Surgical approach and atypical recurrence after radical nephrectomy: considerations for cytoreductive nephrectomy in the metastatic setting

Abstract

Radical nephrectomy (RN) remains an important therapeutic option in the management of renal cell carcinoma (RCC), including in the metastatic setting where cytoreductive nephrectomy (CN) may be pursued in select patients with good performance status and limited disease burden. While typical patterns of recurrence after CN are well established, atypical intraperitoneal recurrences (ATR) have emerged as rare but clinically relevant events in the era of improved systemic therapies and prolonged survival. In this structured literature review, we identified and analyzed 80 studies describing ATR after RN (localized or metastatic). We found that the majority of reported ATRs occurred following minimally invasive surgical approaches, including laparoscopic and robotic-assisted nephrectomy. Risk factors for ATR include high tumor grade, sarcomatoid differentiation, tumor necrosis, and potential surgical factors such as tumor spillage, specimen morcellation, and improper use of retrieval bags. Although technical breaches were implicated in several cases, ATR may also arise independent of these factors, likely reflecting the complex interplay between tumor biology, surgical approach, and host factors. The current evidence is limited by retrospective design, publication bias, and lack of standardization in reporting. Our findings underscore the need for future multicenter prospective studies with consistent definitions and long-term surveillance to better characterize ATR incidence and outcomes. Additionally, technical refinements such as strict adherence to oncologic principles, containment during specimen extraction, and avoidance of morcellation in high-risk cases may mitigate risk. As CN becomes more widely employed alongside modern systemic therapies, understanding and mitigating the risk of ATR will be critical in optimizing surgical decision-making in the metastatic RCC population.

Keywords: Renal cell carcinoma, cytoreductive nephrectomy, atypical recurrence, port-site metastasis, minimally invasive surgery