INTRODUCTION — Renal cell carcinoma (RCC) is responsible for 80 to 85 percent of all primary renal neoplasms. Over 76,000 people are diagnosed with RCC on an annual basis in the United States, with almost 14,000 deaths expected each year [1].
For patients with localized RCC and select patients with advanced RCC, surgery can be curative. This topic will review the role of surgery in the definitive management of RCC.
Related topics include:
●(See "Overview of the treatment of renal cell carcinoma".)
●(See "Radiofrequency ablation and cryoablation for renal cell carcinoma".)
●(See "Role of surgery in patients with metastatic renal cell carcinoma".)
INDICATIONS — The indications for definitive surgery for renal cell carcinoma (RCC) are based on disease stage (table 1) and the extent of disease (algorithm 1). Appropriate candidates include patients with:
●Stage I or II RCC (disease limited to the kidney).
●Stage III RCC, which includes patients with tumor extension into major veins or perinephric tissues and/or enlarged retroperitoneal lymph nodes.
●Involvement of the inferior vena cava (IVC) and/or the cardiac atrium (ie, cavoatrial tumor involvement). (See 'Cavoatrial tumor involvement' below.)
●RCC with direct extension into the ipsilateral adrenal gland (a subset of stage IV RCC), especially if there is no other evidence of metastatic disease. (See 'Adrenal gland involvement' below.)
●The role of cytoreductive nephrectomy in other patients with stage IV RCC is discussed separately. (See "Role of surgery in patients with metastatic renal cell carcinoma", section on 'Cytoreductive nephrectomy'.)
OVERVIEW OF THE SURGICAL APPROACH — For patients undergoing definitive surgical treatment for renal cell carcinoma (RCC), a radical or partial nephrectomy may be performed. (See 'Radical nephrectomy' below and 'Partial nephrectomy' below.)
Factors that can influence surgical approach include:
●Location of the tumor
●Presence of multiple or bilateral tumors (see 'Multiple or bilateral tumors' below)
●Presence of a solitary kidney or compromised contralateral renal function (see 'Solitary kidney' below)
●History of a hereditary kidney cancer syndrome (eg, von Hippel-Lindau disease) (see "Hereditary kidney cancer syndromes")
Our approach is as follows:
●We prefer a radical nephrectomy in patients with tumors >7 cm in size or those involving a more central position of the kidney. In addition, a radical nephrectomy should be performed in patients with any of the following:
•Suspected lymph node involvement (see 'Retroperitoneal lymph nodes' below)
•Tumor with associated renal vein or inferior vena cava (IVC) thrombus (see 'Cavoatrial tumor involvement' below)
•Direct extension into the ipsilateral adrenal gland (see 'Adrenal gland involvement' below)
●Patients with a tumor ≤7 cm should undergo a partial nephrectomy when it is technically feasible in order to preserve renal function, especially in patients with any of the following (see 'Partial nephrectomy' below):
•A solitary kidney (see 'Solitary kidney' below)
•Multiple, small, and/or bilateral tumors (see 'Multiple or bilateral tumors' below)
•Patients with or at risk for chronic renal disease (see 'Baseline renal dysfunction' below)
Patients who are not operative candidates based upon factors such as age or comorbidity may be appropriate for other nephron-sparing approaches if the technical expertise is available. Alternatively, patients with renal tumors <4 cm may be candidates for active surveillance, particularly if they have a limited life expectancy or significant comorbidities that preclude surgical intervention. (See 'Alternative nephron-sparing approaches' below and 'Active surveillance' below.)
Radical nephrectomy — For patients with RCC limited to the kidney, a radical nephrectomy results in a five-year cancer-specific survival rate between 80 and 90 percent [2,3]. However, patients are at risk for long-term renal dysfunction as a result of the procedure, with the reported risk exceeding 30 percent [4]. Hospitals and surgeons doing a higher volume of nephrectomies have lower mortality compared with those institutions with lower volumes [5].
Radical nephrectomy consists of ligation of the renal artery and vein and removal of the kidney, Gerota's fascia, and, on occasion, the ipsilateral adrenal gland. However, in the absence of high risk of local invasion of the adrenal gland, resection of the adrenal gland should be omitted because the incidence of adrenal metastases is uncommon (10 percent or less) [6-8]. (See 'Adrenal gland involvement' below.)
