Editorial comment.

The early diagnostics of kidney tumors is constantly improving thanks to the prophylactic screening of the population with ultrasonography (USG) and the availability of many contemporary techniques such as computed tomography (CT) and magnetic resonance imaging (MRI), which is why many renal tumors are diagnosed incidentally. Despite this, there are still patients with large tumors more than 12 cm in size who do not present with any complaints (e.g., palpable mass, flank pain and gross hematuria).

Operations in case of large kidney tumors are a great challenge for urologists. Based on our experience, we believe that a large tumor size should not be a disqualifying factor for the surgical treatment of a kidney tumor. In such surgeries, the surgeon should choose the transabdominal approach in order to obtain the best visualization of the renal hilum, associated lymph nodes, and neighboring organs. We also consider neoadjuvant targeted therapy to be an ineffective modality for the reduction of tumor size.

Finally, it is of value to mention the usefulness of preoperative renovasography when performed with arterial embolization. It is my opinion that this treatment modality may aid in reducing the size of the tumor prior operation as well as in decreasing intraoperative blood loss and the risk of intraoperative metastasis via the vasculature.

In Bulgaria we have the following policy for the surgical management of giant kidney tumors: (1) the exact diagnosis is achieved with the use of USG, CT, and/or MRI and (2) is accompanied by renovasography and embolization; (3) the surgical removal of the kidney tumor and associated lymph nodes; and (3) the postoperative treatment with TK inhibitors (metastases and fossa of the tumor).

This information is further discussed in the manuscript titled, “There is no place for targeted therapy neoadjuvant treatment in Polish Health System – An analysis of radical nephrectomies in patients with large kidney tumors” [1], and I concur with the authors’ statements.