Purpose The purpose of this guideline is to provide a clinical framework for the diagnosis, evaluation and follow-up of asymptomatic microhematuria. Materials and Methods A systematic literature ...review using the MEDLINE® database was conducted to identify peer reviewed publications relevant to the definition, diagnosis, evaluation and follow-up for AMH. The review yielded 191 evidence-based articles, and these publications were used to create the majority of the guideline statements. There was insufficient evidence-based data for certain concepts; therefore, clinical principles and consensus expert opinions were used for portions of the guideline statements. Results Guideline statements are provided for diagnosis, evaluation and follow-up. The panel identified multiphasic computed tomography as the preferred imaging technique and developed guideline statements for persistent or recurrent AMH as well as follow-up. Conclusions AMH is only diagnosed by microscopy; a dipstick reading suggestive of hematuria should not lead to imaging or further investigation without confirmation of three or greater red blood cells per high power field. The evaluation and follow-up algorithm and guidelines provide a systematic approach to the patient with AMH. All patients 35 years or older should undergo cystoscopy, and upper urinary tract imaging is indicated in all adults with AMH in the absence of known benign causation. The imaging modalities and physical evaluation techniques are evolving, and these guidelines will need to be updated as the effectiveness of these become available. Please visit the AUA website at http://www.auanet.org/content/media/asymptomatic_microhematuria_guideline.pdf to view this guideline in its entirety.
To discuss the use of renal mass biopsy (RMB) for small renal masses (SRMs), formulate technical aspects, outline potential pitfalls and provide recommendations for the practicing clinician.
The ...meeting was conducted as an informal consensus process and no scoring system was used to measure the levels of agreement on the different topics.
A moderated general discussion was used as the basis for consensus and arising issues were resolved at this point.
A consensus was established and lack of agreement to topics or specific items was noted at this point.
Recommended biopsy technique: at least two cores, sampling different tumour regions with ultrasonography being the preferred method of image guidance.
Pathological interpretation: ‘non‐diagnostic samples’ should refer to insufficient material, inconclusive and normal renal parenchyma. For non‐diagnostic samples, a repeat biopsy is recommended. Fine‐needle aspiration may provide additional information but cannot substitute for core biopsy.
Indications for RMB: biopsy is recommended in most cases except in patients with imaging or clinical characteristics indicative of pathology (syndromes, imaging characteristics) and cases whereby conservative management is not contemplated. RMB is recommended for active surveillance but not for watchful‐waiting candidates.
We report the results of an international consensus meeting on the use of RMB for SRMs, defining the technique, pathological interpretation and indications.
Objectives To assess efficacy and morbidity of microwave ablation (MWA) for small renal tumors in an initial cohort of patients. MWA is a recently introduced thermal needle ablation treatment ...modality with theoretical advantages compared with radiofrequency ablation, such as greater intratumoral temperatures, lack of a grounding pad, and superior convection profile. However, experience has been limited in the human kidney. Methods Ten patients with a single, solid-enhancing renal tumor from June 2008 to November 2008 received laparoscopic or computed tomography-guided percutaneous MWA at a tertiary referral center with ≥14 months of follow-up. MWA was performed using the Valleylab Evident, 915-MHz MWA system at 45 W with intraoperative biopsy before ablation, and peripheral fiberoptic thermometry to determine the treatment endpoints. The patients were followed up with contrast-enhanced computed tomography at 1 month, 6 months to 1 year, and annually to monitor for tumor recurrence. Results The follow-up duration for the 6 male and 4 female patients (mean tumor size 3.65 cm, range 2.0-5.5; mean age 69.8 years) was 17.9 months. The recurrence rate, defined by persistent enhancement, was 38% (3 of 8). The intraoperative and postoperative complication rate was 20% and 40%, respectively. Conclusions MWA resulted in poor oncologic outcomes with a significant complication rate at an intermediate level of follow-up. However, MWA has promising theoretical advantages and should not be discarded. Additional studies should be considered to better understand the microwave-tissue interaction and treatment endpoints for different size renal masses before widespread use.
Introduction: Microwave ablation (MWA) uses heat to ablate undesired tissue. Development of pre-planning algorithms for MWA of small renal masses requires understanding of microwave-tissue ...interactions at different operating parameters. The objective of this study was to compare the performance of two MWA systems in in-vivo porcine kidneys.
Methods: Five ablations were performed using a 902-928 MHz system (24 W, 5 min) and a 2450 MHz system (180 W, 2 min). Nonlinear regression analysis of temperature changes measured 5 mm from the antenna axis was completed for the initial 10 s of ablation using the power equation
and after the inflection point using an exponential equation. Thermal damage was calculated using the Arrhenius equation. Long and short axis ablation diameters were measured.
Results: The average 'a' varied significantly between systems (902-928 MHz: 0.0299 ± 0.027, 2450 MHz: 0.1598 ± 0.158), indicating proportionality to the heat source, but 'b' did not (902-928 MHz: 1.910 ± 0.372, 2450 MHz: 2.039 ± 0.366), signifying tissue type dependence. Past the inflection point, average steady-state temperature increases were similar between systems but reached more quickly with the 2450 MHz system. Complete damage was reached at 5 mm for both systems. The 2450 MHz system produced significantly larger short axis ablations (902-928 MHz: 2.40 ± 0.54 cm, 2450 MHz: 3.32 ± 0.41cm).
Conclusion: The 2450 MHz system achieved similar steady state temperature increases compared to the 902-928 MHz system, but more quickly due to higher output power. Further investigations using various treatment parameters and precise thermal sensor placement are warranted to refine equation parameters for the development of an ablation model.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Study Type – Therapy (case series)
Level of Evidence 4
What's known on the subject? and What does the study add?
The natural history of renal angiomyolipomas (AML) shows increasing size and ...increasing risk of haemorrhage. For those patients undergoing treatment, extirpative surgery or renal angio‐embolization has increased morbidity. Due to its haemostatic effect, radio‐frequency ablation (RFA) may be used safely and effectively for the treatment of small (<4 cm), symptomatic renal AML.
This study represents the largest case series reporting on RFA for renal AML.
OBJECTIVES
• To show that radiofrequency ablation (RFA) is safe and effective treatment for renal angiomyolipoma (AML).
• Current treatments to reduce the risk of haemorrhage include tumour extirpation, angio‐embolization, or ablative therapy.
PATIENTS AND METHODS
• Review of our prospective database revealed 15 patients with intraoperative biopsy confirmed renal AML undergoing RFA from February 2002 to March 2010.
• Patients underwent either laparoscopic or computed tomography (CT)‐guided percutaneous RFA using either the Cool‐tip™ (Covidien, Inc. Boulder, CO, USA) or RITA™ (Angiodynamics®, Latham, NY, USA) RFA probe.
• CT at 1 month, 6 months, 1 year, and annually thereafter.
RESULTS
• In all, two male and 13 female patients with seven left‐sided and eight right‐sided tumours with a mean (range) size of 2.6 (1.0–3.7) cm underwent laparoscopic (five) or CT‐guided (10) RFA.
• No intraoperative complications occurred. Minor complications included transient haematuria and intercostals nerve transection. Surgical complications included pneumonia and myocardial infarction.
• There was no radiographic evidence of persistent AML (CT enhancement) at a mean follow‐up of 21 months.
CONCLUSIONS
• The haemostatic effect of RFA allows renal lesions suspicious for AML to be treated without bleeding complications.
• Avoids surgical risk of extirpation or embolization.
• RFA for renal AML is safe and effective.
Abstract Objective Few studies report long-term follow-up of renal cancer treated by radiofrequency ablation (RFA), thus limiting the comparison of this modality to well-established long-term ...follow-up series of surgically resected renal masses. Herein, we report long-term oncologic outcomes of renal cancer treated with RFA in a single institution. Methods and materials We retrospectively reviewed patients treated between November 2001 and October 2012 with laparoscopic-guided or computed tomography–guided RFA. All treatments were performed with real-time thermometry ensuring target ablation temperature (>60°C) was adequately reached. Only patients with biopsy-confirmed T1a-category cancer and a follow-up period>48 months were included in our analysis. Follow-up included office visits, laboratory work, and periodic contrast-enhanced imaging. Survival was calculated using the Kaplan-Meier analysis. Overall complications were reported using the Clavien-Dindo scale. Results Of 434 RFA cases, 53 treatments in 50 patients met the inclusion criteria. Of these, 29 were treated with computed tomography–guided RFA and 24 with laparoscopic-guided RFA. The mean follow-up interval was 65.6 months (48.5–120.2), and the mean renal mass size was 2.3 cm (0.3–4.0). There were 4 (7.5%) local recurrences and 1 case of distant metastases with no local recurrence. The 5-year overall survival was 98%, cancer-specific survival was 100%, and recurrence-free survival was 92.5%. The complication rate was 26.4%, which included 71% of Clavien-Dindo grade I and 29% of grade II. Mean estimated glomerular filtration rate preoperatively and at the most recent follow-up visit was 77 and 66 ml/min, respectively. Conclusions When performed on selected patients, while monitoring real-time temperatures to ensure adequate treatment end points, RFA offers favorable long-term oncologic outcomes approaching those reported for partial nephrectomy.
