Inferior vena cava (IVC) thrombus is a severe presentation of renal cell carcinoma (RCC), traditionally treated by radical nephrectomy and thrombus extraction. However, the risk–benefit balance in elderly patients remains unclear due to limited data. This study aimed to assess surgical outcomes—particularly 90-day mortality—in patients aged ≥ 70 year and to identify risk factors for postoperative mortality.

We retrospectively analyzed data from the prospective French UroCCR national cohort (2007–2023), including 298 patients with RCC with IVC thrombus who underwent surgery in 13 expert centers. Patients were stratified into ≥ 70 vs. <70 year. The primary endpoint was 90-day mortality. Secondary outcomes included overall survival (OS), disease-specific survival (DSS), and predictors of 90-day postoperative mortality. Statistical analyses included univariate and multivariate logistic regression analyses adjusted for renal dysfunction.

Patients aged ≥ 70 year (n = 117) had a 90-day mortality rate of 10.5% compared with 5.5% in those < 70 year (n = 181; p = 0.13). Among patients aged ≥ 80 year (n = 32), the 90-day mortality increased to 19% (p = 0.02). Metastatic disease (OR 3.3, p = 0.01) and preoperative renal dysfunction (OR 3.9, p = 0.02) were significantly associated with 90-day mortality, with renal dysfunction remaining independently associated after adjustment for age (adjusted OR 2.8, p = 0.04). Long-term DSS did not differ between age groups. Study limitations include its retrospective design and the restriction of the cohort to surgical candidates treated in expert centers.

Radical nephrectomy with thrombectomy provides acceptable outcomes in patients aged ≥ 70 year, although ≥ 80 year face higher perioperative risk. Careful patient selection, including thorough preoperative renal function assessment, is crucial. The comparable DSS suggests that age alone should not be considered a contraindication to surgery.