Laparoscopic Renal Cryoablation Research Articles

Cryoablation of renal cell carcinoma: six-year experience with 64 cases

Objective To summarize our clinical experience of cryoablation for renal cancer and to analyze the therapeutic indication, security, selection of cryoablation and outcomes. Methods Sixty-four patients suffered with T1a renal cell carcinoma were enrolled in this study from March 2012 to March 2018. Among them, 5 cases were senile patients(≥80 years), 5 cases complicated with other cancers, 3 cases complicated with renal insufficiency, 4 cases complicated with decompensated cirrhosis, 3 cases with bilateral renal cancer, 4 cases with solitary kidney cancer and 39 cases with some other complications. The preoperative serum creatinine level was(80.5±38.2)μmol/L. The patients underwent laparoscopic single-site (LESS) renal cryoablation, conventional laparoscopic renal cryoablation, or percutaneous image-guided cryoablation according to individual situation. Contrast-enhanced CT scan or MRI were used during the procedures and follow-up was performed. Results All operations were completed successfully and technical success was achieved as well in all cases. Blood transfusion was necessary for 2 cases because of hemorrhage.The mean diameter of the mass was (2.6±0.90)cm , the median volume of blood loss was 50ml(10-110 ml), and the mean operation time was(96.0±24.5)min. The median inpatient hospital stay was 3 d(1-6 d). In one case, digital subtraction angiography(DSA )embolization was performed due to hemorrhage after surgery. None of the other cases had intraoperative or postoperative complications. The serum creatinine level after surgery was not significantly decreased [postoperative (83.8±42.1) μmol/L, P=0.64]. The contrast-enhanced CT or MRI of the kidneys one week postoperatively showed uniform low density in all lesion areas, which represented complete ablation and regression of the tumor. All cases were followed up regularly. One case showed relapse at the 6th month follow-up and underwent cryoablation again. Another case, who was not regularly followed up, relapsed at 69th month after surgery. No relapse was observed in the other cases during the follow-up. Conclusions Renal cancer cryoablation is a safe, feasible and efficacious therapy for the patients who suffered from unresectable T1a renal cell carcinoma because of high surgical risk or multifocal lesions. Key words: Carcinoma, renal cell; Cryoablation; Laparoscopy; Imaging-guided

Computed Tomography Perfusion, Magnetic Resonance Imaging, and Histopathological Findings After Laparoscopic Renal Cryoablation: An In Vivo Pig Model

The present study investigates how computed tomography perfusion scans and magnetic resonance imaging correlates with the histopathological alterations in renal tissue after cryoablation. A total of 15 pigs were subjected to laparoscopic-assisted cryoablation on both kidneys. After intervention, each animal was randomized to a postoperative follow-up period of 1, 2, or 4 weeks, after which computed tomography perfusion and magnetic resonance imaging scans were performed. Immediately after imaging, open bilateral nephrectomy was performed allowing for histopathological examination of the cryolesions. On computed tomography perfusion and magnetic resonance imaging examinations, rim enhancement was observed in the transition zone of the cryolesion 1week after laparoscopic-assisted cryoablation. This rim enhancement was found to subside after 2 and 4 weeks of follow-up, which was consistent with the microscopic examinations revealing of fibrotic scar tissue formation in the peripheral zone of the cryolesion. On T2 magnetic resonance imaging sequences, a thin hypointense rim surrounded the cryolesion, separating it from the adjacent renal parenchyma. Microscopic examinations revealed hemorrhage and later hemosiderin located in the peripheral zone. No nodular or diffuse contrast enhancement was found in the central zone of the cryolesions at any follow-up stage on neither computed tomography perfusion nor magnetic resonance imaging. On microscopic examinations, the central zone was found to consist of coagulative necrosis 1 week after laparoscopic-assisted cryoablation, which was partially replaced by fibrotic scar tissue 4 weeks following laparoscopic-assisted cryoablation. Both computed tomography perfusion and magnetic resonance imaging found the renal collecting system to be involved at all 3 stages of follow-up, but on microscopic examination, the urothelium was found to be intact in all cases. In conclusion, cryoablation effectively destroyed renal parenchyma, leaving the urothelium intact. Both computed tomography perfusion and magnetic resonance imaging reflect the microscopic findings but with some differences, especially regarding the peripheral zone. Magnetic resonance imaging seems an attractive modality for early postoperative follow-up.

