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Pandolfo SD, Loizzo D, Beksac AT, Derweesh I, Celia A, Bianchi L, Elbich J, Costa G, Carbonara U, Lucarelli G, Cerrato C, Meagher M, Ditonno P, Hampton LJ, Basile G, Kim FJ, Schiavina R, Capitanio U, Kaouk J, Autorino R. Percutaneous thermal ablation for cT1 renal mass in solitary kidney: A multicenter trifecta comparative analysis versus robot-assisted partial nephrectomy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:486-490. [PMID: 36216659 DOI: 10.1016/j.ejso.2022.09.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/20/2022] [Accepted: 09/29/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Renal cell carcinoma (RCC) in solitary kidney (SK) represents a challenging scenario. We sought to compare outcomes of robot-assisted partial nephrectomy (RAPN) versus percutaneous thermal ablation (PTA) in SK patients with renal tumors cT1. MATERIALS AND METHODS We performed a multicenter retrospective analysis of SK patients treated for RCC. The PTA group included cryoablation or radiofrequency ablation. We collected baseline characteristics, intraoperative, pathological, and post-operative data. We applied an arbitrary composite "trifecta" to assess surgical, functional, and oncological outcomes, only for malignant histology. RFS analysis was performed using the Kaplan-Meier method. Multivariable regression analysis was performed to determine independent predictors of "trifecta" achievement. RESULTS We included 198 SK patients (RAPN, n = 50; PTA n = 119). Mean clinical tumor size was not significantly different while R.E.N.A.L. score was higher for RAPN (p < 0.001). No differences in intra and major post-procedural complications. Recurrence rate was higher in PTA group but not statistically significant (p < 0.328). No difference in metastasis rate was found (p = 0.435). RFS was 96.1% in RAPN and 86.8% in PTA cohort (p = 0.003) while no difference in PFS was detected (p = 0.1). Trifecta was achieved in 72.5% of RAPN vs 77.3% of PTA (p = 0.481). Multivariable analysis has not detected predictors for Trifecta achievement. CONCLUSION PTA offers good outcomes in the management of SK patients with RCC. Compared with RAPN, it might carry a higher risk of recurrence; on the other hand, re-treatment is possible. Overall, PTA can be safely offered to treat SK patients presenting RCC. In general, it should be preferred in more frail patients to minimize the risk of complications.
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Affiliation(s)
- Savio Domenico Pandolfo
- Division of Urology & Massey Cancer Center, VCU Health, Richmond, VA, USA; Department of Neurosciences, Reproductive Sciences and Odontostomatology, Urology Unit, University of Naples "Federico II", Napoli, Italy.
| | - Davide Loizzo
- Division of Urology & Massey Cancer Center, VCU Health, Richmond, VA, USA; Department of Emergency and Organ Transplantation-Urology, Andrology and Kidney Transplantation Unit, University of Bari, Bari, Italy
| | - Alp T Beksac
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ithaar Derweesh
- Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Antonio Celia
- Department of Urology, San Bassano Hospital, Bassano Del Grappa, Italy
| | - Lorenzo Bianchi
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Jeffrey Elbich
- Department of Radiology, Vascular Interventional Radiology, VCU Health, Richmond, VA, USA
| | - Giovanni Costa
- Department of Urology, San Bassano Hospital, Bassano Del Grappa, Italy
| | - Umberto Carbonara
- Division of Urology & Massey Cancer Center, VCU Health, Richmond, VA, USA
| | - Giuseppe Lucarelli
- Department of Emergency and Organ Transplantation-Urology, Andrology and Kidney Transplantation Unit, University of Bari, Bari, Italy
| | - Clara Cerrato
- Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Margaret Meagher
- Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Pasquale Ditonno
- Department of Emergency and Organ Transplantation-Urology, Andrology and Kidney Transplantation Unit, University of Bari, Bari, Italy
