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Outcomes of Minimally Invasive Nephrectomy Following Immune-Checkpoint Inhibitor Therapy: A Multicenter Propensity Score-Matched Analysis - Beyond the Abstract

Current guidelines recommend immune-checkpoint inhibitor (ICI)-based therapy as the standard first-line treatment of advanced renal cell carcinoma (RCC). Consolidative nephrectomy represents the only curative approach to achieving surgical complete remission among those who respond to upfront systemic therapy. 1 Despite post-ICI inflammatory reactions, studies have demonstrated the feasibility and safety of nephrectomy in this setting.2 However, the indications and outcomes of the minimally invasive (MIS) approach remain incompletely characterized.

In this multicenter study, 158 post-ICI nephrectomies were included. Among these, 76 patients underwent MIS (robotic = 56 and laparoscopic = 20) and 82 underwent an open approach. Patient-related factors were the primary determinants of the surgeon's discretion in selecting the surgical approach, with patients having nonmetastatic vs. metastatic RCC (hazard ratio [HR] 3.1), smaller tumor size (HR 1.2 per cm), and no clinical evidence of inferior vena cava thrombus (HR 29) being more likely to undergo an MIS approach. The open conversion rate in this study was 8%, which is slightly higher than the rates reported in the literature for treatment-naïve cases.3

Given the inherent differences in baseline characteristics between the MIS and open surgery groups, propensity score matching (PSM) was performed, resulting in the inclusion of 56 MIS and 36 open nephrectomies for the outcome analysis. After PSM, the MIS group had lower estimated blood loss and a shorter length of hospital stay compared to the open group. However, 90-day complication and readmission rates were similar between the two groups, and no mortality occurred in either group within 90 days (Figure).3


Figure: Perioperative outcomes of patients undergoing MIS (bold) vs open nephrectomy following ICI for advanced RCC. EBL: estimated blood loss; LOS: length of hospital stay.

Our study is the first to assess the indications and outcomes of the MIS approach for nephrectomy following ICI therapy. Our findings suggest that the primary indications for nephrectomy in this setting largely align with those observed in treatment-naïve cases, though surgical planes may be more challenging in select cases. Moreover, the MIS approach appears to be safe for appropriately selected patients with advanced RCC undergoing post-ICI nephrectomy. Finally, we demonstrated that MIS is associated with improved perioperative outcomes compared to open surgery, even after adjusting for clinical confounders.

Written by: Alireza Ghoreifi,1 & Hooman Djaladat2

  1. SUO Fellow, Department of Urology, Duke University, Durham, NC, USA
  2. Professor of Urology, Department of Urology, University of Southern California, Los Angeles, CA, USA
References:

  1. Ghoreifi A, Vaishampayan U, Yin M, Psutka SP, Djaladat H. Immune Checkpoint Inhibitor Therapy Before Nephrectomy for Locally Advanced and Metastatic Renal Cell Carcinoma: A Review. JAMA Oncol. 2024;10(2):240-248.
  2. Yip W, Ghoreifi A, Gerald T, et al. Perioperative Complications and Oncologic Outcomes of Nephrectomy Following Immune Checkpoint Inhibitor Therapy: A Multicenter Collaborative Study. Eur Urol Oncol. 2023;6(6):604-610.
  3. Ghoreifi A, Sheybaee Moghaddam F, Bronimann S, et al. Outcomes of Minimally Invasive Nephrectomy Following Immune-Checkpoint Inhibitor Therapy: A Multicenter Propensity Score-Matched Analysis. J Endourol. 2025 Feb 27. Epub ahead of print.
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