# Surgical Management of Renal Cell Carcinoma in Transplanted Kidneys—A Narrative Review

## TL;DR

This review discusses the challenges and treatment options for kidney cancer in transplanted kidneys, emphasizing the need for personalized strategies to improve patient and graft survival.

## Contribution

The paper provides a comprehensive narrative review of surgical and non-surgical approaches for managing RCC in transplanted kidneys.

## Key findings

- Nephron-sparing surgery is preferred for small allograft masses due to better outcomes and kidney function preservation.
- Laparoscopic and robotic techniques offer reduced blood loss and faster recovery compared to open surgery.
- Ablative therapies are viable for high-risk patients, preserving allograft function for small renal masses.

## Abstract

While the incidence of renal cell carcinoma (RCC) in kidney transplant recipients is higher than in the general population, surgical decision making, particularly in RCC in transplanted kidneys, is challenging due to immunosuppressive therapies, pre-existing chronic kidney disease and unique anatomical characteristics. This review aimed to evaluate risk factors and treatment options for RCC in transplanted kidneys using the most relevant studies from the PubMed database published between January 1999 and March 2025. Nephron-sparing surgery should be the treatment of choice for small allograft masses, providing favorable oncological outcomes while preserving kidney function. Laparoscopic and robotic partial nephrectomy techniques have demonstrated advantages such as reduced blood loss and shorter recovery time. Also, ablative therapies can be considered for small masses, especially in high-risk surgical candidates. Returning to dialysis after transplantectomy will impact the patient’s survival. Further research is needed to personalize oncological treatment strategies and improve both patient and graft survival.

Renal cell carcinoma (RCC) is the most prevalent solid organ malignancy among kidney transplant recipients, demonstrating substantially higher incidence rates compared to those in the general population. Although RCC is most commonly diagnosed in native kidneys, its development in transplanted kidneys has an infrequent occurrence. The use of immunosuppressive therapies, pre-existing chronic kidney disease and the unique anatomical characteristics of transplanted kidneys represent considerable therapeutic challenges in managing RCC within this patient cohort. Open radical transplantectomy plays a crucial role in curative treatment for localized RCC, whereas nephron-sparing surgery (NSS), in selected cases, can provide similar oncologic benefits while preserving allograft function. Recently, laparoscopic and robotic surgical procedures have demonstrated favorable outcomes as viable alternatives to conventional open surgery. Furthermore, ablative therapies like radiofrequency ablation and cryoablation can be considered therapeutic alternatives for small renal masses, offering the benefit of preserving allograft function, especially in high-risk surgical candidates. Limited data exist regarding the management of metastatic RCC in transplant recipients. Surgery, withdrawal of immunosuppression and systemic adjuvant therapy could be considered. Management of RCC in transplanted kidneys requires a multidisciplinary approach considering patient-specific characteristics, tumor features and the developing landscape of both surgical and non-surgical options. Further research is needed to refine therapeutic strategies in order to achieve optimal oncological outcomes while preserving allograft function.