| | - Lance J Hampton
- Division of Urology & Massey Cancer Center, VCU Health, Richmond, VA, USA
| | - Giuseppe Basile
- Department of Urology, San Raffaele Scientific Institute, Milan, Division of Experimental Oncology/Unit of Urology, URI, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Riccardo Schiavina
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Umberto Capitanio
- Department of Urology, San Raffaele Scientific Institute, Milan, Division of Experimental Oncology/Unit of Urology, URI, IRCCS San Raffaele Hospital, Milan, Italy
| | - Jihad Kaouk
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Riccardo Autorino
- Division of Urology & Massey Cancer Center, VCU Health, Richmond, VA, USA
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Psutka SP, Gulati R, Jewett MAS, Fadaak K, Finelli A, Legere L, Morgan TM, Pierorazio PM, Allaf ME, Herrin J, Lohse CM, Houston Thompson R, Boorjian SA, Atwell TD, Schmit GD, Costello BA, Shah ND, Leibovich BC. A Clinical Decision Aid to Support Personalized Treatment Selection for Patients with Clinical T1 Renal Masses: Results from a Multi-institutional Competing-risks Analysis. Eur Urol 2021; 81:576-585. [PMID: 34862099 DOI: 10.1016/j.eururo.2021.11.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 09/28/2021] [Accepted: 11/01/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Personalized treatment for clinical T1 renal cortical masses (RCMs) should take into account competing risks related to tumor and patient characteristics. OBJECTIVE To develop treatment-specific prediction models for cancer-specific mortality (CSM), other-cause mortality (OCM), and 90-d Clavien grade ≥3 complications across radical nephrectomy (RN), partial nephrectomy (PN), thermal ablation (TA), and active surveillance (AS). DESIGN, SETTING, AND PARTICIPANTS Pretreatment clinical and radiological features were collected for consecutive adult patients treated with initial RN, PN, TA, or AS for RCMs at four high-volume referral centers (2000-2019). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Prediction models used competing-risks regression for CSM and OCM and logistic regression for 90-d Clavien grade ≥3 complications. Performance was assessed using bootstrap validation. RESULTS AND LIMITATIONS The cohort comprised 5300 patients treated with RN (n = 1277), PN (n = 2967), TA (n = 476), or AS (n = 580). Over median follow-up of 5.2 yr (interquartile range 2.5-8.7), there were 117 CSM, 607 OCM, and 198 complication events. The C index for the predictive models was 0.80 for CSM, 0.77 for OCM, and 0.64 for complications. Predictions from the fitted models are provided in an online calculator (https://small-renal-mass-risk-calculator.fredhutch.org). To illustrate, a hypothetical 74-yr-old male with a 4.5-cm RCM, body mass index of 32 kg/m2, estimated glomerular filtration rate of 50 ml/min, Eastern Cooperative Oncology Group performance status of 3, and Charlson comorbidity index of 3 has predicted 5-yr CSM of 2.9-5.6% across treatments, but 5-yr OCM of 29% and risk of 90-d Clavien grade 3-5 complications of 1.9% for RN, 5.8% for PN, and 3.6% for TA. Limitations include selection bias, heterogeneity in practice across treatment sites and the study time period, and lack of control for surgeon/hospital volume. CONCLUSIONS We present a risk calculator incorporating pretreatment features to estimate treatment-specific competing risks of mortality and complications for use during shared decision-making and personalized treatment selection for RCMs. PATIENT SUMMARY We present a risk calculator that generates personalized estimates of the risks of death from cancer or other causes and of complications for surgical, ablation, and surveillance treatment options for patients with stage 1 kidney tumors.
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Affiliation(s)
- Sarah P Psutka
- Department of Urology, University of Washington, Seattle, WA, USA.
