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Laparoscopic Kidney Cryoablation /
Radiofrequency Ablation

Percutaneous Kidney Cryoablation /
Radiofrequency Ablation

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Percutaneous Kidney Cryoablation /
Radiofrequency Ablation

Questions for Dr. Landman
 

Definition:
Percutaneous kidney cryoablation or radiofrequency ablation represents a combination of two minimally invasive surgical technologies that can be used to treat kidney cancer. The term “percutaneous” literally means through the skin. This is appropriate as when performing percutaneous cryoablation for kidney cancer there are no incisions. The needles are placed very precisely directly through the skin by using some type of imaging technology such as a CT scanner, an MRI, or ultrasound targeting. The percutaneous technique helps avoid the larger cut that is associated with traditional “open” surgery, and even the smaller cuts that are used during laparoscopic cryoablation for kidney cancer. During percutaneous cryoablation for kidney cancer, the Urologist works with an interventional radiologist to very precisely place the cryoablation probes into the kidney cancer. Unlike laparoscopic kidney cryoablation, none of the other body’s organs are moved. While this is a very minimally invasive surgical approach, it also means that only some kidney cancers can be treated. Kidney cancers that are located too close to other body structures such as the bowel or ureter cannot be treated with percutaneous cryoablation as these other structures can be damaged .

Cryoablation and radiofrequency ablation are the two techniques by which kidney tumors can be ablated (destroyed) today. The concept of ablation is relatively new in cancer surgery for any disease. Traditionally, surgeons have treated cancer by literally cutting it out. This is a process known as extirpation. In contrast to this approach, ablation is a different concept in that cold energy (cryoablation) or heat energy (radiofrequency ablation) is used to destroy the cancerous tissue at the exact site where it exists in the body. Ablation has been used for many cancers including lung, liver, and prostate. However, the technology is particularly well suited to kidney cancer.

Percutaneous cryoablation or radiofrequency ablation simply refers to the use of an imaging device (CT, MRI or ultrasound) to precisely place the ablation probes directly through the skin to destroy the tumor. The two currently available technologies that are FDA approved and are currently used for kidney cancer treatments are cryoablation, which is often referred to as simply “cryo” or “cryotherapy,” and radiofrequency ablation, which is often called “RF ablation” for short. While surgeons currently use both technologies, it is becoming clear to most kidney cancer specialists that cryoablation is a safer and more effective technology. When the world’s body of medical literature surrounding these two ablation technologies is evaluated, there are half as many patients who fail treatment with cryoablation compared to radiofrequency ablation.

Table: Comparison of world’s literature
comparing radiofrequency and cryoablation series.
From Weld and Landman, British Journal of Urology 96(9): 1224, 2006
Modality
Number of Patients
Follow-up (months)
Recurrence Rate
Complications
Radiofrequency
277
10
7.9%
13.9%
Cryoablation
326
30.8
4.6%
10.6%

More Information

Cryoablation technology uses ice to freeze tumors. The ice created during this procedure is unlike the ice that we see outdoors on cold days or the ice in our cold drinks. Standard ice that we all get from our refrigerators is 32 degrees Farenheit (0 degrees Celcius). Clearly, we can make snowballs or hold ice cubes without damage to our hands as this standard ice is not harmful to live tissues with short-term exposure. In contrast, the ice created for cryoablation procedures is colder than 100 degrees Celcius below zero and can destroy cancer tissue very efficiently. This ice can also be targeted very precisely so that it can be used to destroy a kidney cancer while preserving normal kidney and the normal structures that are near to the kidney.

The ice for kidney cancer cryoablation is created by inserting small probes (like needles) into the tumor.
Figure A

The ice for kidney cancer cryoablation is created by inserting small probes (like needles) into the tumor. Figure A represents a true to life sized cryoablation probe. This probe is less than 1.5mm in diameter and can destroy a large amount of cancer tissue. By clicking on the probe, you will see a life-sized representation of the amount of kidney cancer that this very small probe can eliminate. A single probe like the one demonstrated in the figure, or a group of several of these probes can be used to destroy kidney cancers while preserving the surrounding kidney.

