Percutaneous Image-guided Urologic Procedures

Abstract

Early renal cancer detection, advances in imaging technology, and the development of reliable needle-based ablative therapies have given birth to a new paradigm in the evaluation and treatment of renal neoplasms. This nascent approach has been used primarily in patients at risk for medical complications of traditional surgery, and preliminary therapeutic results from multiple institutions are encouraging. If these suggested benefits continue to be borne out, there is a real possibility that ablative technology will become the standard of care in the majority of patients with small solid renal masses. The potential advantages of ablative therapy are substantial. This technique can be performed on an outpatient basis with sedation, postprocedural pain is minimal, and most patients do not require administration of narcotics. Normal activity can be resumed within a day, as opposed to weeks of convalescence after conventional approaches. Patients who are unable to undergo general anesthesia can now be treated, and those with compromised renal function face a much lower risk of requiring dialysis. These benefits translate into cost reductions, as there are potential collateral advantages to payors, employers, and the economy as a whole. While the arguments for percutaneous ablative therapy are quite cogent, there is a major obstacle to their widespread adoption: turf. This colloquial concept has great historical relevance in all professions, including medicine. It is ingrained in medical students that urologists treat the kidney, the gall bladder is under the purview of the general surgeon, and radiologists interpret images. The rigorous, lengthy, and often rigid preparation involved in the process of postgraduate specialty training serves to reinforce such distinctions. However, innovation continually disrupts these accepted, albeit artificial, domains. With advances in both technique and technology, various providers have retooled themselves to provide novel services to patients. For example, we have witnessed a change in the standard of care for breast biopsy, which has traditionally been an open surgical procedure. With the advent of stereotactic image-guided approaches, radiologists now perform the majority of breast biopsy procedures. Conversely, ultrasonographically (US) guided prostate biopsy, which was introduced by radiologists, has become a standard part of the urologist’s armamentarium. Analogous situations abound across all specialties, with burgeoning growth in endovascular, endoscopic, and radiation oncologic approaches in particular, leading to changes in the management landscape and the principal providers of that management for an entire population of patients. Inherent to many discussions of evolving systems of care is an often skeptical and sometimes adversarial hubris of providers from disciplines competing for the right to provide a novel service. Specialists adopt the position of defending the garrison of their practice from a perceived attack at the gates (1). In this particular case of renal tumor ablation, urologists, who are experts in the biology of renal tumors, are at odds with radiologists, who are experts in the field of imaging. The domains of expertise themselves are dynamic, with the pace of change in our understanding of the relevant disease processes at the molecular level matched by rapidly evolving capabilities of new interventional instrumentation and real-time Published online 10.1148/radiol.2391050973