Principles of nephrectomy for malignant disease.

For many years the prevailing belief was to advocate'radical' nephrectomy via a transperitoneal approach as the standard surgical procedure for renal cell carcinoma (RCC). because the early control of the renal vessels before manipulating the kidney should minimize the likelihood of disseminating tumour cells during surgery. This philosophy was based on retrospective data which were never confirmed in a controlled trial. Since then,evidence has accumulated that some patients maybe better served by an extraperitoneal (translumbar)approach, providing similar oncological efficacy with the added advantage of reduced morbidity. However,these results are again either retrospective or statistically insignificant, and therefore do not allow firm conclusions. Nevertheless, if there is any difference in the possible intraoperative dissemination of tumour, depending on the type of surgical approach, it will be small, requiring analysis in a large randomized multicentre trial. The treatment of choice for disease that is not disseminated is surgery, although the 5-year survival rates for all stages do not exceed 60%, even in contemporary series. Further improvements will probably have to rely on the development of more effective systemic therapy and the application of combined treatments to counter the relatively many patients presenting with advanced stages. Concepts and progress in this field appear to be of major interest for modern uro-oncologists after the advent of immunotherapeutic strategies that require a surgical intervention at some stage of the treatment cascade.