The updated 2017 American Urological Association (AUA) guidelines for localized kidney cancer have been released, focusing on functional outcomes in relation to multiple treatment options.
A guideline panel created to update these guidelines made changes to the lack of index patients, considered the most significant variance between inpatient oncological and functional characteristics. Functional outcomes serve as the focus of the updates guidelines, due to its relationship with quality of life and survival in a patient population unlikely to die from their disease.
The new guidelines emphasize the role of urologists in administering patient counseling that covers both oncological and functional issues, along with the assessment of competing risk to tailor management. Renal mass biopsy is recommended for those tumors at risk of being hematologic, metastatic, inflammatory, in infectious. A discussion should be had with patients who undergo renal mass biopsy to weigh the risks and efficacy of the procedure.
The following treatment options are included in the guidelines:
- Standard of care for patients with cT1a renal masses (≤ 4 cm) should be partial nephrectomy via an open or laparoscopic approach. Physicians should prioritize partial nephrectomy in patients with an anatomical/functional solitary renal unit, those with chronic kidney disease, or evidence of proteinuria.
- Radical nephrectomy should be administered to patients with high tumor complexity in which partial nephrectomy would be too aggressive. In many cases, radical nephrectomy would be unreasonable because of benign or low grade malignancies.
- Thermal tumor ablation is recommended for patients in whom partial nephrectomy is deemed unsafe due to competing medical comorbidities or are unwilling to accept the risks of partial nephrectomy. Physicians should counsel patients on available data showing thermal tumor ablation to be inferior to partial nephrectomy in regards to oncological control with a high risk of needing repeat ablation.
- Active surveillance is recommended for patients in which the competing risks outweigh the benefits of treatment or are unwilling to undergo treatment. Physicians should counsel patients on anticipated treatment triggers and the possible risk of metastatic progression while under surveillance.
The guidelines were presented at the AUA Annual Meeting (May 12-16, 2017; Boston, MA). — Zachary Bessette