Editing Renal Mass and Localized Renal Cancer (2021) (section)

==== Nephrectomy ====
*'''<span style="color:#ff0000">Partial nephrectomy</span>'''
** '''<span style="color:#ff0000">Indications</span>''' (when intervention is necessary for solid or Bosniak 3/4 complex cystic renal mass)
*** '''<span style="color:#ff0000">Absolute (3):</span>'''
***# '''<span style="color:#ff0000">Anatomic or functionally solitary kidney</span>'''
***# '''<span style="color:#ff0000">Bilateral tumors</span>'''
***# '''<span style="color:#ff0000">Known familial RCC syndrome</span>'''
*** '''<span style="color:#ff0000">Relative (6):</span>'''
***# '''<span style="color:#ff0000">cT1a renal masses (preferred over TA and RN)</span>''', not managed with active surveillance
***# '''<span style="color:#ff0000">Pre-existing CKD</span>'''
***# '''<span style="color:#ff0000">Pre-existing proteinuria</span>'''
***# '''<span style="color:#ff0000">Young age</span>'''
***# '''<span style="color:#ff0000">Multifocal masses</span>'''
***# '''<span style="color:#ff0000">Comorbidities that are likely to impact future renal function, including (4):</span>'''
***## '''<span style="color:#ff0000">Moderate to severe hypertension</span>'''
***## '''<span style="color:#ff0000">Diabetes mellitus</span>'''
***## '''<span style="color:#ff0000">Recurrent urolithiasis</span>'''
***## '''<span style="color:#ff0000">Morbid obesity</span>'''
** Surgical considerations
*** Renal function can be optimized by (2):
***# Optimizing nephron mass preservation
***# Avoiding prolonged ischemia
*** Negative surgical margins should be prioritized
**** Extent of normal parenchyma removed should consider the clinical situation and tumor characteristics, including growth pattern, and interface with normal tissue.
***** '''To optimize parenchymal mass preservation, tumor enucleation should be considered in patients with:'''
*****# '''Familial RCC syndromes'''
*****#* '''Aggressive RCC syndromes, such as HLRCC, should be best managed with wide margin PN or RN.'''
*****# '''Multifocal disease'''
*****# '''Severe CKD'''
*'''<span style="color:#ff0000">Radical nephrectomy</span>'''
** '''<span style="color:#ff0000">Indication (1)</span>''' (when intervention is necessary for solid or Bosniak 3/4 complex cystic renal mass):
**# '''<span style="color:#ff0000">If ALL criteria are met (3):</span>'''
**## '''<span style="color:#ff0000">High tumor complexity and PN would be challenging even in experienced hands</span>'''
**## '''<span style="color:#ff0000">No pre-existing CKD or proteinuria</span>'''
**## '''<span style="color:#ff0000">Normal contralateral kidney and new baseline eGFR will likely be > 45 mL/min/1.73m2 even if RN is performed</span>'''
**#* '''<span style="color:#ff0000">If ALL are not met, PN should be considered</span>''' unless there are overriding concerns about the safety or oncologic efficacy of PN.
*'''<span style="color:#ff0000">Lymphadenectomy'''
** '''<span style="color:#ff0000">Indications (1):</span>'''
**#'''<span style="color:#ff0000">Clinically concerning regional lymphadenopathy (for staging purposes)</span>'''
*'''<span style="color:#ff0000">Adrenalectomy</span>'''
** '''<span style="color:#ff0000">Indications</span>'''
***'''<span style="color:#ff0000">Absolute (1):</span>'''
***# '''<span style="color:#ff0000">If preoperative imaging or intraoperative inspection suggests metastasis or adrenal enlargement</span>'''
***#* One exception is when patient has a well-characterized adenoma, which may not mandate surgical excision
*** '''<span style="color:#ff0000">Relative (1):</span>'''
***# '''<span style="color:#ff0000">Locally advanced features are identified preoperatively or during exploration and the gland is in close proximity to the tumour</span>'''
***#* Adrenal may be spared in this setting if the contralateral adrenal gland is absent and the ipsilateral gland demonstrates normal morphology and no malignant involvement.
*Approach
** A minimally invasive approach should be considered when it would not compromise oncologic, functional, and perioperative outcomes.
*'''Other considerations'''
** Adjacent renal parenchyma in the nephrectomy specimen should be evaluated for possible intrinsic renal disease, particularly for patients with CKD or risk factors for developing CKD.
** '''Consider referral to medical oncology when there is concern for (2):'''
**# '''Metastasis'''
**# '''Incompletely resected disease'''