The role of renal surgery in the era of targeted therapy: the urologist's perspective

Renal cell carcinoma (RCC) is increasingly diagnosed at an early stage in many countries, which has likely contributed to the recent leveling of RCC mortality. Nevertheless, despite these advances in diagnosis, up to 30% of patients have metastatic RCC at the time of diagnosis, and around 20-30% of subjects undergoing surgery will suffer recurrence. Following the recent approval and introduction in clinical practice of targeted therapies, the role and timing of surgery is being debated. In particular, targeted therapy agents have shown more favorable response rates than immunotherapy in subjects with advanced disease, and this increased efficacy raises the question whether cytoreductive nephrectomy is still beneficial in this subset of patients. On the basis of the current clinical studies, renal surgery seems to play a fundamental role also in the modern targeted therapy era. The optimal timing of surgery and the role of neoadjuvant treatment in advanced cases are still unclear. Furthermore modern urologists must acquire clinical skills in administering neoadjuvant and adjuvant therapy with noncytotoxic therapies, according to a multidisciplinary model of care for the management of patients with advanced RCC.