Definitive surgical management of renal cell carcinoma

INTRODUCTION — Renal cell carcinoma (RCC) is responsible for 80 to 85 percent of all primary renal neoplasms. Over 81,800 people are diagnosed with RCC on an annual basis in the United States, with almost 15,000 deaths expected each year [1].

For patients with localized RCC and select patients with advanced RCC, surgery can be curative. This topic will review the role of surgery in the definitive management of RCC.

Related topics include:

●(See "Overview of the treatment of renal cell carcinoma".)

●(See "Radiofrequency ablation, cryoablation, and other ablative techniques for renal cell carcinoma".)

●(See "Diagnostic approach, differential diagnosis, and management of a small renal mass".)

●(See "Role of surgery in patients with metastatic renal cell carcinoma".)

INDICATIONS — The indications for definitive surgery for RCC are based on disease stage (table 1) and the extent of disease (algorithm 1). Appropriate candidates include patients with:

●Stage I or II RCC (disease limited to the kidney).

●Stage III RCC, which includes patients with tumor extension into major veins or perinephric tissues and/or enlarged retroperitoneal lymph nodes.

●Involvement of the inferior vena cava and/or the cardiac atrium (ie, cavoatrial tumor involvement). (See 'Cavoatrial tumor involvement' below.)

●RCC with direct extension into the ipsilateral adrenal gland (a subset of stage IV RCC), especially if there is no other evidence of metastatic disease. (See 'Adrenal gland involvement' below.)

●The role of cytoreductive nephrectomy in other patients with stage IV RCC is discussed separately. (See "Role of surgery in patients with metastatic renal cell carcinoma", section on 'Cytoreductive nephrectomy'.)

OVERVIEW OF THE SURGICAL APPROACH

Radical versus partial nephrectomy — For patients undergoing definitive surgical treatment for RCC, a radical or partial nephrectomy may be performed. Our approach is as follows [2] (algorithm 1):

Radical nephrectomy — We prefer a radical nephrectomy in patients with:

●Tumors >10 cm in size.

●Tumors involving a more central position of the kidney.

●Tumors with increased oncologic potential as evidenced by:

•Suspected lymph node involvement (see 'Retroperitoneal lymph nodes' below)

•Tumor with associated renal vein or inferior vena cava thrombus (see 'Cavoatrial tumor involvement' below)

•Direct extension into the ipsilateral adrenal gland (see 'Adrenal gland involvement' below)

Partial nephrectomy — We prefer a partial nephrectomy in order to preserve renal function in patients with:

●Tumor ≤10 cm.

●A partial nephrectomy is technically feasible.

●Comorbidities that are likely to impact renal functions in the future (see 'Indications for nephron-preserving surgery' below):

•A solitary kidney (see 'Solitary kidney' below)

•Multiple, small, and/or bilateral tumors (see 'Multiple or bilateral tumors' below)

•Patients with or at risk for chronic renal disease (see 'Baseline renal dysfunction' below)

Our approach is consistent with the guidelines of the American Urological Association (AUA) [2].

In the randomized trial EORTC 30904, 541 patients with clinical stage T1 or T2 RCC were randomly assigned to partial or radical nephrectomy [3].

●There were 12 local or regional recurrences in 268 patients managed with partial nephrectomy (4.5 percent) compared with 9 of 273 (3 percent) in those managed with radical nephrectomy. The number of patients who developed distant metastases was low in both groups (7 and 6 patients, respectively).

●The 10-year overall survival rate was lower with partial nephrectomy (76 versus 81 percent, hazard ratio (HR) 1.50, 95% CI 1.03-2.16), but only 12 of the 117 deaths in the entire study population were due to RCC. The cancer-specific survival rate was not statistically different (HR 2.06, 95% CI 0.62-6.18).

●After a median follow-up of 6.7 years, fewer patients developed moderate renal dysfunction (estimated glomerular filtration rate [eGFR] <60) after partial nephrectomy (65 versus 86 percent), while the incidence of advanced kidney disease (eGFR <30) was relatively similar (6 versus 10 percent) between partial and radical nephrectomy, and the incidence of kidney failure (eGFR <15) was nearly identical (1.6 versus 1.5 percent) [4].

A 2016 meta-analysis of 107 studies with a majority of T1 renal masses compared partial and radical nephrectomy with a median follow-up of 60 months [5].