Percutaneous Kidney CryoablationTechnique:
Kidney cryoablation can be performed by any technique. Open surgery (large incisions to expose the kidney) is rarely used by experienced kidney surgeons for kidney cryoablation procedures as open surgery is more painful, results in greater bleeding, and has a longer patient recovery time when compared to less invasive techniques such as laparoscopy and percutaneous treatment approaches.

By definition, open surgery is not a minimally invasive technique as it requires larger incisions to access and eliminate kidney cancer. Open surgery refers to the original approach used by surgeons by which a blade is used to create a large incision. Today, some kidney cancers still require open surgery to achieve the best outcome.

Percutaneous Cryoablation
Percutaneous cryoablation is ideally performed in a CT or MRI suite by a Urologist working with an interventional radiologist. While some Urologists and interventional radiologists work alone, the ideal situation is that the two work together as the skill sets of the two specialties combined yield the best outcomes with the lowest complication rates. Prior to scheduling the procedure, each patient should have an extensive consultation with their Urologist regarding the nature of their kidney disease as well as all of the available treatment options. This discussion should review all the advantages and limitations of each surgical and non-surgical approach. The patient arrives in the hospital on the day of surgery and the procedure is usually performed under sedation or with general anesthesia. Sedation is a light anesthesia where the patient is given enough medicine to remain relaxed and calm, but the patient does not go completely to sleep. The use of sedation alone (in contrast to general anesthesia where the patient goes completely to sleep) is advantageous as there are generally less side effects. When sedation alone is used, the patient has less risk of developing adverse symptoms after the procedure. These symptoms generally include nausea and a sore throat. Another advantage of sedation is that no “Foley catheter” is placed. A Foley catheter is used in surgery that requires general anesthesia to drain the bladder, and most patients find this catheter uncomfortable. Overall, the use of sedation rather than general anesthesia is a major advantage of percutaneous cryoablation for kidney cancer.

A complete percutaneous kidney cryoablation procedure can be seen in the video showcase section of the website (percutaneous cryoablation video). The procedure is initiated by the patient moving themselves onto the CT or MRI scanner gantry (bed). A “targeting template” (paper with markers that can be seen with the CT or MRI) is placed on the patient’s back, and images are taken. The CT or MRI images allow the Urologist and interventional radiologist to exactly determine the relationship between the targeting template on the skin and the tumor which lies within the body.

Using the information gained from the targeting template, the skin is marked such that the location of the tumor in relation to skin landmarks has been established. At this point, the sedation medicine is administered so that the patient is comfortable during the rest of the procedure. While the patient is still awake, they generally feel very little discomfort and have little anxiety thanks to the sedation medicine. Numbing medicine is then put in the skin at the site where the ablation probes will be placed. Once proper targeting has been established, a biopsy is taken and then the cryoablation probes are placed into the kidney cancer. The CT or MRI scanner is then used to assure that the cryoablation probe or probes are placed exactly in the location of the tumor. The ablation is then performed by activating the cryoablation machine. The patient is generally awake and comfortable throughout the ablation process. After the percutaneous ablation process has been completed, another CT or MRI scan is done. Using intravenous contrast material, the Urologist and interventional radiologist can confirm that a complete ablation of the kidney cancer has been performed. The entire procedure is usually completed in 45 minutes, and the patient is then immediately transferred to the recovery room.

As no general anesthesia has been given, the patient usually feels very well in the recovery room and can be given a regular diet immediately. Typically, the patient is observed in the hospital overnight and then discharged in the morning if
all is well.

 
MRI Scan of kidney cancer in left kidney prior to percutaneous cryoablation. The white arrow points to the kidney cancer



MRI Scan of kidney cancer in left kidney prior to percutaneous cryoablation. The white arrow points to the kidney cancer
in the left kidney.

CT Scan performed during the percutaneous cryoablation procedure.



CT Scan performed during the percutaneous cryoablation procedure.
The patient is now lying down on the CT scanner. The targeting template can be seen as a series of dots on her skin (yellow arrow), and the white arrow points to the kidney cancer in the
left kidney.

