Updated guidelines improve management of renal masses

The revised guidelines include expanded indications for genetic counseling and address adjuvant therapy for the first time.

Steven A. Campbell, MD, PhD
Steven A. Campbell, MD, PhD

AUA guidelines for the evaluation, management and follow-up of localized renal cancer have been updated for the first time since 2017. The new guidelines are based on critical evaluations of the literature through January 2021.

“By 2020, it became clear that a number of elements in the 2017 guidelines needed to be updated,” said Steven A. Campbell, MD, PhD, chair of the AUA Guidelines Panel and professor of surgery at the Cleveland Clinic in Ohio. “Along with updating, the guidelines for following patients with localized kidney cancer after intervention have been merged with guidelines for evaluation and management. We now have just one guideline instead of two.” 

Dr. Campbell will present an “AUA Guidelines Update” on renal masses during Friday’s plenary session, where he will highlight important changes in several areas, starting with expanded indications for genetic counseling. 

“Over the past decade, our knowledge regarding familial kidney cancer has advanced substantially, and we now recognize that familial etiology is more common than previously appreciated,” Dr. Campbell said. “Based on this, the guidelines have been updated to provide a more comprehensive profile for which patients should be considered for genetic counseling.” 

The revised guidelines also address adjuvant therapy for the first time. The change is a reflection of clinical trials of adjuvant agents showing evidence of potential benefit for some patients. 

Advances in imaging also played into the new guidelines. Magnetic resonance imaging (MRI) with contrast can now be used even in patients with severe chronic kidney disease or end-stage renal disease, thanks to the development of second-and third-generation kidney-sparing gadolinium contrast agents. 

“This is a real game changer for our daily clinical practice,” Dr. Campbell said. “It was always hard to evaluate patients with severe chronic kidney disease or end-stage renal disease because first-generation MRI contrast agents could lead to nephrogenic systemic fibrosis. Now you can just get an MRI in most patients with very little risk at all.” 

Indications for renal mass biopsy have been revised in the new guidelines to emphasize a utility-based approach. If biopsy results could change management or help decide between different management options, the procedure may be appropriate. If a biopsy lacks clear clinical utility, the guidelines advise against doing it. 

Similarly, recommendations for partial versus radical nephrectomy have been clarified to be more useful. Prior recommendations and current non-AUA recommendations generally advise partial nephrectomy “whenever feasible,” Dr. Campbell said. 

“We provide more granular recommendations for who actually needs a radical nephrectomy, with the goal of making sure that patients who need a radical get it, while recognizing that radical nephrectomy can be overutilized,” he explained. 

Indications and rationale for active surveillance have also been clarified to be more specific. Follow-up recommendations for patients on active surveillance are also more detailed than in earlier guidelines. 

“These guidelines are specifically designed for the practicing urologist to offer more useful recommendations to help them manage patients in an optimal manner,” Dr. Campbell said. “If you see patients with renal masses, this session will be useful in your daily practice for the evaluation, counseling, management and surveillance of this patient population.” 

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