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Podcast Transcript: Renal Ablation Technique & Devices

with Dr. Nainesh Parikh

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! You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Biopsying Before Ablation

(2) Risk of Seeding During Renal Biopsy

(3) Thinking like a Urologist

(4) Renal Ablation Setup

(5) Modalities for Renal Ablation

(6) Patient Position for Renal Ablation

(7) Approach to Central Lesions

(8) Role of Pre-Ablation Embolization

(9) Follow-Up After Renal Ablation

(10) Renal Ablation Technique Pearls

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Renal Ablation Technique & Devices with Dr. Nainesh Parikh on the BackTable VI Podcast)
Ep 159 Renal Ablation Technique & Devices with Dr. Nainesh Parikh
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[Dr. Michael Barraza]:
Welcome to the BackTable podcast, your source for all things endovascular or otherwise, minimally invasive. You can find all previous episodes of the podcast on iTunes, Spotify or backtable.com. Subscribe to the podcast. Leave us a review or reach out to us on Twitter or email to let us know how we can make this a more valuable resource for the endovascular community.

Today, we're going to be talking about renal ablations. And I'm joined by Nainesh Parikh. He's at the Moffitt Cancer Center in Tampa Bay. Nain, thanks for joining us.

[Dr. Nainesh Parikh]:
Thank you for having me.

[Dr. Michael Barraza]:
How long have you been in Tampa?

[Dr. Nainesh Parikh]:
So, I came down here a little over five years ago, so 2016, straight out of fellowship. But before that I was at the Brigham for my interventional fellowship, and I was at NYU before that for residency.

[Dr. Michael Barraza]:
And so, you spend all your time at the Cancer Center?

[Dr. Nainesh Parikh]:
Yeah. There's actually three main sites, but the IR group is only at one, the other two are mostly clinic sites. And so, we luckily and fortunately, only cover the one site, which is where we do all of our cases.

[Dr. Michael Barraza]:
That's great.

[Dr. Nainesh Parikh]:
And that's the main site. Yeah, it's great.

[Dr. Michael Barraza]:
And how many doctors are in your practice?

[Dr. Nainesh Parikh]:
So, there's eight physicians. We just hired our eighth about three months ago, and there's seven APPs or NPs, PAs, depends on what state you're located in for what to call them mid-levels, however, you want to term them. But so, there are 15, I guess, technically total.

[Dr. Michael Barraza]:
All IR or IR and DR?

[Dr. Nainesh Parikh]:
Nope, all IR.

[Dr. Michael Barraza]:
That's awesome. And so, the diagnostic radiologists are a separate entity there?

[Dr. Nainesh Parikh]:
Well, so how it happens is, so I guess I can take a second to explain the model. At Moffitt Cancer Center, we have Moffitt Medical Group, which is all of the physicians. So, if you think about the four pillars of Oncology - Medical Oncology, Surgical Oncology, Radiation Oncology, and Interventional Oncology, of course, is important. All of us are employed by Moffitt Medical Group, so it's a physician group practice that is separate from the hospital. Each of the program is site specific, so there's GI Oncology, that encompasses surgical and medical oncology. And then the Radiation Oncology is separate and the Radiology separate. So there's GI, there's GU, there's cutaneous sarcoma, blah, blah, blah, blah, blah, but Radiology is all one and Radiation Oncology is all one.

Within the Department of Radiology, I think we're up to 50 total attendings. And then there's like any other academic place, there's IR specific and then there's body, neuro, whatever it is. When I started, there were six of us. I was the sixth IR physician and we had three APPs or mid-levels. And so, just to give you a sense of the growth of the entire institution, I think we had 225 or 250 doctors and maybe just as many APPs at the institutional level. And then today, we have about 350 doctors and as many APPs and in the Department of Radiology, we have, I think, 50 physicians now and about nine APPs. So, it's been a decent amount of growth.

[Dr. Michael Barraza]:
Wow.

[Dr. Nainesh Parikh]:
Yeah. And we're actually about to hire a ninth IR physician. If anybody's listening that's interested after this discussion, please email me or call me. Sorry for the plug, Mike.

[Dr. Michael Barraza]:
No, I want the plug because I need the email address to send you a CV.

[Dr. Nainesh Parikh]:
Yeah. You got it.

[Dr. Michael Barraza]:
So, hey, but you guys also have a fellowship, right?

[Dr. Nainesh Parikh]:
Mm-hmm (affirmative).

[Dr. Michael Barraza]:
Can you tell me about that?

[Dr. Nainesh Parikh]:
Yeah, yeah, yeah. Thank you for that plug as well, so our trainees come from University of South Florida. It's a great relationship with them. I know a lot of their IR folks as well, they're awesome. But what used to be before IR/DR is that they would come over to us in their fourth or fifth year and then they would do a month at a time and normally, we'd have a resident on rotation the entire year. They're transitioning right now and we're getting the more junior residents as one of the off sites for USF.

But at the same time, a few years ago, we started an Interventional Oncology fellowship. And so, the goal is for folks who want to focus on Oncology from G-tubes and ports of which we do, I don't know, dozens a day up through Y-90 PAE for prostate cancer, which is one of my...

[Dr. Michael Barraza]:
Oh, man.

[Dr. Nainesh Parikh]:
... babies, yeah. There's a recent publication that just came out with our name on it. That came out in July. That was a year and a half of really hard work, but there's a few more that are coming out and we can talk about prostate all day as well.

[Dr. Michael Barraza]:
Don't. I'll take you up on that. We actually did a podcast on PAE for cancer, maybe about a month ago. Sam Mouli came on and talked to us about the study he did was really exciting.

[Dr. Nainesh Parikh]:
Yeah, that was an exciting study. I will tell you that, by way of volume. So, I started the program, the only one out of a dozen at Moffitt right now. I started the program. I've told Aaron about this a bunch of times, but I started the program, I started it about a year after I came. And in the last four years, I just did on Thursday, which was a long day, I did No. 133, 134, 135 all on the same day.

[Dr. Michael Barraza]:
Nice. It's bad ass. Well, we're definitely talking about that today.

[Dr. Nainesh Parikh]:
Yeah, so there's a lot of data coming out that I can't wait to publish.

[Dr. Michael Barraza]:
As soon as you publish it, we're having you back on.

[Dr. Nainesh Parikh]:
Yeah, no. I've told Aaron a bunch of times that I would do anything to talk about it because I work really closely with the radiation oncologist. I'm waiting for one of my prospective studies to open. It's a whole another discussion in terms of dealing with CMS and dealing with the FDA. But actually, my radiation oncologists are waiting for me, believe it or not.

[Dr. Michael Barraza]:
That is so awesome. I can't wait to talk about this. Bad ass.

[Dr. Nainesh Parikh]:
Yeah, so we can talk about that. But I will talk about prostates all day every day.

[Dr. Michael Barraza]:
So, basically, what you're saying is the trainees need to be listening. It's a great opportunity to basically level up on IO and a great place to live. How would prospective trainees go about applying for this fellowship?

[Dr. Nainesh Parikh]:
Yeah, so what I would say is just contact me and I put them in touch with our section head and he's awesome. He also trained at the Brigham's, a Hungarian guy, his name is Bela Kis. He's hilarious. We share a wall. He recruited me down five years ago, and just kind of said, "Go," and he's been nothing but supportive ever since.