Early ligation of the vascular pedicle is important to prevent tumor dissemination at surgery. Of the various open approaches described (eg, thoracoabdominal, extrapleural, and anterior transabdominal), we prefer the anterior transabdominal approach because it offers the ability to remove the tumor through a relatively small incision. However, with large upper-pole tumors, the thoracoabdominal incision may be preferable, allowing palpation of the ipsilateral lung cavity and mediastinum. In addition, this allows the exposure required to resect a pulmonary metastasis if it is identified intraoperatively [9-11].
A radical nephrectomy can be performed as an open surgical procedure or laparoscopically/robotically. The choice of surgical technique should be based on patient-specific considerations (eg, tumor location and size) and the technical expertise available. Regardless of the technique, every effort should be made to remove the specimen intact [12]. In most institutions, laparoscopic nephrectomy has replaced open radical nephrectomy for many patients, especially if the tumor size is less than 10 cm [2,13-15].
The oncologic outcome with laparoscopic radical nephrectomy is equivalent to that with open surgery. As an example, in one series of 116 patients, there was no difference in cancer-specific survival at five years with laparoscopic versus open radical nephrectomy (91 versus 93 percent) [2]. Laparoscopic radical nephrectomy is associated with less blood loss and a shorter recovery period compared with open radical nephrectomy.
The first robotic radical nephrectomy was performed in 2000. According to a large United States database study, the percentage of radical nephrectomies performed robotically increased from 1.5 percent in 2003 to 27 percent in 2015; the use of robotic technology was not associated with a lower overall or major complication rate [16]. On the contrary, the use of the robot for radical nephrectomy has raised concerns about higher cost, longer global operative times, absence of force feedback, and difficulties with conversion for vascular complications. In a systematic review, the authors found no advantage for robotic over standard laparoscopic radical nephrectomy [17]. Although robotic assistance does not appear to offer any incremental benefit over conventional laparoscopic surgery in radical nephrectomy, such benefit does exist in partial nephrectomy. (See 'Partial nephrectomy' below.)
Partial nephrectomy — Patients with tumors ≤7 cm and those at risk for a significant loss of renal function should be managed with a partial nephrectomy if it is technically feasible. Partial nephrectomy results in similar oncologic outcomes compared with radical nephrectomy. In addition, it is associated with a significantly lower risk of chronic renal dysfunction [3,18,19]. (See 'Overview of the surgical approach' above and 'Partial versus radical nephrectomy' below.)
As with radical nephrectomy, both open and laparoscopic/robotic techniques are utilized and result in comparable outcomes [20,21]. Although laparoscopic partial nephrectomy is technically difficult, robotic-assisted, laparoscopic partial nephrectomy has evolved as a technique that offers similar outcomes to open partial nephrectomy yet has the advantage of precision and maneuverability to minimize ischemia times [22]. In a meta-analysis of robotic versus open partial nephrectomy that analyzed 3418 patients, robotic partial nephrectomy had a longer operative time but less blood loss, shorter length of stay, and fewer complications [23]. (See "Robot-assisted laparoscopy" and 'Solitary kidney' below.)
During partial nephrectomy, the kidney should be carefully examined to exclude a synchronous tumor. The importance of this was illustrated in a series of 112 patients with sporadic renal masses who underwent partial nephrectomy [24]. A second lesion was identified in 37 cases, and 8 (7 percent of the entire series) were malignant. In addition, conversion to a radical nephrectomy may be necessary based on intraoperative findings. For example, some urologists convert the surgery to radical nephrectomy in cases with renal vein invasion or sarcomatoid histology on frozen section.
For patients who are candidates for a partial nephrectomy, concomitant adrenalectomy is not routinely indicated. This was illustrated in a series of 2065 patients undergoing partial nephrectomy at a single institution, of whom a concomitant adrenalectomy was performed in 48 cases (2 percent) [25]. At final pathology, only 3 of the 48 patients (7 percent) had adrenal invasion or metastasis, and 3 others had a separate adrenal neoplasm.
Significance of margin status — A positive surgical margin does not necessarily predict recurrence.
The overall risk of recurrence is low, but there are conflicting data regarding the prognostic implications of a positive surgical margin, particularly in high-risk patients [26-28].
●In one study involving almost 1344 patients who underwent nephron-sparing surgery, surgical margins were positive in 77 cases (5.5 percent) [26]. Compared with patients with negative surgical margins, those who had positive margins had equivalent rates of local recurrence-free survival (97 versus 98 percent) and metastasis-free survival (95 percent in both groups) at five years.
