Editing Management of Localized and Locally Advanced Disease (section)

== Management summary (as per 2014 CUA Surgical Management of RCC Consensus Statement) ==

* '''cT1a disease'''
** '''PN recommended'''
** '''Consider laparoscopic RN for tumours not amenable to PN'''
** '''Consider TA (RFA or cryotherapy) in patients with high surgical risk.'''
*** '''A biopsy should be obtained before or at the time of ablation'''
** '''Consider active surveillance in the elderly or infirm'''
*** Not yet recommended for the young and fit
*** Patients must be counselled on the potential of systemic (1.1%) or local progression (12%)
*** Follow-up must include serial imaging
* '''cT1b disease'''
** '''PN when technically feasible'''
** '''Laparoscopic RN should be offered if a PN is not feasible; open RN if laparoscopic surgery not feasible.'''
** '''Ablative modalities are not recommended for these tumours due to the high rate of incomplete ablation in lesions > 4 cm'''
* '''cT2'''
** '''RN; PN in highly selected cases'''
*** '''The role of extended PN for tumours > 7 cm is controversial, and the consideration of such highly selected cases should be limited to experienced surgeons'''
* '''cT3'''
** '''RN – open, laparoscopic or robotic assisted'''
*** '''Resection of vascular thrombus when applicable (usually open)'''
*** '''Resection of all gross disease including hilar or retroperitoneal extension'''
*** '''Patients with tumours > 7 cm should raise suspicion of involvement of peri-renal tissues, such as Gerota’s fascia or renal sinus fat'''
** '''PN may be attempted in highly selected cases by experienced surgeons.'''
* '''cT4'''
** '''RN with resection of adjacent organs, such as the adrenal gland, liver, pancreas, diaphragm, and bowel, if feasible'''
** '''Regional lymphadenectomy should be considered for adequate pathologic staging'''
* '''IVC and renal vein thrombus'''
** '''In the presence or absence of distant metastases, tumour thrombus should be resected if technically feasible in appropriately selected patients'''
** '''It is recommended that these operations be performed in a centre with experience and with an availability of a multidisciplinary team as these complex procedures have significant risk of morbidity and mortality.'''
** '''Tumour thrombectomy with cytoreductive nephrectomy in the metastatic setting should be considered for all patients secondary to the poor outcome associated with untreated intravascular disease.'''
* '''M+'''
** '''See Advanced Kidney Cancer Chapter Notes'''