ABLATION

SMALL RENAL MASS

Introduction

Last updated: apr 5, 2023

  • Increasing incidental renal masses found (<4 cm)
  • Mostly age > 70 y
  • 83% US, 15% CT
  • 25% benign, 65% indolent RCC, 10% agressive
  • The smaller the more benign
  • Increased detection, but no reduction in mortality

 

Presentation

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Indications

AUA

  • Clinicians should consider TA as an alternate approach for the management of cT1a solid renal masses <3 cm in size. For patients who elect TA, a percutaneous technique is preferred over a surgical approach whenever feasible to minimize morbidity.
  • Both radiofrequency ablation (RFA) and cryoablation may be offered as options for patients who elect TA.
  • A RMB should be performed prior to (preferred) or at the time of ablation to provide pathologic diagnosis and guide subsequent surveillance.
  • Counseling about TA should include information regarding an increased likelihood of tumor persistence or local recurrence after primary TA relative to surgical excision, which may be addressed with repeat ablation if further intervention is elected.

 

Contra indications

Absolute

  • Coagulation disorder or use of anticoagulants
  • Untreated hypertension
  • Hydronefrosis
  • Bacterial pyelonephritis
  • Parenchymal kidney disease

Relative

  • Pacemeakers
    • Sensing failures were observed in 8 (32.0%) and pacing failures in 4 (16.0%) patients. Prolonged pauses and induction of tachyarrhythmias were observed. No pacemaker damage was seen although it is reported by other investigators. We recommend deactivation of implanted generators and an external bipolar pacing electrode.
  • Non cooperative patient
  • Anantomical variants/disorders

 

Workup

  • Patient is discussed in MDO (Multidisciplinary Consultation)
  • Biopsy
  • Outpatient information consultation with both the urologist and interventional radiologist
  • Pre-operative examination by anesthesiology

 

Pre procedural

  • Anticoagulation check
  • Placement of an epidural by anesthesiology
  • Urinary catheter
  • Lab tests (INR, PT, APTT, GFR)

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Materials

Essentials

  • Ultrasound
  • CT
  • Ablation device/generator (Dolphi M150E)
  • Ablation Needle (Dolphi)
  • Infusion set
  • NaCl 0.9% from the freezer
  • Glucose solution
  • Sterile drapes
  • Sterile gauzes
  • Optape
  • 10 cc syringe
  • Blue needle for anaesthesia
  • Lidocaine 2%
  • Ultrasound cover
  • Sterile gloves

Non-Essentials

 

Positioning the patient

  • Head-first
  • Prone

My Image
 

The procedure in steps

  • Time-out
  • Positioning the patient
  • Wash with chlorhexidine and cover with sterile drapes
  • Planning scan
  • Administer bolus (if effect is insufficient, call APS at 7667)
  • Optional: hydrodissection
  • Place a single 15G, 15 cm needle under CT guidance
  • Ablation for 8 minutes at 75 W
  • Control scan after IV contrast
  • Set epidural at 2 ml/h
  • Sign-out

 

Tips and tricks

  • See "complications"

 

Complications

Bleeding

In an effort to reduce bleeding complications, we have begun performing preablation tumor embolization of renal masses larger than 5 cm in diameter.

Ureter

Cryoablation has provided better out- comes than RFA for the treatment of central renal tumors. 3-year local tumor control rates of 98% for those treated with cryoablation compared with 78% for those treated with RFA.

Urinomas and infundibular strictures have been reported after RFA of central renal masses. Although cryoablation is generally thought to be less damaging to the renal collecting system than RFA, cryoablation of central renal masses has been associated with major bleeding complications

When a renal tumor is 1 cm or less from the proximal ureter, an externalized 5- to 7-French ureteral stent is placed before the procedure and irrigated with sterile fluid during the ablation.

These stents can generally be re- moved within 24 hours after ablation; however, internalization of the stent for approxi- mately 2 months may be considered if there is significant concern that the ablation zone extended to involve the ureter.

Adrenal

Tumors located in the anterior or medial upper pole of the kidney may put the adrenal gland at risk for thermal injury

In cases where the ablation zone will almost assuredly extend to involve the adrenal gland, α-receptor block- ade for 7–10 days before ablation should be considered

Bowel

Maneuvers to minimize the risk of bowel injury include simple changes in patient position (e.g., rolling the patient) and injection of either gas (pneumodisplacement) or fluid (hydrodisplacement).

When the tumor is 1 cm or less from the bowel, we generally perform hydrodisplacement by placing a 5-French catheter (Yueh centesis needle, Cook Medical) along the margin of the tumor and injecting sterile fluid (5% dextrose in water for RFA).