1094 Outcomes after laparoscopic assisted renal cryoablation: A retrospective EuRECA multinational analysis

1094 Outcomes after laparoscopic assisted renal cryoablation: A retrospective EuRECA multinational analysis

Salvage extirpative surgery for recurrent disease following laparoscopic renal cryoablation for T1 renal masses

RESULTS: A total of 17 patients with recurrent disease following RCA as defined by an enhancing lesion with interval growth were managed with partial (1) or total (16) nephrectomy. The median age was 65 years. Mean tumor size at initial RCA was 3.78 cm and 5.94 cm at salvage surgery. Tumor histology was clear cell carcinoma in all cases. 3 low grade cases, 8 intermediate and 6 high grade cases were identified. Median time from RCA to salvage surgery was 29 months. Radical nephrectomy was performed in robotic laparoscopic (12) or open (3) fashion; 2 robotic cases required open conversion. Overall, median operative time was 233 minutes, and median blood loss was 200 mL. Three patients experienced postoperative complications, including ileus, acute blood loss and wound infection. During a median follow-up of 58.5 months, 2 patients developed metastases, and 7 died (2 from disease, 5 from other causes). The metastatic free, cancer specific and overall survival was 88%, 94% and 82%, respectively. CONCLUSIONS: Salvage extirpative surgery for recurrent disease following primary RCA provides good renal functional and oncologic outcomes. Minimally invasive surgery can be performed in most cases, but can be complicated by perirenal fibrosis and scarring associated with RCA.

Minimally Invasive Partial Nephrectomy Versus Laparoscopic Cryoablation for Patients Newly Diagnosed with a Single Small Renal Mass

BackgroundMinimally invasive partial nephrectomy (MIPN) and laparoscopic renal cryoablation (LRC) are two treatment options increasingly used for small renal masses. ObjectiveTo compare perioperative, oncologic, and functional outcomes after MIPN and LRC. Design, setting, and participantsWe included 372 consecutive patients newly diagnosed with a single small renal mass and treated with either MIPN or LRC at a single institution. InterventionMIPN and LRC. Outcome measurements and statistical analysisRegression models were used to evaluate the impact of surgical treatment (MIPN vs LRC) on perioperative, oncologic, and functional outcomes. Results and limitationsOverall, 206 patients (55%) underwent MIPN and 166 (45%) were treated with LRC. In multivariate analysis, the rate of postoperative complications was significantly lower in the MIPN compared to the LRC group (20% vs 28%; adjusted difference –11%; p=0.02) after adjusting for age at surgery, American Society of Anesthesiologists score (1 vs 2 vs 3), and tumor size. The median follow-up was similar in the two groups (43 and 39 mo for MIPN and LRC, respectively). In univariate Cox regression analysis, treatment type was not significantly associated with disease-free survival (hazard ratio 1.06, 95% confidence interval [CI] 0.45–2.52; p=0.9). The disease-free survival rate at 5 yr was 92% in MIPN and 93% in LRC patients. In multivariate linear regression analysis, LRC was significantly associated with a higher estimated glomerular filtration rate (eGFR) at 6 mo compared to MIPN (coefficient 4.68, 95% CI 0.06–9.30; p=0.047) after adjusting for age at surgery, tumor size, and preoperative eGFR. There was no significant association between surgical treatment and postoperative eGFR at 3 yr after surgery (coefficient –2.36, 95% CI –7.55 to 2.83; p=0.4). Limitations include the retrospective study design and selection bias. ConclusionsMIPN and LRC provided similar cancer control and comparable renal function at intermediate-term follow-up. Both surgical techniques emerged as viable treatment options for patient newly diagnosed with a single small renal mass. Further multi-institutional studies with longer follow-up and nephrometry scores are needed to corroborate our findings. Patient summaryIn patients newly diagnosed with a single small renal mass, minimally invasive partial nephrectomy and laparoscopic renal cryoablation provided similar cancer control and comparable renal function at intermediate-term follow-up.

The application of PADUA scoring system for predicting complications of laparoscopic renal cryoablation.

