U R O L O G I C O N C O L O G Y the Contemporary Role of Surgery in Kidney Cancer 2. Surgical Treatment for Localized Rcc 2.1 Radical Nephrectomy

Surgical treatment retains its place in this setting in the form of cytoreductive nephrectomy 6,7. Further, the discovery of the von Hippel–Lindau (VHL) gene and the understanding gained of the molecular biology of the disease have set the stage for an exciting new era of targeted therapies 8. However, the role of cytoreductive nephrectomy with the new tyrosine kinase inhibitors (tkis) remains to be defined. The present review touches on the indications and controversies surrounding surgical treatments for rcc. The evolution of surgical techniques and the introduction of laparoscopy are also discussed. In 1963, Robson and colleagues published the seminal work that laid the foundations of surgical treatment for rcc as we know it today 9,10. Key surgical steps in achieving adequate and safe oncologic control were identified, including early vascular control and renal excision preserving Gerota's fascia, thus ensuring that surgical margins are away from the tumour. Other concepts put forward by Robson included adrenal gland excision within Gerota's fascia and extended ipsilateral lymphadenectomy from the crus of the diaphragm to the bifurcation of the aorta. These latter practices are not universally applied in the contemporary surgical approach, mostly because of a stage shift in rcc toward localized disease and because of the new imaging modalities. Nonetheless, the description of a radical nephrectomy remains one of the pillars of the treatment of localized rcc; all technical refinements developed thereafter have been guided by its basic principles. Contemporary treatment of rcc is a factor of tumour size and location, presence of venous thrombus, and patient characteristics. Many incisions have been described, including flank, subcostal, midline, and thoraco-abdominal. Long-term oncologic results for open radical nephrectomy have been consistently reproduced and serve as a benchmark for other surgical ABSTRACT The diagnosis and treatment of renal cell carcinoma (rcc) has been the subject of major changes since the late 1980s. Initially, surgery was the only treatment available, but more recently, systemic therapies have been developed, and their introduction has modified some of the surgical indications for rcc. In addition, refinements in surgical technique and the introduction of minimally invasive approaches have revolutionized patient care and bear the promise of even more improvements to come. This paper provides an up-to-date overview of recent developments in the surgical treatment of rcc.