European Association of Urology Guidelines on Renal Cell Carcinoma: The 2022 Update

Key guideline recommendations

1. Increasing physical activity, stopping smoking completely and weight loss in people with obesity are the main preventive measures to reduce the risk of renal cell carcinoma.

   Strong

2. Perform genetic assessment in patients aged under 46 years, with bilateral or multifocal tumours, and/or with a first-‎ or second-degree relative with renal cell carcinoma, and/or a close relative with a known pathogenic variant, and/or specific histological features suggesting a hereditary form.

   Strong

3. Offer surgery to achieve cure in localised renal cell carcinoma.

   Strong

4. Offer partial nephrectomy (sparing part of the kidney) to patients with T1 tumours.

   Strong

5. Offer active surveillance or thermal ablation to frail and/or comorbid patients with small renal masses.

   Weak

6. Perform percutaneous biopsy of the renal mass before, not at the same time as, thermal ablation.

   Strong

7. Do not routinely offer thermal ablation for tumours larger than 3 cm or cryoablation for tumours larger than 4 cm.

   Weak

8. Offer adjuvant pembrolizumab to patients with ccRCC after surgery with curative intent who are at risk of recurrence as defined in the trial (pT2 grade 4 or pT3 any grade; pT4 any grade; pN+‎ any grade).

   Weak

9. Do not perform cytoreductive nephrectomy in patients with MSKCC poor risk.

   Strong

10. In intermediate-risk patients with an asymptomatic synchronous primary tumour who require systemic therapy, do not perform immediate cytoreductive nephrectomy, and start systemic therapy without nephrectomy.

    Weak

11. Offer ipilimumab plus nivolumab to treatment-naïve patients with IMDC intermediate-‎ and poor-risk cc-mRCC.

    Strong

12. Administer nivolumab + ipilimumab, pembrolizumab + axitinib, lenvatinib + pembrolizumab and nivolumab + cabozantinib in centres experienced with combination immunotherapy and with appropriate supportive care within a multidisciplinary team.

    Weak

13. According to the guideline's first-line algorithm (Figure 7.1), the standard of care for cc-mRCC in IMDC favourable risk is nivolumab/cabozantinib, pembrolizumab/axitinib or pembrolizumab/lenvatinib; and in intermediate and poor risk, these three combinations or nivolumab/ipilimumab. For patients who cannot receive or tolerate an immune checkpoint inhibitor: sunitinib or pazopanib (and in intermediate and poor risk, cabozantinib).

    Level of evidence 1b (cabozantinib: 2a)

Study population

Endpoints

Clinical significance and place in guidelines

Limitations