Assessing the Contemporary Role of Cytoreductive Nephrectomy in Metastatic Renal Cell Carcinoma: Another Step in the Right Direction

Abstract

There are three important clinical questions regarding whether cytoreductive nephrectomy (CN) should be performed in metastatic renal cell carcinoma (mRCC): (1) Does CN extend survival in the average patient in the targeted therapy era? (2) Is the timing of CN important (ie, before or after targeted therapy)? (3) Could we do a better job at selecting CN candidates? The first two questions are being addressed with two level 1–evidence ongoing randomized clinical trials (CARMENA [NCT0093033] and SURTIME [NCT01099423]). In this month’s issue of European Urology, Gershman et al [1] reported their retrospective large single-center study addressing the third question. They examined the association of clinicopathologic features with postoperative complications (30 d), prolonged length of stay, and delay in the receipt of systemic therapy (ST) among 294 mRCC patients treated with CN between 1990 and 2009. In this selected cohort, the authors found an overall low rate of postoperative complications (12%) and only a 5% rate of grade 3 complications. Median time to ST was 56 d after CN. Despite the low rate of postoperative complications, up to 61% of patients did not receive ‘‘timely ST,’’ which was defined as ST within 60 d of surgery. Gershman et al [1] should be congratulated for addressing an important topic in the surgical management of mRCC. Based on their report, some aspects deserve specific mention. First, the cohort they relied on represents a highly selected population in terms of baseline tumor burden after surgery. Indeed, only 36% of the patients had more than