Available active surveillance follow-up protocols for small renal mass: a systematic review



To evaluate follow-up strategies for active surveillance of renal masses and to assess contemporary data.


We performed a comprehensive search of electronic databases (Embase, Medline, and Cochrane). A systematic review of the follow-up protocols was carried out. A total of 20 studies were included.


Our analysis highlights that most of the series used different protocols of follow-up without consistent differences in the outcomes. Most common protocol consisted in imaging and clinical evaluation at 3, 6, and 12 months and yearly thereafter. Median length of follow-up was 42 months (range 1–137). Mean age was 74 years (range 67–83). Of 2243 patients 223 (10%) died during the follow-up and 19 patients died of kidney cancer (0.8%). The growth rate was the most used parameter to evaluate disease progression eventually triggering delayed intervention. Maximal axial diameter was the most common method to evaluate growth rate. CT scan is the most used, probably because it is usually more precise than kidney ultrasound and more accessible than MRI. Performing chest X-ray at every check does not seem to alter the clinical outcome during AS.


The minimal cancer-specific mortality does not seem to correlate with the follow-up scheme. Outside of growth rate and initial size, imaging features to predict outcome of RCC during AS are limited. Active surveillance of SRM is a well-established treatment option. However, standardized follow-up protocols are lacking. Prospective, randomized, trials to evaluate the best follow-up strategies are pending.

This is a preview of subscription content, access via your institution.

Fig. 1

Data availability

We declare that all materials and all data are available and do not involve plagiarism.


  1. 1.

    Finelli A, Ismaila N, Bro B et al (2017) Management of small renal masses: American society of clinical oncology clinical practice guideline. J Clin Oncol 35(6):668–680. https://doi.org/10.1200/JCO.2016.69.9645

    Article  PubMed  Google Scholar 

  2. 2.

    Volpe A (2016) The role of active surveillance of small renal masses. Int J Surg 36(Pt C):518–524. https://doi.org/10.1016/j.ijsu.2016.06.007

    Article  PubMed  Google Scholar 

  3. 3.

    Kane CJ, Mallin K, Ritchey J et al (2008) Renal cell cancer stage migration: analysis of the national cancer data base. Cancer. https://doi.org/10.1002/cncr.23518

    Article  PubMed  Google Scholar 

  4. 4.

    Chawla SN, Crispen PL, Hanlon AL et al (2006) The natural history of observed enhancing renal masses: meta-analysis and review of the world literature. J Urol. https://doi.org/10.1016/S0022-5347(05)00148-5

    Article  PubMed  Google Scholar 

  5. 5.

    Gill IS, Aron M, Gervais DA, Jewett MAS (2010) Clinical practice. Small renal mass. N Engl J Med 362(7):624–634. https://doi.org/10.1056/NEJMcp0910041

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Smaldone MC, Kutikov A, Egleston BL et al (2012) Small renal masses progressing to metastases under active surveillance: a systematic review and pooled analysis. Cancer. https://doi.org/10.1002/cncr.26369

    Article  PubMed  Google Scholar 

  7. 7.

    Jewett MAS, Rendon R, Lacombe L et al (2015) Canadian guidelines for the management of small renal masses (SRM). J Can Urol Assoc. https://doi.org/10.5489/cuaj.2969

    Article  Google Scholar 

  8. 8.

    Kunkle DA, Egleston BL, Uzzo RG (2008) Excise, ablate or observe: the small renal mass dilemma—a meta-analysis and review. J Urol 179(4):1227–1233; discussion 1233–1234. https://doi.org/10.1016/j.juro.2007.11.047

  9. 9.

    Volpe A, Panzarella T, Rendon RA et al (2004) The natural history of incidentally detected small renal masses. Cancer. https://doi.org/10.1002/cncr.20025

    Article  PubMed  Google Scholar 

  10. 10.

    Lamb GWA, Bromwich EJ, Vasey P, Aitchison M (2004) Management of renal masses in patients medically unsuitable for nephrectomy—natural history, complications, and outcome. Urology. https://doi.org/10.1016/j.urology.2004.05.039

    Article  PubMed  Google Scholar 

  11. 11.

    Haramis G, Mues AC, Rosales JC et al (2011) Natural history of renal cortical neoplasms during active surveillance with follow-up longer than 5 years. Urology. https://doi.org/10.1016/j.urology.2010.09.031

    Article  PubMed  Google Scholar 

  12. 12.

    Fernando HS, Duvuru S, Hawkyard SJ (2007) Conservative management of renal masses in the elderly: our experience. Int Urol Nephrol. https://doi.org/10.1007/s11255-006-9119-0

    Article  PubMed  Google Scholar 

  13. 13.

    Uzosike AC, Patel HD, Alam R et al (2018) Growth kinetics of small renal masses on active surveillance: variability and results from the DISSRM registry. J Urol. https://doi.org/10.1016/j.juro.2017.09.087

    Article  PubMed  Google Scholar 

  14. 14.