●The cancer-specific survival rates were not different between radical and partial nephrectomy, but both decreased with tumor stage (97 versus 98.8 percent for T1a, 91 versus 90 percent for T1b, 82.5 versus 86.7 percent for T2 tumors).

●Partial nephrectomy was associated with a smaller decline in postoperative glomerular filtration rate (weighted mean difference -3.6, 95% CI -4.1 to -3.2) than radical nephrectomy, and a lower incidence of chronic kidney disease (CKD) stage 3 or above (risk ratio 0.39, 95% CI 0.30 to 0.51).

●Partial nephrectomy was associated with more blood transfusions and urological complications than radical nephrectomy, but the overall complication rates were similar.

Similarly, a 2023 meta-analysis of 31 studies associated partial nephrectomy with a decreased risk of postoperative early-stage CKD and cardiovascular events compared with radical nephrectomy. However, no benefit of was observed in advanced CKD, new-onset or worsening hypertension, myocardial infarction, and cardiovascular mortality [6].

Open versus minimally invasive approaches — A radical nephrectomy can be performed as an open surgical procedure or laparoscopically/robotically. The choice of surgical technique should be based on patient-specific considerations (eg, tumor location and size) and the technical expertise available. In most institutions, laparoscopic nephrectomy has replaced open radical nephrectomy for many patients, especially if the tumor size is less than 10 cm. According to a large United States database study, the percentage of radical nephrectomies performed robotically increased from 1.5 percent in 2003 to 27 percent in 2015 [7]. In randomized trials, laparoscopic radical nephrectomy led to less postoperative pain and a faster return to normal activities than open nephrectomy [8]. Long-term oncological outcomes after laparoscopic radical nephrectomy for RCC are excellent and appear comparable to those of open surgery [9,10].

As with radical nephrectomy, both open and laparoscopic/robotic partial nephrectomy techniques are utilized and result in comparable outcomes [11,12]. Although laparoscopic partial nephrectomy is technically difficult, robotic-assisted, laparoscopic partial nephrectomy has evolved as a technique that offers similar outcomes to open partial nephrectomy yet has the advantage of precision and maneuverability to minimize ischemia times [13,14]. In several meta-analyses of robotic versus open partial nephrectomy, robotic partial nephrectomy had a longer operative time, but less blood loss, shorter length of stay, and fewer complications [15,16]. In a meta-analysis of comparative nonrandomized studies, although robotic assistance does not appear to offer any incremental benefit over conventional laparoscopic surgery in radical nephrectomy [17,18], such benefit does exist in partial nephrectomy [19]. Nevertheless, there are still some challenging partial nephrectomies that are safer done open rather than minimally invasively.

RADICAL NEPHRECTOMY — For patients with RCC limited to the kidney, a radical nephrectomy results in a five-year cancer-specific survival rate between 80 and 90 percent [3,9,20,21]. However, patients are at risk for long-term renal dysfunction as a result of the procedure, with the reported risk exceeding 30 percent [22-24]. Hospitals and surgeons doing a higher volume of nephrectomies have lower mortality compared with those institutions with lower volumes [25,26].

Techniques — Radical nephrectomy consists of ligation of the renal artery and vein and removal of the kidney, Gerota fascia, and, on occasion, the ipsilateral adrenal gland. However, in the absence of high risk of local invasion of the adrenal gland, resection of the adrenal gland should be omitted because the incidence of adrenal metastases is uncommon (10 percent or less) in clinically localized RCC [27-29]. (See 'Adrenal gland involvement' below.)

Early ligation of the vascular pedicle is important to prevent tumor dissemination at surgery [30]. Of the various open approaches described (eg, thoracoabdominal, extrapleural, and anterior transabdominal), we prefer the anterior transabdominal approach because it offers the ability to remove the tumor through a relatively small incision. However, with large upper-pole tumors, the thoracoabdominal incision may be preferable, allowing palpation of the ipsilateral lung cavity and mediastinum. In addition, this allows the exposure required to resect a pulmonary metastasis if it is identified intraoperatively [31]. Minimally invasive approaches are discussed elsewhere. (See 'Open versus minimally invasive approaches' above.)