To evaluate the clinical application of preoperative aspects and dimensions used for anatomical (PADUA) scoring system in predicting perioperative surgical outcomes in patients undergoing laparoscopic cryoablation (LCA). A total of 95 consecutive renal tumors treated with LCA between January 2007 and April 2013 were collected. Renal tumors were categorized into low- (6-7), moderate- (8-9), and high-complexity (10-13) groups according to PADUA indices. Demographics, perioperative variables, and complication rates were compared among three groups. Surgical conversion, blood loss >100 mL, tumor fracture, and incomplete ablation were regarded as intraoperative complications (IOCs). All postoperative complications (POCs) were graded using the Clavien-Dindo system. The risk for complications was assessed by univariate and multivariate logistic regression analyses. The estimated blood loss during LCA was associated with PADUA score. There were 17 (17.9%) IOCs and 20 (21.1%) POCs. Blood loss (>100 mL) was the most common IOC, which occurred in 10 (10.5%) patients. For POC, there were 15 (15.8%) minor complications (Clavien 1-2) and 5 (5.3%) major complications (Clavien 3a). Higher grade of PADUA scores was significantly correlated with the increase incidence of IOC and POC. The PADUA score was an independent predictive factor for POC, and the patients with moderate and high PADUA scores had an over sixfold and 17-fold higher risk compared to the patients with low scores, respectively. Our findings demonstrated, for the first time, the PADUA scoring system is an efficient assessment tool for predicting the perioperative complications in patients undergoing laparoscopic renal cryoablation.

Long-term oncologic outcomes of laparoscopic renal cryoablation as primary treatment for small renal masses

IntroductionData regarding long-term oncologic outcomes of laparoscopic renal cryoablation (LRC) as first treatment for small renal masses (SRMs) are lacking. We hypothesized that LRC might provide an effective long-term cancer control in patients with a single cT1a SRM without a previous history of renal cell carcinoma (RCC). Materials and methodsThe study design was a retrospective analysis of 174 consecutive patients who received LRC as first treatment for a single computed tomography or magnetic resonance imaging contrast-enhancing cT1a SRM between 2000 and 2013. Patients with a previous history of RCC were excluded. Treatment failure was evaluated 1 day after surgery. Local recurrence, metachronous SRM, systemic progression, disease relapse, cancer-specific mortality, and all-cause mortality were evaluated 10 years after surgery. Kaplan-Meier plots were used to depict outcome-free survival rate. ResultsMedian patient age was 66 years. Median tumor size was 20mm. Median follow-up was 48 months. Among patients with biopsy-proven RCC (63%, n = 109), the treatment failure–free rate was 98%. The 10-year recurrence-free survival rate was 95% and the 10-year metachronous SRM–free survival rate was 87%. The 10-year systemic progression–free survival rate was 100% and the 10-year disease relapse–free survival rate was 81%. The cancer-specific mortality–free survival rate was 100%, and the all-cause mortality–free survival rate was 61%. ConclusionsLRC provides safe long-term cancer control in patients newly diagnosed with a single cT1a SRM. Treatment failure and local recurrence are uncommon. Systemic progression–free survival and cancer-specific–free survival are optimal.

Laparoscopic Cryoablation for Clinical Stage T1 Renal Masses: Long-term Oncologic Outcomes at the Medical College of Wisconsin

To report the long-term oncologic outcomes of laparoscopic cryoablation for clinical stage T1 renal masses at the Medical College of Wisconsin. A retrospective chart review was performed evaluating patients who underwent laparoscopic cryoablation for renal masses at the Medical College of Wisconsin between February 2000 and October 2009. A total of 171 renal masses in 144 patients were treated by laparoscopic cryoablation during the study period. After excluding patients with <5 years follow-up and those with >clinical stage I disease, 112 renal masses treated in 92 patients remained for analysis. Mean patient age was 59.6 years (standard deviation [SD], 12.5 years). Mean lesion size was 2.3 cm (SD, 0.94 cm). Mean age adjusted Charlson comorbidity index was 4.55 (SD, 1.69). Mean follow-up was 97.9 months (SD, 24.8 months). Overall survival among all patients was 80.9%. Lesions were biopsy proven to be malignant in 70 patients (76.3%). Of those with biopsy-proven malignancy, there were 6 recurrences, 14 non-cancer-related deaths, and 1 cancer-related death, leading to an overall survival of 77.6%, progression-free survival of 91.0%, and cancer-specific survival of 98.5%. We report the largest published series of laparoscopic renal cryoablation with the longest follow-up. Our series indicates that laparoscopic cryoablation is both an efficacious treatment for clinical stage T1 renal masses and provides excellent long-term oncologic outcomes.

