Clinical characteristics, surgical pathways, and outcomes of upper tract urothelial carcinoma with venous tumor thrombus: a multicenter retrospective study with a predominantly robotic approach

Upper tract urothelial carcinoma (UTUC) with venous tumor thrombus is exceedingly rare and highly aggressive, and its anatomical complexity poses major surgical challenges in the absence of standardized operative strategies. We retrospectively reviewed UTUC patients who underwent radical nephroureterectomy with thrombectomy at the First and Third Medical Centers of the Chinese PLA General Hospital. Baseline, perioperative, and pathological data were collected. Overall survival (OS), disease-free survival (DFS), perioperative renal function, and the applicability of the Mayo and “301” classifications were evaluated. By August 2024, 11 patients (7 men; 60.45 ± 8.68 years) were included. Flank pain and gross hematuria were the most common symptoms. On preoperative MRI-based assessment, Mayo thrombus levels 0, I, II, III, and IV were observed in 2, 2, 5, 1, and 1 patient(s), respectively. Using the 301 classification, levels 0, 0a, I, II, III, and IV were observed in 1, 1, 4, 3, 1, and 1 patient(s), respectively. Ten patients underwent robot-assisted radical nephroureterectomy with thrombectomy and IVC reconstruction or patch angioplasty when needed; one patient required conversion to open surgery. Median operative time was 222 min (IQR 170–255), and median blood loss was 300 mL. One perioperative death occurred after massive postoperative hemorrhage, corresponding to a perioperative mortality rate of 9.1% (1/11), while short-term renal function was largely preserved in the remaining patients. Pathology showed high-grade urothelial carcinoma in all cases, mostly pT3–T4 with frequent necrosis and other aggressive features. At a median follow-up of 14 months (IQR, 3–32; range, 0–58) for the entire cohort, 1-year OS and DFS were 63.6% (95% CI: 29.7–84.5) and 36.4% (95% CI: 11.2–62.7), respectively. Most recurrences or progression developed within 12 months postoperatively. For selected patients with UTUC and venous tumor thrombus, a grade-based, predominantly robotic surgical approach is feasible within a multidisciplinary setting, but the observed perioperative mortality underscores the need for careful risk assessment. However, early recurrence and limited survival highlight the aggressive nature of this disease. Larger prospective studies are needed to validate these findings and refine surgical management.