So, my practice I started five years ago, I actually always, I actually matched in Urology before I did IR, but I never started because I wanted to do IR, but I always had the interest in Urology. So, I always knew that I wanted to work closely with the GU guys. We have a great GU program down there or down here, I should say. And they've been really open and awesome about sending over cases and stuff like that. And so, I've kind of tried to be the GU person. So I do, probably, so we have about nine slots for ablation a week, Tuesday, Wednesday, Thursday.

[Dr. Michael Barraza]:
Wow.

[Dr. Nainesh Parikh]:
Yeah. And I usually am doing, usually, so as I said, been fortunate. And again, I hesitate to be egotistical or anything like that. I'm honestly just telling numbers, but usually I'm doing two to four renal mass ablations a week and two to four PAEs a week.

[Dr. Michael Barraza]:
That's pretty great.

[Dr. Nainesh Parikh]:
Yeah, we set it up right.

[Dr. Michael Barraza]:
So, just a reminder, they're hiring.

[Dr. Nainesh Parikh]:
Right, right. And Tampa is one of these places that's actually awesome and has been growing like crazy. And the volume at Moffitt is just, that's what I'm saying, in the administrative side, we're trying to figure out how to handle the volume, which is a good problem.

[Dr. Michael Barraza]:
I mean, so after all this? I mean, do I even need to come down for an interview? This sounds great. I don't know.

[Dr. Nainesh Parikh]:
It's pretty good. I'm lucky that I got recruited here. I'm lucky that like most things in life, success is mostly luck based, so I think.

[Dr. Michael Barraza]:
Well, and but it sounds like you guys have built it a lot in the last year. And so, I would guess being Moffitt Cancer Center that you guys are pretty Onc-heavy practice, yeah?

[Dr. Nainesh Parikh]:
Yeah. It's all Onc. So, I can tell you right now we're doing... so here, here's our setup. We have three main angio rooms - two Siemens and one Toshiba, which is that 4D CT, I was telling you about. We have two dedicated CT scanners for biopsies and ablations. We have an ultrasound room. We have a C-arm. Actually, we have two arms for C-arms and we have a clinic room. So, by clinic volume, PAEs, Y-90s, splenic embos, kyphoplasty, SUC stents, any ablation - liver and renal, we're seeing in clinic before and after. Sometimes, we'll be the ones following them primarily. We're seeing, I think I just looked at the numbers, anywhere from 1500 to 1700 outpatient clinic visits a year.

[Dr. Michael Barraza]:
Whoa.

[Dr. Nainesh Parikh]:
Yeah, so and we have a fully baked clinic. There's eight providers and seven APPs, so we have a fully baked clinic. And then we have a fully baked inpatient consult service. We're getting anywhere from five to 10 a day and those are ton of G-tubes, ton of malignant biliary drains, ton of malignant hydronephrosis, all that kind of stuff.

[Dr. Michael Barraza]:
Well, I mean, it's a good reminder that IO is a very wide net. It's not all ablations. It's not all Y-90. I mean, it's cancer patients have a lot of pathology, and so.

(1) Biopsying Before Ablation

[Dr. Nainesh Parikh]:
Right. And also, I should say this for any trainees or any prospective people interested in coming, I will say, you got to be ready to do biopsies. I'm biopsying 1-cm lung masses five times a day. I mean, the way that it ends up working out, probably 50% of your clinical days are spent on a biopsy service, whether ultrasound or CT-guided. And of that, you're the one that has to biopsy the smallest stuff, so biopsying the pancreas, biopsying the center of the kidney. It's not fun biopsying lung lesions, central lung lesions, small lung lesions, but the problem is that in an Oncology Center tissue drives both diagnosis and therapy. And so, often and more often than not, molecular markers end up determining both prognosis and targeted therapy, so they need a ton of tissue.

[Dr. Michael Barraza]:
See, I don't see that as a negative, but I think it's a very realistic thing for a lot of people in practice for me and that's how I get a lot of work. I mean, I tell you, every lung ablation that I've ever done has come from a lesion that I have biopsied and made a phone call. And that, I think that that's especially for people who are not going to be in a traditional academic center, that is going to be part of your practice. And I think it's a great part of practice building.

[Dr. Nainesh Parikh]:
Yeah. And I think you're absolutely right. I think a lot of folks don't always understand. It's not calling in saying, "Hey, I can ablate this, and can you send for ablation?" It's just saying, "Yeah, I'm having to do the biopsy. By the way, we can ablate it if you want, but do whatever you want. Call me if you need it."

[Dr. Michael Barraza]:
Totally. If you become the person who is doing the hard biopsies, the ones that a lot of people don't want to do, you become a very reliable part of that cancer team. For me, that was one of the ways I worked myself in at my new job was, I said yes to a lot of the ones that other people had said, "I don't think I can do it.

[Dr. Nainesh Parikh]:
Right. And that's what we try to engender anybody that we're hiring. It's like, "Listen, all the folks in the community around us, they're doing great work, but they're not cancer-specific." And they're not thinking, "Well, the patient is really going to need that tissue, somehow or another, so do your best to try to make sure that you do the patient right and get tissue for them." So, you're absolutely right. For IO, you have to think Y-90s are great, ablations are great, all that stuff is awesome, but it really kind of starts with venous access and biopsy.

[Dr. Michael Barraza]:
Totally agree. So, I mean, we could spend and we have spent entire episodes talking about different types of ablation, just for the purpose of time and just keeping a cohesive topic, we're just going to be focusing on renal ablations. I would imagine you guys are doing a ton.

[Dr. Nainesh Parikh]:
Yeah. So like I was saying, the way we have it is that we have a dedicated scanner. It's funny. We're actually limited by Anesthesiology right now just because we're turning over our chairman. But right now, we have three slots on Tuesdays, three slots on Wednesday, and two on Thursday, and that's eight slots total. And we're still booked out probably, I don't know, three, four weeks at least.

[Dr. Michael Barraza]:
That's impressive. We want more. So, well, where are they coming from? I mean, are they coming from Urology, Med Onc?

[Dr. Nainesh Parikh]:
Yeah, so they kind of come from everywhere. If I break down how, it's mostly liver and kidney. We have dedicated GU and GI tumor boards. We even have a dedicated liver tumor board. That's just for the hepatobiliary surgeons, the medical oncologists. And remember, we're disease specific and even within disease specialties. There's really truly site-specific books. So, I'm very close with one of the medical oncologists. He does HCC and cholangio and that's it. There's another person who does HCC, but she also does esophagus and that's it. There's another person who does esophagus and pancreas and that's it.
So, most of the time, folks are pretty on top of exactly what the updated guidelines are. We do have pathways at Moffitt, which are our own pathways. They're pretty closely aligned with NCCN pathways. So, most of our liver ablations probably come from our tumor boards. There's always a "healthy discussion" about what should be ablated and what should be resected or et cetera, et cetera. We could go down that path, but we don't need to. In terms of renal masses-

[Dr. Michael Barraza]:
I have those conversations every week.

[Dr. Nainesh Parikh]:
Yeah, exactly. And you have to. I mean, it's just, you have to keep having the conversation. In terms of renal mass ablation, though, the majority of them come from GU inside Moffitt. And that's one thing that we're lucky about because everybody's working for the same physician practice, nobody really cares and the GU guys I have to say, I have to give them real kudos. Because in their notes, they'll say, especially for lesions that are 2 cm or smaller, they'll say, "We discussed active surveillance, we discussed ablation, and we discussed surgery."

[Dr. Michael Barraza]:
That's super cool.

[Dr. Nainesh Parikh]:
Yeah. And so, I can't emphasize enough just talking to them, but even more so knowing your own data, and knowing the data that's out there.

