Minimally invasive and nephron-sparing surgery for renal cell carcinoma: a nationwide analysis of 228,185 nephrectomies in Germany, 2011–2024

Abstract Purpose Nephron-sparing and minimally invasive surgery are recommended for localised renal cell carcinoma, but the supporting evidence comes largely from expert centres. We examined whether their advantages hold in routine care and whether access is equitable. Methods We analysed all 228,185 adult nephrectomies performed for renal malignancy in the German hospital discharge census between 2011 and 2024. Outcomes were in-hospital mortality, a composite of major adverse cardiac and cerebrovascular events extended for renal surgery (MACCE-RN), acute kidney injury, dialysis and length of stay. Access was compared by mixed-effects logistic regression with random hospital intercepts, procedure type by inverse probability of treatment weighting. Results The minimally invasive share rose from 19.7% to 59.4%, robot assistance from 9.7% to 79.4% of those procedures, and partial nephrectomy overtook radical nephrectomy in 2017, reaching 62.5% by 2024. Minimally invasive access showed lower adjusted odds of death (odds ratio 0.49, 95% confidence interval 0.42–0.56), MACCE-RN (0.56, 0.52–0.60) and acute kidney injury (0.57, 0.54–0.60), and a 26% shorter stay, with no difference in dialysis. Partial nephrectomy showed lower odds of death (0.61) and dialysis (0.41), without broadening to higher-risk patients. Uptake depended on the treating hospital: minimally invasive surgery had ever been performed in 17.9% of the smallest centres and 95.9% of the largest. Conclusion Both approaches became predominant and reproduced in routine care the advantages reported from expert centres, but their adoption depended on hospital volume rather than on patient characteristics. Administrative data lack tumour stage and follow-up beyond discharge.