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metachronous metastatic disease. It underscores the importance of updated patient selection criteria when
considering patients for cytoreductive nephrectomy.

Appropriate patient selection criteria for cytoreductive nephrectomy cannot be overstated. Certainly, those
with poor performance status who require prolonged recovery from surgery before beginning systemic
therapy are unlikely to benefit. Further, those with a high metastatic disease burden outside the kidney and
who cannot be significantly debulked are also likely best served with upfront systemic therapy.
Alternatively, those with symptoms from the primary tumor (pain or hematuria) are likely to benefit from
nephrectomy, if just for palliative reasons.

The question remains for those with good performance status and limited metastatic disease burden. These
are the patients who are potentially most likely to benefit from removing their primary tumor, but high-
quality evidence is needed in the current immunotherapy era. While the upcoming SWOG trial will
hopefully answer some of these questions, the discrepancy between the rapid advances in systemic therapy
and the time necessary to complete and analyze randomized surgical trials (i.e., a decade or more),
cytoreductive nephrectomy may remain an operation without high-quality, up-to-date data to guide clinical
decision making.

DECLARATIONS
Authors’ contributions
Responsible for the paper, concept, design, literature search, manuscript preparation and editing: Cross BW,
Cookson MS

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
Both authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2021.

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