Cytoreductive Nephrectomy Following Immunotherapy: Evolution, Pearls, and Pitfalls of Treatment.

Introduction: Renal Cell Carcinoma (RCC) is among the most frequently diagnosed malignancies in both genders with over 81,000 estimated cases in 2024. Despite increasing incidence of renal cell carcinomas <4 cm, up to 1/3 of patients diagnosed with RCC exhibit metastatic disease (mRCC) at time of diagnosis. Cytoreductive nephrectomy (CN), a procedure which encompasses the surgical removal of the primary tumor in patients with metastatic disease, was offered upfront as standard of care during the cytokine era; however, as systemic treatment has evolved, the role of CN in mRCC patients has become less clear. Purpose of Review: We sought to review the evolution of CN in mRCC patients from historical treatments through current standard of care considering ongoing clinical trials and perioperative considerations for CN in patients treated with tyrosine kinase inhibitors (TKI) and immune checkpoint inhibitors (ICI). Conclusion: CN following immunotherapy is safe and beneficial in appropriately selected patients. The choice to perform CN in patients with mRCC amidst an ever-changing treatment landscape is nuanced. Clinical trial enrollment is critical to refine selection criteria and timing of CN. As treatment options continue to progress, shared decision-making and multidisciplinary collaboration remain paramount in selecting the optimal treatment course for each patient.