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Name:
Percutaneous Radiofrequency Ablation for Kidney Cancer
Description:
Percutaneous Radiofrequency Ablation for Kidney Cancer
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/3a850137-cc06-4347-99a0-dbcf10a82151/videoscrubberimages/Scrubber_5.jpg?sv=2019-02-02&sr=c&sig=TUqPl0QDkEADCTSlX7XZNd1T2Ubo5NpZLIQsQ3lX6aE%3D&st=2026-04-02T15%3A31%3A46Z&se=2026-04-02T19%3A36%3A46Z&sp=r
Duration:
T00H10M41S
Embed URL:
https://stream.cadmore.media/player/3a850137-cc06-4347-99a0-dbcf10a82151
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/3a850137-cc06-4347-99a0-dbcf10a82151/Percutaneous Radiofrequency Ablation for Kidney Cancer.mp4?sv=2019-02-02&sr=c&sig=G2x6GpLicO0dNuiRfJHXlcU%2BC%2Fqbx%2FBB2NUPKQeAiZ8%3D&st=2026-04-02T15%3A31%3A47Z&se=2026-04-02T17%3A36%3A47Z&sp=r
Upload Date:
2023-10-19T00:00:00.0000000
Transcript:
Language: EN.
Segment:1 INTRODUCTION AND PATIENT INDICATIONS.
SPEAKER 1: Technique for percutaneous radiofrequency ablation for small renal masses. In this video, we describe the technique for percutaneous radiofrequency ablation as performed at our institution. A brief review of procedural equipment, troubleshooting scenarios, and clinical outcomes is also provided. The ideal candidate for a radiofrequency ablation or RFA is a patient with a posterior solitary mass 2 to 3 centimeters in size.
SPEAKER 1: The perfect candidate has comorbidities and/or a solitary kidney, and maximally benefits from the low risk profile and quick recovery associated with the procedure. Contraindications include uncorrectable coagulopathy and hilar tumors. The patient in this video is a 74-year-old male initially on active surveillance with an enlarging right renal mass suspicious for malignancy.
SPEAKER 1: His relevant comorbidities include hypertension, diabetes, squamous cell carcinoma of the jaw, which is currently in remission. His prior surgical history is significant for resection of carcinoma of the mouth. His baseline creatinine is 1.15 with an estimated glomerular filtration rate of greater than 60. His tumor is 1.9 centimeters posteromedially located in the right upper pole.
SPEAKER 1: And his MRI features consistent with renal cell carcinoma.
Segment:2 INSTRUMENTS AND PREOPERATIVE PREPARATION.
SPEAKER 1: RFA systems are either temperature or impedance-based. Temperature-based systems directly monitor ablation temperatures, which is our preferred system. This gives the proceduralist proof that the target tissues have reached a target temperature for a preset amount of time. We utilize the RITA 1500 RX generator.
SPEAKER 1: Probes maybe dry or wet. The latter utilizes a constant saline infusion to minimize charring and allow for a larger ablation zone. Monopolar electrodes are more commonly used for radiofrequency ablation of renal lesions. Though bipolar electrodes that generate an elliptical ablation zone are also available. We use the Starburst XL probe, which is a dry probe with monopolar electrodes.
SPEAKER 1: This houses nine deployable tines and four thermocouples. The tips house the thermistors, which are used to heat the tissue slowly and uniformly so that the tumor is thoroughly ablated and charring is avoided. The tines are expandable to cover ablation diameters of three to five centimeters. This probe is also available in a flexible model.
SPEAKER 1: Anesthesia, radiology, and neurology teams are all involved with the RFA treatment at our institution. These teams must be coordinated. Patients are made nothing per os at midnight the night prior to the procedure. And any anti-coagulation is held the appropriate number of days before surgery if applicable. The patients must be counseled preoperatively about any risks associated with the procedure and informed consent is obtained.
SPEAKER 1: After patients are placed under anesthesia, a Foley catheter is placed to allow monitoring of urine appearance.
Segment:3 POSITIONING.
SPEAKER 1: The patients are then placed in the prone position with gel rolls below the axilla on either side of the abdomen to facilitate ventilation during the procedure. The arms are tucked at the patient's sides using foam pads to protect these from the CT gantry.
SPEAKER 1: Foam pads are placed under any pressure points, especially the knees. The patient is secured to the table. The team must have easy IV access for general patient safety and for IV contrast administration. Prophylactic antibiotics are administered. Grounding pads are placed on the posterior thighs, ensuring excellent skin contact.
