When a patient presents with an apparently localized renal cell cancer (RCC), the time'honored dogma has been, "remove the kidney and save the patient's life." This paradigm was appropriate when Dr. Robson1 was operating, at a time when cancer-specific mortality overwhelmingly drove overall mortality. However, the average patient who presents with a renal mass today is not the same patient that Dr. Robson would have seen. With the widespread use of CT imaging, renal tumors are diagnosed at progressively smaller sizes and lower stages; logic would lead us to believe that earlier diagnosis and treatment would lead to improved survival. Instead we find that most patients with localized RCC rarely die of disease after treatment2 and that overall survival has actually worsened, despite prompt treatment.3 It is becoming increasingly clear that this "treatment disconnect" calls into question the current paradigm, which is radical nephrectomy (RN) >90% of localized RCC.4
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