[Dr. Michael Barraza]:
Knowing data that supports a competing modality for treatment and that's really great. It's sort of refreshing.

[Dr. Nainesh Parikh]:
Right. So, it's gone so far. And again, we're very fortunate at Moffitt because we kind of all worked together. But I'm giving talks with them on renal masses, both for biopsy and for ablation. So, I'm giving the talk on ablation, they're giving the talk on partial nephrectomy, and we're both talking about the same outcomes. Right?

[Dr. Michael Barraza]:
Well, let's talk about that now.

[Dr. Nainesh Parikh]:
Sure.

(2) Risk of Seeding During Renal Biopsy

[Dr. Michael Barraza]:
Biopsies. You hear different things. I remember in training being taught, if you're confident it's a renal cell, don't biopsy it, because the risk of seeding. Where did they and you stand on that?

[Dr. Nainesh Parikh]:
The risk of seeding has only been proven by one case report. There's never been a large series that's shown any seedings.

[Dr. Michael Barraza]:
I still fight that.

[Dr. Nainesh Parikh]:
Right. And if you look at the data, I've actually given talks on this, there's no such thing that demonstrates that seeding is a real possibility with coaxial technique. The seeding that occurred and that has been reported happened with multiple passes, number one. So, in my mind, biopsy, you should never be afraid to biopsy renal mass because of seeding. You also shouldn't be afraid to biopsy renal mass because of bleeding, right? I mean, I think it was a nephrologist that once said, "If it stopped bleeding then you're not biopsying it correctly. You're not biopsying the kidney correctly." And that's especially true for renal mass.

The reason I say that is because if you're comfortable with any angiography, which any general IR should be, you should be able to stop any bleeding that's happening because of the kidney itself. Even a lumbar, if you're through and through the lumbar. So, I can't remember the last time I biopsied a kidney with a 20-gauge. I do 18.

[Dr. Michael Barraza]:
Me, too, every time.

[Dr. Nainesh Parikh]:
Every time and we really should, because even though there's a bleeding risk, you got to be the one who's an expert to make sure you get tissue. So, I believe in biopsy, almost all of the time, I don't necessarily think that it needs to be done before ablation, kind of up to the referer if they really feel that it's necessary. But if it's walking like a duck and talking like a duck, I think it's still important to biopsy. And so, my default is biopsy at the time of ablation if it hasn't been biopsied already.

[Dr. Michael Barraza]:
I biopsy at the time of ablation after my probes are in place.

[Dr. Nainesh Parikh]:
That's exactly right. I couldn't agree more, at least one probe depending on the size of the mass.

[Dr. Michael Barraza]:
Right, because I got burned, my first year out of fellowship and I did the biopsy first and then there's blood. I didn't know where the lesion was. And then you have the choice, I get a big ablation zone or I bring him back.

[Dr. Nainesh Parikh]:
Yeah. And oh, man, I couldn't imagine. I would kill myself if I had to. But actually, some of, I try to teach this to the younger folks that come on board. And unfortunately, they ended up having hematomas, just from probe placement, because the kidney is so much less forgiving than the liver. But normally, I'll always teach place your probes first, biopsy later, particularly with a partially or fully cystic lesion, right? Because you're totally hosed if you try to biopsy one of those.

[Dr. Michael Barraza]:
Right. They shrink down. It's like, "Where's the solid part?"

[Dr. Nainesh Parikh]:
It's like a flat tire.

[Dr. Michael Barraza]:
Right. And I've been surprised so many times that these ones that are so cystic and there's no way that's a cancer, and then you send it off and it...

[Dr. Nainesh Parikh]:
Papillary.

[Dr. Michael Barraza]:
... happens to be RCC.

[Dr. Nainesh Parikh]:
Or papillary renal cell. Yeah, for sure.

[Dr. Michael Barraza]:
I've really only had one where, because I biopsy at the time of ablation every time except for the rare occasion where I'll have to do it first. And I've only had one that looked very much an RCC. It came back. It was just recent, and it was an unusual AML. It just didn't have, it had no macroscopic bat or anything like it, but when you get it back and its oncocytoma or oncocytic neoplasm. I mean, you're still probably treating those anyway and I don't think it would have changed my plan.

[Dr. Nainesh Parikh]:
No. And that goes to, or that speaks to counseling of the patient, so I'm sure you agree. But I feel very strongly and the people that came before us that trained us, always tried to instill this in us, you got to have a clinic, right? And so, you have to counsel these, you can't cancel these patients on the day of. It just doesn't make sense.

[Dr. Michael Barraza]:
It's too much.

[Dr. Nainesh Parikh]:
Yeah. And I mean, you have to tell them, "Listen, there is a not insignificant chance that this has benign. And if you feel you'd rather undergo two procedures, fine. 99% of the time, patients will say, "No, it's fine, just get it out or take care of it, as long as it's not surgical." But it is our responsibility to ensure that those patients know that there's at least, I don't know, 5, 10% chance that this is benign. Smaller the mass, the higher the likelihood statistically and from the research that it's benign.

(3) Thinking like a Urologist

[Dr. Michael Barraza]:
I give the reminder, so 98% of mine come from Urology. And I always remind him, it's like, "You're sitting here by a urologist who is planning on removing this surgically. And so either way, this thing is getting removed."

[Dr. Nainesh Parikh]:
Right. And yeah, to your earlier point, I meant to answer the question, the majority of the renal mass ablations are coming from Urology, and they come from our GU tumor board or direct from Urology. And the majority are, if they are less than 2 cm then they've grown. Because they've been on active surveillance or if they're between 2 and 4 cm, either they're a partial with recurrence on the contralateral or ipsilateral side or if they're larger than 4 cm, they're not a good search.

[Dr. Michael Barraza]:
Yeah, exactly. And just for the listener, I didn't know until maybe a year or two ago that, for them, if they've had a partial and they get recurrence, that automatically is a nephrectomy for them.

[Dr. Nainesh Parikh]:
In the ipsilateral kidney?

[Dr. Michael Barraza]:
Yes.

[Dr. Nainesh Parikh]:
Oftentimes, yes, it is. Yep.

[Dr. Michael Barraza]:
Yeah, at least where I was hoping that was a nephrectomy every time that ipsilateral recurrence at that same site.

[Dr. Nainesh Parikh]:
Yep. Well, and you have to understand, the reason that that's the case is because that kidney has already been cross-clamped. They've already put their sutures in. And so, I think it's less about the recurrence and scientific risk. I think it's more about the procedural risk.

[Dr. Michael Barraza]:
Yeah, that's a good point.

[Dr. Nainesh Parikh]:
Yeah. So, again, I think it's key for all of us to be thinking like the urologist. I mean, this is true in PAE as well. You have to be thinking how they are and when they're thinking about recurrence, either at their margin or even in the ipsilateral kidney, but away from their site. They're like, "Well, what are we going to do now? And how much kidney do I really think I can leave?" Right? We are always when we're embolizing, this is also when I tell the younger guys like, "Remember, when we're embolizing, we're trying to get into some little tiny 3-mm vessel and coil it off or deliver embolic, so that we save the kidney, right? Save normal parenchyma." And I understand, it's just the way surgery works.