●In another multi-institutional review of 1240 patients who underwent partial nephrectomy for localized RCC, positive surgical margins were identified in 97 cases (7.8 percent) [28]. A positive surgical margin was associated with an increased risk of recurrence compared with those with negative surgical margins for those classified as high risk (pathologic T2-T3a or Fuhrman grade III to IV disease; hazard ratio [HR] 7.4, 95% CI 2.75-20.34 on multivariate analysis). In patients with low-risk disease (pathologic T1 and Fuhrman grade I to II), no increased risk of recurrence was detected.
Our approach is to proceed with surveillance following partial nephrectomy in all patients with RCC, regardless of the margin status. Other options would include repeat excision, completion radical nephrectomy, or thermal ablation. However, since local recurrence is uncommon, surveillance is the preferable option. (See 'Post-treatment surveillance' below.)
Role of frozen section — Patients who undergo a partial nephrectomy for RCC are at risk that surgery will not completely remove the tumor and that positive margins may be identified at final pathology. Whether a frozen section should be performed in these patients is controversial. While a frozen section reduces the risk of a positive margin (and, therefore, leaving tumor behind), the limited data suggest that performing a frozen section does not influence survival outcomes [29].
If an open surgical procedure is done, our approach is to perform a frozen section because it allows further tissue resection if necessary and increases the likelihood that the entire tumor has been removed. When these procedures are being done laparoscopically or robotically, the opportunity to resect further tumor is more limited. In those circumstances, a frozen section is not usually performed.
Partial versus radical nephrectomy — The oncologic outcomes reported for observational studies and one randomized trial appear to be very similar for those managed with partial nephrectomy compared with radical nephrectomy [3,30-34].
In the randomized trial, 541 patients with clinical stage T1 or T2 RCC were randomly assigned to partial or radical nephrectomy [3].
●There were 12 recurrences in 268 patients managed with partial nephrectomy (4.5 percent) compared with 9 of 273 (3 percent) in those managed with radical nephrectomy. The number of patients who developed distant metastases was low in both groups (7 and 6 patients, respectively).
●The 10 year overall survival rate was lower with partial nephrectomy (76 versus 81 percent, HR 1.50, 95% CI 1.03-2.16), but only 12 of the 117 deaths in the entire study population were due to RCC.
Retroperitoneal lymph nodes — Our approach is to perform an extended lymphadenectomy for patients deemed to be at an increased risk for lymph node involvement (eg, tumor grade 3 or 4, sarcomatoid histology, T3 or T4 tumor, presence of coagulative necrosis) and in patients with suspected nodal metastases on preoperative imaging [35,36]. For patients with no preoperative evidence of abdominal node involvement and not at an increased risk of nodal metastases, we typically limit the lymphadenectomy to the renal hilum as there is no apparent benefit to an extended lymphadenectomy.
The only data from a randomized trial, from the European Organization for Research and Treatment of Cancer (EORTC) 30881 trial, evaluated 772 patients who were assigned to radical nephrectomy alone or radical nephrectomy with lymph node dissection [37]. At a median follow-up of over 12 years, there were no differences in overall survival or deaths due to cancer in the two treatment arms. However, only 4 percent of patients in this study had pathologically involved lymph nodes, limiting the interpretation of these results [38].
Large retrospective series have given conflicting results on whether lymph node dissection may be beneficial:
●In a study involving over 9500 patients, in which 58 percent had node-positive disease, an increase of 10 lymph nodes retrieved for every one positive node identified was associated with a 10 percent absolute improvement in five-year disease-specific survival [39]. However, the extent of lymphadenectomy had no impact on survival among patients with no evidence of nodal involvement on final pathology.
●In an analysis of 1797 patients who underwent radical nephrectomy at the Mayo Clinic over a 20 year period, 606 underwent concurrent lymph node dissection [40]. Among those undergoing lymph node dissection, 111 (6.2 percent) had pathologic involvement of the regional lymph nodes. With a median follow-up of 10.6 years, there was no statistically significant difference in the risk of distant metastases, cancer-specific mortality, or all-cause mortality.
●In another analysis involving 871 patients, the rate of nodal involvement was 38 percent. Metastases were identified only in grossly identified lymph nodes; all microscopic nodes examined were negative for RCC [41].
