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Page 2 of 11 Pecoraro et al. Mini-invasive Surg 2024;8:29 https://dx.doi.org/10.20517/2574-1225.2023.90

INTRODUCTION
Bilateral kidney cancers account for approximately 3% of renal tumors . Although bilateral renal tumors
[1]
remain common in patients with genetic renal cell carcinoma (RCC) syndromes [von Hippel-Lindau (VHL)
syndrome, tuberous sclerosis, Birt-Hogg-Dubé syndrome] in which a precise DNA related defect can be
identified, the majority of bilateral kidney cancer patients showed sporadic, nonfamilial bilateral renal
[2,3]
tumors .
Many factors have contributed to the increase in the prevalence of bilateral renal tumors including the
overall growth of kidney cancer incidence rates, early detection due to cross-sectional imaging, increased
life expectancy and longer follow-up periods of cancer survivors .
[4-7]
However, the management and decision-making in these cases are controversial, and both the European
Association of Urology (EAU) and the American Urological Association (AUA) Guidelines suggest that
[9]
[8]
patients presenting with bilateral renal masses should undergo genetic counseling and a nephron-sparing
approach; however, any standardized disease management is still recommended.

Furthermore, an increasing rate of these patients harboring small renal masses (SRM) at diagnosis has been
observed. This reads that along with nephron sparing surgery (NSS) also active surveillance (AS) and
ablative therapies (ATs) should be considered.

Regarding AS, sporadic bilateral synchronous renal masses (BSRM) showed no clinically meaningful
differences from unilateral SRMs in terms of progression and development of metastatic disease [10-12] .

Similarly, ablative techniques provide an alternative to surgery and minimize treatment-related morbidity,
particularly for patients with significant comorbidity and pre-existing renal conditions such as chronic
kidney disease and/or multiple RCC or genetic RCC related syndrome [13-15] . In this review article, we provide
an overview of each possible treatment option for BSRMs.

PREOPERATIVE MANAGEMENT
The National Cancer Institute proposed an algorithm for the workup and management of patients with
[16]
bilateral, multifocal, and known or suspected hereditary syndromes.

Pre-treatment characterization is crucial as the rationale of staged surgery focuses on obtaining an accurate
surgical anatomy assessment, a definitive histology of one side mass and on the concordance probability
between BSRMs. Differently, in order to find the gap of indication for simultaneous surgery, a patient
selection must be performed through pre-treatment mass characterization by advanced novel imaging
methods [i.e., positron emission tomography (PET)/computed tomography (CT), multiparametric
magnetic resonance imaging (mpMRI)], and histogenetic analysis (i.e., biomarkers, biopsy) in order to
differentiate as precisely as possible benign from malignant BSRMs. This point of focus will probably be
unraveled with the advances and implementation of novel imaging methods and genetic analysis.

Novel imaging methods have been shown to improve the pre-treatment characterization of renal masses,
such as mpMRI, molecular imaging, radiomics and artificial intelligence to enhance the interpretation of
imaging studies.