Laparoscopic Renal Cryoablation Versus Laparoscopic Partial Nephrectomy for the Treatment of Small Renal Masses: A Systematic Review and Meta-analysis of Comparative Studies

For small renal masses (SRMs), open partial nephrectomy represents the therapeutic standard of care, and laparoscopic partial nephrectomy (LPN) has provided encouraging outcomes. Laparoscopic renal cryoablation (LRC) could be regarded as an alternative to surgical excision in selected patients, if perioperative complication rates and oncologic results are comparable. However, the short- and long-term outcomes of LRC versus LPN have not been adequately assessed. This study evaluated the safety and efficacy of LRC compared with LPN in the treatment of SRMs. A systematic search of the Medline, Scopus, and CNKI databases and the Cochrane Library was performed up to October 1, 2013. Outcomes of interest assessing the two techniques included demographic and clinical baseline characteristics, surgical and oncological variables, renal function, and complications. Nine eligible trials (555 cases and 642 controls) assessing LRC versus LPN were identified, including two prospective and seven retrospective studies. Patients undergoing LRC were significantly older (weighted mean difference [WMD], 6.48 years; 95% confidence interval [CI], 3.12-9.83; P<.001) and had a higher solitary kidney rate (odds ratio [OR]=3.76; 95% CI, 2.05-6.92; P<.001). Although LRC was associated with shorter operative time (WMD, -54.28 minutes; 95% CI, -83.79 to -24.78; P<.001), less blood loss (WMD, -111.75 mL; 95% CI, -147.96 to -75.53; P<.001), lower risk of conversion (OR=0.17; 95% CI, 0.05-0.60; P=.005), and fewer overall complications (OR=0.53; 95% CI, 0.29-0.98; P=.04), especially the rate of intraoperative complications (OR=0.20; 95% CI, 0.07-0.58; P=.003) and major complications (OR=0.45; 95% CI, 0.25-0.81; P=.008), patients having LPN might still benefit from a significantly lower local recurrence rate (OR=13.03; 95% CI, 4.20-40.39; P<.001) and lower distant metastasis rate (OR=9.05; 95% CI, 2.31-35.51; P=.002). Compared with LPN, LRC was associated with reliable perioperative safety, comparable renal function, and fewer complications; however, LRC may still result in a higher risk of tumor progression. Therefore, our meta-analysis suggested that LRC was associated with worse oncological outcomes than LPN but that LRC may be indicated in selected patients with significant comorbidity. Because of the inherent limitations of the included studies, further large sample, prospective, multicenter, and long-term follow-up studies are awaited to corroborate these findings.

98 Long-term oncologic outcomes of laparoscopic renal cryoablation: 10 years results from a single institution

98 Long-term oncologic outcomes of laparoscopic renal cryoablation: 10 years results from a single institution

OP3-05 LONG-TERM ONCOLOGIC OUTCOMES OF LAPAROSCOPIC RENAL CRYOABLATION: 10 YEARS RESULTS FROM A SINGLE INSTITUTION

INTRODUCTION AND OBJECTIVES: Laparoscopic renal cryoablation [LRC] is an effective minimally invasive treatment option for small renal masses [SRMs], but evidences regarding long-term oncologic safety are still lacking. The aim of this study is to evaluate the longterm oncological outcomes of LCR in patients with at least one SRM. METHODS: The study design is an observational, retrospective analysis of prospectively collected data of 189 consecutive patients who underwent LRC between 2000 and 2013. Overall, 214 cT1a contrast enhanced SRMs were diagnosed on CT or MRI scan and subsequently treated with LRC. Surgery consisted of transperitoneal or retroperitoneal access to the renal cavity, kidney mobilization, laparoscopic ultrasound evaluation, ultrasound-guided biopsy of the lesion, puncture of the SRM with the cryoprobes and double freeze-thaw cycle extending the ice ball approximately 1 cm beyond the tumor edge. Patients were evaluated on post-operative day 1 with MRI to assess the treatment efficacy: residual disease was defined as persistent enhancing tissue in the treated area. Follow-up was determined using serial MRI at 1, 6, 12, 24, 36, 48, 60, 72 and 120 months. Local recurrence after LRC was defined as the presence of an enhancing nodule in the treated area increasing in size. The outcome of the study was to evaluate the 5 years disease free survival, cancer specific survival and overall survival. RESULTS: Mean follow up was 55.6 months (range 1-156). Mean patient age was 63.42 (range 25 88). Median tumor size was 21 mm (range 7 40). The mean ice-ball diameter after surgery was 44.8 mm (range 18 80), and it decreased over time: MRI showed a mean iceball diameter of 35.0, 23.3, 18.5, 13.5, 11.7, 9.5, 6.4, 5.8 and 2.4 mm at 1, 6, 12, 24, 36, 48, 60, 72 and 120 months, respectively (p<0.001). Histologic examination revealed 135 renal cell carcinoma, 57 benign lesions and 22 non-diagnostic tissues. Overall 10 patients patients developed a metachronous renal neoplasm located in a different site than the cryoablated area. Among patients diagnosed with a renal malignancy, only one showed residual disease after surgery and was effectively treated with a 2nd look LRC, while 4 patients developed a local recurrence. Median time to local recurrence was 18 months (range 6 48). Five-years disease free survival, cancer specific survival and overall survival were 96.91%, 100% and 95.1%, respectively. CONCLUSIONS: Laparoscopic renal cryoablation ensures optimal cancer control outcomes at long term follow-up. These results should be taken into account in patients with small renal masses.

