Surgical approaches to early stage kidney cancer

With the continued routine use of cross-sectional imaging, the incidence of early stage localized renal cell carcinoma (RCC) or the small renal mass continues to rise. Treatment options for localized RCC include surgical excision, ablative techniques, and active surveillance. All treatment paradigms have excellent short-term, intermediate-term, and long-term, when available, oncologic outcomes, and each technique offers various advantages and disadvantages compared to the other treatment alternatives. In spite of or because of all these available, effective treatment approaches, the decision to treat a particular patient with localized RCC in a certain manner is relatively subjective and based on practitioner and patient biases. Considering recent data that has questioned the utility of active intervention for localized RCC, especially in the elderly, attempts have been made to quantify the risk/benefit of treatment. Also, reproducible measures of renal tumor anatomy as well as the refinement of the measurement of renal function have been created and advocated to more accurately assess the oncologic risk of localized RCC against the risks of treatment-related adverse events and chronic kidney disease. In this chapter, we review the existing treatment options for localized RCC contextualized against the risks of competing health comorbidities and chronic kidney disease. Furthermore, we discuss the utility of reproducible, objective methods to preoperatively define salient renal mass anatomy and how this can potentially objectify treatment decision-making. Finally, in this chapter, we attempt to provide a standardized platform whereby the treatment decision-making process for localized RCC accounts for all the available objective data in order to arrive at the optimal treatment decision for each individual patient based on the risks and benefits of treatment.