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Page 4 of 11 Pecoraro et al. Mini-invasive Surg 2024;8:29 https://dx.doi.org/10.20517/2574-1225.2023.90

NON-SURGICAL TREATMENT
In this context, AS and AT are also considered valid options in the treatment of BSRMs [10,12] .

AS
AS is increasingly recognized as a safe option for patients with SRMs, including those with bilateral
synchronous renal tumors. Both the EAU and AUA guidelines support AS in patients where surgery is
high-risk or unnecessary due to slow tumor growth.

AS should be considered a valid option in both hereditary and sporadic syndromes.

[26]
The strategy of combining AS with minimally invasive interventions, especially in hereditary syndromes ,
allows for the preservation of renal function and provides metastasis-free survival based on the assumption
that renal tumors less than 3 cm in size show low rate of metastases and progression.

Regarding non-hereditary bilateral synchronous, AS combined with delayed interventions is a valid option
as demonstrated by a TUCAN database study [10,12] .

They observed 33 patients harboring synchronous SRMs and treated with AS with a mean follow-up of
more than six years, comparing their oncological outcomes with their unilateral counterparts.

Specifically, the intervention and growth rate and the development of metastases within BSRM patients
were similar, as for metastasis-free, disease-specific or overall survival to those with unilateral SRM. These
[8,9]
findings agree with current European and American guidelines , showing that BSRMs under AS tend to
have outcomes similar to unilateral SRMs, with low rates of metastasis and cancer-specific mortality [12,27] .
Close monitoring with regular imaging is crucial to detect progression that might necessitate delayed
intervention.

Ablative techniques
For patients unsuitable for surgery or those with genetic syndromes that predispose them to multiple
bilateral renal tumors, ATs [e.g., radiofrequency ablation (RFA) and cryoablation (CA)] provide a nephron-
sparing alternative. Both the EAU and AUA guidelines support these approaches in appropriate cases. RFA
and CA are minimally invasive and can be performed percutaneously or laparoscopically. Studies
demonstrate high local control rates (e.g., 93.1% for RFA), with minimal impact on renal function. CA, in
particular, has been associated with lower rates of renal function decline compared to partial nephrectomy.
However, both methods may require repeat treatments for tumor recurrence or incomplete ablation.

Ablative techniques are fit for patients with kidney cancer genetic syndromes because of the increased
likelihood of multiple bilateral renal tumors (VHL syndrome, tuberous sclerosis, and Birt-Hogg-Dubé
syndrome). However, also in the treatment of sporadic BSRM, these techniques are a valid option, as
reported in two studies [28,29] . According to European and American guidelines, RFA and CA are associated
with lower perioperative morbidity compared to surgery and are suitable for patients with small, localized
tumors [30,31] or those with high surgical risk [32-34] .

Specifically, RFA and CA are the main used ablative techniques for the treatment of BSRM [28,29] , both of
which could be performed percutaneously, open or via a laparoscopic approach.