Use of Surveillance Imaging Following Treatment of Small Renal Masses

With the increasing incidence of small renal masses, there is greater use of ablation, nephron sparing surgery and surveillance compared to radical nephrectomy. However, patterns of care in the use of posttreatment imaging remain uncharacterized. The purpose of this study is to determine the rate of posttreatment imaging after various treatments for small renal mass. Using SEER (Surveillance, Epidemiology and End Results)-Medicare data during 2005 to 2009, we identified 1,682 subjects diagnosed with small renal mass and treated with open partial nephrectomy (330), minimally invasive partial nephrectomy (160), open radical nephrectomy (404), minimally invasive radical nephrectomy (535), thermal ablation (212) and surveillance (42). Use of imaging was compared within 24 months of treatment and multivariate regression models were constructed to identify factors associated with increased imaging use. On adjusted analyses thermal ablation was associated with almost eightfold greater odds of surveillance imaging compared with open radical nephrectomy (OR 7.7, 95% CI 1.01-59.4). Specifically, thermal ablation was associated with increased computerized tomography (OR 5.28) and magnetic resonance imaging (OR 2.19) use and decreased ultrasound use (OR 0.59). Minimally invasive partial nephrectomy (OR 3.28) and open partial nephrectomy (OR 3.19) were also associated with increased computerized tomography use to a lesser extent. Subjects undergoing nephron sparing surgery undergo more posttreatment imaging compared to open radical nephrectomy. Although possibly associated with lower morbidity, thermal ablation is associated with significantly greater use of imaging compared to other small renal mass treatments. This may increase costs and radiation exposure, although further study is needed for confirmation.

RENAL Nephrometry Score Is Associated With Complications After Renal Cryoablation: A Multicenter Analysis

To analyze outcomes and complications of percutaneous (PRC) and laparoscopic renal cryoablation (LRC) using the radius, endophytic, nearness to collecting system, anterior/posterior, and location (RENAL) nephrometry system. Retrospective multicenter analysis of 154 consecutive patients who underwent either ultrasound-guided LRC (n= 88) or computed tomography (CT)-guided PRC (n= 66) from March 2003 to December 2011. RENAL score and demographics were compared to postoperative complications (Clavien). Multivariable analysis was carried out for factors associated with development of postprocedure complications. Mean age was 68 years (94 men/60 women). Median follow-up was 34 months (range 23.6-45.6 months). Mean tumor size was 2.6 ± 1 cm. Mean RENAL score was 5.2 ± 1.4. Differences in (A)nterior/posterior component and (H)ilar domain of the RENAL scores were noted, with PRC favoring posterior tumors and hilar lesions compared to LRC (P< .001 and P= .044, respectively). There were 14.9% complications, all of which were low-grade (Clavien 1,2). There were no differences in complications between LRC and PRC (15.9% vs 13.6%, P= .82). Most common complication type was hemorrhagic in 9 of 154 patients (5.8%); significant increase in the hemorrhagic complication rate was noted for patients with "N" ("nearness") component score of 2 or 3 (5/36, or 13.9%), compared to patients with "N" score of 1 (4/115 or 3.5%, P= .033). multivariable analysis demonstrated that increasing RENAL score was associated with postprocedure complications (odds ratio [OR]= 1.37, P= .025). When separated into individual domains, multivariable analysis revealed that "N" score 3 was significantly associated with postoperative complications (OR 16.15, P= .027). Increasing RENAL score was associated development of postprocedure complications after renal cryotherapy. Further investigation is requisite to elucidate the role of RENAL nephrometry score in risk stratification prior to renal cryotherapy.

