Metastatic Surgery in Advanced Renal Cell Carcinoma

Management of patients with advanced and metastatic renal cell carcinoma is a challenging task, which often demands a multidisciplinary approach. In the cytokine immunotherapy era, cytoreductive nephrectomy in combination with immunotherapy was shown to be superior to immunotherapy alone, thus making cytoreductive nephrectomy a cornerstone of treatment. In the more recent era of targeted molecular therapies, cytoreductive nephrectomy seems to still retain its role in management of these patients despite lack of level 1 evidence so far. However, proper patient selection has been shown to be of utmost importance to assure benefit from this surgical endeavor. Prospective trials aiming to inform the field regarding efficacy as well as timing of cytoreductive nephrectomy in the targeted therapy era are underway and eagerly awaited, despite encountering challenges during study enrollment. Additionally, the recent introduction of checkpoint inhibitors once again targeting the immune axis is changing treatment landscape and challenging the benefit of cytoreductive nephrectomy. Metastasectomy on the other hand is currently being utilized for patients with relatively indolent oligometastatic disease. Despite lack of level 1 evidence, available evidence supports longterm remission with metastasectomy for some patients. This chapter aims to summarize the currently available evidence for cytoreductive nephrectomy as well as metastasectomy and give an outlook into the future with regard to new developments in this arena.