Surgical considerations for patients with metastatic renal cell carcinoma

•We review the role of cytoreductive nephrectomy (CN) in metastatic disease.•We review evidence for multiple criteria used to assess patients for CN.•We review various surgical approaches to CN.•CN remains a mainstay of treatment for metastatic patients.

Among patients with renal cell carcinoma (RCC), 25–30% present with metastatic disease at the time of initial diagnosis. Despite the ever-increasing array of treatment options available for these patients, surgery remains one of the cornerstones of therapy. Proper patient selection for cytoreductive surgery is paramount to its effective use in the management of patients with metastatic RCC despite the decrease in reported morbidity rates. We explore the evolving role cytoreductive surgery in metastatic RCC spanning the immunotherapy era to the targeted therapy era. Despite significant advances in the management of patients with metastatic RCC, further evidence on the definitive role of cytoreductive surgery in the targeted therapy era is awaited through large randomized trials.