For a 2-cm mass, they're going to take half a kidney. So, they're like, "What do you want me to do? I mean, I can't enucleate it, so I'm just going to take half the kidney." And by the way, the thing is bleeding [a lot], you can't just decide you're going to take a little tiny piece of it. You're like, "Oh, crap. EBL was going to be at least 2 units or something or 2000." And they're just like, "Yeah, of course. It's because they're doing a partial nephrectomy department of reckoning." So, when you start thinking surgically like that, you're like, "Oh, yeah, okay. Now, I understand why they're saying that."

(4) Renal Ablation Setup

[Dr. Michael Barraza]:
Yeah, man, that's great. Think like a urologist. That's going to be a tagline used for this episode. I like it. So, let's talk about modalities. What are you using microwave, cryo, IRE?

[Dr. Nainesh Parikh]:
So, everything we do is with general anesthesia, unless there's a reason that the patient can't undergo general anesthesia.

[Dr. Michael Barraza]:
Me, too.

[Dr. Nainesh Parikh]:
And it's a little bit of overkill, I agree. You can do it with moderate sedation and all this bullshit. But honestly, it's like, it's just a pain in the ass. Now, I-

[Dr. Michael Barraza]:
Such a pain in the ass.

[Dr. Nainesh Parikh]:
Right. So I use CT fluoro for everything, even a 15-cm subcutaneous mass, I'll use CT fluoro, just because I've gotten so fast with it. And another reason to use anesthesia, I don't get to the modalities of the actual ablation, but just understand our setup. The reason I use anesthesia also is because with one big breath hold, I can usually place two to three probes in one breath hold. Yeah, so if it's a multiprobe placement, which a lot of these are, especially for the cryos, which is my default, by the way, but I'll get into that. Normally, I use CT fluoro, so that the probes will just be placed very quickly. And I usually will try to do at least each probe with one breath hold.

And we've got a Siemens SOMATOM, I think, Force. Technically, I think it's dual energy. I actually don't remember, but it's fully decked out with the interventional package. And this is another thing and we can go through these tidbits, but I tell the junior guys, "You need to know how to operate the machine. You need to know how to flip in between fluoro and-"

[Dr. Michael Barraza]:
I could not agree with you more.

[Dr. Nainesh Parikh]:
Right.

[Dr. Michael Barraza]:
You're going to have that case where somebody's out and the tech in there say, "I have no idea how to work this and I'm learning as I go."

[Dr. Nainesh Parikh]:
Yeah. You're only, you're like a year out, right?

[Dr. Michael Barraza]:
No, I'm four.

[Dr. Nainesh Parikh]:
You're four, so we are right around the same timeframe. So, yeah. I mean, once I started, actually, that was the reason I learned it because one of our main techs and all of the people at Moffitt are great, but one of our techs was out, so they had a diagnostic guy inside. And I was in a lung and of course, the patient was bleeding and in pain. And I was like, "I need to scan. Give me fluoro VAC." And he's like, "I don't know how." And I'm like, "Are you kidding me? What do you mean?"

[Dr. Michael Barraza]:
This is your job. You have to fix this.

[Dr. Nainesh Parikh]:
Right. And so for then on, I was like, I just need to learn this.

[Dr. Michael Barraza]:
Oh, it's totally, you totally do. I need to learn it and instead, what I do is I just schedule all my ablations the day that my favorite tech is here.

[Dr. Nainesh Parikh]:
Yeah, no, I full heartedly suggest learning whatever system you have.

[Dr. Michael Barraza]:
Yeah. Well, it's just completely unreasonable for me to get mad at the tech to learn how to work the equipment that I'm supposed to know how to work

[Dr. Nainesh Parikh]:
Correct. You're the leader of the team, you got to know all the jobs, you got to know all the responsibility. And that's something that I try to engender in a lot of our younger folks like, "Listen, maybe it was different when surgeons could throw scalpels across the operating room, that doesn't work anymore.”

[Dr. Michael Barraza]:
Right. Those probes are expensive. You can't throw them at people.

(5) Modalities for Renal Ablation

[Dr. Nainesh Parikh]:
Right, exactly. So, as far as modalities, it all depends on the exophytic-ness of the lesion. Entirely exophytic lesions, I will use microwaves. And so what I say is, I use microwave whenever I can. And what that ends up being is probably a 70/30 split, 70% cryo, 30% microwave, I have a very low threshold to use cryo, to not use microwave. And so, if it's partially exophytic, I can't say that all, it has to be 50% partially exophytic or anything like that, right? It's all about if you see any contact or any real proximity with the renal sinus fat or with the collecting system. I have no problem freezing through and through the collecting system.

[Dr. Michael Barraza]:
Interesting.

[Dr. Nainesh Parikh]:
Yeah, I do it all the time and people think I'm crazy. Right, through the center of the collecting systems? I was like, "Yeah, I'm just going to freeze right into it." And I've not had a renal pelvic injury as a result. And I'm getting a little more aggressive with my microwave, but I just feel as though that microwave zone, the burning zone, could really cause renal pelvic stricture or renal pelvic injury. And what's the point, right? I mean, what's the benefit?

[Dr. Michael Barraza]:
I agree, it saves me 30 minutes to use microwave but that was the first thing in my new job that I needed when I started this. You guys got to get, they were using microwave for everything. I started like, "I got to have cryo available."

[Dr. Nainesh Parikh]:
No, you have to.

[Dr. Michael Barraza]:
Yeah, I agree. If you're doing enough of them. For me, the other thing is like I just, for anything central or anything near the spine, I really, I have to be able to see that ablation zone. And with microwaves, sometimes, again, you get your predicted ablation zone, but we've all seen them get bigger or smaller than we expect.

[Dr. Nainesh Parikh]:
So, let me say something about that, actually. So two things. First of all, as far as availability, for anybody trying to set up a practice, remember, it's not just the 30 minutes that it takes us that's extra. You have to think about the hospital having both of the gases available depending on the system, the techs knowing how to restock the system, the space to have those gigantic tanks, even though I know Endocare got bought up by Varian, who got bought out by Siemens is now going to a tankless system at some point.

[Dr. Michael Barraza]:
Interesting.

[Dr. Nainesh Parikh]:
Yeah, eventually they want to. But I know that even still, you have those big blue tanks in the room, right? So there, you definitely, if you're going to get cryo as I'm sure you know, you've got to make sure that that part's thought out as well.

[Dr. Michael Barraza]:
Yeah, that's a really good point.

[Dr. Nainesh Parikh]:
It's just something to keep in mind.

[Dr. Michael Barraza]:
But a lot of the systems have very reasonable policies and systems in place to get you in to using their equipment.

[Dr. Nainesh Parikh]:
Yeah. No, that's true. That's true. They're very good about it.

[Dr. Michael Barraza]:
You may not have to purchase the whole unit.

[Dr. Nainesh Parikh]:
Usually, not. In fact, quite the opposite. Normally, you can get them to place their unit depending on your volume and we could talk about that as well. But what I will tell you about seeing the ablation zone, I cryo a lot of renal cell mets into the bone and I even will cryo primary bony lesions, like I recently cryo'd a chondroblastoma. It was like a recurrent chondroblastoma in a young woman and like this, because we're program specific and pretty close with the sarcoma folks also.

And so, this is a good buddy of mine. He was like, "Man," He's like, "I went in and resected twice. It was in the greater trochanter. It just will not go away." And I was like, "All right. I'll try it." It's like there's bone graft in there and all sorts of crap. I'm just like, "I don't know what's what." And I actually had to pin down our MSK guy. I created a conference tumor board with him. I was like, "Guys, could you tell me where I'm supposed to actually freeze? Where do you think the recurrence is?" And so it was a really vertical lesion, he had gone into the center of it and I curetted out the chondroblastoma and I had to go at the top and at the bottom. And he was like, "Listen, dude, just blast away."