    Li XS, Yao L, Gong K et al (2012) Growth pattern of renal cell carcinoma (RCC) in patients with delayed surgical intervention. J Cancer Res Clin Oncol. https://doi.org/10.1007/s00432-011-1083-0

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Crispen PL, Viterbo R, Fox EB et al (2008) Delayed intervention of sporadic renal masses undergoing active surveillance. Cancer. https://doi.org/10.1002/cncr.23268

    Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Liaw CW, Winoker JS, Mehrazin R (2018) Imaging protocols for active surveillance in renal cell carcinoma. Curr Urol Rep 19(10):81. https://doi.org/10.1007/s11934-018-0830-z

    Article  PubMed  Google Scholar 

  17. 17.

    Celtik KE, Shah PH, Patel VR et al (2017) Active surveillance for incidental renal mass in the octogenarian. World J Urol. https://doi.org/10.1007/s00345-016-1961-9

    Article  PubMed  Google Scholar 

  18. 18.

    Lee SW, Sung HH, Jeon HG et al (2016) Size and volumetric growth kinetics of renal masses in patients with renal cell carcinoma. Urology. https://doi.org/10.1016/j.urology.2015.10.051

    Article  PubMed  Google Scholar 

  19. 19.

    Mason RJ, Abdolell M, Trottier G et al (2011) Growth kinetics of renal masses: analysis of a prospective cohort of patients undergoing active surveillance. Eur Urol. https://doi.org/10.1016/j.eururo.2011.02.023

    Article  PubMed  Google Scholar 

  20. 20.

    Pierorazio PM, Johnson MH, Ball MW et al (2015) Five-year analysis of a multi-institutional prospective clinical trial of delayed intervention and surveillance for small renal masses: the DISSRM registry. Eur Urol. https://doi.org/10.1016/j.eururo.2015.02.001

    Article  PubMed  Google Scholar 

  21. 21.

    Finelli A, Cheung DC, Al-Matar A et al (2020) Small renal mass surveillance: histology-specific growth rates in a biopsy-characterized cohort. Eur Urol. https://doi.org/10.1016/j.eururo.2020.06.053

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Diaz de Leon A, Pedrosa I (2017) Imaging and screening of kidney cancer. Radiol Clin North Am 55(6):1235–1250. https://doi.org/10.1016/j.rcl.2017.06.007

    Article  PubMed  Google Scholar 

  23. 23.

    Donat SM, Diaz M, Bishoff JT et al (2013) Follow-up for clinically localized renal neoplasms: AUA guideline. J Urol. https://doi.org/10.1016/j.juro.2013.04.121

    Article  PubMed  Google Scholar 

  24. 24.

    Crispen PL, Viterbo R, Boorjian SA et al (2009) Natural history, growth kinetics, and outcomes of untreated clinically localized renal tumors under active surveillance. Cancer. https://doi.org/10.1002/cncr.24338

    Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Rosales JC, Haramis G, Moreno J et al (2010) Active surveillance for renal cortical neoplasms. J Urol. https://doi.org/10.1016/j.juro.2010.01.024

    Article  PubMed  Google Scholar 

  26. 26.

    Kouba E, Smith A, McRackan D et al (2007) Watchful waiting for solid renal masses: insight into the natural history and results of delayed intervention. J Urol. https://doi.org/10.1016/j.juro.2006.09.064

    Article  PubMed  Google Scholar 

  27. 27.

    Campi R, Sessa F, Corti F et al (2020) Triggers for delayed intervention in patients with small renal masses undergoing active surveillance: a systematic review. Minerva Urol Nefrol. https://doi.org/10.23736/S0393-2249.20.03870-9

    Article  PubMed  Google Scholar 

  28. 28.

    Canvasser NE, Stouder K, Lay AH et al (2016) The usefulness of chest X-rays for T1a renal cell carcinoma surveillance. J Urol. https://doi.org/10.1016/j.juro.2016.02.068

    Article  PubMed  Google Scholar 

  29. 29.

    Doornweerd BHJ, de Jong IJ, Bergman LM, Ananias HJK (2014) Chest X-ray in the follow-up of renal cell carcinoma. World J Urol. https://doi.org/10.1007/s00345-013-1176-2

    Article  PubMed  Google Scholar 

  30. 30.

    Kassiri B, Cheaib JG, Pierorazio PM (2019) Patients with small renal masses undergoing active surveillance-is yearly chest imaging necessary? J Urol. https://doi.org/10.1097/JU.0000000000000079

    Article  PubMed  Google Scholar 

  31. 31.

    Yamashita Y, Ariyoshi A, Sakamoto K (1989) The therapeutic value of lymph node dissection for renal cell carcinoma. Nishinihon J Urol 51:777–781

    Google Scholar 

  32. 32.

    Gong IH, Hwang J, Choi DK et al (2012) Relationship among total kidney volume, renal function and age. J Urol. https://doi.org/10.1016/j.juro.2011.09.005

    Article  PubMed  Google Scholar 

  33. 33.

