Clinical outcomes of retroperitoneal lymph node dissection in patients with cT 3–4 N x M 0 non–clear cell renal cell carcinoma.

472 Background: Non–clear cell renal cell carcinoma (nccRCC) comprises 20–25% of renal cancers and exhibits distinct biological behavior and poorer outcomes compared to clear cell RCC. The clinical value of retroperitoneal lymph node dissection (RPLND) in locally advanced nccRCC remains uncertain. This study aimed to evaluate the oncologic outcomes and prognostic factors associated with RPLND in patients with cT3–4 Nx M0 nccRCC. Methods: We retrospectively reviewed 64 patients with cT3–4 Nx M0 nccRCC who underwent radical nephrectomy and RPLND between 2004 and 2025. Clinicopathologic features, recurrence patterns, and survival outcomes were analyzed. Disease-free survival (DFS) and overall survival (OS) were estimated by Kaplan–Meier analysis and compared by log-rank test. Prognostic factors were identified using univariate and multivariate Cox regression. Results: The cohort included 39 females (60.9%) and 25 males (39.1%) with a mean age of 46.8 years. Pathologic nodal involvement was present in 34 patients (53.1%). The median follow-up was 48 months; median DFS and OS were 14.6 and 56.2 months, respectively. The 1-, 3-, and 5-year DFS rates were 48.7%, 27.6%, and 23.1%, with OS rates of 93.5%, 68.2%, and 51.4%. On multivariate analysis, pathological nodal positivity (DFS: HR 4.00, 95% CI 1.86–8.54, p < 0.001; OS: HR 7.15, 95% CI 1.55–33.06, p = 0.012) and sarcomatoid differentiation (DFS: HR 3.76, 95% CI 1.52–9.29, p = 0.004; OS: HR 3.40, 95% CI 1.13–10.21, p = 0.029) were independent adverse prognostic factors. Recurrence occurred in 32.8% of patients, predominantly in lymph nodes (28.1%). Distant metastases most frequently involved lymph nodes (28.1%), lungs (21.9%), liver (15.6%), and bone (14.1%). DFS and OS varied significantly by histologic subtype (DFS: p = 0.0041; OS: p = 0.047), with collecting duct and unclassified RCC associated with the poorest outcomes. Conclusions: RPLND is feasible in patients with cT3–4 Nx M0 nccRCC and yields critical prognostic information. Pathologic nodal status and sarcomatoid differentiation are strong predictors of recurrence and survival. Marked heterogeneity across histologic subtypes underscores the need for subtype-specific risk stratification and tailored postoperative management.