Focal Therapy in Renal Cell Carcinoma: Which Modality Is Best?

ContextThermal ablation of small renal tumours is an established treatment modality in selected cases. Many groups have published their experiences. However, a major drawback of most of the previously published reviews and meta-analyses is their retrospective nature, the heterogeneity of included studies, and the limitations of a short-term oncologic follow-up. For those reasons, firm conclusions are still lacking.ObjectiveTo assess the best combination of ablation technique and approach in those renal tumours deemed suitable for ablation.Evidence acquisitionA PubMed search was performed (up to December 2010) of the world literature on thermal ablation of renal tumours. To assess oncologic outcomes, we selected reports with a minimum follow-up of 36 mo and with appropriately documented pathologic results specifying the number of biopsy-proven renal cell carcinomas (RCCs). To assess perioperative complications we selected series with substantial caseloads of at least 70 cases and comparative series among techniques.Evidence synthesisAll long-term series of thermal ablation for small renal masses show a recurrence-free survival (RFS) of 84–94% with a cancer-specific survival (CSS) of 89–100%. Some cases with previous (partial) nephrectomy for RCC are included in the series with lowest RFS and CSS. No distinct differences exist between radiofrequency ablation (RFA) and cryoablation (CA).Initial failure and overall complication rates are higher for the percutaneous approach compared with laparoscopy. The major complication rate is slightly lower, ultimate survival is comparable, and length of stay and patient convalescence are favourable for the percutaneous approach, regardless of the modality.ConclusionsLow-quality evidence shows that CA or RFA modalities have a low major-complication rate, preserve renal function, and provide acceptable, oncologic, long-term outcomes. The percutaneous approach has a high rate of initial failure, but seems to be less costly.