Contrast-Enhanced Ultrasound for the Evaluation of the Cryolesion After Laparoscopic Renal Cryoablation: An Initial Report

Stringent radiological follow-up is essential after renal tumor ablation. Drawbacks of postablation follow-up by contrast-enhanced computed tomography (CECT) are the associated ionizing radiation and nephrotoxic contrast agent. Contrast-enhanced ultrasound (CEUS) has shown potential to demonstrate microvasculature without using either ionizing radiation or toxic contrast agent. We assessed the concordance of enhancement patterns of CEUS and CECT/MRI in cryolesion assessment after laparoscopic renal cryoablation (LCA). From 01/2006 to 01/2009, a CEUS was performed before and after LCA (3 and 12 months) in addition to regular CECT/MRI. Using an enhancement score (0=no enhancement, 1=rim enhancement, 2=diffuse enhancement, 3=localized enhancement, 4=no enhancement defect), the cryolesion was assessed by both modalities, and concordance of enhancement score was assessed. In total, 45 tumors were included (29 biopsy proven renal cell carcinoma (RCC), mean size 2.66 cm). One cryoablation failed, resulting in a nonenhancing cryolesion apart from the persisting renal tumor. There were no postablation recurrences during the study period. Pre-LCA: Both modalities were available in 26 cases. In 20 out of 26, there was concordance of enhancement score (77%, all cases score 3 or 4). Three months: Both modalities were available in 32 cases. Enhancement score corresponded in 23 out of 32 cases (72%). Seven cases showed enhancement on CECT/MRI ("1" in six cases, "4" in one case) with enhancement score "0"on CEUS. Two cases showed enhancement on CEUS without enhancement on CECT/MRI (specificity 92%, negative predictive value [NPV] 77%). Except one case, all enhancement resolved on subsequent imaging. Twelve months: Both modalities were available in 21 tumors. Enhancement score corresponded in 19 out of 21 cases (91%). Two cases showed enhancement on CEUS without enhancement on CECT/MRI (specificity 90%, NPV 100%). This pilot study shows that CEUS is a safe imaging technique with high concordance of enhancement score between CEUS and CECT/MRI. While cross-sectional imaging seems sensible to demonstrate successful ablation at first follow-up, CEUS might be used to diminish the burden of contrast-enhanced cross-sectional imaging in the long-term follow-up.

Laparoscopic Renal Cryoablation: Single Institutional Experience from South America

Objective: Minimal invasive thermal ablative techniques are emerging as a viable option for patients who are not candidates for open, laparoscopic or robotic-assisted partial nephrectomy. Cryoablation is a low risk alternative with good oncologic outcomes. We present our initial experience with cryoablation for small renal masses using the laparoscopic approach. Patients and Methods: We prospectively collected the perioperative data of patients undergone renal cryoablation at our institution. From May/2009 to January/2011, 41 patients with incidental small renal mass were submitted to laparoscopic cryoablation. Results: The mean patient age was 58.8 years. The mean operative time was 115.4 ± 60.3 min and no patient needed blood transfusion. The mean of size tumors was 2.8 cm (1-5 cm). Intraoperative biopsies showed 27 (65%) malignant tumors, 5 (12%) oncocytomas, two (6%) angiomyolipomas 7 (17%) inconclusive. With a mean follow-up of 16 months (12-21), there were no significant differences between creatinine, estimated glomerular filtration rate and hemoglobin level before and after the procedure. There was no open conversion, kidney loss, urinary fistula, dialysis requirement or re-operations. Conclusion: Laparoscopic renal cryoablation is safe, with low complication rate and short learning curve.

