AUA 2018: Controversies in Urology: Kidney Cancer – Treatment with Thermal Ablation – CON Rebuttal

San Francisco, CA (UroToday.com) Craig Rogers, MD gave a talk supporting Ketan Badani, MD in his opinion favoring partial nephrectomy (PN) over ablation for small renal masses (SRM). There is no doubt that PN is a more definitive therapy than ablation treatments. PN is the gold standard of treatment for clinical stage T1a disease. Robust data demonstrate excellent oncologic outcomes. PN allows complete pathological evaluation, and although it harbors the increased risk of urologic complications, it does not entail a higher risk of overall complications. 

Ablative techniques according to the recent AUA guidelines are an alternate approach for SRM < 3 cm. In ablation, we do not obtain pathological results, and we lack high quality long-term data. Furthermore, there is clearly a higher local recurrence rate with ablation than with PN.

Ablative modalities are not ideal for all tumors. All conditions must be just right for this treatment to be successful. These conditions include the proper age of the patient (not too old or too young), the comorbidities of the patient must be taken into account, patient preferences must be considered as well, the location of the tumor must not include tumors that are close to critical structures, the tumor must not be too endophytic, and lastly, the tumors cannot be too complex. All these conditions must be met in order to even consider ablation as an option.

The AHRQ metanalysis comparing PN vs. ablative techniques is the biggest and most comprehensive metanalysis [1] to date, which compares both modalities. It took into account 107 studies between 1997-2015, with 794 written pages! The results showed excellent and similar results for CSS (median 5 years 95%). However, PN is more favorable with regards to lower recurrence rates.

In conclusion, PN is the gold standard and is a more definitive treatment than ablative techniques. It has a broader applicability and more robust evidence, ablation is suitable for only a small percentage of patients. Ablation should be reserved only for patients with an appropriate tumor, higher risk for undergoing PN, or patients that are uncomfortable with surveillance. Lastly, we should not extrapolate ablation data to younger healthier patients with larger tumors.



Presented by: Craig Rogers, MD, FACS, Vattikuti Urology Institute, Detroit Michigan, USA

Written by:  Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA

References:
Pierorazio PM, Johnson MH, Patel HD, Sozio SM, Sharma R, Iyoha E, Bass EB, Allaf ME. Management of Renal Masses and Localized Renal Cancer. Comparative Effectiveness Review No. 167. (Prepared by the Johns Hopkins University Evidence-based Practice Center under Contract No. 290-2012-00007-I.) AHRQ Publication No. 16-EHC001-EF. Rockville, MD: Agency for Healthcare Research and Quality; February 2016.

Read the Preceding Presentation:
Controversies in Urology: Kidney Cancer – Treatment with Thermal Ablation – CON
Read the Opposing Argument: 
Controversies in Urology: Kidney Cancer – Treatment with Thermal Ablation – PRO 
Read the Opposing Argument Rebuttal: 
Controversies in Urology: Kidney Cancer – Treatment with Thermal Ablation – PRO Rebuttal
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