NG256 is now the authoritative UK reference, mapped explicitly to NHS practice, GIRFT operational guidance, and the National Genomic Test Directory.
The guideline has several key changes that candidates should be aware of.
This is the single most exam-relevant change. NG256 introduces a new risk-stratified imaging schedule (Table 2). This is broadly in line with EAU guidance but recommends CT chest, abdomen and pelvis (rather than CT chest and abdomen alone), and low-risk surveillance is slightly less intensive.
| Risk tier | EAU-based practice | NICE NG256 Table 2 |
|---|---|---|
| Low risk | CT C/A at 6, 18, 30 months then 2-yearly | CT chest, abdomen AND pelvis at Y1, Y3, Y5 → discharge |
| Intermediate | Scans at 6M, Y1, Y2, Y3, Y4, Y5 → 2-yearly or discharge | No change |
| High risk | Scans at 3M, 6M, 12M, 18M, Y2, Y3, Y4, Y5 → 2-yearly or discharge | No change |
| Positive margin after PN | "Intensified surveillance" | Upgrade to next highest risk tier |
Maximum follow-up is slightly more prescriptive in NICE guidance. Low risk is only for 5 years. Intermediate and high-risk patients should be considered for discharge at 5 years; if not discharged, a scan every 2 years with discharge discussed at each clear scan, with definitive discharge at 10 years unless there is a specific reason not to.
NG256 accepts six validated tools for clear cell RCC — Leibovich 2003, SSIGN, UISS, Karakiewicz, Kattan, and Sorbellini — leaving the choice to the local MDT. Note that EAU guidance recommends using the Leibovich 2003 score.
For papillary RCC, the recommendation is specific: use VENUSS — which is also the case in EAU guidance.
For chromophobe RCC, there's a pragmatic pathological approach based on fat invasion, sarcomatoid differentiation, and nodal status using the Leibovich 2018 score. Knowing which tool goes with which histology is a high-yield exam point.
NICE gives explicit guidance on when to consider a renal biopsy. The guideline suggests offering biopsy for suspected localised or locally advanced RCC when the lesion is ≤4 cm and has a solid component large enough to sample, and considers it for larger lesions in specific circumstances.
Importantly, biopsy is not offered when it won't change management, when the tumour has grown into the renal vein or IVC in a surgical candidate, or when tissue sampling is difficult or infeasible.
Before ablation or SABR: Biopsy is mandatory. Pre-treatment histological confirmation is required.
For heritable syndromes, the nuance is critical and could be tested:
NG256 formalises four non-pharmacological options for localised RCC and Bosniak 3/4 cysts, with clear size-based thresholds:
For surgery itself, NICE specifies a preference for robot-assisted partial nephrectomy where the lesion can be entirely excised with preservation of remaining tissue. For total nephrectomy, minimally invasive is preferred. This is the first UK guideline to name robot-assisted PN as the preferred modality. EAU guidance is not as prescriptive and states that partial nephrectomy "can be performed, either by open, pure laparoscopic or robot-assisted approach, based on surgeon's expertise and skills."
For lesions over 2 cm, active surveillance has a higher risk of growth and spread, and is not recommended unless surgery is not an option or is declined. Moving from AS to treatment is driven by:
Low-dose surveillance can alternate CT with ultrasound or MRI to reduce cumulative radiation. After 5 years of stability, discharge becomes an option.
This is where the exam gets specific about UK context. The NICE-approved first-line options are:
Whilst this is primarily oncological knowledge, it is worth knowing that pembrolizumab + axitinib is specifically not recommended by NICE (TA650) — whereas it is included within EAU guidance.
Definitely worth knowing: adjuvant pembrolizumab (TA830) is the only NICE-approved adjuvant option for increased-risk post-nephrectomy disease — adjuvant sunitinib is no longer recommended. Which patients qualify for adjuvant pembrolizumab is fair game in the exam.
NG256 puts into practice what you probably already know from CARMENA and SURTIME. For a new presentation with widespread metastatic disease who is fit for systemic therapy, SACT comes first. Cytoreductive nephrectomy is considered later — typically after a durable partial response in the metastatic sites, when most remaining disease is at the primary and surgery is technically suitable.
Upfront cytoreductive nephrectomy is reserved for oligometastatic disease where immediate SACT is not indicated, or for symptom control.
The use of the IMDC score is recommended and is definitely something to be familiar with.
NG256 dedicates a section to people with a genetic predisposition to RCC. With specific guidance on when to assess and how treatment differs, this is easy exam fodder. Key points include:
Offer genetic testing for: age 46 or younger, multiple renal tumours, first- or second-degree family history of renal cancer, syndromic signs (cerebellar or spinal haemangioblastoma, spontaneous pneumothorax), or histology of FH- or SDH-deficient RCC. This triggers referral via the National Genomic Test Directory pathway.
If you're sitting Part 1 this year, three practical priorities:
Here's the uncomfortable truth about exam prep in 2026: a paid question bank that was excellent in 2024 may now contain dozens of questions with wrong answers.
Guidelines change. Technology appraisals publish. Trial data matures. Keeping question banks current is invisible work — until it isn't. When an updated guideline drops, the candidates who suffer are the ones whose resources haven't been touched since the last annual refresh.
At Urobank, every major piece of UK urological guidance triggers a structured review cycle:
Ultimately, it doesn't matter how many questions a question bank has if they're wrong or out of date. What matters is that the content is relevant and aligned with up-to-date guidelines and evidence.
For another example of Urobank staying up to date, check out our blog on the latest AAST renal trauma guideline. If you're using Urobank, you don't need to wonder — the work is done.
Every RCC question on Urobank is updated to reflect NG256 alongside EAU guidance — so you're never caught out by a guideline change.