R.E.N.A.L. Nephrometry Score Accurately Predicts Complications Following Laparoscopic Renal Cryoablation

The R.E.N.A.L. nephrometry is a standardized scoring system that quantifies the complexity of kidney tumors. We evaluated our experience with laparoscopic cryoablation and determined the ability of nephrometry to predict complications. We reviewed the records of all patients who underwent laparoscopic cryoablation from July 2005 to February 2010 at 3 institutions. The composite R.E.N.A.L. score was determined using preoperative imaging, and tumors were categorized as low (4-6), moderate (7-9) or high complexity (10-12). Perioperative data were analyzed to determine the presence of complications. The distribution of surgical complications and tumor categories was compared using the chi-square and Student's t test. Logistic regression was used to analyze the association between nephrometry score and postoperative complications. A total of 210 patients underwent laparoscopic cryoablation, 77 of whom had available preoperative imaging. Mean patient age was 64.5 years and mean tumor size was 2.6 cm (range 1 to 4.5). Mean nephrometry score was 6.1 (range 4 to 12). Of the tumors 47 (61%) were categorized as low, 23 (30%) as moderate and 7 (9%) as high complexity lesions. Overall there were 15 (19.5%) complications, including 7 (9.5%) major and 8 (10%) minor complications. There was a significant difference in complication rates among the low (47 patients, 0%), moderate (23 patients, 35%) and high complexity (7 patients, 100%) groups, respectively (p <0.001). On multivariate analysis nephrometry score was independently associated with a higher risk of postoperative complications (OR 2.23, 95% CI 1.05-2.11, p = 0.008). In a multi-institutional cohort of patients undergoing laparoscopic cryoablation, the R.E.N.A.L. nephrometry score is independently associated with the occurrence of complications. Therefore, nephrometry can be used to successfully stratify patients in terms of anticipated risk of complications which, in turn, may help with surgical decision making.

Reply

We support the conclusions of this thoughtful editorial comment. Although our long-term review of laparoscopic cryoablation demonstrates cancer recurrence rates that are higher than those reported for partial nephrectomy, 1 Klatte T. Grubmüller B. Waldert M. et al. Laparoscopic cryoablation versus partial nephrectomy for the treatment of small renal masses: systematic review and cumulative analysis of observational studies. Eur Urol. 2011; 60: 435-443 Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar , 2 Novara G. Ficarra V. Is laparoscopic cryoablation a less invasive and effective procedure to treat small renal masses?. Eur Urol. 2011; 60 (discussion 446-447): 444-445 Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar with appropriate follow-up and treatment of recurrences, our 6-year cancer-specific survival was 100%. Our data support a role for cryoablation in select comorbid patients, as suggested in the editorial review as well as published American Urological Association (AUA) guidelines. 3 Campbell S.C. Novick A.C. Belldegrun A. et al. Guideline for management of the clinical T1 renal mass. J Urol. 2009; 182: 1271-1279 Abstract Full Text Full Text PDF PubMed Scopus (1502) Google Scholar Editorial CommentUrologyVol. 80Issue 2PreviewThis excellent long-term analysis of laparoscopic cryoablation of renal cell carcinoma brings to light some of the important advantages and disadvantages all practicing urologist should be aware of. Sixty-two patients with biopsy proven renal cell carcinoma were followed with magnetic resonance imaging (MRI) for on average over 6 years (76 months). Disease-free survival was a laudable 80%, cancer-specific survival 100%, and overall survival 76.2% in this group of patients, who obviously had other comorbidities making them candidates for laparoscopic renal cryoablation. Full-Text PDF

