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COMMENTARY

Harrison K. Rhee and John A. Libertino

Lahey Clinic Medical Center, Burlington, Massachusetts, U.S.A.

Several treatments have been challenging open radical nephrectomy, the gold standard treatment for renal cell carcinoma. Open partial nephrectomy has been shown to have similar oncologic results while preserving nephron mass and renal function. Laparoscopic radical nephrectomy has been shown to have less morbidity than open radical nephrectomy and is quickly becoming the treatment of choice for those masses not amenable to partial nephrectomy. Specialized centers have been pushing the forefront of minimally invasive, extirpative surgery with the routine use of laparoscopic partial nephrectomy. Research into nonextirpative, ablative techniques such as cryoablation and radio frequency ablation has given urologists even more treatment options when addressing renal lesions. The ultimate goal of each of these techniques is to effectively eradicate tumors with maximal oncologic efficacy while minimizing morbidity and mortality. The aforementioned procedures have certain difficulties with each of those tasks, and radiofrequency ablation is no exception.

Avoiding significant open or laparoscopic surgery is the major benefit of radiofrequency ablation. This benefit includes decreased blood loss, lower analgesia requirement, shorter hospital stay, quicker return to normal activities, and preservation of nephron mass when compared with radical nephrectomy. Rare complications such as extension of the coagulation lesion into surrounding organs or thrombosis of major renal vessels have been avoided with selection of small, peripheral, posterior tumors. While the benefits of this therapy may outweigh the need for surgical resection in the patient with significant comorbidities, the majority of patients with renal masses require a procedure with established, long-term cure rates.

Despite the benefits of radiofrequency ablation, treatment efficacy has not been fully established. Technology to evaluate radiofrequency ablation in real time is not currently adequate to determine the true extent of lesions at the time of treatment. Data from several groups has shown that persistent or new enhancement on computed tomography scan after treatment mandate two or more total treatments for primary radiofrequency ablation failures. Also, the use of nonenhancement of the lesion on computed tomography scan after treatment does not fully establish the treatment margins as adequately as histology. Clinical trials where tissue is immediately resected after treatment have shown conflicting results regarding histologic evidence of cell viability. Because treatment effects may not be fully realized on immediate examination, we believe that further data needs to be gathered with treatment and delayed resection for pathologic evaluation. This should be correlated with contrast-enhancement evaluation on computed tomography-scan because the ultimate goal would be to evaluate treatment efficacy by noninvasive means.

Several situations may push radiofrequency ablation up the treatment algorithm. As mentioned, in those patients with comorbidities that preclude surgical resection with open or laparoscopic radical or partial nephrectomy, radiofrequency ablation may be a viable treatment alternative. This group of patients may be the ideal group for radiofrequency ablation therapy although long-term, disease-free follow-up may not be easily evaluated secondary to non-disease-specific mortality. Laparoscopic partial nephrectomy demands excellent skills including the very difficult task of intracorporeal suturing for reconstruction of the collecting system and for ligation of bleeding vessels. Therefore, a potential use of radiofrequency ablation may be as an intraoperative adjunct to this procedure by facilitating hemostasis and decreasing blood loss. radiofrequency ablation treatment of lesions may preclude the need for hemostatic suturing and allow a clean operative field for further closure of the surgical defect.

Further long-term results regarding overall survival, disease-free survival, morbidity, and mortality need to be established across institutions to fully compare this technique to current therapies of surgical resection. As further data regarding the clinical significance of small renal lesions becomes available, the utility of minimally invasive, nonextirpative, ablative therapies such as radio frequency ablation may become more clear. Until these data become available, radiofrequency ablation will remain an investigational modality that should only be offered to those patients who are unable to undergo surgical resection.

CHAPTER

LAPAROSCOPIC RADICAL NEPHROURETERECTOMY: TECHNIQUES FOR THE MANAGEMENT OF DISTAL URETER AND BLADDER CUFF

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