Refining the use of cytoreductive nephrectomy in metastatic renal cell carcinoma

Cytoreductive nephrectomy (CN) was regarded standard of care for patients with metastatic renal cellcarcinoma (mRCC) in the cytokine era. After the introduction of therapies targeting the vascular endothelial growth factor (VEGF) and mammalian target of rapamycin (mTOR) pathways, improved median survival and primary tumor responses are observed. Prognostic models have been validated and the clinical significance of tumor heterogeneity and histological subtypes has been recognized. These changes in the understanding and treatment of mRCC require assessment of CN. This review discusses the original context in which the efficacy of CN was established and the advances in treatment that have changed that context. Potential refinements in the use of CN that may reduce overall morbidity by limiting its use to those most likely to benefit are reviewed.