Retroperitoneal lymph nodes — Lymph node dissection need not be performed routinely in patients with localized kidney cancer and clinically negative nodes [2]. Our approach is as follows:

●We perform an extended lymphadenectomy for patients deemed to be at an increased risk for lymph node involvement (eg, tumor grade 3 or 4, sarcomatoid histology, T3 or T4 tumor, presence of coagulative necrosis) and in patients with suspected nodal metastases on preoperative imaging [32,33]. Lymph nodes from the ipsilateral great vessel and the interaortocaval region should be removed from the crus of the diaphragm to the common iliac artery [34].

●For patients with no preoperative evidence of abdominal node involvement and not at an increased risk of nodal metastases, we typically perform a limited lymphadenectomy which removes the lymph nodes in the renal hilum, as there is no apparent therapeutic benefit to a more extended lymphadenectomy.

The only data from a randomized trial, from the European Organization for Research and Treatment of Cancer (EORTC) 30881 trial, evaluated 772 patients who were assigned to radical nephrectomy alone or radical nephrectomy with lymph node dissection [35]. At a median follow-up of over 12 years, there were no differences in overall survival or deaths due to cancer in the two treatment arms. However, only 4 percent of patients in this study had pathologically involved lymph nodes, limiting the generalizability of these results [36].

Large retrospective series have not been able to confirm a survival benefit for lymph node dissection among patients undergoing radical nephrectomy for nonmetastatic RCC [37-39]. Thus, lymph node dissection for RCC is primarily for staging and prognostic purposes. Patients with lymph node involvement confirmed on final pathology may be eligible for adjuvant therapy. (See 'Adjuvant therapy' below.)

Cavoatrial tumor involvement — RCC is complicated by cavoatrial tumor involvement in about 10 percent of cases [40]. For patients with evidence of thrombus involving the inferior vena cava (IVC) and/or right atrium (ie, cavoatrial involvement) but without evidence of distant or nodal metastases, we proceed with thrombectomy at the time of radical nephrectomy [41]. In such patients, thrombectomy can provide immediate palliation of symptoms with five-year survival rates up to 70 percent [42,43]. Patients with a lower tumor thrombus level (I/II) and those with a lower body mass index have better survival after thrombectomy [42].

The extent of thrombectomy depends on the extent of involvement of the tumor [44]. Four stages of cavoatrial tumor involvement have been described (figure 1):

●Level I – Thrombus <2 cm above the renal vein

●Level II – Thrombus below the intrahepatic vena cava

●Level III – Thrombus involves the intrahepatic vena cava but is below the diaphragm

●Level IV – Thrombus involves the atrium

For patients with thrombus extending up to the major hepatic veins, a simple thrombectomy may suffice [45]. For patients whose thrombus extends above the major hepatic veins, cardiopulmonary bypass with or without hypothermic circulatory arrest may be required to achieve a complete resection.

However, postoperative morbidity and mortality can be significant [46], including the rare complication of intraoperative tumor embolization [47]. Although no perioperative strategies are warranted to prevent embolization, patients who had an embolic event preoperatively should be treated with heparin. IVC filters are generally avoided as they need to be placed above the renal veins, and if they become blocked, they can impair function of the remaining kidney.

Adrenal gland involvement — For patients with solitary ipsilateral adrenal metastases identified by preoperative imaging studies, we proceed with adrenalectomy at the time of nephrectomy. This approach is supported by a series of 648 patients who underwent radical nephrectomy combined with adrenalectomy over a 20-year period [48]. In this series, 48 patients (7 percent) had adrenal metastases, of which 13 were solitary adrenal metastases without other evidence of systemic disease. Median overall survival for patients without any metastatic disease was 13.8 years; for those with isolated solitary adrenal metastases without other systemic spread, median survival was 11.7 years. In contrast, median survival for those with lymph node metastases or distant metastases was approximately one year.

In addition, an adrenalectomy may be performed in patients who may be at risk for direct extension into the adrenal gland, including patients with upper-pole lesions >4 cm or upper-pole non-organ-confined tumor (T3 or greater). However, the benefit of adrenalectomy in this setting is less clear-cut [49]. Adrenalectomy should not be performed if the contralateral adrenal gland is absent and the ipsilateral gland demonstrates normal morphology and no malignant involvement [29].

