{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T13:34:14Z","timestamp":1781616854350,"version":"3.54.5"},"reference-count":98,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2026,3,26]],"date-time":"2026-03-26T00:00:00Z","timestamp":1774483200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Victor Babe\u0219 University of Medicine and Pharmacy Timi\u0219oara\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t              https:\/\/ror.org\/00afdp487"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Cancers"],"abstract":"<jats:p>Background\/Objectives: Renal cell carcinoma (RCC) with venous tumor thrombus (VTT) extending into the inferior vena cava (IVC) occurs in 4\u201310% of patients and represents one of the most technically demanding scenarios in urologic surgery. Open radical nephrectomy with en bloc thrombectomy remains the gold standard for infradiaphragmatic disease (Mayo Levels 0\u2013III), offering the only realistic prospect for long-term cure. This narrative review provides a technically oriented, evidence-based guide for surgical urologists managing these complex cases. Methods: PubMed\/MEDLINE, Scopus, and Web of Science were searched (1970\u2013March 2025) using terms related to RCC, venous tumor thrombus, IVC thrombectomy, and perioperative management. Priority was given to prospective studies, systematic reviews, large retrospective cohorts, and current guidelines (EAU 2025, NCCN v2.2024). Original intraoperative photographs supplement procedural descriptions. Results: We detail the complete perioperative pathway: VTT classification (Mayo\/AJCC), multimodal imaging, patient optimization, and level-specific open surgical techniques\u2014ranging from Satinsky clamping for Level 0\u2013I thrombi to full piggyback liver mobilization with hepatic vascular exclusion for Level III disease. Contemporary perioperative mortality is &lt;2% at high-volume centers (reported in single and multicenter retrospective series from high-volume institutions), with 5-year cancer-specific survival of approximately 50\u201360% in non-metastatic cases. Adjuvant pembrolizumab is now a standard of care following the KEYNOTE-564 trial. Neoadjuvant immune checkpoint inhibitor plus tyrosine kinase inhibitor combinations show promising VTT downstaging rates (44\u2013100%), though their role remains investigational. Robotic-assisted thrombectomy demonstrates favorable perioperative outcomes for Level I\u2013II thrombi at experienced centers. Conclusions: Open surgery remains the cornerstone of curative treatment for RCC with infradiaphragmatic VTT, requiring meticulous preoperative planning and multidisciplinary collaboration at high-volume centers. Integration of perioperative systemic therapies and robotic-assisted approaches holds promise for further improving outcomes in this challenging patient population.<\/jats:p>","DOI":"10.3390\/cancers18071080","type":"journal-article","created":{"date-parts":[[2026,3,26]],"date-time":"2026-03-26T15:10:24Z","timestamp":1774537824000},"page":"1080","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Open Surgical Management of Renal Cell Carcinoma with Infradiaphragmatic Venous Tumor Thrombus (Mayo Levels 0\u2013III): The Epitome of Surgical Self-Reliance in Urology"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2520-7636","authenticated-orcid":false,"given":"Dorin","family":"Novacescu","sequence":"first","affiliation":[{"name":"Department II of Microscopic Morphology, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adelina","family":"Baloi","sequence":"additional","affiliation":[{"name":"Doctoral School, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania"},{"name":"Department X\u2014Surgery II, Discipline Anesthesia and Intensive Care, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Silviu","family":"Latcu","sequence":"additional","affiliation":[{"name":"Doctoral School, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania"},{"name":"Department XV, Discipline of Urology, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5755-179X","authenticated-orcid":false,"given":"Flavia","family":"Zara","sequence":"additional","affiliation":[{"name":"Department II of Microscopic Morphology, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dorel","family":"Sandesc","sequence":"additional","affiliation":[{"name":"Department X\u2014Surgery II, Discipline Anesthesia and Intensive Care, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8933-3060","authenticated-orcid":false,"given":"Cristina-Stefania","family":"Dumitru","sequence":"additional","affiliation":[{"name":"Department II of Microscopic Morphology, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cristian","family":"Condoiu","sequence":"additional","affiliation":[{"name":"Doctoral School, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Razvan","family":"Bardan","sequence":"additional","affiliation":[{"name":"Department XV, Discipline of Urology, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-0140-701X","authenticated-orcid":false,"given":"Vlad","family":"Dema","sequence":"additional","affiliation":[{"name":"Doctoral School, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania"},{"name":"Department XV, Discipline of Urology, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Radu","family":"Caprariu","sequence":"additional","affiliation":[{"name":"Department XV, Discipline of Radiology and Medical Imaging, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6567-4407","authenticated-orcid":false,"given":"Talida Georgiana","family":"Cut","sequence":"additional","affiliation":[{"name":"Department XIII, Discipline of Infectious Diseases, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alin","family":"Cumpanas","sequence":"additional","affiliation":[{"name":"Department XV, Discipline of Urology, Victor Babes University of Medicine and Pharmacy Timisoara, E. 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