Robot‑assisted versus open radical nephrectomy and venous tumor thrombectomy: perioperative and oncologic outcomes-an inverse probability of treatment weighting analysis.

BACKGROUND: Open radical nephrectomy and venous thrombectomy (ORN‑VT) is standard for renal cell carcinoma with tumor thrombus (RCC-TT), but robot‑assisted radical nephrectomy and venous thrombectomy (RARN‑VT) may improve outcomes. We used inverse probability of treatment weighting (IPTW) to compare perioperative and oncologic results. METHODS: This retrospective cohort study included 418 patients (239 RARN‑VT, 179 ORN‑VT) treated at a high‑volume center between 2014 and 2025. IPTW balanced 19 baseline covariates using the covariate balancing propensity score method. Weighted regression was used for perioperative outcomes, and weighted Cox regression for progression‑free survival (PFS) and overall survival (OS). Propensity score matching (PSM) and an overlapping time‑period analysis (2020-2025) were performed as sensitivity analyses. RESULTS: After IPTW, all covariates were well balanced. RARN‑VT was associated with significantly shorter operation time (β =  - 91.63), less estimated blood loss (β =  - 885.05), lower transfusion volume (β =  - 561.32), shorter length of stay (β =  - 2.79), and reduced odds of blood transfusion (OR = 0.26) and any postoperative complication (OR = 0.44) (all P < 0.001). PFS showed no significant difference between approaches (log‑rank P > 0.05). Both sensitivity analyses confirmed the association between RARN‑VT and better perioperative outcomes. CONCLUSIONS: For RCC and TT patients, RARN‑VT was associated with improved perioperative outcomes. Prospective or randomized studies are warranted to further explore the oncological equivalence or superiority of the robotic approach.