Outcomes of Open Radical Nephrectomy for Advanced Renal Malignant Tumors in the Minimally Invasive Era: Findings From a Single Institution Over 17 Years

Background and objective There has been a growing shift toward minimally invasive surgical approaches, including laparoscopic and robotic techniques, in the management of renal tumors. However, many centers are still performing open surgery for large or complex tumors, particularly those with nodal or vascular invasion, due to concerns about oncologic adequacy and technical limitations. This cohort study discusses the experience at a single institution over 17 years with cases where the urology multidisciplinary team (MDT) reached a consensus to proceed with open surgery electively for optimal oncologic control, especially in patients with high-risk or anatomically challenging disease. Methods A retrospective review was conducted of 105 patients who underwent open radical nephrectomy (ORN; including nephroureterectomy) with either curative or cytoreductive intent between January 2007 and June 2024. Data collected included tumor size, clinical stage, nodal status, venous involvement, perioperative outcomes, disease-specific survival (DSS), and overall survival (OS). Preoperative intervention entailing renal arterial embolization was also recorded. Results The median tumor size was 10.7 cm, with 69 patients (66%) having tumors ≥10 cm. Locally advanced disease (T3-T4) was present in the majority of cases. Inferior vena cava (IVC) tumor thrombus was identified in 21 patients (20%), while 47 patients (45%) had renal vein thrombus. Clinically positive lymph nodes (cN1) were seen in 40 patients (38%), with pathological confirmation available in a subset. Lymphadenectomy was performed in 51 patients (49%), and IVC thrombectomy in 22 patients (21%). Preoperative embolization was used in 14 patients (13.3%) to facilitate vascular control. No patients received neoadjuvant systemic therapy. Major complications (Clavien-Dindo grade ≥III) were observed in 4% of patients, with 30-day mortality in three cases. Survival outcomes were assessed using Kaplan-Meier analysis. Conclusions ORN continues to be performed for large, node-positive renal tumors and those with vascular-invasive features. Despite the advances in minimally invasive surgery (MIS), open surgery continues to offer critical advantages in exposure, vascular control, and complete tumor resection. Surgical proficiency in open techniques must be maintained within a multidisciplinary urologic oncology practice.