Well, one thing I will tell you about cryo that I think is different than microwave is for some reason, you do get these huge zones and it causes such a crazy inflammatory reaction in soft tissues that you have to be really careful. She ended up having basically footdrop when she woke up and it was because the sciatic nerve, which was 4 cm away, but jus tall the inflammation in that area had irritated the nerve. And so, I saw her yesterday or two days ago with my colleague in clinic and she's getting better and she'll probably get full recovery, but it's going to take six months right? So, with the cryo, it's a double-edged sword.

They're a bigger zone oftentimes and you can definitely see the cryo zone, that I agree in the kidney you definitely want that and even near the spine and stuff like that. But you got to be careful because the zone especially with. And again, we use Endocare, which is the Varian system or the Siemens system. I typically will use 24s, which is like the max dimension of the oblong ablation zone is 24 mm and they're probably 14-gauge needles or something like that and they're super sharp. But I mean, they make pretty big zones. That ablation zone is very real when you see that ice ball forming.

[Dr. Michael Barraza]:
Yeah. I'm using the formerly Khalil, now Boston Scientific system, which is just the one I know.

[Dr. Nainesh Parikh]:
We use that in fellowship.

[Dr. Michael Barraza]:
Yeah, they're all good systems. But no cryo, I've gotten aware with these ablation zones. One of the things I worry about most these days after doing, I don't know how many, I'm now paying more attention to, I'm worried more about nerve injuries than I am about, you know? I've never had a bowel injury. Knock on wood. It's a nerve injury, they're making me nervous. The ones next to the spine and then the genitofemoral nerve, and you know?

[Dr. Nainesh Parikh]:
Yeah, so they always say, "So, point at the thing you don't want to touch," right? And whether it's bowel anteriorly, especially for these crazy anterior lesions or if it's a real skinny person and you're close to the spine, I completely agree with you. The nerve injury seems to be the thing that starts to get out as if they're superficial. Then you're right up underneath the rib and you're getting some sort of intercostal nerve injury or something.

I couldn't agree more. I have not, again, knock on wood, had a bowel injury. I haven't had, I think I've cryo'd into the liver, almost intentionally, just to make sure I got the ablation zone. Had no issues. Like I said, I've cryo'd through and through the collecting system, the center part of it, haven't had an issue, so lucky there. And I've done that several times, probably more than a dozen times.

[Dr. Michael Barraza]:
That's awesome.

[Dr. Nainesh Parikh]:
Where I've gotten burned, quite literally, is when I'm cryo-ing superficial like you're saying or something close to a nerve. And then the other thing I do worry about is the proximal ureter kind of past the infundibulum and the renal pelvis and kind of the just the proximal descending ureter. I just never know what's really going to happen if you cryo that, right? I'm pretty aggressive about freezing right through the center of the collecting system, but I don't know why it's different in my mind, maybe because it's just a structure kind of floating out there in the fat.

[Dr. Michael Barraza]:
No, I agree. And I don't know any data that tells me that I'm more or less likely to get an injury with a specific device. But those ones in my head, I feel a little bit safer with cryo, for the ones that are near the ureter, but I don't know that there's a real reason for that.

[Dr. Nainesh Parikh]:
Yeah, I don't know. I mean, yeah, you're absolutely right. There's no real good data that I know of that suggests that one modality is better than the other as far as ureteral injury, but at the same time, so it's weird. The microwave system always seems to be a smaller burn than what I give it credit for, especially in the kidney. And we use, we have AngioDynamics and MicroThermX, actually.

(6) Patient Position for Renal Ablation

[Dr. Nainesh Parikh]
We tried a bunch of different things. I have to tell you. The reason I like, I use the AngioDynamics almost exclusively and the reason is because the needle is sharper than you could ever imagine.

[Dr. Michael Barraza]:
Oh, it's wonderful. It matters. We've all had those where you're pushing the kidney out of the way because it's so hard, and you just have to.

[Dr. Nainesh Parikh]:
Right. And it's actually a matter more for the kidney than the liver because the liver seems to be far more stable in place and forgiving. The kidney as you're saying, you're trying to push and all of a sudden on your next scan whether it's fluoro or it's for acquisition, you think you're halfway through the kidney and it's pushed away 4 cm deep.

[Dr. Michael Barraza]:
Right. Pushes it off or slides off and goes next to the kidney or directly into the kidney.

[Dr. Nainesh Parikh]:
Right. And actually for that reason another tidbit, I pretty much will insist that all of my patients are prone. I don't even. I usually don't even do them supine unless you absolutely have to or can, but almost all of them prone.

[Dr. Michael Barraza]:
Yeah. I'll do prone unless it's a high left near the pancreas or I have to get away from the colon or I'll tell you about this later. My favorite thing is going transhepatic for a high renal lesion.

[Dr. Nainesh Parikh]:
That's funny. Yeah. No, I didn't, I've never even really, guess nearly had to or thought about it. But I guess you could, yeah, that's ballsy.

[Dr. Michael Barraza]:
So, a high renal lesion that's near the spine, and I don't want to hit the spine. And if I have the choice or even though, I'm necessarily high when if I have to choose between going through a bunch of liver and going through a bunch of extra kidney, I'm going to choose liver every time for me.

[Dr. Nainesh Parikh]:
Interesting.

[Dr. Michael Barraza]:
I love transhepatic, but anyway, prone for 98% for me.

[Dr. Nainesh Parikh]:
Yeah, and prone and I've tried a couple of words like left side down or something like that and it's just, it doesn't.

[Dr. Michael Barraza]:
I hate it.

[Dr. Nainesh Parikh]:
I would never do. I don't even do biopsies left side down or anything like that. I just-

[Dr. Michael Barraza]:
I hate one side down. They just start to gradually drift down over the course. In particular, when I was a resident, I was doing an ablation, that side down, and the patient literally fell over onto his side onto the probe and basically impaled himself. He was totally fine, it missed everything, but it's scarred for life.

[Dr. Nainesh Parikh]:
Yeah, so I would recommend anybody setting up a practice, just get GA if you can and go completely prone every time.

[Dr. Michael Barraza]:
I agree. GA all day.

[Dr. Nainesh Parikh]:
Yeah, for sure.

[Dr. Michael Barraza]:
Yeah. And if you have to move the patient, you have to move the patient and that's not the end of the world.

[Dr. Nainesh Parikh]:
No.

[Dr. Michael Barraza]:
I swear, I still think it's easier to do, to move the patient under GA than when they're sedated.

[Dr. Nainesh Parikh]:
Yeah, definitely. When they're sedated, good luck.

(7) Approach to Central Lesions

[Dr. Michael Barraza]:
Yeah. So, let's talk about your approach to the central lesions near the collecting system. Found that you're doing mostly cryo for these, but sounds like you're able to get pretty aggressive with these.

[Dr. Nainesh Parikh]:
Yes. So, the kind of size cut-off for me, I guess I don't really have one. Because I figure if they're truthfully, if they're referring and the patient can't get surgery then I should try to do what I can do. So, I mean, 9-cm lesion with renal venous thrombosis. No, thanks, that's a little much. Would I do a 9-cm lesion? Yes. Would I do it? Prove it. When I insist on an embolization first, yes. When I say that our outcomes are probably not going to be as good as surgery, yes. And the data does show that when you get above four centimeters, really above five, our data falls off compared to surgery, which is expected. And I would concede that and we should to anybody asking above a certain number, it's just we're not going to perform as well.

