EURURO Vol. 72 No. 2

175 320

Platinum Priority – Editorial
Referring to the article published on pp. 171–174 of this issue
Morbidity of Metastasectomy for Renal Cell Carcinoma:
Emerging Evidence and Unmet Needs
Andrea Minervini Riccardo Campi, Alberto Lapini, Marco Carini
Department of Urology, University of Florence, Careggi Hospital, Florence, Italy
Metastatic renal cell carcinoma (mRCC) represents a
complex clinical scenario owing to the heterogeneity of
baseline patient and disease characteristics
The dynamic changing paradigm induced by the
introduction of targeted therapies has revolutionized
the treatment philosophy, setting new challenges regarding
the benefit and timing of cytoreductive nephrectomy and
surgical metastasectomy (SM) in the context of multimodal
approaches . Current European Association of Urology
(EAU) and European Society of Medical Oncology (ESMO)
guidelines consistently state that no general recommenda-
tions can be made as to whether a patient should be referred
for SM . Nevertheless, the removal of all metastatic
lesions, when technically feasible and clinically appropriate,
provides the only potentially curative treatment for mRCC
patients . Indeed, a recent systemic review and meta-
analysis showed that despite the low quality of evidence
available, median overall survival ranged between 36.5 and
142 mo after complete SM, compared to 8.4–27 mo after
incomplete SM. Incomplete SM cases had greater adjusted
overall mortality, with a hazard ratio of 2.37 (95%
confidence interval 2.03–2.87; p < 0.001) . The results
of a previous systematic review also pointed towards a
benefit of complete SM in terms of overall and cancer-
specific survival, despite the substantial risk of selection
bias and confounding in the studies included
With all of this acknowledged, a relevant question arises.
What is the price to pay for SM in mRCC patients? Assessing
the morbidity of SM plays a key role in decision-making and
in defining the best balance between benefits and harms of
surgery in this complex patient group from urological,
oncological, and public health perspectives. Unfortunately,
this topic has not been sufficiently addressed by the
literature to date, and represents a critical unmet need.
In this issue of European Urology, Meyer et al describe
in-hospital complication rates after SM in a contemporary
cohort of patients with mRCC. Using the National Inpatient
Sample (NIS) database, they identified 45 279 patients
diagnosed with mRCC between 2000 and 2011. The SM rate
was 2.4%. SM was predominantly performed for lung, bone,
and liver lesions. Overall and major (Clavien III–IV)
complications occurred in 45.7% and 25.1% of patients,
respectively. The in-hospital mortality rate was 2.4%.
On univariate analysis, age and hepatic metastases
(compared to any other site) were independent predictors
of overall complications, while a high comorbidity burden
was an independent predictor of major complications. The
authors also found a significantly lower likelihood of overall
complications among pulmonary resections (compared to
any other site) and of major complications among patients
with private insurance.
The authors should be commended for their valuable
efforts in addressing a complex research need in the rapidly
changing scenario of mRCC. As the NIS represents the
largest publicly available all-payer inpatient health care
database in the USA, a major strength of the study is the
possibility to provide reliable estimates of national rates of
in-hospital complications after SM for RCC. Thus, the study
represents a pioneering first step towards a more compre-
hensive evidence-based definition of perioperative mor-
bidity of SM (and its predictors), opening new perspectives
and research opportunities.
However, caution is needed in clinical interpretation of
the results of this study because of many concerns regarding
ava ilable at
journal homepage:
DOI of original article: .
* Corresponding author. Clinica Urologica I, Azienda Ospedaliera Careggi, Universita` di Firenze, Viale San Luca, 50134 Firenze, Italy.
Tel. +39 05 52758011; Fax: +39 05 52758014.
E-mail address: (A. Minervini).
0302-2838/# 2017 Published by Elsevier B.V. on behalf of European Association of Urology.