Jiménez Juan A, Zhang Zhiling, Zhao Juping, Abouassaly Robert, Fergany Amr, Gong Michael, Kaouk Jihad, Krishnamurthi Venkatesh, Stein Robert, Stephenson Andrew, Campbell Steven C
Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
Department of Urology, University Hospitals Case Medical Center, Cleveland, Ohio.
J Urol. 2016 Mar;195(3):594-600. doi: 10.1016/j.juro.2015.09.078. Epub 2015 Sep 28.
Cryoablation and radio frequency ablation are attractive modalities for small renal masses in patients with substantial comorbidities. However, salvage extirpative therapy for local recurrence after thermal ablation can be challenging due to associated perinephric fibrosis.
Patients with thermal ablation refractory tumors requiring surgical salvage from 1997 to 2013 were identified and retrospectively reviewed.
A total of 27 patients were treated surgically after cryoablation (18) or radio frequency ablation (9) failed. Subjective assessment indicated moderate/severe fibrosis in 22 cases (81%). Partial nephrectomy was preferred in all patients but was not possible in 12, primarily due to unfavorable tumor size/location. In the intended partial nephrectomy group (15) open surgery was performed in all patients and completed in 14, with the procedure aborted in 1 due to extensive perinephric fibrosis. Radical nephrectomy was planned in 12 patients, of whom 8 were treated laparoscopically with 1 requiring conversion to open. Median estimated blood loss was 225 ml. Overall 17 patients experienced no complications and 4 had minor complications. However, 6 patients experienced more significant complications (Clavien III-IVb). Since January 2008 partial nephrectomy was performed more frequently (12 of 17, or 71% vs 2 of 10, or 20% for previous cases, p=0.02).
Surgical salvage after failed thermal ablation is feasible in most instances, and partial nephrectomy is often possible but can be challenging due to associated perinephric fibrosis. The difficulty of surgical salvage should be recognized as a potential limitation of the thermal ablation treatment strategy. Prospective studies of thermal ablation vs partial nephrectomy should be prioritized to provide higher quality data about the merits and limitations of each approach.
对于合并症较多的患者，冷冻消融和射频消融是治疗小肾肿块的有吸引力的方式。然而，由于相关的肾周纤维化，热消融后局部复发的挽救性切除治疗可能具有挑战性。
确定并回顾性分析了1997年至2013年因热消融难治性肿瘤而需要手术挽救的患者。
冷冻消融（18例）或射频消融（9例）失败后，共有27例患者接受了手术治疗。主观评估显示22例（81%）存在中度/重度纤维化。所有患者均首选部分肾切除术，但12例无法进行，主要是由于肿瘤大小/位置不利。在计划进行部分肾切除术的组（15例）中，所有患者均接受了开放手术，14例完成手术，1例因广泛的肾周纤维化而中止手术。12例患者计划进行根治性肾切除术，其中8例接受了腹腔镜手术，1例需要转为开放手术。估计中位失血量为225毫升。总体而言，17例患者无并发症，4例有轻微并发症。然而，6例患者出现了更严重的并发症（Clavien III-IVb级）。自2008年1月以来，部分肾切除术的实施更为频繁（17例中的12例，即71%，而之前的病例为10例中的2例，即20%，p=0.02）。
在大多数情况下，热消融失败后的手术挽救是可行的，部分肾切除术通常可行，但由于相关的肾周纤维化可能具有挑战性。手术挽救的困难应被视为热消融治疗策略的潜在局限性。应优先进行热消融与部分肾切除术的前瞻性研究，以提供关于每种方法优缺点的更高质量数据。
