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Surgery for renal cell carcinoma in two European urologic clinics: To compare or compete?this standard has been confirmed for decades, urologistsnow question whether it should still be considered thegold standard, given the continual advances in surgicaltechniques and our improved knowledge of prognosticfactors. As a result, it is in any case no longer consideredthe gold standard for the management of small tumors,and options for surgical procedures now extend to openpartial nephrectomy, laparoscopic nephrectomy, and evenlaparoscopic partial nephrectomy (13, 14). Laparoscopicpartial nephrectomy requires advanced surgical experiencebut is gaining increasing acceptance in the urologiccommunity (15).Our comparative study shows that despite well-equippedfacilities and experienced surgeons, the application of novelsurgical techniques strongly depends on diagnostics andearly detection of renal masses in the population. In termsof the treatment of small renal tumors, there is no significantdifference between the two clinics except for a preferencefor retroperitoneal access in the Italian centre andtransperitoneal access in Bulgaria. The main difference inthe proportion of minimally invasive surgery is attributableto the greater number of early stage tumors diagnosed inBari as compared to Varna and of course, to the laparoscopicapproach in the Italian clinic which is completelylacking at the Bulgarian clinic. Laparoscopic treatment isalready a standard of care according to the EAU guidelinesbut it is burdened by a considerable learning curve.Pathoanatomical parameters of renal cell tumors define thetype of surgery performed and for this reason the TNMstaging system provides good prognostic information, butthere has been much debate about its accuracy. Primarytumor size is a key component of the TNM staging systemand remains one of the most important prognostic factorsfor RCC. The most recent revision (2002) of the TNM stagingsystem established the subdivision of T1 into T1a andT1b, using a 4 cm threshold which introduces limits to surgicaloptions (16, 17).The mean size of the renal masses detected in Varna, andthe significantly greater number of N+ and M+ patients atthe time of treatment, offered no options for different typesof surgery. The results of our analysis show that in terms ofsurgery the Bulgarian clinic has not only to gain animproved experience of laparoscopic techniques but aboveall of diagnostics and early detection of renal cell cancer.This could involve the institution of a thorough screeningprogram for RCC, performing ultrasonography in theentire population at risk in the region.The higher percentage of accidental identification of RCCin Bari shows better screening for the disease or simplymore frequently performed ultrasonographic or CT scanexaminations in this population. This could be the keypoint in the early detection of RCC and could easily beimproved in Bulgaria.The relatively high incidence of advanced disease andmRCC at the Varna urology clinic also raises the issue ofnonsurgical treatment options. The systemic treatment ofRCC has long been a significant problem for urologists andmedical oncologists due to the lack of response to conventionaltherapeutic strategies and poor survival observed inthe majority of patients. Current EAU guidelines approvetherapy with tyrosine-kinase inhibitors in metastatic RCC,which is a routine practice in the Italian but not in theBulgarian clinic. This emphasizes the need to study thegenetics and molecular pathology of this disease in order tobetter predict the response to treatment and prognosis inindividual patients. Further research into prognosis andtherapy should be directed towards an optimal use of newmolecules.CONCLUSIONSSurgery remains the standard of care for localized RCCand also offers the best chance of achieving a cure. Theemphasis here is on ‘localised’, which is the key point,together with new emerging options for adjuvant therapyfor RCC. Early detection is crucial for performing apartial nephrectomy – the EAU standard procedure forT1a disease. The role of multitargeted therapy in themanagement of localized RCC remains to be defined,and until evidence appears to the contrary, nephrectomywill continue to be recommended. This brief comparisonbetween the clinics in Bari and Varna has revealed hugedifferences in the surgical approach, strongly dependenton early detection and general health care, which canmake the difference between comparing and competingwithin the EAU guidelines. 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