Patients who are deemed to be poor surgical candidates due to the extent of nodal involvement should be offered medical therapy. (See "Overview of the treatment of renal cell carcinoma", section on 'Advanced renal cell carcinoma'.)
Prognosis — Multiple factors influence the prognosis following definitive surgery for nonmetastatic RCC, including histology, grade, and extent of disease. Results from surgery (radical or partial nephrectomy) are illustrated by a retrospective cohort of 3633 patients who underwent surgery between 1980 and 2010 at the Mayo Clinic [42]. The series included 2726 patients with clear cell carcinoma (75 percent), 60 with papillary carcinoma (17 percent), and 222 with chromophobe carcinoma (6 percent).
●For patients with clear cell carcinoma, the 5, 10, and 15 year progression-free survival rates were 74, 67, and 60 percent, respectively, and the cancer-specific survival rates were 84, 76, and 70 percent, respectively.
●For patients with papillary carcinoma, the 5, 10, and 15 year progression-free survival rates were 91, 88, and 86 percent, respectively, and the cancer-specific survival rates were 95, 92, and 90 percent, respectively.
●For patients with chromophobe carcinoma, the 5, 10, and 15 year progression-free survival rates were 87, 82, and 77 percent, respectively, and the cancer-specific survival rates were 93, 89, and 88 percent, respectively.
SPECIFIC MANAGEMENT ISSUES
Baseline renal dysfunction — For patients with preoperative renal dysfunction and those at risk for chronic kidney disease, a partial nephrectomy should be performed when technically feasible in order to preserve renal function. (See 'Partial nephrectomy' above.)
The impact on subsequent renal function after a partial versus radical nephrectomy was evaluated in a study of 662 patients who had a solitary cortical lesion <4 cm, an apparently healthy contralateral kidney, and a baseline serum creatinine less than 1.4 mg/dL [4]. Three years after surgery, patients undergoing partial nephrectomy had a significantly lower likelihood of renal dysfunction than those undergoing radical nephrectomy (5 versus 36 percent, respectively).
Multiple or bilateral tumors — Up to 15 percent of patients with papillary tumors and 8 percent of those with other histologic subtypes have multicentric tumors [43]. In addition, between 1 and 4 percent of patients with sporadic tumors have bilateral renal cell carcinomas (RCCs) [44].
For patients who have multiple and/or bilateral tumors, some experts advocate active surveillance and defer intervention until any lesion increases to 3 cm or larger [45]. This size criterion was derived from studies in patients with von Hippel-Lindau disease, in whom preservation of renal parenchyma is critically important because of the high likelihood of additional subsequent renal lesions. If nephrectomy is indicated, we prefer a partial nephrectomy if technically feasible because the goal is to maintain as much renal function as possible without compromising long-term outcomes [46]. (See 'Active surveillance' below and 'Partial nephrectomy' above.)
Further discussions of von Hippel-Lindau disease and other hereditary kidney cancer syndromes are presented separately. (See "Hereditary kidney cancer syndromes" and "Clinical features, diagnosis, and management of von Hippel-Lindau disease", section on 'Renal cell carcinomas'.)
Solitary kidney — For RCC in a patient with a solitary kidney, we perform a partial nephrectomy whenever possible. This may on rare occasions require removal of the kidney followed by dissection of the tumor outside of the body (ie, extracorporeal treatment or bench dissection) and subsequent auto-transplantation. However, there are only low-quality data to inform the benefits and risks of this approach. In one study, only 6 of 16 patients who underwent this approach were free of malignancy and did not require dialysis [47].
Cavoatrial tumor involvement — For patients with evidence of thrombus involving the inferior vena cava (IVC) and/or right atrium (ie, cavoatrial involvement), we proceed with thrombectomy at the time of radical nephrectomy [48]. This approach should only be performed by surgeons experienced in these techniques and should be limited to patients without evidence of distant or nodal metastases.
RCC is complicated by cavoatrial tumor involvement in fewer than 10 percent of cases [49]. Four stages of cavoatrial tumor involvement have been described (figure 1) [50,51]:
●Level I – Thrombus <2 cm above the renal vein
●Level II – Thrombus below the intrahepatic vena cava
●Level III – Thrombus involves the intrahepatic vena cava but is below the diaphragm
●Level IV – Thrombus involves the atrium
Thrombectomy can provide immediate palliation of symptoms with five-year survival rates up to 72 percent in the absence of nodal or distant metastases [52,53]. The extent of thrombectomy depends on the extent of involvement of the tumor [50,52,54]:
●For patients with thrombus extending up to the major hepatic veins, a simple thrombectomy may suffice.
