Surgical management in metastatic renal cell carcinoma

The management of metastatic renal cell carcinoma (mRCC) is evolving rapidly. In the era of anti-angiogenic treatments, the Carmena trial showed no benefit of upfront cytoreductive nephrectomy compared to sunitinib alone for patients with intermediate or poor prognosis. The Surtime trial suggests that deferred nephrectomy after initiation of systemic therapy may be a better strategy. In the current era of immune checkpoint inhibitors, the role and optimal timing of nephrectomy is still unknown. Delayed nephrectomy after response to systemic therapy seems to be an interesting approach, especially for residual kidney disease in patients with radiological complete response at metastatic sites, and may achieve good oncological outcomes in selected patients. However, due to the technical complexity and complication rates, post-immunotherapy surgery should be performed in expert centres. Surgery could also be integrated into the management of mRCC metastases and surgical resection may be discussed in selected cases.