Which specialist should a patient with a renal mass see first?

Specialist Referral for Renal Mass Evaluation

Patients with a renal mass should first be referred to a urologist who should lead the evaluation and counseling process. 1

Initial Evaluation Process

• A urologist should coordinate the diagnostic workup and treatment planning for all patients with renal masses, incorporating multidisciplinary input when necessary 1, 2
• The urologist will obtain high-quality, multiphase cross-sectional abdominal imaging (typically CT or MRI) to characterize and stage the renal mass 1, 2
• Laboratory evaluation including comprehensive metabolic panel, complete blood count, and urinalysis will be ordered to assess renal function and rule out other conditions 1, 2
• Chest imaging should be included in the metastatic evaluation when renal malignancy is suspected 1

Specialist Involvement Based on Clinical Scenario

• Nephrology consultation should be considered for patients with:

  • High risk of chronic kidney disease (CKD) progression 1
  • eGFR less than 45 ml/min/1.73 m² 1, 3
  • Confirmed proteinuria 1, 2
  • Diabetes with pre-existing CKD 1
  • When post-intervention GFR is expected to be less than 30 ml/min/1.73 m² 1, 3

• Genetic counseling should be recommended for:

  • All patients ≤46 years of age with renal masses 1, 2
  • Patients with multifocal or bilateral renal masses 1, 2
  • Personal or family history suggesting familial renal neoplastic syndrome 1, 2

Management Pathway After Initial Urologic Evaluation

• The urologist will lead the counseling process about management options including:

  • Partial nephrectomy 1
  • Radical nephrectomy 1
  • Thermal ablation techniques 1
  • Active surveillance 1

• For complex cases requiring multidisciplinary input, additional specialists may include:

  • Interventional radiologists (for ablative procedures) 4
  • Medical oncologists (for systemic therapy if metastatic disease) 2
  • Radiation oncologists (in select cases) 2

Common Pitfalls to Avoid

• Delayed urologic referral: Even small renal masses carry metastatic potential and require prompt urologic evaluation 4, 5
• Bypassing urologic evaluation: Sending patients directly to interventional radiology or nephrology without urologic assessment may lead to suboptimal care planning 1, 5
• Inadequate imaging: Non-contrast studies are insufficient for proper characterization of renal masses; contrast-enhanced studies are essential unless contraindicated 2, 6
• Missing hereditary syndromes: Failure to recognize patients who need genetic evaluation can impact both patient and family management 1, 2

Special Considerations

• For patients with impaired renal function where contrast is contraindicated, MRI may be preferred over CT for mass characterization 7, 6
• Renal mass biopsy should be considered when the mass is suspected to be hematologic, metastatic, inflammatory, or infectious 1
• Patients with incidentally found kidney masses should always be referred to urology first for evaluation, even if nephrology follow-up may also be needed 5