[Should cytoreductive nephrectomy be performed in patients with metastatic renal cell carcinoma and what is the scientific rationale?]

Between 15 and 20% of patients diagnosed with renal cell carcinoma suffer from metastatic disease by the time of diagnosis. In the immunotherapy era, the standard treatment was to perform cytoreductive nephrectomy (CN) followed by treatment with interferon α. This was based on two prospective randomized trials and their combined analysis. Since the introduction of targeted therapy, the use of CN came into question and the number of performed CN has declined. Two trials (CARMENA and SURTIME) evaluating the role of CN in the times of targeted therapy have either closed early or are recruiting slowly and will probably not be able to answer this question. Thus, we need to focus on retrospective data consisting of several analyses with large numbers of patients. These analyses all seem to show a benefit in overall survival, and adjusted for prognostic factors CN represents an independent predictor of longer survival. A correlation between expected life span and efficacy of CN has been shown with a survival rate that is three times higher after 3 years. Only patients with low performance status, low life expectancy, cerebral metastases, and old age did not benefit from CN. Furthermore, symptom control of large primary tumors without response to systemic therapy and the fact that all reports of long-term remission or long survival rates are associated with the use of CN are theoretical aspects speaking in favor of this treatment. This leads to the recommendation to perform CN in all patients with good performance status in all important guidelines.