The XLII meeting of the CAU (Confederación Americana de Urología) was held October 4 to 7, 2023, in Santiago de Chile featuring a huge variety of academic activities of high scientific level, with professors and speakers from countries all around the globe. One of the highlighted topics was renal cell carcinoma (RCC), which was discussed in instructional courses, plenary sessions, and abstracts.

Among the notable offerings was the course, “Update in the Management of Nonmetastatic RCC.” In it, some colleagues from member countries of CAU participated as professors to address current topics about localized RCC. Dr Ignacio Tobia (Argentina) commented on the current state of active surveillance as part of the initial management of small renal masses, both globally and in Latin America, and discussed the points of controversy regarding the need to perform a renal mass biopsy in patients initially approached with active surveillance. Dr Francisco Rodríguez-Covarrubias (Mexico) spoke about the comparison between enucleation and resection during nephron-sparing surgery, as well as the advantages and disadvantages of each of these techniques, and whether radical nephrectomy still has a role in stage 1 tumors. Finally, Dr Ricardo Castillejos (Mexico) spoke about the role of adjuvant systemic therapy in patients with RCC and high risk for recurrence or progression treated surgically. He compared the results of previous clinical trials based on tyrosine kinase inhibitors with those of current drugs such as checkpoint inhibitors, which appear to have a slight advantage in terms of disease-free survival.

During the plenary sessions, Dr Gonzalo Vitagliano (Argentina) spoke about modern intraoperative navigation techniques, which allow planning a partial nephrectomy to treat endophytic tumors or highly complexity masses with higher precision by allowing better visualization of the anatomy as well as better positioning of instruments. On the other hand, Dr Josep Maria Gaya (Spain) pointed out that criteria for performing a robotic partial nephrectomy via retroperitoneal approach include tumors located on the posterior aspect of the kidney, previous abdominal surgeries, retroperitoneal tumor recurrences, and tumors in patients with peritoneal dialysis. He highlighted that the advantages of this approach include direct access to the renal artery, without the need to ligate gonadal and lumbar veins, or to mobilize colon, duodenum, liver, or spleen, or rotate the kidney. Dr Marcelo Kerkebe (Chile) spoke about technical factors to consider for optimizing postoperative results in partial nephrectomy and detailed the differences between enucleation and resection, concluding that enucleation allows better oncological outcomes in selected cases while providing good results regarding kidney function. Dr Lee Ponsky (US) detailed the evolution of radiosurgery in the treatment of kidney cancer and the reasons why urologists should participate in this therapeutic modality. He highlighted that radiosurgery options include stereotactic body radiation therapy and stereotactic ablative radiation therapy. Among their advantages, he mentioned that they are minimally invasive techniques not requiring general anesthesia and that they are useful to treat tumors close to the renal hilum or those of large dimensions.

Dr Stephen Boorjian (US) spoke about the surgical management of RCC with venous thrombus. He highlighted that patients in this stage of the disease must be evaluated thoroughly since these tumors progress rapidly. Therefore, imaging studies must be updated before surgery. He insisted on “not taking shortcuts” and planning surgery carefully; otherwise, surgeons must be aware of technical risks, including thrombus dislodgment, inadequate renal vein stump to secure, or narrowing of the inferior vena cava. He recommended the retrohepatic technique for level III thrombi, with early ligation of renal artery, liver mobilization, contralateral renal vein control, distal inferior vena cava control, hepatic flow control (Pringle maneuver), suprahepatic inferior vena cava control (in this sequence), and, finally, removal of thrombus. He stressed that for all cases, including patients with level IV thrombi, having a multidisciplinary team with urologists, liver, and cardiovascular surgeons is of paramount relevance.

Finally, Dr Juan Pablo Sade (Argentina) spoke about the systemic treatment of advanced kidney cancer, highlighting that combination therapies (PD-1 inhibitors plus VEGF [vascular endothelial growth factor] inhibitors) offer approximately 60% of response (either complete or partial), being less than 40% with VEGF inhibitors alone. He described the design of the LITESPARK 022 trial on the combination of belzutifan (HIF-2α inhibitor) plus pembrolizumab compared to pembrolizumab alone and its promising preliminary results. He also spoke about perioperative systemic management (neoadjuvant/adjuvant) and the importance of initial response to treatment. He concluded that immunotherapy is the standard of care in metastatic disease and that current survival outcomes are superior to those of previous decades.