700 FOLLOW-UP OF LAPAROSCOPIC RENAL CRYOABLATION (LRC) BY CONTRAST ENHANCED ULTRASOUND

You have accessJournal of UrologyKidney Cancer: Evaluation and Staging II1 Apr 2012700 FOLLOW-UP OF LAPAROSCOPIC RENAL CRYOABLATION (LRC) BY CONTRAST ENHANCED ULTRASOUND Kurdo Barwari, Hessel Wijkstra, Jean de la Rosette, and Pilar Laguna Kurdo BarwariKurdo Barwari Amsterdam, Netherlands More articles by this author , Hessel WijkstraHessel Wijkstra Amsterdam, Netherlands More articles by this author , Jean de la RosetteJean de la Rosette Amsterdam, Netherlands More articles by this author , and Pilar LagunaPilar Laguna Amsterdam, Netherlands More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.784AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Stringent radiological follow-up (FU) after ablation is essential and commonly performed by means of CT-scans with contrast. Major drawbacks of CT are the associated exposure to ionizing radiation and nephrotoxic contrast-agent. CEUS (Contrast Enhanced Ultrasound ) has shown potential to demonstrate microvasculature without using ionizing radiation nor a toxic contrast-agent. In this pilot study we assessed whether CEUS can be used as the imaging modality for follow-up after LRC. METHODS From Jan. 2006-Mar. 2009 a CEUS (the index test) was performed before and after renal cryoablation (at 3 and 12 months) in addition to the regular cross sectional imaging with contrast (the reference test). Using a perfusion/enhancement-score (PS) (0=no perfusion/enhancement, 1=rim perfusion/enhancement, 2=diffuse perfusion/enhancement, 3=localized perfusion/enhancement, 4=no perfusion/enhancement defect) the perfusion resp. enhancement in the lesion was assessed on both modalities (CEUS and CT /MRI) at all moments in time. Analysis was aimed at concordance of PS and presence of false negative/positive results. RESULTS In total 45 cases (45 tumors) were included of which 29 biopsy proven RCC. Mean tumor size was 2.66 (SD 0.77) cm. There were no post-procedural persistent tumors at 3 months, nor did any recurrences develop during the 12 month study period. Pre-LRC: In 26 tumors both modalities were present. In 20/26 there was concordance of PS (77%). There were no cases with no perfusion on one modality (PS 0) and at least PS=1 on the other modality. 3m FU: In 31 tumors both modalities were present. In 25/31 there was concordance of PS (81%). 4/31 cases showed enhancement on the CT-scan (all PS 1) without perfusion on CEUS (13%). In all cases enhancement on CT disappeared on subsequent scans. 2/31 cases showed perfusion on CEUS without enhancement on CT (7%). 12m FU: In 21 tumors both modalities were present. In 19/21 there was concordance of PS (91%). There were no cases with enhancement on CT without perfusion on CEUS and 2/21 cases with perfusion on CEUS without enhancement on CT (10%). CONCLUSIONS CEUS is a safe imaging technique enabling visualization of microvasculature. There is a high concordance of PS between CEUS and CT in all points of time. There were few false-positive CEUS-images. This pilot study suggests that CEUS might be useful as the FU-modality after LRC without exposure to ionizing radiation and nephrotoxic contrast-agent. Expansion of the cohort including recurrences is needed before routine implementation of CEUS in the FU-algorithm. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e286-e287 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kurdo Barwari Amsterdam, Netherlands More articles by this author Hessel Wijkstra Amsterdam, Netherlands More articles by this author Jean de la Rosette Amsterdam, Netherlands More articles by this author Pilar Laguna Amsterdam, Netherlands More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1112 Laparoscopic renal mass cryoablation: Relation between comorbidity and post-operative complications.

1112 Laparoscopic renal mass cryoablation: Relation between comorbidity and post-operative complications.

BioGlue Iceball Stabilization to Minimize the Risk of Hemorrhage During Laparoscopic Renal Cryoablation

To evaluate the application of a BioGlue adhesive shell to minimize iceball fracture. Iceball fracture and hemorrhage is common with laparoscopic cryoablation (LCA) of larger (>4 cm) renal tumors. Twenty large iceballs were created in porcine kidneys using 3 cryoablation probes in a nonsurvival study. Each kidney underwent an upper and lower pole ablation. One pole in each kidney was covered with 5 mL of BioGlue and the opposite pole served as a control. A double freeze-thaw cycle was performed (10 minutes freeze and 5 minutes active thaw) in both renal poles simultaneously. The probes were removed and the sites were monitored for 20 minutes under direct vision. Fracture length (mm), severity of fracture depth, severity of bleeding (absent, mild, moderate, severe), and estimated blood loss (EBL) (mL) were recorded. In the control group, the mean fracture length was 1.9 mm (range, 0-3 mm). Blood loss was absent in 10%, mild in 60%, and moderate in 30% of ablations. The mean EBL was 20.5 mL (range, 0-50 mL). For the BioGlue ablations, there were no parenchymal fractures. Blood loss was mild in 30% and absent in 70% of sites with an average EBL of 5 mL (range, 0-20). Two bleeding sites occurred as a result of subcapsular hematomas caused by initial probe placement. BioGlue application minimized the frequency and magnitude of renal fracture. EBL was lower with BioGlue application and most sites demonstrated no postablation bleeding. Further clinical study of the BioGlue shell should be performed to confirm these results.