A 58-year-old man presents with a 4.5 cm left renal mass on CT characterised by heterogeneous enhancement, areas of calcification, and fat. The renal vein is not involved and there are no distant metastases. What is the MOST appropriate management?

• A Radical nephrectomy is always preferred for masses >4 cm
• B Active surveillance with CT at 3 months
• C Percutaneous biopsy followed by neoadjuvant sunitinib before surgery
• D Partial nephrectomy (nephron-sparing surgery) is preferred if technically feasible ✓

Explanation

For localised renal cell carcinoma (RCC) T1–T2, partial nephrectomy (nephron-sparing surgery, NSS) is the preferred approach whenever technically feasible, as it preserves renal function without compromising oncological outcome compared to radical nephrectomy. EAU guidelines endorse NSS for T1a (<4 cm) as mandatory and T1b (4–7 cm) as preferred when technically possible by an experienced surgeon. Radical nephrectomy is not automatically preferred for >4 cm unless NSS is not feasible. Active surveillance is for small (<3 cm) incidentalomas in comorbid elderly patients. Pre-operative biopsy is not routinely required for typical enhancing renal masses in fit patients.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.