After the percutaneous cryoablation procedure is done the patient receives contrast material and a CT done prior to leaving the room demonstrates excellent ablation of the tumor. The darker area in the kidney confirms that the area has been well ablated (white arrow).
  After the percutaneous cryoablation procedure is done the patient receives contrast material and a CT done prior to leaving the room demonstrates excellent ablation of the tumor. The darker area in the kidney confirms that the area has been well ablated (white arrow).

Candidates for percutaneous kidney cryoablation:
There are a number of important patient and tumor parameters that are critical in deciding the type of treatment that is best for a small renal mass. Considerations are numerous but include: the size and general radiographic appearance of the mass, the local anatomy of the mass, the overall age and health condition of the patient, overall kidney function, the number of lesions in the kidney, patient personal preference, etc.

Cryoablation is a very promising new approach to kidney cancer. Several large medical centers have produced data demonstrating that kidney cancer is cured in approximately 95% of patients who undergo percutaneous cryoablation. However, 10 year follow-up information on patients having undergone cryoablation is not yet available. As such, cryoablation is not usually performed in very young patients under normal circumstances. While there are no strict age criteria, slightly older patients who may have some associated medical problems are generally considered good candidates for kidney cryoablation. The cryoablation procedure is typically associated with very little bleeding, few complications, and a speedy recovery. As patients typically tolerate cryoablation very well, people with kidney masses and other associated medical conditions are generally good candidates for renal cryoablation.

Additionally, patients with kidney cancers who have poor kidney function or only one kidney are also good candidates for renal cryoablation as the technique does not require the surgeon to control the blood supply to the kidney. Percutaneous kidney cryoablation is also often a good option for patients with more than one kidney cancer in a kidney as the probes can be placed into the different kidney cancer sites without damage to the rest of the kidney. Other techniques such as open and laparoscopic partial nephrectomy require the surgeon to temporarily block the blood supply to the kidney which may have some negative effect on kidney function. With percutaneous cryoablation, the kidney cancer can be treated while the rest of the kidney suffers no ill effects, as no interruption of the kidney’s blood supply is required.

Patients who have inherited diseases like Von Hippel-Lindau disease often have multiple kidney cancers in one or both kidneys. Occasionally, people who do not have this type of inherited disease also can have more than one kidney cancer within a kidney. As cryoablation destroys only the cancer and leaves the majority of the kidney intact, it is a good approach for people with more than one cancer in a kidney.

Advantages and disadvantages of percutaneous kidney cryoablation:
An advantage of kidney cryoablation is that it can be, in selected cases, performed percutaneously (with no incisions and the probes being placed directly through the skin) or laparoscopically (with small incisions), thus making it is a minimally invasive procedure for the treatment of kidney cancer. The minimally invasive nature of the procedure means that it can be performed with minimal blood loss and without a large incision. After surgery, a minimally invasive approach translates into significantly less pain, a shorter hospital stay, and more rapid recovery when compared with open surgery. Percutaneous cryoablation remains by far the least invasive active treatment approach for kidney cancer as no general anesthesia is required, there is no manipulation of organs surrounding the kidney, and there is a very low risk of complications.

Overall, the minimally invasive nature of percutaneous cryoablation allows kidney cancer to be treated with minimal disruption in patients’ lives. Return to the routine activities of life is very much expedited by the minimally invasive surgical approach.

The recovery from percutaneous kidney cryoablation for kidney cancer is truly remarkable. Patients routinely leave the hospital on the first day after surgery feeling well. Most patients describe a “soreness” that feels like they have done some exercise. There are no formal incisions or cuts, but rather a small bandage over the puncture sites. Unlike all other surgical approaches (including open surgery and laparoscopy), patients undergoing percutaneous kidney cryoablation for kidney cancer have very little recovery time. Patients are back to a full energy level in a couple of days. While it is generally suggested that no strenuous activity be performed for two weeks, most patients feel well almost immediately.

Also, in contrast to “extirpative procedures” (procedures that cut out cancer such as laparoscopic and open partial nephrectomy or radical nephrectomy) in which the cancer is cut out, patients who undergo ablation have less risk of some complications such as bleeding and urine leakage. Clearly, any time the kidney undergoes surgery, there is a chance of bleeding. However, the risk of bleeding is decreased by not having to cut into the kidney as is typically done with laparoscopic or open partial or radical nephrectomy. Similarly, not cutting into the kidney minimizes the risk of disrupting the kidney’s “collecting system (plumbing within the kidney which transports urine), which is a complication known as “urine leak.”