SPEAKER 1: This is critical to prevent burns. Pads should be at the same level perpendicular to the long access. A radio opaque grid is then placed on the skin overlying the kidney. And a preoperative CT scan is obtained using a contrast bolus and 3 millimeter slices for preoperative planning.
Segment:4 FINDER NEEDLE, PROBE PLACEMENT, AND RENAL MASS BIOPSY.
SPEAKER 1: At our institution, the interventional radiology team obtains renal access.
SPEAKER 1: A finder needle is placed into the kidney and moved up to the tumor using the grid as a marker. Serial CT scans may be required to be sure that the needle is placed in the appropriate orientation. Breath hold may be employed to maintain positioning of the kidney for probe placement. The probe is then placed using the finder needle as a guide with a goal of abutting the probe tip to the tumor perpendicularly at its borders.
SPEAKER 1: Once placement is perfect, we move on to tine deployment. A renal mass biopsy is often done adjacent to the probe if indicated. The probe must be in perfect position first in the event that the biopsy causes bleeding and distorts the image. In cases where biopsy is previously performed or the patient has known malignant disease, this step may be omitted.
Segment:5 TINE DEPLOYMENT.
SPEAKER 1: Tine deployment must be done quickly and with reasonable force to puncture the tumor rather than push the tissue away, which can happen with slower deployments. Occasionally, it is necessary to overshoot the tine deployment by 1 to 2 millimeters and then to pull back to the appropriate position. The tines must border the spherical tumor, especially in the deep portion of the tumor.
SPEAKER 1: Of note, the ablation zone extends roughly 3 millimeters beyond the tip of each tine, which allows for successful ablation even in areas where tine placement is not perfect. Occasionally, tine deployment requires several CT scans until satisfactory placement is achieved.
Segment:6 ABLATION AND PROBE REMOVAL.
SPEAKER 1: At our institution, the urology team performs the ablation. The probe and grounding pads are connected to the radiofrequency ablation generator.
SPEAKER 1: We perform two cycles of heating with a 30-second down period between cycles. Target temperatures during heating or above 105 degrees Celsius. The length of the heating cycle depends on the diameter of the ablation zone. For tumors less than two centimeters, a five-minute cycle is used. Monitoring of the thermocouple temperatures is performed in real time.
SPEAKER 1: And tines with excessive temperatures may be taken briefly offline during treatment to maintain uniform average temperatures. Real-time monitoring allows reassurance that the target tissue is being adequately treated and confirms the absence of a large heat sink. Maintenance of probe temperature above 70 degrees Celsius during the cool down phase suggests appropriate tissue ablation in each of the tines.
SPEAKER 1: At the completion of treatment, tract ablation is then performed. The tines are retracted and the probe is withdrawn roughly 1 centimeter, maintaining a treatment temperature greater than 70 degrees Celsius. The probe is then withdrawn entirely. A second contrast enhanced CT is repeated to assess the completeness of ablation and potential complications.
SPEAKER 1: If all looks well, the patient is moved to the supine position. And the Foley catheter is removed if the urine is clear. They are awoken and taken to the PACU for recovery. Following ablation, most patients recover in PACU and are suitable for discharge home within several hours.
Segment:7 POST-OPERATIVE CARE.
SPEAKER 1: Transient pain or discomfort is common with significant pain or paresthesias long term in up to 4% of patients.
SPEAKER 1: Hematuria occurs in about 1% and can generally be managed conservatively. Evaluation for pneumothorax should be performed when probe placement occurs above rib 12. Following initial ablation, patients should be followed with contrast-enhanced cross-sectional imaging.
Segment:8 TROUBLESHOOTING.
SPEAKER 1: Several scenarios may render successful RFA more challenging.
SPEAKER 1: For obese patients or difficult to reach tumors, flexible probes may be used. Safe RFA treatment also requires adequate distance from bowel and collecting system. We typically maintain at least 1 centimeter between the deepest tine and adjacent bowel. Hydrodissection or pneumodissection can be used to achieve safe treatment distances. And irrigated ureteral stents may be considered when proximity to the collecting system is of concern.
SPEAKER 1:
Segment:9 OUTCOMES AND REFERENCES.
SPEAKER 1: Complication rates following RFA are low, with similar major and minor Clavien-grade complications to partial nephrectomy but more favorable morbidity with regard to transfusion rates, hospital length of stay, and conversion to radical nephrectomy. Reported complication rates range from 1.3% to 2.1% for ureteral stricture, 0.4% to 1.2% for vascular injury or hemorrhage, and 0.4% for urine leak, nerve injury, pneumothorax, and ablation site abscess.
