Summary of Recommendations

Document Overview

Design and created by Guideline Central in participation with the European Association of Urology.

Renal Cell Carcinoma

European Association of Urology

Publication Date: Apr 1, 2026

Page Last Updated: Aug 5, 2026

Immunotherapy

First line Treatment for metastatic clear cell RCC patients
- Offer nivolumab plus ipilimumab, pembrolizumab plus axitinib, lenvatinib plus pembrolizumab or nivolumab and cabozantinib to patients with International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) intermediate- or poor risk-disease. (Strong)
- Offer pembrolizumab plus axitinib, lenvatinib plus pembrolizumab or nivolumab and cabozantinib or nivolumab plus ipilimumab or sunitinib or pazopanib for IMDC favourable risk disease. (Weak)
- Offer sunitinib or pazopanib to patients with any IMDC risk who cannot receive or tolerate immune checkpoint inhibition. (Strong)
- Offer cabozantinib to patients with IMDC intermediate- and poor-risk clear cell metastatic renal carcinoma (cc-mRCC) who cannot receive or tolerate immune checkpoint inhibition. (Strong*)
- Patients who do not receive the full four doses of ipilimumab due to toxicity should continue on single-agent nivolumab, where safe and feasible. Re-challenge with combination therapy requires expert support after discontinuation for toxicity. (Weak)
Sequencing systemic therapy for metastatic clear cell RCC
- Sequence systemic therapy in treating metaststic RCC. (Strong)
- Offer carbozantinib or other vascular endothelial growth factor (VEGF)-tyrosine kinase inhibitors as second-line therapy to patients refractory to nivolumab plus ipilimumab or axitinib plus pembrolizumab or cabozantinib plus nivolumab or lenvatinib plus pembrolizumab. (Weak)
- Sequencing the agent not used as second-line therapy (nivolumab or cabozantinib) for third- line therapy is recommended. (Weak)
- Offer nivolumab or cabozantinib for those patients who received first line VEGF targeted therapy alone. (Strong)
- Treatment past progression can be justified but requires close scrutiny and the support of an expert multi-disciplinary team. (Weak)
- Do not re-challenge patients who stopped immune checkpoint inhibitors because of toxicity without expert guidance and support from a multi-disciplinary team. (Strong)
- Do not offer programmed death-ligand 1 (PD-L1) combination therapy after progression after immune checkpoint inhibition combination. (Weak)
- Offer immune checkpoint inhibitor combination therapy for advanced clear cell metastatic renal carcinoma with sarcomatoid features. (Weak)

Recommendation Grading

Level	Type of Evidence
1a	Evidence obtained from meta-analysis of randomised trials
1b	Evidence obtained from at least one randomised trial
2a	Evidence obtained from one well-designed controlled study without randomisation
2b	Evidence obtained from at least one other type of well-designed quasi-experimental study
3	Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports
4	Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities

Strength	Description
S	Strong recommendation
W	Weak (conditional) recommendation

Document Overview

Document Title: Renal Cell Carcinoma

Authoring Society: European Association of Urology

Document Publication Date: Apr 1, 2026

Page Last Reviewed/Updated: Aug 5, 2026

Document Type: Guideline

Country of Publication: European

Full Text Freely Available: Yes

Full Text Guideline: d56bochluxqnz.cloudfront.net/documents/full-guideline/EAU-Guidelines-on-Renal-Cell-Carcinoma-2026_2026-07-05-195750_dguv.pdf

Source Citation: Bex A, Ghanem YA, Albiges L, Bonn S, Campi R, Capitanio U, Dabestani S, Hora M, Klatte T, Kuusk T, Lund L, Marconi L, Palumbo C, Pignot G, Powles T, Schouten N, Tran M, Volpe A, Bedke J. European Association of Urology Guidelines on Renal Cell Carcinoma: The 2025 Update. Eur Urol. 2025 Mar 10:S0302-2838(25)00139-3. doi: 10.1016/j.eururo.2025.02.020. Epub ahead of print. PMID: 40118739.

Supplemental Implementation Resources

Pocket Guide

Document Scope, Criteria, and Use Cases

Document Objectives: The European Association of Urology (EAU) renal cell carcinoma (RCC) guideline panel has updated their evidence-based guidelines and recommendations for the management of RCC. Here we present a summary of the 2025 RCC guidelines updated with standardised methodology to provide reproducible evidence for the management of RCC. Clinical practise recommendations were updated in all chapters of the RCC guidelines on the basis of a structured literature search. The studies included were predominantly retrospective with matched or unmatched cohorts based on single- or multi-institutional data. Several prospective studies and RCTs provided data that resulted in recommendations based on higher levels of evidence. Specifically, updates include new recommendations on stereotactic body radiotherapy for localised RCC, adjuvant therapy, systemic therapy for clear-cell RCC in later lines, other subtypes, and a new chapter on hereditary RCC.

Scope: Assessment and Screening, Diagnosis, Management, Treatment

Diseases/Conditions (MeSH): D002292 - Carcinoma, Renal Cell

Keywords: kidney cancer, renal cell carcinoma (RCC)

Inclusion Criteria: Male, Female, Adult, Older Adult

Health Care Settings: Ambulatory, Operating and Recovery Room, Outpatient, Radiology Services

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant

Renal Cell Carcinoma

Summary of Recommendations

Epidemiology, Aetiology, and Pathology

Epidemiology, Aetiology, and Screening

Management of Other Renal Tumours

Diagnostic Evaluation

Diagnostic Assessment of RCC

Genetic Assessment of RCC

Prognostic Factors

Disease Management

Patient Involvement in Kidney Cancer Treatment

Smoking Cessation

Treatment of Localised RCC

Radical and Partial Nephrectomy Techniques

Therapeutic Approaches as Alternatives to Surgery

Treatment of Locally Advanced RCC

Neoadjuvant and Adjuvant Therapy

Advanced/Metastatic RCC

Local Therapy of Metastases in Metastatic RCC

Systemic Therapy for Advanced/Metastatic RCC

Chemotherapy

Single-Agent Targeted Therapy in Metastatic Clear-Cell RCC

Immunotherapy

Systemic Therapy in Papillary Metastatic RCC

Systemic Therapy in Chromophobe and Unclassified RCC

Locally-Recurrent RCC After Treatment of Localised Disease

Hereditary and Syndrome Specific RCC

Follow-Up in RCC

Recommendation Grading

Document Overview

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases