of Pooled Effect Sizes for Oncological and Surgical Outcomes Stratified by Tumor Thrombus Level. Forest plots summarizing the pooled effect sizes for oncological and surgical outcomes, stratified by low-grade (Mayo levels 0-II) and high-grade (Mayo levels III-IV) tumor thrombi. A) Forest plot for cancer-specific mortality (CSM), comparing laparoscopic (LAP) and robotic-assisted (RA) approaches. The plot displays the proportion of cancer-specific mortality with 95% confidence intervals for low-grade and high-grade tumor thrombi. B) Forest plot for conversion rates, comparing LAP and RA approaches. The plot shows the proportion of cases converted to open surgery with 95% confidence intervals for low-grade and high-grade tumor thrombi. Each plot includes heterogeneity statistics (I²) to assess variability across studies. Figure 6. Forest Plots of Pooled Effect Sizes for Transfusion Rates and Distant Metastasis Stratified by Tumor Thrombus Level. Forest plots summarizing the pooled effect sizes for transfusion rates and distant metastasis, stratified by low-grade (Mayo levels 0-II) and high-grade (Mayo levels III-IV) tumor thrombi. A) Forest plot for transfusion rate s , comparing laparoscopic (LAP) and robotic-assisted (RA) approaches. The plot displays the proportion of patients requiring blood transfusions with 95% confidence intervals for low-grade and high-grade tumor thrombi. B) Forest plot for distant metastasis rates, comparing LAP and RA approaches. The plot shows the proportion of patients developing distant metastasis with 95% confidence intervals for low-grade and high-grade tumor thrombi. Each plot includes heterogeneity statistics (I²) to assess variability across studies. Figure 7. Forest Plots of Pooled Effect Sizes for Length of Stay and Local Recurrence Stratified by Tumor Thrombus Level. Forest plots summarizing the pooled effect sizes for length of stay (LOS) and local recurrence rates, stratified by low-grade (Mayo levels 0-II) and high-grade (Mayo levels III-IV) tumor thrombi. A) Forest plot for length of stay (LOS), comparing laparoscopic (LAP) and robotic-assisted (RA) approaches. The plot displays the median length of hospital stay (in days) with 95% confidence intervals for low-grade and high-grade tumor thrombi. B) Forest plot for local recurrence rates, comparing LAP and RA approaches. The plot shows the proportion of patients experiencing local recurrence with 95% confidence intervals for low-grade and high-grade tumor thrombi. Each plot includes heterogeneity statistics (I²) to assess variability across studies. Information & Authors Information Version history V1 Version 1 21 March 2025 Peer review timeline Published Current Oncology Version of Record 28 Apr 2025 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Authors Affiliations Yiting Wu 0000-0001-7997-741X Sichuan University West China Hospital Department of Nephrology View all articles by this author Shuyang Feng Sichuan University West China Hospital Department of Urology View all articles by this author Ping Fu [email protected] Sichuan University West China Hospital Department of Nephrology View all articles by this author Metrics & Citations Metrics Article Usage 168 views 118 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Yiting Wu, Shuyang Feng, Ping Fu. Minimally Invasive Surgical Techniques for Renal Cell Carcinoma with Intravenous Tumor Thrombus: A Systematic Review of Laparoscopic and Robotic-Assisted Approaches. Authorea . 21 March 2025. DOI: https://doi.org/10.22541/au.174254416.64126585/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . Format Please select one from the list RIS (ProCite, Reference Manager) EndNote BibTex Medlars RefWorks Direct import Tips for downloading citations document.getElementById('citMgrHelpLink').addEventListener('click', function() { popupHelp(this.href); return false; }); $(".js__slcInclude").on("change", function(e){ if ($(this).val() == 'refworks') $('#direct').prop("checked", false); $('#direct').prop("disabled", ($(this).val() == 'refworks')); }); View Options View options PDF View PDF Figures Tables Media Share Share Share article link Copy Link Copied! Copying failed. Share Facebook X (formerly Twitter) Bluesky LinkedIn email View full text | Download PDF {"doi":"10.22541/au.174254416.64126585/v1","type":"Article"} Now Reading: Share Figures Tables Close figure viewer Back to article Figure title goes here Change zoom level Go to figure location within the article Download figure Toggle share panel Toggle share panel Share Toggle information panel Toggle information panel Go to previous graphic Go to next graphic Go to previous table Go to next table All figures All tables View all material View all material xrefBack.goTo xrefBack.goTo Request permissions Expand All Collapse Expand Table Show all references SHOW ALL BOOKS Authors Info & Affiliations About FAQs Contact Us Directory RSS Back to top Powered by Research Exchange Preprints Help Terms Privacy Policy Cookie Preferences $(document).ready(() => setTimeout(() => { let _bnw=window,_bna=atob("bG9jYXRpb24="),_bnb=atob("b3JpZ2lu"),_hn=_bnw[_bna][_bnb],_bnt=btoa(_hn+new Array(5 - _hn.length % 4).join(" ")); $.get("/resource/lodash?t="+_bnt); },4000)); (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'9fe6e11baa5bdfa9',t:'MTc3OTIzMzMyMA=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();