SPEAKER 1: In the appropriately selected patient, oncologic outcomes similar to surgical extirpation may be achieved with RFA with comparable local recurrence-free and metastasis-free survival rates. As maturation of initial RFA experience across institutional series has matured, intermediate and long term oncologic outcomes have been encouraging. We hope this video has been informative and provided additional information regarding the technique for percutaneous radiofrequency ablation for small renal masses.
SPEAKER 1:
Segment:1 INTRODUCTION AND PATIENT INDICATIONS.
SPEAKER 1: Technique for percutaneous radiofrequency ablation for small renal masses. In this video, we describe the technique for percutaneous radiofrequency ablation as performed at our institution. A brief review of procedural equipment, troubleshooting scenarios, and clinical outcomes is also provided. The ideal candidate for a radiofrequency ablation or RFA is a patient with a posterior solitary mass 2 to 3 centimeters in size.
SPEAKER 1: The perfect candidate has comorbidities and/or a solitary kidney, and maximally benefits from the low risk profile and quick recovery associated with the procedure. Contraindications include uncorrectable coagulopathy and hilar tumors. The patient in this video is a 74-year-old male initially on active surveillance with an enlarging right renal mass suspicious for malignancy.
SPEAKER 1: His relevant comorbidities include hypertension, diabetes, squamous cell carcinoma of the jaw, which is currently in remission. His prior surgical history is significant for resection of carcinoma of the mouth. His baseline creatinine is 1.15 with an estimated glomerular filtration rate of greater than 60. His tumor is 1.9 centimeters posteromedially located in the right upper pole.
SPEAKER 1: And his MRI features consistent with renal cell carcinoma.
Segment:2 INSTRUMENTS AND PREOPERATIVE PREPARATION.
SPEAKER 1: RFA systems are either temperature or impedance-based. Temperature-based systems directly monitor ablation temperatures, which is our preferred system. This gives the proceduralist proof that the target tissues have reached a target temperature for a preset amount of time. We utilize the RITA 1500 RX generator.
SPEAKER 1: Probes maybe dry or wet. The latter utilizes a constant saline infusion to minimize charring and allow for a larger ablation zone. Monopolar electrodes are more commonly used for radiofrequency ablation of renal lesions. Though bipolar electrodes that generate an elliptical ablation zone are also available. We use the Starburst XL probe, which is a dry probe with monopolar electrodes.
SPEAKER 1: This houses nine deployable tines and four thermocouples. The tips house the thermistors, which are used to heat the tissue slowly and uniformly so that the tumor is thoroughly ablated and charring is avoided. The tines are expandable to cover ablation diameters of three to five centimeters. This probe is also available in a flexible model.
SPEAKER 1: Anesthesia, radiology, and neurology teams are all involved with the RFA treatment at our institution. These teams must be coordinated. Patients are made nothing per os at midnight the night prior to the procedure. And any anti-coagulation is held the appropriate number of days before surgery if applicable. The patients must be counseled preoperatively about any risks associated with the procedure and informed consent is obtained.
SPEAKER 1: After patients are placed under anesthesia, a Foley catheter is placed to allow monitoring of urine appearance.
Segment:3 POSITIONING.
SPEAKER 1: The patients are then placed in the prone position with gel rolls below the axilla on either side of the abdomen to facilitate ventilation during the procedure. The arms are tucked at the patient's sides using foam pads to protect these from the CT gantry.
SPEAKER 1: Foam pads are placed under any pressure points, especially the knees. The patient is secured to the table. The team must have easy IV access for general patient safety and for IV contrast administration. Prophylactic antibiotics are administered. Grounding pads are placed on the posterior thighs, ensuring excellent skin contact.
SPEAKER 1: This is critical to prevent burns. Pads should be at the same level perpendicular to the long access. A radio opaque grid is then placed on the skin overlying the kidney. And a preoperative CT scan is obtained using a contrast bolus and 3 millimeter slices for preoperative planning.
Segment:4 FINDER NEEDLE, PROBE PLACEMENT, AND RENAL MASS BIOPSY.
SPEAKER 1: At our institution, the interventional radiology team obtains renal access.
SPEAKER 1: A finder needle is placed into the kidney and moved up to the tumor using the grid as a marker. Serial CT scans may be required to be sure that the needle is placed in the appropriate orientation. Breath hold may be employed to maintain positioning of the kidney for probe placement. The probe is then placed using the finder needle as a guide with a goal of abutting the probe tip to the tumor perpendicularly at its borders.
SPEAKER 1: Once placement is perfect, we move on to tine deployment. A renal mass biopsy is often done adjacent to the probe if indicated. The probe must be in perfect position first in the event that the biopsy causes bleeding and distorts the image. In cases where biopsy is previously performed or the patient has known malignant disease, this step may be omitted.
Segment:5 TINE DEPLOYMENT.
SPEAKER 1: Tine deployment must be done quickly and with reasonable force to puncture the tumor rather than push the tissue away, which can happen with slower deployments. Occasionally, it is necessary to overshoot the tine deployment by 1 to 2 millimeters and then to pull back to the appropriate position. The tines must border the spherical tumor, especially in the deep portion of the tumor.
SPEAKER 1: Of note, the ablation zone extends roughly 3 millimeters beyond the tip of each tine, which allows for successful ablation even in areas where tine placement is not perfect. Occasionally, tine deployment requires several CT scans until satisfactory placement is achieved.
Segment:6 ABLATION AND PROBE REMOVAL.
SPEAKER 1: At our institution, the urology team performs the ablation. The probe and grounding pads are connected to the radiofrequency ablation generator.
SPEAKER 1: We perform two cycles of heating with a 30-second down period between cycles. Target temperatures during heating or above 105 degrees Celsius. The length of the heating cycle depends on the diameter of the ablation zone. For tumors less than two centimeters, a five-minute cycle is used. Monitoring of the thermocouple temperatures is performed in real time.
SPEAKER 1: And tines with excessive temperatures may be taken briefly offline during treatment to maintain uniform average temperatures. Real-time monitoring allows reassurance that the target tissue is being adequately treated and confirms the absence of a large heat sink. Maintenance of probe temperature above 70 degrees Celsius during the cool down phase suggests appropriate tissue ablation in each of the tines.
SPEAKER 1: At the completion of treatment, tract ablation is then performed. The tines are retracted and the probe is withdrawn roughly 1 centimeter, maintaining a treatment temperature greater than 70 degrees Celsius. The probe is then withdrawn entirely. A second contrast enhanced CT is repeated to assess the completeness of ablation and potential complications.
SPEAKER 1: If all looks well, the patient is moved to the supine position. And the Foley catheter is removed if the urine is clear. They are awoken and taken to the PACU for recovery. Following ablation, most patients recover in PACU and are suitable for discharge home within several hours.
Segment:7 POST-OPERATIVE CARE.
SPEAKER 1: Transient pain or discomfort is common with significant pain or paresthesias long term in up to 4% of patients.
SPEAKER 1: Hematuria occurs in about 1% and can generally be managed conservatively. Evaluation for pneumothorax should be performed when probe placement occurs above rib 12. Following initial ablation, patients should be followed with contrast-enhanced cross-sectional imaging.
Segment:8 TROUBLESHOOTING.
SPEAKER 1: Several scenarios may render successful RFA more challenging.
SPEAKER 1: For obese patients or difficult to reach tumors, flexible probes may be used. Safe RFA treatment also requires adequate distance from bowel and collecting system. We typically maintain at least 1 centimeter between the deepest tine and adjacent bowel. Hydrodissection or pneumodissection can be used to achieve safe treatment distances. And irrigated ureteral stents may be considered when proximity to the collecting system is of concern.
SPEAKER 1:
Segment:9 OUTCOMES AND REFERENCES.
SPEAKER 1: Complication rates following RFA are low, with similar major and minor Clavien-grade complications to partial nephrectomy but more favorable morbidity with regard to transfusion rates, hospital length of stay, and conversion to radical nephrectomy. Reported complication rates range from 1.3% to 2.1% for ureteral stricture, 0.4% to 1.2% for vascular injury or hemorrhage, and 0.4% for urine leak, nerve injury, pneumothorax, and ablation site abscess.
SPEAKER 1: In the appropriately selected patient, oncologic outcomes similar to surgical extirpation may be achieved with RFA with comparable local recurrence-free and metastasis-free survival rates. As maturation of initial RFA experience across institutional series has matured, intermediate and long term oncologic outcomes have been encouraging. We hope this video has been informative and provided additional information regarding the technique for percutaneous radiofrequency ablation for small renal masses.
SPEAKER 1:
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