[Dr. Michael Barraza]:
I would love to not do those.

[Dr. Nainesh Parikh]:
Right. That being said, a central lesion, I kind of look at it, it's like when you're playing golf, and you're trying to carry 200 yards over just water, they tell you not to think of the water, right? You're only looking at the pin. And to me, it's like you kind of just don't look at anything in your way. You're like, "Well, I'm going to have to go right into that thing." And I've had a few. There was one where one of my urology colleagues, it was a bilobar mass or maybe even two masses on one, he respected the more superficial one, and I can't blame him, he didn't even see the one below it.

And then on the follow-up scan, because they only follow up six months later, lo and behold, this thing was getting bigger. He was like, "I think I missed the mass." And I was, "Oh, that's interesting." And it was probably a 2.5-cm mass, just kind of nestled in the center of the mid and lower pole calyx. And he was like, "You think you could do anything?" He was like, "I was having to take the whole kidney out," as he talks about it. And I was like, "Yeah, let me have a chance." So, went right through his pledgets with two 24s and blasted it, and patient did great. The patient was really happy.

And probably, we need to publish at some point central lesions because in our practice with me and my colleagues, we have a decent amount of them. But I would just say, the two things to worry about would, of course be, if it's central of the kidney, you got to be careful that your probe doesn't go through and through the center, like the main renal artery or the anterior posterior main renal artery. So, there's a difference between pointing at the thing you don't want to freeze and skewering the renal artery. And I would just-

[Dr. Michael Barraza]:
You're not supposed to do that.

[Dr. Nainesh Parikh]:
You're not supposed to do that. And so, that's about the only thing I would say. But it doesn't mean that you can't take a trajectory that's away from the renal artery, but it's not still central. So I would just say, remember that central lesions can be done, you have to also remember that based on your trajectory, the part near the renal artery might be the area of recurrence, so you have to be cognizant of that.

And it's hard on our diagnostic colleagues, they're not there. They can't review all of our probes. They don't know what we're doing. And so, when you're following those patients up, you have to insist that the diagnostic guy or girl you trust is really looking hard at the deep area or whatever the area is by the vessel. I think that's kind of the takeaway for me of what I've learned.

[Dr. Michael Barraza]:
Okay. Is there a role for stents or pyeloperfusion or anything? I don't think I've ever done that since I was a resident.

[Dr. Nainesh Parikh]:
So, it's been published. People use it. I know that it can work, although you never know in those patients, if it didn't work without it, right? My feeling about pyeloperfusions and stents to prevent renal pelvic injury. And when I've done cryo right through the center of the renal pelvis, I've not had an issue. So, I don't see the point of the pyeloperfusion and stents and I'm sure there are listeners out there that would be up in arms and say, "No, there's this one situation where you really should do it" and all that. I haven't encountered it yet. And I think I looked at my numbers before, I think in five years, it's been maybe even a couple of thousand renal mass ablations, something like that. So, it's been a decent amount and I haven't had to use pyeloperfusion yet.

[Dr. Michael Barraza]:
Totally. I mean, and it sounds like that you're also dealing with the same problem I am, it's you're just really, really good.

[Dr. Nainesh Parikh]:
Yeah. God, I don't know about all that. Like I said, lucky is probably more accurate.

(8) Role of Pre-Ablation Embolization

[Dr. Michael Barraza]:
What about pre-ablation embolization?

[Dr. Nainesh Parikh]:
So, I'm a huge proponent and I have a low threshold for doing that. And so really, my size cutoff is between four and five. It depends on the orientation of the mass depends on location of the mass. It depends on a few different things, how hypervascular I think it is, I've been burned before. Last guy I did actually. It was kind of a mess. It was heart failure. That was the guy who had the 5.5-cm mass because the anterior, I did a pre-op embo, it had little tiny wispy vessels that I delivered 2 ccs of embolic into the lipiodol contrast mix, shrank pretty much nothing at all, because it wasn't hypervascular. Three weeks later, I usually bring them back three to six weeks later.

Usually when I do pre-op embolization, I will usually use a couple of ccs of lipiodol mixture, so I can stay in the tumor, and I use that first. And then I'll follow with ones to threes or threes to fives just to back it up. But I do like staining the tumor as much as I possibly can. And then I usually bring them back three to six weeks later. And then like I said, my size cut off is usually between four and five, depending on the orientation. If you can get that nice oblong shape in a trajectory that makes sense, then you do it. I mean, you don't need to do the pre-op embolization. But if you think you can't, then I would definitely favor it.

And I always think it's not there's anything to lose by doing it. It's going to be rare that you're going to shut down half the kidney. And I always will say, because what I tell our trainees, "Remember, when you're doing a pre-op embolization, that perfect is the enemy of good." I mean, I say that anyway. "But you don't have to pick off every vessel. You don't have to go to complete stasis, like so that it's perfect. You need to just do a decent job, so that you can control any potential bleeding in addition to making sure you get volume reduction." So, that's not your endpoint, your endpoint is the ablation.

And so, I always err on the side of doing it. I don't feel like it can hurt, but most of the time, I will do like above 5 cm, it's almost a must. And then between four and five, that's where I say, "Well, it could use it." And then less than four, I usually don't do it. And then normally, I bring it back three to six weeks later. I will put in my order, please bring back in three to six weeks. I don't do any, I don't see them in clinic in between. I don't get imaging because it doesn't matter. And as long as their tests, their lab tests are okay, it doesn't make any difference. And the urologist love it actually.

[Dr. Michael Barraza]:
Interesting. Okay.

[Dr. Nainesh Parikh]:
Yeah. No. They're all for it. They're like, "Great. You can actually do this?" I'm like, "Yeah." And I'm like, "Listen, if they're not a good surgical candidate for lung disease or anything else," I'm like, "Listen, just let me embolize it," and like, "We'll be fine." And so, they're happy with that as well. There's been some times that I'll use the mono modality for controlling the tumor.

It's a different discussion you have with the patient, obviously, but the ability to say, "Listen, we can treat it and we can knock it back. I don't think I can be 100% about it. But if you're in such bad heart failure that you can't get, they might not be able to get you off the table, if you've got such bad COPD or fibrosis or whatever it is that's going on, why don't we just do an angio under moderate sedation. And at least, give some longevity there."

[Dr. Michael Barraza]:
Totally. I actually think you can make a really strong argument for doing that for the patients that are poor surgical care candidates because the worst case scenario for that urologist that sent it to you is for them to have to operate a bleed in the ablation bed. That's worst case scenario for that patient, that doctor.

[Dr. Nainesh Parikh]:
Right. Yeah, so I just, oftentimes if they're referring, there's some issue going on and if it's a surgical risk situation, I don't think it's going to be a big deal to just embolize them and then put the fight another day. Maybe things will improve, maybe not. And a lot of those patients are so sick that they're just like, "Listen, if you can just throw me a bone with this kidney cancer. Great. I know I got other fish to fry."

[Dr. Michael Barraza]:
Yeah. How many? How soon are you bringing them back for follow-up imaging?

[Dr. Nainesh Parikh]:
Sure. So I always will bring it back four weeks later. And that reason is, again, in the pre-op counseling, I always tell them that I'll bring them back four weeks later, because I don't do a post ablation scan with contrast. Unless they're bleeding, I don't do a post ablation scan, so I'll always say, "I think I got it," presuming that I feel that way. And then I'll bring them back four weeks later with imaging. And of course, if there's a recurrence. And the recurrence rate or residual, whichever you want to call it, it really should be less than 5%, if not even lower. So, if you're in your practice, and you feel like you're seeing a lot of residual or recurrence, you want to change something about what you're doing.

