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The field of urology has undergone massive changes in the 10 years sinceNature Reviews Urology launched as Nature Clinical Practice Urology. In this Viewpoint, members of the Nature Reviews Urologyadvisory board describe what they think has been the biggest change or issue in urology over the past decade, and give their predictions for the direction of the field over the next 10 years.

Recent advances have been exciting in the genomics of and targeted therapeutics for renal cell carcinoma (RCC). New agents have been approved for advanced RCC, a novel agent targeting hypoxia-inducible factor 2α has shown considerable promise and molecular characterization of papillary RCC provides the foundation for development of targeted therapeutic approaches for this disease.

Radiofrequency ablation and cryoablation of the small renal mass have emerged as treatment options for patients who are not surgical candidates or who elect not to undergo surgery. Besides concerns regarding the definition of treatment success and the difficulty of salvage procedures, incomplete ablation might potentially create a tumour microenvironment that promotes cancer progression.

Clear cell renal cell carcinoma (CCRCC) is characterized by mutation of the VHL gene and loss of a segment of chromosome 3. A new study using multi-region exome sequencing has identified substantial intratumoral heterogeneity within large primary CCRCCs, which has profound implications for understanding tumor evolution and for developing effective therapies.

For decades, complete removal of the kidney with all the contents of the Gerota's fascia (including the adrenal gland) has been a standard procedure for treating renal cell carcinoma (RCC). Two recent articles argue against routine adrenalectomy, and encourage adrenal preservation for the vast majority of patients with RCC.

Several advances in kidney cancer have occurred over the past decade, including the discovery of mutations in chromatin remodelling genes and genomic heterogeneity in clear cell renal cell carcinoma (ccRCC). Altered metabolic patterns in ccRCC and papillary RCC have become apparent, and new drugs for ccRCC have been approved.

Each of the kidney cancer genes identified so far interact with cell metabolism pathways involved in energy, nutrient, iron or oxygen sensing. Here, Linehan and colleagues argue that targeting the fundamental cell metabolic abnormalities provides a unique opportunity to develop novel forms of therapy for this disease.

Heat shock protein 90 (HSP90) plays a major role in many cancers, including tumors of the prostate and kidney. Its function in cell regulation makes it a potential target for treatments against cancer. This Review provides insights into the role of HSP90 in urologic cancers and discusses the data from clinical trials examining the use of HSP90 inhibitors in the treatment of patients with urologic cancers.

In this Review, Bratslavsky and Linehan address the management of the challenging group of patients with bilateral, multifocal, recurrent renal cell carcinoma. They discuss the treatment options and outcomes for these patients, highlight the importance of maximal renal preservation, and outline a management strategy developed from their own experience in treating these patients.

Birt–Hogg–Dubé (BHD) syndrome is an inherited renal cancer syndrome caused by germline mutations in theFLCNgene on chromosome 17. Manifestations include benign cutaneous fibrofolliculomas, bilateral pulmonary cysts and spontaneous pneumothoraces, and kidney tumours. In this Review, Schmidt and Linehan provide an overview of BHD syndrome, discussing the molecular genetics, diagnosis, and management of this rare disorder.

In this Review, Kauffman and colleagues summarize contemporary understanding of the molecular biology underlyingTFE3 and TFEB gene-fusion-associated (translocation) renal cell carcinomas. They discuss the candidate mechanisms and signalling pathways thought to contribute to the oncogenesis of these tumours, and describe TFE3 and TFEBfusion genetic organization.