    Schiavina R, Borghesi M, Dababneh H et al (2015) Small renal masses managed with active surveillance: predictors of tumor growth rate after long-term follow-up. Clin Genitourin Cancer. https://doi.org/10.1016/j.clgc.2014.08.006

    Article  PubMed  Google Scholar 

  34. 34.

    Mueller-Lisse UG, Mueller-Lisse UL, Meindl T et al (2007) Staging of renal cell carcinoma. Eur Radiol. https://doi.org/10.1007/s00330-006-0554-1

    Article  PubMed  Google Scholar 

  35. 35.

    ACR Committee M on CD and C (2015) Manual on Contrast Media, v10.1

  36. 36.

    Vogel C, Ziegelmüller B, Ljungberg B et al (2019) Imaging in suspected renal-cell carcinoma: systematic review. Clin Genitourin Cancer. https://doi.org/10.1016/j.clgc.2018.07.024

    Article  PubMed  Google Scholar 

  37. 37.

    Platzek I, Zastrow S, Deppe PE et al (2010) Whole-body MRI in follow-up of patients with renal cell carcinoma. Acta radiol. https://doi.org/10.3109/02841851003724846

    Article  PubMed  Google Scholar 

  38. 38.

    Krishna S, Murray CA, McInnes MD et al (2017) CT imaging of solid renal masses: pitfalls and solutions. Clin Radiol 72(9):708–721. https://doi.org/10.1016/j.crad.2017.05.003

    CAS  Article  PubMed  Google Scholar 

  39. 39.

    Gorin MA, Rowe SP, Allaf ME (2015) Nuclear imaging of renal tumours: a step towards improved risk stratification. Nat Rev Urol 12(8):445–50. https://doi.org/10.1038/nrurol.2015.122

    Article  PubMed  Google Scholar 

  40. 40.

    Beisland C, Hjelle KM, Reisæter LAR, Bostad L (2009) Observation should be considered as an alternative in management of renal masses in older and comorbid patients. Eur Urol. https://doi.org/10.1016/j.eururo.2008.12.031

    Article  PubMed  Google Scholar 

  41. 41.

    O’Connor KM, Davis N, Lennon GM et al (2009) Can we avoid surgery in elderly patients with renal masses by using the Charlson comorbidity index? BJU Int. https://doi.org/10.1111/j.1464-410X.2008.08275.x

    Article  PubMed  Google Scholar 

  42. 42.

    Lane BR, Abouassaly R, Gao T et al (2010) Active treatment of localized renal tumors may not impact overall survival in patients aged 75 years or older. Cancer. https://doi.org/10.1002/cncr.25184

    Article  PubMed  Google Scholar 

  43. 43.

    Parker PA, Alba F, Fellman B et al (2013) Illness uncertainty and quality of life of patients with small renal tumors undergoing watchful waiting: a 2 year prospective study. Eur Urol. https://doi.org/10.1016/j.eururo.2013.01.034

    Article  PubMed  PubMed Central  Google Scholar 

  44. 44.

    Tang DH, Nawlo J, Chipollini J et al (2017) Management of renal masses in an octogenarian cohort: is there a right approach? Clin Genitourin Cancer. https://doi.org/10.1016/j.clgc.2017.05.011

    Article  PubMed  Google Scholar 

  45. 45.

    Siu W, Hafez KS, Johnston WK, Wolf JS (2007) Growth rates of renal cell carcinoma and oncocytoma under surveillance are similar. Urol Oncol Semin Orig Investig. https://doi.org/10.1016/j.urolonc.2006.07.018

    Article  Google Scholar 

  46. 46.

    Jewett MAS, Mattar K, Basiuk J et al (2011) Active surveillance of small renal masses: progression patterns of early stage kidney cancer. Eur Urol 60:39–44. https://doi.org/10.1016/j.eururo.2011.03.030

    Article  PubMed  Google Scholar 

  47. 47.

    McIntosh AG, Ristau BT, Ruth K et al (2018) Active surveillance for localized renal masses: tumor growth, delayed intervention rates, and >5 yr clinical outcomes[figure presented]. Eur Urol. https://doi.org/10.1016/j.eururo.2018.03.011

    Article  PubMed  Google Scholar 

Download references

Author information




All authors have contributed to the information and material submitted for publication and all authors have read and approved the manuscript. GR: data collection, data analysis, and manuscript writing. NP: data collection, data analysis, and manuscript writing. MCM: data collection, data analysis, and manuscript writing.

Corresponding author

Correspondence to M. Carmen Mir.

Ethics declarations

Conflict of interest

Authors have no direct or indirect commercial financial incentives associated with publishing the manuscript.

Human participants and/or animals

No research involving human participants and/or animals.

Informed consent

No informed consent required.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Rebez, G., Pavan, N. & Mir, M.C. Available active surveillance follow-up protocols for small renal mass: a systematic review. World J Urol (2021). https://doi.org/10.1007/s00345-020-03581-6

Download citation


  • Small renal masses
  • Active surveillance
  • Follow-up
  • Kidney mass elderly
  • Senior
  • Geriatric
  • Aging
  • Octogenarian