Reply to Aaron M. Potretzke, Jeffrey A. Larson and Sam B. Bhayani's Letter to the Editor re: R. Houston Thompson, Tom Atwell, Grant Schmit, et al. Comparison of Partial Nephrectomy and Percutaneous Ablation for cT1 Renal Masses. Eur Urol 2015;67:252–9

Abstract

The grade for the level of evidence supporting the last statement was an A [1]. Our experience with cT1 renal masses differs from the guideline statements, and we sought to compare percutaneous ablation with the reference standard of care, namely partial nephrectomy (PN) [2]. We agree that longer follow-up is needed, and perhaps with additional investigation, endpoints such as cancerspecific survival can be appropriately compared. Moreover, as stated in our paper, we hope our results demonstrate the need for a prospective randomized trial [2]. Nevertheless, there are two commentsmade by Potretzke et al. that we would particularly like to address. The first is that ‘‘RFA [radiofrequency ablation] is a notably inferior technology to cryoablation, PN, or RN [radical nephrectomy].’’Wedonot believe our results support this statement, and in factweobserved similar local recurrence-free survival among cT1a patients treated with RFA, cryoablation, and PN [2]. In our experience, bleeding complications from RFA are reduced compared with cryoablation [3], and when used appropriately, RFA has a role in the treatment armamentarium for small (<3 cm) and peripheral renal masses. Second, the notion that our manuscript contributes to the ‘‘death of PN era’’ is simply not our intention, nor do we interpret our results this way. Indeed, wewere one of the first institutions to show a renal functional advantage [4] and an overall survival advantage [5] for PN compared with RN, and have continued todocument the advantagesof PN, even for benign renal masses [6], and have further supported PN using a meta-analysis that included the EORTC 30904 trial [7]. The vast majority of cT1a renal masses treated at Mayo Clinic Rochester are managed with PN, as are the majority of cT1b renalmasses [8].We believe our data demonstrate that PN is associated with outstanding oncologic outcomes, allows for completepathologic evaluationof the tumor, andreduces the need and frequency for postoperative imagingwith contrast; however,we also believe our data support that percutaneous ablation is amore reasonable alternative treatmentmodality than current clinical guidelines suggest [1,9].