Surgical management of large renal tumors

In addition to an increased occurrence of small, localized, incidentally discovered renal cell carcinomas (RCCs), there has been an upward trend in the incidence of advanced renal tumors per unit of population and in disease mortality worldwide. As radical nephrectomy remains the standard of care in treating localized RCC, this manuscript focuses on surgical approaches. We defined 'large renal tumors' as those greater than 7 cm or those with venous involvement. We discuss operative strategies in both open and laparoscopic surgery as well as approaches to special circumstances, including patients with tumor thrombus and the indications for nephron-sparing surgery in patients with greater than T2 RCC. The literature pertaining to controversial areas such as preoperative renal artery embolization and the clinical utility of metastectomy and cytoreductive therapy are also reviewed. The theoretical basis and potential applications of neoadjuvant therapy for larger renal tumors is examined as well.