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

San Francisco, CA ( Ketan Badani, MD gave a talk on the disadvantages of thermal ablations for small renal masses (SRM). The first issue discussed was the problem of incomplete ablation. He began by describing a systematic review and metanalysis of laparoscopic vs. percutaneous cryotherapy for renal tumors. This was an analysis of 1475 patients, with incomplete ablation rates of 3.9% in laparoscopy and 7.4% in percutaneous approach. This by itself is a high percentage and poses a problem.

The second issue discussed was treatment failure. This paper showed that 33% of patients treated with the percutaneous approach had a repeat procedure, 16.6% had surgery, 36.6% were continued to be surveyed, and 1 patient had died. Other papers described a repeat procedure rate of 8% with a recurrence rate of 15%. Obviously high recurrence and treatment failure rates are very problematic.

The third issue was the difficult implementation of salvage surgery. A study by Jimanez et al. demonstrated that in a single center experience of 27 patients who failed treatment with thermal ablations, PN was not possible in 12 patients.

A metanalysis assessing PN vs. thermal ablations included 15 studies with 1974 patients undergoing thermal ablation vs. 2519 patients undergoing PN. The rate of local recurrence and metastasis were similar, but thermal ablations were associated with higher all-cause mortality (HR 2.11, p<0.05), and higher cancer specific mortality (HR 3.84, p<0.05). Another recently published review of 4 studies comparing PN to cryoablation demonstrated the oncologic outcomes favoring PN.

The last issue covered by Dr. Badani was the rate of complications in both treatment modalities (thermal ablation and PN) showing no difference in length of hospital stay between both modalities, with a very similar complications rate in both groups. Bleeding and hematuria are the most common complications, associated with advanced age, increased tumor size, increased number of cryoprobes and central position.

The AUA guidelines still recommend PN as the gold standard for SRMs, and thermal ablations only as an alternate approach.

In conclusion, Thermal ablations according to Dr. Badani should not be used. This is due to several reasons, including the complication rate is equivalent to that of PN, it is considerably less effective then PN, and retreatment failure being a very real problem, making salvage surgery not always easy. This, in turn, results in a higher rate of open surgery and radical nephrectomy. Lastly, according to Dr. Badani, we should not choose thermal ablation for patients who are to sick. If sick in such a way not enabling them to undergo PN, then they should not be treated, but rather be monitored with active surveillance.

Presented by: Ketan Badani, MD, Ichan School of Medicine at Mount Sinai

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

Read the Succeeding Presentation:  
Controversies in Urology: Kidney Cancer – Treatment with Thermal Ablation – CON Rebuttal
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