Context: The European Association of Urology Guideline Panel for Renal Cell Carcinoma (RCC) has prepared evidence-based guidelines and recommendations for RCC management. Objectives: To provide an update of the 2010 RCC guideline based on a standardised methodology that is robust, transparent, reproducible, and reliable. Evidence acquisition: For the 2014 update, the panel prioritised the following topics: percutaneous biopsy of renal masses, treatment of localised RCC (including surgical and nonsurgical management), lymph node dissection, management of venous thrombus, systemic therapy, and local treatment of metastases, for which evidence synthesis was undertaken based on systematic reviews adhering to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Relevant databases (Medline, Cochrane Library, trial registries, conference proceedings) were searched (January 2000 to November 2013) including randomised controlled trials (RCTs) and retrospective or controlled studies with a comparator arm. Risk of bias (RoB) assessment and qualitative and quantitative synthesis of the evidence were performed. The remaining sections of the document were updated following a structured literature assessment. Evidence synthesis: All chapters of the RCC guideline were updated. For the various systematic reviews, the search identified a total of 10 862 articles. A total of 151 studies reporting on 78 792 patients were eligible for inclusion; where applicable, data from RCTs were included and meta-analyses were performed. For RCTs, there was low RoB across studies; however, clinical and methodological heterogeneity prevented data pooling for most studies. The majority of studies included were retrospective with matched or unmatched cohorts based on single or multi-institutional data or national registries. The exception was for systemic treatment of metastatic RCC, in which several RCTs have been performed, resulting in recommendations based on higher levels of evidence.

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We systematically reviewed the literature to assess the safety and diagnostic performance of renal tumour biopsy (RTB). The results suggest that RTB has good accuracy in diagnosing renal cancer and its subtypes, and it appears to be safe. However, the quality of evidence was moderate, and better quality studies are required to provide a more definitive answer.

Local treatment of metastases such as metastasectomy or radiotherapy remains controversial in the treatment of metastatic renal cell carcinoma. To investigate the benefi ts and harms of various local treatments, we did a systematic review of all types of comparative studies on local treatment of metastases from renal cell carcinoma in any organ. Interventions included metastasectomy, radiotherapy modalities, and no local treatment. The results suggest that patients treated with complete metastasectomy have better survival and symptom control (including pain relief in bone metastases) than those treated with either incomplete or no metastasectomy. Nevertheless, the available evidence was marred by high risks of bias and confounding across all studies. Although the fi ndings presented here should be interpreted with caution, they and the identifi ed gaps in knowledge should provide guidance for clinicians and researchers, and directions for further research.

when cancer prevalence increased, for overall cancer (r=-0.64, p<0.0001) and csPCa 20 (r=-0.75, p=0.032). Eight studies fulfilled the inclusion criteria for meta-analysis. 21Seven reported results for overall PCa. When the overall PCa prevalence increased 22 from 30% to 60%, the combined NPV estimates decreased from 88% (95% 23 confidence interval (95% CI), 77-99%) to 67% (95% CI, 56-79%) for a cut-off score 24 of 3/5. Only one study selected for meta-analysis reported results for Gleason ≥7 25 cancers, with a positive biopsy rate of 29.3%. The corresponding NPV for a cut-off 26 score of ≥3/5 was 87.9%. 27Conclusion: mpMRI NPV varied greatly depending on study design, cancer 28 prevalence, and definitions of positive mpMRI and csPCa. Because cancer 29 prevalence was highly variable among series, risk stratification of patients should be 30 the initial step before considering prebiopsy mpMRI and defining those in whom 31 biopsy may be omited when the mpMRI is negative.

Recent randomized trials have demonstrated a survival benefit for a front-line ipilimumab and nivolumab combination therapy, and pembrolizumab and axitinib combination therapy in metastatic clear-cell renal cell carcinoma. The European Association of Urology (EAU) Guidelines Panel has updated its recommendations based on these studies.

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