Large, marginally resectable tumors — For patients with a large tumor deemed to be only marginally resectable, preoperative renal arterial embolization may be an option to reduce vascularity and lower the risk of intraoperative hemorrhage at the time of planned nephrectomy [50]. However, the limited data has not associated it with either a survival benefit or a technical benefit compared with patients who proceed with nephrectomy alone [51,52].

PARTIAL NEPHRECTOMY — Patients with tumors ≤10 cm and those at risk for a significant loss of renal function should be managed with a partial nephrectomy if it is technically feasible. As noted above, partial nephrectomy results in similar oncologic outcomes compared with radical nephrectomy in appropriately selected patients. In addition, it is associated with a significantly lower risk of chronic renal dysfunction [3,53,54]. (See 'Radical versus partial nephrectomy' above.)

Indications for nephron-preserving surgery — Absolute indications for nephron-preserving approach such as partial nephrectomy include solitary kidney, bilateral tumors, or known familial RCC [2]. Relative indications include patients with baseline kidney dysfunction (eg, chronic kidney disease [CKD] or proteinuria).

Solitary kidney — For RCC in a patient with a solitary kidney, we recommend a partial nephrectomy whenever possible. In a series of over 1000 renal mass in solitary kidney, over 80 percent underwent partial nephrectomy [55]. As only 25 to 30 percent of a solitary kidney needs to be preserved to avoid renal replacement therapy, partial nephrectomy is feasible for most patients with a solitary kidney [56,57]. Indeed, studies report that only 2 to 12 percent of patients with a solitary kidney require permanent dialysis after partial nephrectomy [55,58,59].

Multiple or bilateral tumors — Up to 15 percent of patients with papillary tumors and 8 percent of those with other histologic subtypes have multicentric tumors [60]. In addition, between 1 and 4 percent of patients with sporadic tumors have bilateral RCCs [61].

For patients who have multiple and/or bilateral tumors, some experts advocate active surveillance and defer intervention until any lesion increases to 3 cm or larger [62]. This size criterion was derived from studies in patients with von Hippel-Lindau disease, in whom preservation of renal parenchyma is critically important because of the high likelihood of additional subsequent renal lesions [63]. If nephrectomy is indicated, we prefer a partial nephrectomy if technically feasible because the goal is to maintain as much renal function as possible without compromising long-term outcomes [64].

While most patients with familial RCC have two functional kidneys, they are very likely to experience bilateral tumors, tumor recurrence, and require multiple renal surgeries throughout their lifetime [65]. As such, for most RCC syndrome patients, it is important to hold off surgery until the tumor(s) are larger than 3 cm and utilize a partial nephrectomy whenever possible [62]. Further discussions of von Hippel-Lindau disease and other hereditary kidney cancer syndromes are presented separately. (See "Hereditary kidney cancer syndromes" and "Clinical features, diagnosis, and management of von Hippel-Lindau disease", section on 'Renal cell carcinomas'.)

Baseline renal dysfunction — For patients with preoperative renal dysfunction and those at risk for chronic kidney disease, a partial nephrectomy should be performed when technically feasible in order to preserve renal function. (See 'Partial nephrectomy' above.)

The impact on subsequent renal function after a partial versus radical nephrectomy was evaluated in a study of 662 patients who had a solitary cortical lesion <4 cm, an apparently healthy contralateral kidney, and a baseline serum creatinine less than 1.4 mg/dL [22]. Three years after surgery, patients undergoing partial nephrectomy had a significantly lower likelihood of renal dysfunction than those undergoing radical nephrectomy (5 versus 36 percent, respectively).

Techniques — During partial nephrectomy, the kidney should be carefully examined to exclude a synchronous tumor. The importance of this was illustrated in a series of 112 patients with sporadic renal masses who underwent partial nephrectomy [66]. A second lesion was identified in 37 cases, and 8 (7 percent of the entire series) were malignant. In addition, conversion to a radical nephrectomy may be necessary based on intraoperative findings. For example, some urologists convert the surgery to radical nephrectomy in cases with renal vein invasion or sarcomatoid histology on frozen section.