Nerve

Tumors in the medial lower pole of the kidney may put the nerves along the anteri- or aspect of the psoas muscle at risk of thermal injury. Injury to the genitofemoral or lateral femoral cutaneous nerves may result in sensory deficits or paresthesias. We have seen a 3.9% nerve injury rate with renal RFA and a 0.6% nerve injury rate with renal cryoablation

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Post-op

  • Further management by anaestesiologist

 

Follow-up

  • Difficult to assess shortly after ablation. UpToDate suggests 3, 6, 12, 18, 24 month and thereafter yearly

 

Report

TOP. Procedure onder epiduraal, op CT. Patient in buikligging. Wassen met chloorhexidine en steriel afdekken. Planscan. Hydrodissectie. Plaatsen van een solitaire 15G, 15 cm naald onder CT controle. Ablatie 8 min, 75 W. Controle scan na iv contrast, geen residuaal aankleurend tumorweefsel aanwezig. Procedure goed verdragen. Geen complicaties. SOP.

 

Literature

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  1. J. Mark Ryan, MD, S. M. Key, Siobhan A. Dumbleton, MD, and Tony P. Smith, MD Nonlocalized Lower Gastrointestinal Bleeding: Provocative Bleeding Studies with Intraarterial tPA, Heparin, and Tolazoline J Vasc Interv Radiol 2001 Nov;12(11):1273-7

  2. Baum ST. Arteriographic diagnosis and treatment of gastrointestinal bleeding. In Baum ST, Pentecost MJ, eds. Abrams' angiography interventional radiology. 2nd ed. Philadelphia, Pa:Lippincott, Williams & Wilkins, 2006:488.

  4. Poultsides GA, Kim CJ, Orlando R 3rd, et al. Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy, and predictors of outcome. Arch Surg. 2008;143:457-461.

  5. Eriksson LG, Sundbom M, Gustavsson S, Nyman R. Endoscopic marking with a metallic clip facilitates transcatheter arterial embolization in upper peptic ulcer bleeding. J Vasc Interv Radiol. 2006;17:959-964.

  6. Dixon S, Chan V, Shrivastava V et al. Is there a role for empiric gastroduodenal artery embolization in the management of patients with active upper GI hemorrhage? Cardiovasc Intervent Radiol. 2013 Aug;36(4):970-7.

  7. Shin JH. Recent update of embolization of upper gastrointestinal tract bleeding. Korean J Radiol 2012;13 Suppl 1:S31-S39.

  9. van Leerdam ME. Epidemiology of acute upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol. 2008;22(2):209-24.

  10. Sildiroglu O, Muasher J, Arslan B, Sabri SS, Saad WE, Angle JF, Matsumoto AH, Turba UC. Outcomes of patients with acute upper gastrointestinal nonvariceal hemorrhage referred to interventional radiology for potential embolotherapy. J Clin Gastroenterol. 2014;48(8):687-92.

  11. Strate LL, Gralnek IM. ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Am J Gastroenterol. 2016 Apr;111(4):459-74.

  13. van Dam J, Brugge WR. Endoscopy of the upper gastrointestinal tract. N Engl J Med. 1999;341(23):1738-48.

  15. Lefkovitz Z, Cappell MS, Lookstein R, Mitty HA, Gerard PS. Radiologic diagnosis and treatment of gastrointestinal hemorrhage and ischemia. Med Clin North Am. 2002 Nov;86(6):1357-99.

  16. Lee EW, Laberge JM. Differential diagnosis of gastrointestinal bleeding. Tech Vasc Interv Radiol 2004; 7: 112-22

  18. Strate LL, Gralnek IM. ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Am J Gastroenterol. 2016 Apr;111(4):459-74.

  19. Chaudhry V, Hyser MJ, Gracias VH, Gau FC. Colonoscopy: the initial test for acute lower gastrointestinal bleeding. Am Surg. 1998 Aug;64(8):723-8.

  20. Cummings CL. Value of early capsular endoscopy for severe gastrointestinal bleeding. J Natl Med Assoc. 2004;96(12):1653-6.

  21. Appleyard M, Glukhovsky A, Swain P. Wireless-capsule diagnostic endoscopy for recurrent small-bowel bleeding. N Engl J Med. 2001;344(3):232-3.

  24. Lim JK, Ahmed A. Endoscopic approach to the treatment of gastrointestinal bleeding. Tech Vasc Interv Radiol. 2004 Sep;7(3):123-9.

  25. Nicholson AA, Ettles DF, Hartley JE, et al. Transcatheter coil embolotherapy: a safe and effective option for major colonic haemorrhage. Gut 1998; 43:79–84.