[Dr. Michael Barraza]:
Right. Change something up. For me, most of the time, I have a recurrence, I was expecting a higher risk of recurrence.

[Dr. Nainesh Parikh]:
Yeah, well, they've already had a partial. And then they've had a recurrence on the same kidney or on the other side and then, that's what I'm saying. Oftentimes, when I go back and look at these challenging ones that I've had to go back on once or even twice, it's by the vessel. And that's the one where you almost have to be a little more aggressive with the freeze or the burn because of the heat sick. Then it's usually me bringing it up to the diagnostic guys saying like, "Are you sure you don't see some enhancement there?" And they're like, "Oh, maybe." And I'm the one saying, "Yeah, I'm worried about it."

But usually them bring them back in a month just to make sure. And remember, that's different than the urologist, right? Our tagline is think like the urologist, so that's different. Those guys usually bring them back in six months.

[Dr. Michael Barraza]:
I didn't realize that.

[Dr. Nainesh Parikh]:
Yeah, they usually bring them back way later. And so, the patients are always wondering like, "I got to come back so soon?" You're like, "Yeah, it's because we did an image-guided approach."

[Dr. Michael Barraza]:
Right. We're going to take some pictures.

[Dr. Nainesh Parikh]:
Right. And also, we could always just do it again, if we need to. It's not like surgery where we're making huge incisions or again, everything all set up. It's a procedure.

[Dr. Michael Barraza]:
That goes into every one of my consent discussions is, "We may be doing this again, but that's okay, it's not. You're getting a Band-Aid, not a bunch of stitches. We can do this.

(9) Follow-Up After Renal Ablation

[Dr. Nainesh Parikh]:
Yeah. And so, I always will bring it back in a month, and then I'll usually bring it back six months later. And then we follow all of the primary renal cell carcinomas that are referred to us. Meaning usually, these patients incidentally found, either they're counseled on the outside and then they want to come to Moffitt or they're referred to Moffitt for an incidentally found renal cell. They're not VHL-associated and they get referred to us because they're 2 cm or less, which means that they saw the urologist once. And which means that I'm basically setting up a survivorship clinic.

So, the way the urologist think about it is for those straightforward clinical cases, you've got to follow him for five years to make sure there's no recurrence, and then you can kind of discharge them. So, for the straightforward ones, bring them back in a month, then bring them back six months later, then follow them annually for five years. If their recurrence from a post partial or something that, or anything more complicated, I'll usually actually call the urologist and say, "Tell me what you want me to do for follow up or I'll just send it back to you."

(10) Renal Ablation Technique Pearls

[Dr. Michael Barraza]:
One of the thing I want to ask you is just something that you have picked up in the last few years out, a pearl or a tip or something about ablation, that's not necessarily obvious. Like for me, mine was going to be the transhepatic for the medial right renal lesions. I'm sure you've learned something in the last few years.

[Dr. Nainesh Parikh]:
Yeah, well, I'll tell you a couple things, and we didn't get to talk about it. One thing is hydrodissection for the kidney works. So, the reason I think it works is not because I think it protects the organs, I mean, it probably does. But when I say it works, I mean for some reason, the perirenal fascia just works the way you want it to even anteriorly. So, if you can get your needle just even approximately close, your dissection needle and it's still a shit ton of sterile water or saline, just go for it. And it usually will dissect the way you want. So, that's the first thing I'll say about hydrodissection.

I will also say, please, for all the people starting this, place your probes first then hydrodissect. Don't do it in the other order. It may make sense to you at the time to hydrodissect first, but please don't do that. Just like biopsy, always place your probes first. That is the first thing that your goal should be because shit can go wrong quickly.

[Dr. Michael Barraza]:
And shit can move.

[Dr. Nainesh Parikh]:
That's what I mean. And if you're lucky, you place your probes, you do a biopsy, it's bleeding a little bit and you've got your own hemo dissection. So, it's like always do that shit last, but so then the other thing I'll say. And especially because the patients are prone, don't be afraid to use air. I've used air plenty of times.

[Dr. Michael Barraza]:
Just room air?

[Dr. Nainesh Parikh]:
Yeah, I mean, you're probably inserting it through the coaxial were or somehow anyway.

[Dr. Michael Barraza]:
When do you do air instead of fluid?

[Dr. Nainesh Parikh]:
Yeah, so if you're anterior and there's bowel and if you just like if the fluid is not working or it's tracking cranial-caudal in a different direction, sometimes the air because the density will go the opposite direction. They do have these air filters that we used in fellowship, but people would look at me crazy at Moffitt. They're, "What the hell are you talking about?" That was Harvard, so they had everything. But if you can insert a little bit of air, you might be surprised as to what happens.

[Dr. Michael Barraza]:
I'll try that. I've never used air. Once I used, there's a colon in the way that was just, he was all air-filled or anything else. So, one time I took a needle and just jammed it into the colon and just bled out farts for about 10 minutes to decompress it. The room smelled terrible, but it worked.

[Dr. Nainesh Parikh]:
It works. Well, the other thing you can do with that because we get these crazy biopsies, it's like requests to try to biopsy colon or something. I mean, it is so hard to stick the colon or the small intestine.

[Dr. Michael Barraza]:
Totally.

[Dr. Nainesh Parikh]:
Right? I mean, it's why we don't do primary J-tubes. So if you need to, take your blunt needle and just move it out of the way manually.

[Dr. Michael Barraza]:
They move, so I actually will go transcolonic or through a small bowel for biopsies routinely and I'll try to do it on purpose. And the amazing thing is when you try to do it, it moves it out of the way about 60% of the time.

[Dr. Nainesh Parikh]:
Yeah, it's just the mesentery that it ends up just, it moves. So, what I will say is the air and this becomes more important, I think with ureter and with some of the small bowel anteriorly, air can help. Air is actually kind of crazy.

[Dr. Michael Barraza]:
I'm going to try that. That's great.

[Dr. Nainesh Parikh]:
Yeah, just take a 20-cc syringe, fill it up and inject it.

[Dr. Michael Barraza]:
Especially because when I'm doing saline, and I'll put a little contrast in there sometimes, no matter how little contrast I do in that hydrodissection fluid, it's always too much.

[Dr. Nainesh Parikh]:
Yeah, I don't put contrast in there.

[Dr. Michael Barraza]:
No, it's making a smoothie that has banana in it, you put a little bit of banana in there, it becomes a banana smoothie. You put any contrast in there, it's so bright, you can't see anything.

[Dr. Nainesh Parikh]:
Right. So then the other things I'll say, so that was hydro and pneumo dissection. The other things I'll say, so don't be afraid of central lesions, just be afraid of the vessels. And as we talked about before, point at the thing you don't want to, freeze, but don't skewer the vessel. And it sounds hilarious, but it's actually true, right? Because people say, "Oh, you're going to go central. Yeah, I can go through the clotting system to freeze, but you really do have to be cognizant of those main renal vessels because those will kill you. Those are the things that that sucks, so don't be afraid.

And then the other thing I'll say is, I am a huge proponent of CT fluoro. I mean, huge. To me, it's like if you have it available on your system, and this is just for all CT-guided procedures, but if you haven't, it's like driving a Ferrari and not taking it to the racetrack, right? Or not opening it up. It's like you've got this car, you've got this technology, and you're only using it to go to the grocery store.