A formal lymphadenectomy is usually not performed during a partial nephrectomy, as partial nephrectomy is typically performed for smaller tumors with lower incidence of nodal metastasis. For patients who are candidates for a partial nephrectomy, concomitant adrenalectomy is not routinely indicated. This was illustrated in a series of 2065 patients undergoing partial nephrectomy at a single institution, of whom a concomitant adrenalectomy was performed in 48 cases (2 percent) [27]. At final pathology, only 3 of the 48 patients (7 percent) had adrenal invasion or metastasis, and three others had a separate adrenal neoplasm.

Significance of margin status — Unlike those who undergo a radical nephrectomy, patients who undergo a partial nephrectomy for RCC are at risk that surgery will not completely remove the tumor and that positive margins may be identified at final pathology. A positive surgical margin has been linked with inferior oncologic outcomes, such as a higher recurrence rate, in many studies [67-69].

Whether a frozen section should be performed in these patients is controversial. While a frozen section reduces the risk of a positive margin (and, therefore, leaving tumor behind), the limited data suggest that performing a frozen section does not influence survival outcomes [70]. As such, our approach is to perform a frozen section if an open surgical procedure is done because it allows further tissue resection if necessary and increases the likelihood that the entire tumor has been removed. When these procedures are being done laparoscopically or robotically, the opportunity to resect further tumor is more limited. In those circumstances, a frozen section is not usually performed.

There are conflicting data regarding the prognostic implications of and treatment options for a positive final surgical margin, particularly in high-risk patients [71-73]. Given that a positive surgical margin does not necessarily predict recurrence, and that a higher recurrence rate does not necessary predict worse survival in this population [74,75], our approach is to proceed with surveillance following partial nephrectomy in all patients with RCC, regardless of the margin status [76]. Other options would include repeat excision, completion radical nephrectomy, or thermal ablation. However, since local recurrence is uncommon (<10 percent), surveillance is the preferable option for management of the renal primary, with adjuvant immunotherapy considered for control of systemic recurrence in appropriate patients [74,75]. (See 'Post-treatment surveillance' below and "Overview of the treatment of renal cell carcinoma", section on 'Adjuvant therapy for locoregional disease'.)

Enucleation — Enucleation refers to the removal of the tumor itself without dissection into the uninvolved renal parenchyma. For RCC, enucleation has been most commonly used in patients with familial RCC, multifocal disease, or severe CKD to optimize parenchymal mass preservation [77].

There are no prospective data comparing enucleation with partial nephrectomy. Limited retrospective data suggest it is comparable to surgery as a treatment of small renal lesions [78,79]. Until more data become available, we suggest a partial nephrectomy with excision of the tumor and a rim of normal parenchyma, rather than enucleation.

ALTERNATIVES TO SURGICAL THERAPY — For patients with localized RCC who are not surgical candidates for whatever reason, nonsurgical approaches, including thermal ablation (radiofrequency ablation or cryotherapy) or active surveillance (for tumors <4 cm), are appropriate alternatives. These options are discussed in other topics. (See "Radiofrequency ablation, cryoablation, and other ablative techniques for renal cell carcinoma" and "Overview of the treatment of renal cell carcinoma", section on 'Active surveillance in nonsurgical candidates'.)

ADJUVANT THERAPY — For patients treated with definitive surgery for RCC, the use of adjuvant therapy is discussed separately. (See "Overview of the treatment of renal cell carcinoma", section on 'Adjuvant therapy for locoregional disease' and "Overview of the treatment of renal cell carcinoma", section on 'Adjuvant therapy after metastasectomy'.)

POST-TREATMENT SURVEILLANCE — The optimal surveillance strategy after potentially curative treatment for RCC has not been well studied. Follow-up should be based upon the individual patient's risk for recurrence. (See "Surveillance for metastatic disease after definitive treatment for renal cell carcinoma".)

SPECIAL CONSIDERATIONS DURING THE COVID-19 PANDEMIC — The COVID-19 pandemic has increased the complexity of cancer care. Important issues include balancing the risk from delaying cancer treatment versus harm from COVID-19, minimizing the number of clinic and hospital visits to reduce exposure whenever possible, mitigating the negative impacts of social distancing on delivery of care, and appropriately and fairly allocating limited healthcare resources. Specific guidance for decision-making for cancer surgery on a disease-by-disease basis is available from the American College of Surgeons, from the Society for Surgical Oncology, and from others. These and other recommendations for cancer care during active phases of the COVID-19 pandemic are discussed separately. (See "COVID-19: Considerations in patients with cancer".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Cancer of the kidney and ureters".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Beyond the Basics topic (see "Patient education: Renal cell carcinoma (kidney cancer) (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Indications for surgery – For patients with nonmetastatic renal cell carcinoma (RCC) who are operative candidates, surgical resection is potentially curative (see 'Indications' above). The role of cytoreductive nephrectomy in other patients with metastatic RCC is discussed separately. (See "Role of surgery in patients with metastatic renal cell carcinoma", section on 'Cytoreductive nephrectomy'.)