  26. Zuckier LS. Acute gastrointestinal bleeding. Semin Nucl Med. 2003 Oct;33(4):297-311.

  27. Imbembo AL, Diverticular disease of the colon. In: Sabiston D, Editor. Textbook of Surgery (14th edn). Philadelphia, PA:WB Saunders, 1992:910.

  29. Loffroy R, Rao P, Ota S, De Lin M, Kwak BK, Geschwind JF. Embolization of acute nonvariceal upper gastrointestinal hemorrhage resistant to endoscopic treatment: results and predictors of recurrent bleeding. Cardiovasc Intervent Radiol. 2010 Dec;33(6):1088-100. doi: 10.1007/s00270-010-9829-7. Epub 2010 Mar 16.

  31. Eriksson LG, Sundbom M, Gustavsson S, Nyman R. Endoscopic marking with a metallic clip facilitates transcatheter arterial embolization in upper peptic ulcer bleeding. J Vasc Interv Radiol. 2006 Jun;17(6):959-64.

  32. Anthony S, Milburn S, Uberoi R. Multi-detector CT: review of its use in acute GI haemorrhage. Clin Radiol. 2007 Oct;62(10):938-49.

  33. Ernst O, Bulois P, Saint-Drenant S, Leroy C, Paris JC, Sergent G. Helical CT in acute lower gastrointestinal bleeding. Eur Radiol. 2003;13(1):114-7

  34. Mirsadraee S, Tirukonda P, Nicholson A, Everett SM, McPherson SJ. Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review. Clin Radiol 2011;66:500-509.

  35. Loffroy R, Guiu B, D'Athis P, Mezzetta L, Gagnaire A, Jouve JL, Ortega-Deballon P, Cheynel N, Cercueil JP, Krausé D. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 2009 May;7(5):515-23.

  36. Aina R, Oliva VL, Therasse E, et al. Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol 2001;12:195-200.

  37. Mirsadraee S, Tirukonda P, Nicholson A, Everett SM, McPherson SJ. Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review. Clin Radiol 2011;66:500-509.

  38. Loffroy R, Guiu B, Cercueil JP, Lepage C, Latournerie M, Hillon P, Rat P, Ricolfi F, Krausé D. Refractory bleeding from gastroduodenal ulcers: arterial embolization in high-operative-risk patients. J Clin Gastroenterol. 2008 Apr;42(4):361-7.

  39. Loffroy R, Guiu B, D'Athis P, Mezzetta L, Gagnaire A, Jouve JL, Ortega-Deballon P, Cheynel N, Cercueil JP, Krausé D. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 2009 May;7(5):515-23.

  40. Poultsides GA, Kim CJ, Orlando R 3rd, Peros G, Hallisey MJ, Vignati PV. Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy, and predictors of outcome. Arch Surg 2008;143:457-461.

  42. Gordon RL, Ahl KL, Kerlan RK, Wilson MW, LaBerge JM, Sandhu JS, Ring EJ, Welton ML. Selective arterial embolization for the control of lower gastrointestinal bleeding. Am J Surg. 1997;174(1):24-8.

  43. Funaki B, Kostelic JK, Lorenz J, Ha TV, Yip DL, Rosenblum JD, et al. Superselective microcoil embolization of colonic hemorrhage. AJR Am J Roentgenol 2001;177:829-836 7.

  44. Bandi R, Shetty PC, Sharma RP, Burke TH, Burke MW, Kastan D. Superselective arterial embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2001;12:1399-1405.

  45. Maleux G, Roeflaer F, Heye S, Vandersmissen J, Vliegen AS, Demedts I, et al. Long-term outcome of transcatheter embolotherapy for acute lower gastrointestinal hemorrhage. Am J Gastroenterol 2009;104:2042-2046

  46. Leitman IM, Paull DE, Shires GT 3rd. Evaluation and management of massive lower gastrointestinal hemorrhage. Ann Surg 1989;209:175-180

  47. Rosenkrantz H, Bookstein JJ, Rosen RJ, Goff WB 2nd, Healy JF. Postembolic colonic infarction. Radiology 1982;142:47-51.

  48. Koh DC, Luchtefeld MA, Kim DG, Knox MF, Fedeson BC, Vanerp JS, et al. Efficacy of transarterial embolization as definitive treatment in lower gastrointestinal bleeding. Colorectal Dis 2009;11:53-59

  49. Lipof T, Sardella WV, Bartus CM, Johnson KH, Vignati PV, Cohen JL. The efficacy and durability of super-selective embolization in the treatment of lower gastrointestinal bleeding. Dis Colon Rectum 2008;51:301-305

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