[Dr. Michael Barraza]:
No. And that's me, man. That shit is sitting in my garage right now and I'm not using it.

[Dr. Nainesh Parikh]:
I would, I don't know how to, I'll fly to Shreveport. Aaron's wife that's, his wife is my cousin. And so that's how, we used to go to Shreveport every summer.

[Dr. Michael Barraza]:
Wow.

[Dr. Nainesh Parikh]:
Yeah, that's how I know Aaron.

[Dr. Michael Barraza]:
I didn't know that. Okay.

[Dr. Nainesh Parikh]:
Yeah, so we used to go to Shreveport all the time. You said you're Shreveport or Baton Rouge?

[Dr. Michael Barraza]:
Baton Rouge.

[Dr. Nainesh Parikh]:
All right, well, I've been to Baton Rouge.

[Dr. Michael Barraza]:
When is that? Are you for an occasional lung biopsy and once every six months where I do a lung ablation.

[Dr. Nainesh Parikh]:
No, I do. I think it's the opposite. I'm telling you, I actually and this is on my list of crap to publish after all the prostate stuff, I think it results in higher quality and fewer complications.

[Dr. Michael Barraza]:
What?

[Dr. Nainesh Parikh]:
Yeah. I used to use it all the time. Because then you become the expert in it.

[Dr. Michael Barraza]:
I know. That probably, you are just so extraordinarily, unusually talented.

[Dr. Nainesh Parikh]:
Yeah. Everybody says that.

[Dr. Michael Barraza]:
And maybe I don't need it now. I'm kidding. But all right, I'll do it. On my next ablation, I'll do it and I will give you all the credit.

[Dr. Nainesh Parikh]:
Then use it for the biopsies, too. I'm telling you, just use it. The actual time on the table is cut in probably by 70, 80%.

[Dr. Michael Barraza]:
Okay, I trust you. I'll do it.

[Dr. Nainesh Parikh]:
My techs are so happy. They're like, "Oh, Dr. Freeze is here."

[Dr. Michael Barraza]:
Are they really?

[Dr. Nainesh Parikh]:
Yeah, it's easier. They're so happy.

[Dr. Michael Barraza]:
Mine love me for not using it. I'm the only one who doesn't.

[Dr. Nainesh Parikh]:
No, my tech is actually the opposite. "Why can't you convince these other guys to use it?" And so, one of the younger guys has, another younger guy won't, a younger woman that we just hired, she's not sure and I keep giving her shit. I'm like, "Dude, do you want to get with times or do you want to be operating in 1990s?"

[Dr. Michael Barraza]:
I got a cryo next week. I'll do it.

[Dr. Nainesh Parikh]:
Yeah, do it on the biopsy suite. I'm telling you and let me know. And I mean, I'll come. Is it a Siemens machine?

[Dr. Michael Barraza]:
I'm embarrassed to say I don't even know what it is. I can't remember.

[Dr. Nainesh Parikh]:
It's probably Siemens. So, if you need help, text me. I will gladly help everybody.

[Dr. Michael Barraza]:
They know how to do it. It will be fine. What I need to do is optimize it. So I'm faster with it. Right now, it is not faster for me, yet.

[Dr. Nainesh Parikh]:
Right. And so, that's what I was saying when I'm placing four or five probes, the probe placement total takes me probably 10 minutes at most.

[Dr. Michael Barraza]:
That's impressive.

[Dr. Nainesh Parikh]:
And that's why the anesthesiologist likes me, that's why the techs like me, they're like, "Oh, that Parikh great." And so, I'm like, "Listen, and this is the other thing when you do use fluoro, I walk in because all of our CRNAs are different in the anesthesiologists are different, I always say the same thing.

I'm like, "This is like a bank robber. Do exactly as I say and it will go smoothly. So please, always do end expiration breath hold. Don't do it halfway through the expiration or anything like that, even when you guys sign out for lunch, please tell the person exactly how you did the end-expiration breath hold because it's going to matter for my pro placement because I do everything with one breath hold."

[Dr. Michael Barraza]:
So, I think that actually may be one of the most important points you shared, end-expiration breath hold. I think that's super important. Just the consistency of that, like trying to guess you're going to be wrong.

[Dr. Nainesh Parikh]:
Right. And that's actually the reason I like the fluoro because every time if I could show how the case goes, it's not like, "I want the fluoro because I want to check the position after I push the needle in." I mean, I do, but actually, I do it because I want to make sure position is stable right before I push the needle even further. And so, that's actually the biggest advantage of the fluoro.

[Dr. Michael Barraza]:
I think you convinced me to try it. My next multiple probe case, I'm going to do it that.

[Dr. Nainesh Parikh]:
I thought you just said your next case is ureter.

[Dr. Michael Barraza]:
My next case isn't a multiple probe one.

[Dr. Nainesh Parikh]:
It is not or is?

[Dr. Michael Barraza]:
My next case, the one I have next week, I think I can probably get away with one, so.

[Dr. Nainesh Parikh]:
But this is where I would push you and be like, "Dude, just do it. Trust me."

[Dr. Michael Barraza]:
So, just do it either way? Okay, I'll do it. I will.

[Dr. Nainesh Parikh]:
Just do it, either way. I told you, do it on every single case and you'll see a guy like you with four years' experience within, I don't know, 10 or 15 cases will all of a sudden be like, "Oh, this is way quicker."

[Dr. Michael Barraza]:
Okay, I'm in.

[Dr. Nainesh Parikh]:
And then you'll have time, you'll have more time for prostate, with us.

[Dr. Michael Barraza]:
There you go. But now, I have prostate cancer in both because I didn't do a fellowship in IO at Moffitt Cancer Center.

[Dr. Nainesh Parikh]:
That's right, Mike.

[Dr. Michael Barraza]:
Which our listeners should be paying attention to. What did I miss? Is there anything big that I forgot to cover?

[Dr. Nainesh Parikh]:
No, man, I mean, the biggest thing is follow your patients in clinic, make sure you're presenting the data because data never lies. I'm happy to share all the data that I presented before that's publicly available, but I've gathered it and put it in a talk, so I'm happy to share it if anybody needs it to go convince the urologist to send over those small renal masses.

[Dr. Michael Barraza]:
I love it, man. Thank you. I appreciate having you on. I learned a lot. I'm sure the listeners did, too. And you're probably going to be hearing from a lot of them looking for jobs or fellowships.

[Dr. Nainesh Parikh]:
Good, man. Make sure they have my contact info. Would love to talk to anybody.

[Dr. Michael Barraza]:
Yeah, guys. Feel free to reach out to us, too. I can put you in touch my new friend. All right, we're good.

[Dr. Nainesh Parikh]:
All right, let's go Tampa Bay.

Podcast Contributors

Dr. Nainesh Parikh discusses Renal Ablation Technique & Devices on the BackTable 159 Podcast

Dr. Nainesh Parikh

Dr. Nainesh Parikh is a practicing interventional radiologist with Moffitt Cancer Center in Tampa, Florida.

Dr. Michael Barraza discusses Renal Ablation Technique & Devices on the BackTable 159 Podcast

Dr. Michael Barraza

Dr. Michael Barraza is a practicing interventional radiologist (and all around great guy) with Radiology Associates in Baton Rouge, LA.

Cite This Podcast

BackTable, LLC (Producer). (2021, October 11). Ep. 159 – Renal Ablation Technique & Devices [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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