●Radical versus partial nephrectomy – For patients undergoing definitive surgical treatment for RCC, either a radical or partial nephrectomy may be performed. Our approach is as follows (algorithm 1) (see 'Radical versus partial nephrectomy' above):

•For patients with a primary tumor ≤4 cm, we recommend a partial nephrectomy rather than radical nephrectomy (Grade 1B). In such patients, partial nephrectomy is oncologically equivalent to radical nephrectomy with a lower risk of future renal compromise. (See 'Partial nephrectomy' above.)

•For patients with a primary tumor between 4 and 10 cm, we suggest a partial nephrectomy when it is technically feasible, especially in the presence of a solitary kidney, multiple and/or bilateral renal tumors, familial RCC syndrome, and baseline renal dysfunction (chronic kidney disease [CKD] or proteinuria) (Grade 2C). (See 'Indications for nephron-preserving surgery' above.)

•For patients with a primary tumor >10 cm or those involving a more central position of the kidney, we perform a radical nephrectomy. (See 'Radical nephrectomy' above.)

●Open versus minimally invasive surgery – Both radical and partial nephrectomy can be performed as an open surgical procedure or laparoscopically/robotically. The choice of surgical technique should be based on patient- and tumor-specific considerations (eg, tumor location and size) and the technical expertise available. (See 'Open versus minimally invasive approaches' above.)

●Radical nephrectomy – Radical nephrectomy consists of early ligation of the renal artery and vein and removal of the kidney, Gerota fascia, and, on occasion, the ipsilateral adrenal gland. (See 'Radical nephrectomy' above.)

•Lymphadenectomy – Patients with RCC should undergo a lymph node dissection at the time of radical nephrectomy. Lymph node dissection for RCC is primarily for staging and prognostic purposes. (See 'Retroperitoneal lymph nodes' above.)

-For patients with suspected retroperitoneal lymph node involvement and those at high risk for nodal involvement, we perform an extended lymphadenectomy at the time of radical nephrectomy.

-For patients in whom retroperitoneal lymph node involvement is not suspected and those at low risk for nodal involvement, we perform a limited lymph node dissection concentrated around the renal hilum.

•Cavoatrial tumor involvement – For patients with tumor thrombus involvement of the inferior vena cava (IVC) or right atrium but no nodal or distant metastasis, we recommend tumor thrombectomy at the time of radical nephrectomy (Grade 1B). (See 'Cavoatrial tumor involvement' above.)

•Adrenal gland involvement – Patients with RCC that directly extends to the ipsilateral adrenal gland and those at risk for invasion of the adrenal gland should undergo adrenalectomy at the time of radical nephrectomy. However, adrenalectomy should not be performed if the contralateral adrenal gland is absent and the ipsilateral gland demonstrates normal morphology and no malignant involvement. (See 'Adrenal gland involvement' above.)

●Partial nephrectomy – Partial nephrectomy results in similar oncologic outcomes compared with radical nephrectomy in appropriately selected patients. In addition, it is associated with a significantly lower risk of chronic renal dysfunction. (See 'Partial nephrectomy' above.)

•Margin status – For patients undergoing partial nephrectomy, we aim for negative surgical margins. We may obtain frozen section in open cases, where additional resection is feasible, but not minimally invasive cases. We proceed with surveillance for local recurrence following partial nephrectomy in all patients with RCC, regardless of the margin status. A positive surgical margin has been associated with a higher recurrence rate in some studies, but not a worse survival rate. (See 'Significance of margin status' above.)

•Enucleation – For patients undergoing partial nephrectomy, we suggest dissecting the tumor with a margin of surrounding parenchyma rather than enucleation (Grade 2C). (See 'Enucleation' above.)