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Michael A S Jewett
- Departments of Surgery (Urology) and Surgical Oncology, Princess Margaret Cancer Center and University Health Network, University of Toronto, Toronto, Canada
| | - Kamel Fadaak
- Department of Urology, King Fahd Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Antonio Finelli
- Departments of Surgery (Urology) and Surgical Oncology, Princess Margaret Cancer Center and University Health Network, University of Toronto, Toronto, Canada
| | - Laura Legere
- Departments of Surgery (Urology) and Surgical Oncology, Princess Margaret Cancer Center and University Health Network, University of Toronto, Toronto, Canada
| | - Todd M Morgan
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Phillip M Pierorazio
- Department of Urology, Brady Urological Institute, Department of Urology at Johns Hopkins, Baltimore, MD, USA
| | - Mohamad E Allaf
- Department of Urology, Brady Urological Institute, Department of Urology at Johns Hopkins, Baltimore, MD, USA
| | - Jeph Herrin
- Division of Cardiology, Yale School of Medicine, New Haven, CT, USA; Health Research & Educational Trust, Chicago, IL, USA
| | - Christine M Lohse
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Grant D Schmit
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Nilay D Shah
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
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Zhou W, Herwald SE, Uppot RN, Arellano RS. Impact of Body Mass Index on Perioperative Complications and Oncologic Outcomes in Patients Undergoing Thermal Ablation for Renal Cell Carcinoma. J Vasc Interv Radiol 2020; 32:33-38. [PMID: 33308948 DOI: 10.1016/j.jvir.2020.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/30/2020] [Accepted: 07/30/2020] [Indexed: 10/22/2022] Open
Abstract
PURPOSE To determine effect of body mass index (BMI) on safety and cancer-related outcomes of thermal ablation for renal cell carcinoma (RRC). MATERIALS AND METHODS This retrospective study evaluated 427 patients (287 men and 140 women; mean [SD] age, 72 [12] y) who were treated with thermal ablation for RCC between October 2006 and December 2017. Patients were stratified by BMI into 3 categories: normal weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), and obese (≥ 30 kg/m2). Of 427 patients, 71 (16%) were normal weight, 157 (37%) were overweight, and 199 (47%) were obese. Complication rates, local recurrence, and residual disease were compared in the 3 cohorts. RESULTS No differences in technical success between normal-weight, overweight, and obese patients were identified (P = .72). Primary technique efficacy rates for normal-weight, overweight, and obese patients were 91%, 94%, and 93% (P = .71). There was no significant difference in RCC specific-free survival, disease-free survival, and metastasis-free survival between obese, overweight, and normal-weight groups (P = .72, P = .43, P = .99). Complication rates between the 3 cohorts were similar (normal weight 4%, overweight 2%, obese 3%; P = .71). CONCLUSIONS CT-guided renal ablation is safe, feasible, and effective regardless of BMI.
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Affiliation(s)
- Wenhui Zhou
- Department of Radiology, Stanford Medicine, Stanford, California
| | - Sanna E Herwald
- Department of Radiology, Stanford Medicine, Stanford, California
| | - Raul N Uppot
- Department of Interventional Radiology, Massachusetts General Hospital, 55 Fruit Street, GRB 293, Boston, MA 02114
| | - Ronald S Arellano
- Department of Interventional Radiology, Massachusetts General Hospital, 55 Fruit Street, GRB 293, Boston, MA 02114.
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Editorial Comment on "Thermal Ablation of Renal Cell Carcinoma in Patients With Morbid Obesity: Assessment of Technique, Safety, and Oncologic Outcomes". AJR Am J Roentgenol 2020; 216:996. [PMID: 32812802 DOI: 10.2214/ajr.20.24470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Thermal Ablation of Renal Cell Carcinoma in Patients With Morbid Obesity: Assessment of Technique, Safety, and Oncologic Outcomes. AJR Am J Roentgenol 2020; 216:989-996. [PMID: 32755206 DOI: 10.2214/ajr.20.23803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND. Obesity is a worldwide problem that impacts patient health as well as the morbidity associated with surgical procedures. Thus, patients with morbid obesity may not be suitable candidates for curative surgery. For this patient population, thermal ablation may be an effective alternative to nephrectomy. OBJECTIVE. The purpose of this study was to determine the feasibility, oncologic outcomes, and survival of patients with morbid obesity and renal cell carcinoma treated with thermal ablation. MATERIALS AND METHODS. A retrospective analysis was performed of 107 patients treated with CT-guided renal ablation for clinical T1 renal cell carcinoma between February 2005 and December 2017. Patients were stratified into two cohorts on body mass index of ≥ 40 kg/m2 (morbidly obese) and body mass index (weight in kilograms divided by the square of height in meters) of ≥ 40 (morbidly obese) and 18.5-24.9 (normal weight). Anesthetic and radiation dosages, procedure time, residual disease, and local recurrence, and adverse events were analyzed between the two groups. Kaplan-Meier statistics were used to evaluate cancer-related outcomes for each group. RESULTS. Thirty-four patients were morbidly obese, and 73 patients had normal weight. Morbid obesity was associated with longer procedural duration (p = .001), sedative doses (p = .002) and radiation exposure (p = .001) than normal weight. Hematomas were more prevalent in patients with morbid obesity than in those of normal weight (p = .01), but treatment efficacy and local recurrences were comparable with those for normal-weight individuals (p = .81 and p = .12, respectively). Cancer-related outcomes were equivalent between the two groups based on 5 years of imaging observation data. CONCLUSION. CT-guided thermal ablation remains technically feasible, well-tolerated, and effective in patients with morbid obesity and renal cell carcinoma, with the caveat of increased risk of perinephric hematoma, anesthesia dose, and radiation exposure. CLINICAL IMPACT. CT-guided thermal ablation can be considered a safe and effective treatment for renal cell carcinoma in patients with morbid obesity.
