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Pecoraro et al. Mini-invasive Surg 2024;8:29 https://dx.doi.org/10.20517/2574-1225.2023.90 Page 3 of 11

For example, the use of mpMRI or 99mTc-sestamibi (SestaMIBI, MIBI) single photon emission computed
tomography (SPECT)/CT has shown promising initial results to diagnose clear cell RCC (ccRCC) via a clear
[19]
cell likelihood score (ccLS) in SRMs [17,18] and for the differentiation between benign and low-grade RCC .
This has many clinical implications in the decision-making process as reported in the collaborative review
by Roussel et al. .
[20]
Preoperative assessment should also include renal function assessment with renal scintigraphy to better
delineate split renal function at baseline which will be helpful for surgical planning, type of access and
treatment choice [21,22] .

Advancements in imaging technologies, such as mpMRI and 99mTc-sestamibi SPECT/CT, are significantly
enhancing the preoperative characterization of renal masses. These technologies aid in distinguishing
benign lesions from malignant ones, which can inform the decision-making process regarding whether to
pursue AS or surgical intervention. Furthermore, as our understanding of the genetics of RCC progresses -
especially concerning hereditary syndromes - genetic testing is becoming an essential aspect of patient
management. This shift toward personalized care allows for the development of treatment plans tailored to
individual genetic and molecular profiles, which is expected to influence future clinical guidelines. However,
despite these advancements, there remains a notable gap in randomized trials that directly compare
outcomes between simultaneous and staged surgeries and between surgical and ablative treatments. Long-
term studies are still necessary to assess oncological outcomes and the preservation of renal function, which
will help refine current treatment protocols.

TREATMENT STRATEGIES
[8]
The EAU guidelines emphasize a nephron-sparing approach in the treatment of BSRMs, especially for
patients with predisposing genetic conditions, such as VHL syndrome, Birt-Hogg-Dubé syndrome, or
tuberous sclerosis complex. For patients without hereditary conditions, the focus remains on maximizing
the preservation of renal function while providing oncological control. Similarly, AUA guidelines support
[9]
a nephron-sparing strategy and genetic testing for patients with BSRMs.

Preoperative treatment planning is necessary to achieve two important targets: complete tumor resection
and the maintenance of renal function adequate to keep the patient off hemodialysis.

Surgeons can choose between a simultaneous or a two-step approach.

Most surgeons prefer a two-different-step approach. The main reason is the contralateral kidney
compensation to face a period of transitory unilateral renal insufficiency.

On the contrary, others prefer simultaneous bilateral intervention which could reduce mental and physical
stress, require single anesthesia, less medication, less blood loss, shorter hospital stay and convalescence,
along with considerable cost savings.

Moreover, the increase of SRM detection as the first presentation of kidney cancer has led to a treatment
change. Alongside NSS, AS and AT have been emerging as alternatives in SRM treatment. Scientific data
prove that SRMs have little potential for metastasis and disease-related mortality due to their benign or low-
grade histology [23-25] .