While cryoablation is a very promising treatment for kidney cancer, there are some limitations to this treatment. Laparoscoipc cryoablation is not a good treatment for larger tumors. Indeed, under most circumstances, cryoablation should not be considered for kidney cancers that are greater than 4-cm (1 3/4 inches) in size.

As cryoablation is a new technique for treating kidney cancer, there is no information available on the long-term results of the technique. Certainly, this lack of information is a limitation of the technology. However, at present, several major centers have reported three year and even five year follow-up data that is very promising with high cure rates.

Follow-up after percutaneous cryoablation:
Biopsy results - The results of the kidney biopsy are returned from the laboratory approximately one week after surgery. Your surgeon will usually call you at home with these results.

Activity after surgery - While patients will typically be able to do routine activities such as eating and taking care of every day needs, it is generally suggested that no heavy lifting or vigorous activity be performed for two weeks to allow the body to recover. While it is surgeon dependent, most surgeons will suggest only light lifting (less than 10lbs), gentle activity, and no driving for one to two weeks after surgery. Unlike open and even laparoscopic surgery where it is typical for patients to feel drained or lack energy for several weeks after surgery, with percutaneous ablation patients generally feel completely well in one or two days. However, every patient is different and recovery is somewhat variable.

Wound care and bandages -
With percutaneous kidney cryoablation, wound care is generally very easy as there are only small puncture sites. The dressings (bandages) usually consist of a Band-Aid or two and are usually removed by the patient at home the first or second day after surgery. Often there is a small amount of swelling in the area around the ablation site. This is normal and will usually resolve in several days to a week. If the ablation sites should become red, hot or have any type of drainage, the patient should call his/her physician to be seen in the office.

Patient two weeks after percutaneous kidney cryoablation. The two red dots are healing puncture sites. Note that the small scar below is from a prior surgery for kidney stones.

Patient two weeks after percutaneous kidney cryoablation. The two red dots are healing puncture sites. Note that the small scar below is from a prior surgery for kidney stones.

Bathing - Swimming and bathing in a tub should not be done for one or two days after surgery, but showering is usually permitted immediately after the percutaneous cryoablation procedure. The shower should be with regular soap and water. An effort should be made not to allow the shower to directly hit the wounds for the first several days. The wounds should be cleaned with a dry and clean towel and left uncovered. Swimming or complete submersion of the body can be done after the second day. A small amount of swelling is typical for the first few days after the percutaneous kidney cryoablation procedure. There should be no significant redness, heat or drainage from the puncture sites. However, if there is any significant leakage from the wound or if the wound should become red, hot, tender, or swollen, you should contact your doctor immediately.

Follow-up visit – Your doctor will typically call with the biopsy results one week after the surgery has been performed. A follow-up visit with the surgeon is usually scheduled approximately four weeks after the procedure has been done. At the follow-up visit wounds are checked and follow-up radiographic imaging is scheduled. Typically, an MRI or CT scan is scheduled for three months after the procedure has been performed. Depending on the biopsy results and the results of this radiographic evaluation, a future follow-up regimen is then established.

 

 
Video Showcase

Cryoablation Video

Cryoablation Patient Interview

Cryoablation Patient Testimonial

Percutaneous Renal Cryoablation

Laparoscopic Partial Nephrectomy

Laparoscopic Radical         Nephrectomy

Robotic Partial Nephrectomy

Complementary Mangement Strategies

More details on metastatic how
kidney cancer spreads

What are the challenges in treating metastatic kidney cancer?

How does metastatic kidney cancer affect my body?

How common is metastatic kidney cancer?

Which organs are most likely to be affected by metastatic kidney cancer?

What is the prognosis of people with metastatic kidney cancer?

As a patient with metastatic kidney cancer, what should I do?

Treatment for Metastatic Kidney Cancer

Why is metastatic cancer worse than localized cancer?

How is metastatic kidney cancer treated?

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