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Monfardini L, Gennaro N, Della Vigna P, Bonomo G, Varano G, Maiettini D, Bonello L, Solbiati L, Orsi F, Mauri G. Cone-Beam CT-Assisted Ablation of Renal Tumors: Preliminary Results. Cardiovasc Intervent Radiol 2019; 42:1718-1725. [PMID: 31367773 DOI: 10.1007/s00270-019-02296-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 07/24/2019] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Renal ablation is a recognized treatment modality for small renal masses. Cone-beam CT (CBCT) has been recently used in interventional oncology as a promising new guidance device, but this technology still needs to be validated for renal ablations. We aimed to assess the technical success of CBCT applications in renal ablative treatments. MATERIALS AND METHODS Between March 2016 and June 2018, 14 patients (mean age 69, range 54-83, 7F, 7M) underwent 21 renal ablations for histologically proven renal cell carcinoma (RCC). All treatments were performed with ultrasound (US) and CBCT guidance under general anesthesia in a dedicated angiography room setting. CBCT was mainly used to assess needle placement and to exclude complications at the end of the procedure. In two small lesions (< 1 cm), pre-acquired CBCT was co-registered with real-time US to obtain a US-CBCT fusion image guidance for tumor ablation. RESULTS Whether used alone or in combination with other imaging modalities, CBCT was proven to be technically successful in all 21 procedures to guide or assist tumor ablation. A primary technical efficacy of thermal ablation was achieved in 19/21 ablations (90.1%) at 1 month. Mean procedure duration was 100.2 min (range 160-64). Mean length of hospital stay was 2 days (range 1-10 days). All patients are still under active surveillance for a mean follow-up of 14.5 months (range 4-26 months). CONCLUSIONS CBCT for renal ablation guidance is a viable tool. Larger series are needed to compare it to MDCT.
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Affiliation(s)
- Lorenzo Monfardini
- Department of Radiology, Fondazione Poliambulanza Istituto Ospedaliero, 25124, Brescia, Italy
| | - Nicolò Gennaro
- Training School in Radiology, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy.
| | - Paolo Della Vigna
- Division of Interventional Radiology, European Institute of Oncology, IEO, IRCCS, 20141, Milan, Italy
| | - Guido Bonomo
- Division of Interventional Radiology, European Institute of Oncology, IEO, IRCCS, 20141, Milan, Italy
| | - Gianluca Varano
- Division of Interventional Radiology, European Institute of Oncology, IEO, IRCCS, 20141, Milan, Italy
| | - Daniele Maiettini
- Division of Interventional Radiology, European Institute of Oncology, IEO, IRCCS, 20141, Milan, Italy
| | - Luke Bonello
- Medical Imaging Department, Mater Dei Hospital, Triq Dun Karm, Msida, 2090, Malta
| | - Luigi Solbiati
- Department of Radiology, Humanitas Clinical and Research Hospital, 20089, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, 20089, Pieve Emanuele, Milan, Italy
| | - Franco Orsi
- Division of Interventional Radiology, European Institute of Oncology, IEO, IRCCS, 20141, Milan, Italy
| | - Giovanni Mauri
- Division of Interventional Radiology, European Institute of Oncology, IEO, IRCCS, 20141, Milan, Italy
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Abstract
Renal cell carcinoma is a common malignancy with increasing incidence due to the incidental detection of non-symptomatic small renal masses on imaging. Management of these small tumors has evolved toward minimally invasive nephron-sparing techniques which include partial nephrectomy and image-guided ablation. Cryoablation and radiofrequency ablation are the most utilized ablation modalities with the former more suited for larger and central renal masses due to intra-procedural visualization of the ablation zone and reduced pelvicalyceal injury. In this article, we review the epidemiology and natural history of renal cell carcinoma, the role of biopsy, and the management options available-surgery, image-guided ablation, and active surveillance-with a focus on cryoablation. The clinical outcomes of the longer term maturing cryoablation data are discussed with reference to partial nephrectomy and radiofrequency ablation. Image-guided ablation has often been the management choice in patients deemed unfit for surgery; however, growing evidence from published series demonstrates image-guided ablation as a sound alternative treatment with equivalent oncological outcomes and minimal patient impact.