A robotic approach for IVC thrombus extending up to the major hepatic veins (level III) has been described [55].
●For patients whose thrombus extends above the major hepatic veins, cardiopulmonary bypass with or without hypothermic circulatory arrest may be required to achieve a complete resection.
However, postoperative morbidity and mortality can be significant, as illustrated in the following examples:
●In one series, 8 of 22 patients (36 percent) had severe complications, and 2 patients died within one month of surgery [51].
●Patients are also at risk for the rare complication of intraoperative tumor embolization. Although the data are limited, it appears to be associated with a high mortality rate. Although only 5 of 282 patients (1.8 percent) developed an intraoperative embolus in one series, 3 of these patients died as a result [56].
Although no perioperative strategies are warranted to prevent embolization, patients who had an embolic event preoperatively should be treated with heparin. IVC filters are generally avoided as they need to be placed above the renal veins, and if they become blocked, they can impair function of the remaining kidney.
Adrenal gland involvement — For patients with solitary ipsilateral adrenal metastases identified by preoperative imaging studies, we proceed with adrenalectomy at the time of nephrectomy. In addition, an adrenalectomy should be performed in patients who may be at risk for direct extension into the adrenal gland, including patients with upper-pole lesions >4 cm or upper-pole non-organ-confined tumor (T3 or greater).
This approach is supported by a series of 648 patients who underwent radical nephrectomy combined with adrenalectomy over a 20 year period [8]. In this series, 48 patients (7 percent) had adrenal metastases, of which 13 were solitary adrenal metastases without other evidence of systemic disease. Median overall survival for patients without any metastatic disease was 13.8 years; for those with isolated solitary adrenal metastases without other systemic spread, median survival was 11.7 years. In contrast, median survival for those with lymph node metastases or distant metastases was approximately one year.
Large, marginally resectable tumors — For patients with a large tumor deemed to be only marginally resectable, preoperative renal arterial embolization may be an option to reduce vascularity and lower the risk of intraoperative hemorrhage at the time of planned nephrectomy [57]. However, the limited data show this is not associated with a survival benefit compared with patients who proceed with nephrectomy alone [58].
ALTERNATIVE NEPHRON-SPARING APPROACHES — For patients who are not surgical candidates for whatever reason, nephron-sparing approaches, including enucleation and thermal ablation (radiofrequency ablation or cryotherapy), are appropriate alternatives. In addition, select patients with small renal tumors <4 cm may be candidates for active surveillance, particularly if they have a limited life expectancy. (See "Diagnostic approach, differential diagnosis, and management of a small renal mass" and 'Active surveillance' below.)
Enucleation — Enucleation refers to the removal of the tumor itself without dissection into the uninvolved renal parenchyma. Although limited data suggest it is comparable to surgery as a treatment of small renal lesions, we prefer to proceed with partial nephrectomy whenever possible. In addition, there are no prospective data comparing enucleation with partial nephrectomy.
The outcomes following enucleation were reported in one series of over 200 patients, all of whom had a tumor <4 cm (median dimension 2.9 cm) [59]. There were no complications reported, and the cancer-specific survival rate at 10 years was 95 percent. Until more data become available, however, we prefer to proceed with a partial nephrectomy, excising the tumor with a rim of normal parenchyma, rather than enucleation.
Thermal ablation techniques — For older patients and those with significant comorbidities that increase the risks of surgery, thermal ablation (ie, cryotherapy or radiofrequency ablation) is an appropriate alternative to resection. (See "Radiofrequency ablation and cryoablation for renal cell carcinoma", section on 'Outcomes'.)
Multiple series have reported excellent short-term disease control with both radiofrequency ablation and cryoablation [60]. Limited long-term outcomes in nonsurgical patients are also encouraging [61,62]. Although these results appear comparable to those with partial nephrectomy or radical nephrectomy, additional long-term follow-up is required before these techniques can be considered as an alternative to surgery in patients who are candidates for a definitive surgical resection.
ACTIVE SURVEILLANCE — The development and widespread use of improved imaging modalities (eg, magnetic resonance imaging [MRI], computed tomography [CT]) has led to an increased detection of small renal masses (defined as tumor size <4 cm). For individuals with a small renal mass, active surveillance may be an appropriate alternative to immediate treatment, particularly for patients with significant comorbidity or a short life expectancy [63]. (See "Diagnostic approach, differential diagnosis, and management of a small renal mass".)
