Renal Ablation

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Pre-Procedure Prep


Renal cell carcinoma
• American Urological Association supports thermal ablation for T1a tumors which is <4 cm
• < 4 cm can be curable with one treatment
• T1b tumors: >4 cm but <7 cm - usually requires more probes and/or staging of the procedure
• Stage IV disease of metastasis who are not surgical candidates

Renal cell carcinoma:
• Slow growing tumor: on average, grows ~3 mm/year
• Rare to have metastasis when primary <4 cm


• Life expectancy <12 months
• Uncorrectable coagulopathy
• No safe percutaneous window
• Invasion of renal vein or regional lymph node involvement- advanced stage.
• Active infection

Things to Check

• History and physical
• Labs- creatinine, INR, platelets
• Prior imaging- CT and/or MRI
• Consent for procedure and anesthesia

Procedure Steps

Thermal Ablation Techniques

• Cryoablation
• Microwave
Data suggests RFA and cryoablation are similar in efficacy
Data on microwave is less robust

Cryoablation using combination CT and US guidance described below:
Positioning: prone or decubitus
Perform preliminary CT to confirm lesion position, size and adjacent structures.
Test probes in bowl or test tube of normal saline

Ultrasound Guidance for Initial Probe Positioning

• For many patient's US guidance can be faster and more efficient for placement
• Helps evaluate the tumor in 3-D plane
• If using multiple probes, try and keep probes parallel

Once probes in final position using US guidance, confirm positioning with CT
• Evaluate probe position within the tumor
• Evaluate probe position with regards to adjacent structures: renal pelvis, ureter, lung, diaphragm, bowel, adrenal
• Evaluate ablation zone: 5-10 mm (consider full 10 mm margins if feasible)
• Probes no more than 2 cm apart
Opportunity to use protective maneuvers if needed such as hydrodissection


• Cycles may vary with manufacturer
• 10 minute freeze with 8 minute active thaw - 2 cycles
• See cell death at -20° C
• Can visualize "ice ball" during freeze cycle
• Can turn on and off probes during freeze cycles to sculpt ablation zone
Remove probes when temperature reaches 10° C

Ice Ball

• Seen at 0°C
• Approximates ablation zone; does not perfectly delineate lethal ablation zone
• Lethal isoderm is 2-3 mm within the ice ball



• Flu-like symptoms (post-ablation syndrome) - fever, fatigue, myalgia. Manage conservatively with antipyretics. Common
• Hemorrhage
• Bowel injury
• Abscess formation/Infection
• Ureteral injury or stricture
• Genitofemoral nerve: anterolateral surface of psoas
• Lower intercostal nerve

Post-Procedural Care

• Monitor patient for at least 2 hours
• Monitor for pain, bleeding, and adjacent structure injury such as pneumothorax
• Discharge home same day if hemodynamically stable, voiding and tolerating po intake
• Discharge medications: anti-inflammatories, antiemetics, and opioids for breakthrough pain
• Most patients will feel back to baseline within 8-10 days


• Clinic visits with imaging before clinic
• Surveillance can vary
• Consider CT/MR at 3 and 6 months
• If disease free at 6 months, CT/MR at 12, 18 and 24 months
• If disease free at 24 months, CT/MR at 3, 4 and 5 years


• T1a lesions treated with ablation similar to partial and radical nephrectomy
• > 95% cancer-specific 5 year survival with thermal ablation
• ~90% overall survival at 5 years with thermal ablation

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Renal Ablation Literature

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Imaging-guided percutaneous renal ablation as a viable alternative to surgery and how to run a successful renal tumor ablation program.

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Join The Discussion


[1] Xing M, Kokabi N, Zhang D, Ludwig JM, Kim HS. Comparative Effectiveness of Thermal Ablation, Surgical Resection, and Active Surveillance for T1a Renal Cell Carcinoma: A Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked Population Study. Radiology. 2018;288(1):81‐90. doi:10.1148/radiol.2018171407
[2] National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) Kidney Cancer. Version 3.2018.
[3] Pierorazio PM, Johnson MH, Patel HD, et al. Management of Renal Masses and Localized Renal Cancer: Systematic Review and Meta-Analysis. J Urol. 2016;196(4):989‐999. doi:10.1016/j.juro.2016.04.081
[4] Gunn AJ, Gervais DA. Percutaneous ablation of the small renal mass-techniques and outcomes. Semin Intervent Radiol. 2014;31(1):33‐41. doi:10.1055/s-0033-1363841
[5] Uppot RN, Silverman SG, Zagoria RJ, Tuncali K, Childs DD, Gervais DA. Imaging-guided percutaneous ablation of renal cell carcinoma: a primer of how we do it. AJR Am J Roentgenol. 2009;192(6):1558‐1570. doi:10.2214/AJR.09.2582
[6] BackTable, LLC (Producer). (2017, November 1). Ep 15 – Renal Ablation Therapies [Audio podcast]. Retrieved from

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