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Affiliation(s)
- Nirav Patel
- Department of Radiology, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, United Kingdom.
| | - Alexander J King
- Department of Radiology, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, United Kingdom
| | - David J Breen
- Department of Radiology, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, United Kingdom
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Zargar H, Atwell TD, Cadeddu JA, de la Rosette JJ, Janetschek G, Kaouk JH, Matin SF, Polascik TJ, Zargar-Shoshtari K, Thompson RH. Cryoablation for Small Renal Masses: Selection Criteria, Complications, and Functional and Oncologic Results. Eur Urol 2016; 69:116-28. [DOI: 10.1016/j.eururo.2015.03.027] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 03/11/2015] [Indexed: 12/27/2022]
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Wagstaff P, Ingels A, Zondervan P, de la Rosette JJMCH, Laguna MP. Thermal ablation in renal cell carcinoma management: a comprehensive review. Curr Opin Urol 2015; 24:474-82. [PMID: 25051022 DOI: 10.1097/mou.0000000000000084] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW This article provides an overview of recent developments in the field of thermal ablation for renal cell carcinoma and focuses on current standard techniques, new technologies, imaging for ablation guidance and evaluation, and future perspectives. RECENT FINDINGS Emerging long-term data on cryoablation and radiofrequency ablation (RFA) show marginally lower oncologic outcomes compared to surgical treatment, balanced by better functional and perioperative outcomes. Reports on residual disease vary widely, influenced by different definitions and strategies in determining ablation failure. Stratifying disease-free survival after RFA according to tumor size suggests 3 cm to be a reasonable cut off for RFA tumor selection. Microwave ablation and high-intensity focal ultrasound are modalities with the potential of creating localized high temperatures. However, difficulties in renal implementation are impairing sufficient ablation results. Irreversible electroporation, although not strictly thermal, is a new technology showing promising results in animal and early human research. SUMMARY Although high-level randomized controlled trials comparing thermal ablation techniques are lacking, evidence shows that thermal ablation for small renal masses is a safe procedure for both long-term oncologic and functional outcomes. Thermal ablation continues to be associated with a low risk of residual disease, for which candidates should be properly informed. RFA and cryoablation remain the standard techniques whereas alternative techniques require further studies.
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Affiliation(s)
- Peter Wagstaff
- Department of Urology, Academic Medical Center, Amsterdam, Netherlands *Peter Wagstaff and Alexandre Ingels contributed equally to the writing of this article
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Larcher A, Fossati N, Mistretta F, Lughezzani G, Lista G, Dell’Oglio P, Abrate A, Sun M, Karakiewicz P, Suardi N, Lazzeri M, Montorsi F, Guazzoni G, Buffi N. Long-term oncologic outcomes of laparoscopic renal cryoablation as primary treatment for small renal masses. Urol Oncol 2015; 33:22.e1-22.e9. [DOI: 10.1016/j.urolonc.2014.09.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 09/02/2014] [Accepted: 09/05/2014] [Indexed: 12/20/2022]
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Abstract
Although percutaneous ablation of small renal masses is generally safe, interventional radiologists should be aware of the various complications that may arise from the procedure. Renal hemorrhage is the most common significant complication. Additional less common but serious complications include injury to or stenosis of the ureter or ureteropelvic junction, infection/abscess, sensory or motor nerve injury, pneumothorax, needle tract seeding, and skin burn. Most complications may be treated conservatively or with minimal therapy. Several techniques are available to minimize the risk of these complications, and patients should be appropriately monitored for early detection of complications. In the event of a serious complication, prompt treatment should be provided. This article reviews the most common and most important complications associated with percutaneous ablation of small renal masses.
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