For patients with a large (≥4 cm) renal mass but comorbid medical conditions precluding surgery, the median growth rate was 0.4 cm per year and there were no significant predictors of growth [64]. The five-year probability of other-cause mortality was 22 percent (95% CI 14 to 32 percent) compared with 6 percent (95% CI 2 to 13 percent) from metastatic progression of kidney cancer.
ADJUVANT THERAPY — For patients treated with definitive surgery for renal cell carcinoma (RCC), the use of adjuvant therapy is discussed separately. (See "Overview of the treatment of renal cell carcinoma", section on 'Adjuvant therapy for locoregional disease' and "Overview of the treatment of renal cell carcinoma", section on 'Adjuvant therapy after metastasectomy'.)
POST-TREATMENT SURVEILLANCE — The optimal surveillance strategy after potentially curative treatment for renal cell carcinoma (RCC) has not been well studied. Follow-up should be based upon the individual patient's risk for recurrence. (See "Surveillance for metastatic disease after definitive treatment for renal cell carcinoma".)
SPECIAL CONSIDERATIONS DURING THE COVID-19 PANDEMIC — The COVID-19 pandemic has increased the complexity of cancer care. Important issues include balancing the risk from delaying cancer treatment versus harm from COVID-19, minimizing the number of clinic and hospital visits to reduce exposure whenever possible, mitigating the negative impacts of social distancing on delivery of care, and appropriately and fairly allocating limited healthcare resources. Specific guidance for decision-making for cancer surgery on a disease-by-disease basis is available from the American College of Surgeons, from the Society for Surgical Oncology, and from others. These and other recommendations for cancer care during active phases of the COVID-19 pandemic are discussed separately. (See "COVID-19: Considerations in patients with cancer".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Cancer of the kidney and ureters".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Beyond the Basics topic (see "Patient education: Renal cell carcinoma (kidney cancer) (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Nephrectomy techniques – For patients with renal cell carcinoma (RCC) who are operative candidates, surgical resection is potentially curative. (See 'Indications' above.)
•For patients with a primary tumor >7 cm, we perform a radical nephrectomy. Although these patients are usually not candidates for nephron-sparing surgery, a partial nephrectomy is reasonable if it is technically feasible. (See 'Radical nephrectomy' above.)
•For patients with a primary tumor <7 cm, we recommend a partial nephrectomy rather than radical nephrectomy when it is technically feasible (Grade 1B). (See 'Partial nephrectomy' above.)
•Patients with a solitary kidney, those with multiple and/or bilateral renal tumors, and those with baseline renal dysfunction should undergo a partial nephrectomy whenever possible. This will increase their chances of preserving renal function. (See 'Overview of the surgical approach' above.)
●Lymphadenectomy – Patients with RCC should undergo a lymph node dissection at the time of radical nephrectomy. For patients with suspected retroperitoneal lymph node involvement and those at high risk for nodal involvement, we recommend an extended lymphadenectomy at the time of radical nephrectomy (Grade 1B). For patients in whom retroperitoneal lymph node involvement is not suspected and those at low risk for nodal involvement, we suggest a limited lymph node dissection concentrated around the renal hilum (Grade 2B). (See 'Retroperitoneal lymph nodes' above.)
●Cavoatrial tumor involvement – For patients with involvement of the inferior vena cava (IVC), we recommend surgery rather than medical therapy (Grade 1B). These patients should undergo thrombectomy at the time of radical nephrectomy. (See 'Cavoatrial tumor involvement' above.)
●Adrenal gland involvement – For patients with RCC that directly extends to the ipsilateral adrenal gland and those at risk for invasion of the adrenal gland, we recommend surgery rather than medical therapy (Grade 1B). Surgery can be potentially curative in this subset of patients with stage IV RCC. These patients should undergo adrenalectomy at the time of radical nephrectomy. (See 'Adrenal gland involvement' above.)
●Alternatives to nephrectomy – For patients who are poor candidates for nephrectomy, other treatment options include enucleation, thermal ablation, and active surveillance, depending on the size of the renal mass and the associated comorbidities of the patient. (See 'Alternative nephron-sparing approaches' above and 'Active surveillance' above.)
