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Renal Ablation

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Ep 159 Renal Ablation Technique & Devices with Dr. Nainesh Parikh

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Pre-Procedure Prep

Indications

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

Contraindications

• 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

Renal Ablation Podcasts

Listen to leading physicians discuss renal ablation on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.

Episode #159

Renal Ablation Technique & Devices

Dr. Nainesh Parikh from Moffitt Cancer Center discusses his approach to ablation of small renal masses, including workup, technique, and device selection. He also tells us why he has the best job ever!

Episode #41

Teaming Up With Urology to Treat Renal Masses

Urologist Dr. Arthur Caire and IR Dr. Shelby Bennett discuss their approaches to treating renal masses, including ways in which IR and Urology collaborate, laparoscopic versus percutaneous ablation, follow-up imaging, and more.

Episode #15

Renal Ablation Therapies

In podcast Episode 15 we discuss renal ablation therapies with Mike Devane MD and Ahmed Kamel MD, PhD, FSIR

Procedure Steps

Thermal Ablation Techniques

• Cryoablation
• RFA
• 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

Ablate

• 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

Post-Procedure

Complications

• 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

Follow-Up

• 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

Outcomes

• 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

Renal Ablation Demos

Watch video walkthroughs of renal ablation on the BackTable VI expanded content network.

Percutaneous Cryoablation of Kidney Cancer

References

[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 https://www.backtable.com/shows/vi

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