Urologic approaches to metastatic renal cell carcinoma.

The treatment of choice for nondisseminated disease is surgery. However, the 5-year survival rates for all stages do not exceed 60%, even in contemporary series. Further improvement will most likely have to await the development of a more effective systemic therapy and the application of combined treatment modalities to counter the relatively high number of patients presenting with advanced stages. Treatment options in metastatic disease include nephrectomy alone, sometimes in combination with metastasectomy in selected cases, or cytoreductive surgery followed by immunotherapy. Alternatively, one may apply immunotherapy initially and perform adjuvant nephrectomy in the case of a response, or proceed with immunotherapy as a monotherapy. Nevertheless, long-term survival rates range merely from 5 to 10%, depending strongly on patient selection criteria. Concepts and progress in this field appear to be of major interest for modern urooncologists following the advent of immunotherapeutic strategies that require a surgical intervention at some stage of the treatment cascade.