Abstract The diagnosis of incidental small renal masses (SRM) has increased during the past two decades secondary to the increased use of various abdominal imaging modalities. In the past decade ...there has been a shift from radical nephrectomy to nephron sparing surgery techniques where partial nephrectomy has become the standard of care. Thermal ablation (TA) modalities such as freezing or heating delivered percutaneously for the treatment of small renal masses (SRM) is now offered in many Institutions as a treatment option. Clinical guidelines have indicated that TA is appropriate for select patients that are medically high risk or elderly. In our institution and in select centers, TA is discussed and often offered for all patients with SRM as equivalent treatment without respect to age or co-morbidities. As provider experience improves and long-term outcome studies become available, TA is becoming increasingly accepted as a potential new standard of care for solid SRM. This review will highlight the role of image guided radiofrequency ablation (RFA) techniques and their application focusing on the different imaging modalities for RFA application which, most commonly, include percutaneous (Magnetic Resonance Imaging (MRI) and computerized tomographic (CT). Our aim is to summarize those studies along with long term follow up.
Purpose With the exponential growth of robotic urological surgery, particularly with robot assisted radical prostatectomy, guidelines for safe initiation of this technology are a necessity. Currently ...no standardized credentialing system exists to our knowledge to evaluate surgeon competency and safety with robotic urological surgery performance. Although proctoring is a modality by which such competency can be evaluated, other training tools and guidelines are needed to ensure that the requisite knowledge and technical skills to perform this procedure have been acquired. We evaluated the current status of proctoring and credentialing in other surgical specialties to discuss and recommend its application and implementation specifically for robot assisted radical prostatectomy. Materials and Methods We reviewed the literature on safety and medicolegal implications of proctoring and the safe introduction of surgical procedures to develop recommendations for robot assisted radical prostatectomy proctoring and credentialing. Results Proctoring is an essential mechanism for robot assisted radical prostatectomy institutional credentialing and should be a prerequisite for granting unrestricted privileges on the robot. This should be differentiated from preceptoring, wherein the expert is directly involved in hands-on training. Advanced technology has opened new avenues for long-distance observation through teleproctoring. Although the medicolegal implications of an active surgical intervention by a proctor are not clearly defined, the role as an observer should grant immunity from malpractice liability. Conclusions The implementation of guidelines and proctoring recommendations is necessary to protect surgeons, proctors, institutions and, above all, the patients who are associated with the institutional introduction of a robot assisted radical prostatectomy program. With no current guidelines we anticipate this article will serve as a catalyst of interorganizational discussion to initiate regulatory oversight of surgeon certification and proctorship.
Abstract Objectives Treatment options for small renal tumors have evolved from radical nephrectomy (RN) to partial nephrectomy (PN), thermal ablation, or active surveillance. With the advancement of ...techniques, costs differences are unclear. The objective of this study is to compare the 6-month costs associated with nephron-sparing procedures for cT1a renal tumors. Materials and methods We performed a review of patients diagnosed with a solitary cT1a renal mass who underwent surgical treatment from June 2008 to May 2011. Open partial nephrectomy (OPN), robot-assisted partial nephrectomy (RLPN), laparoscopic radio-frequency ablation (LRFA), or computed tomography guided radio frequency ablation (CTRFA) was performed on 173 patients. Cost data were collected for surgical costs, associated hospital stay, and the 6-month postoperative period. Results Patients underwent surgery, including 52 OPN, 48 RLPN, 44 LRFA, and 29 CTRFA. Median total costs associated were $17,018, $20,314, $13,965, and $6,475, for OPN, RLPN, LRFA, and CTRFA, respectively. When stratified by approach differences were noted for total cost ( P < 0.001), operating room (OR) time ( P < 0.001), surgical supply ( P < 0.001), and room and board ( P < 0.001) in univariable analysis. Multivariable linear regression ( R2 = 0.966) showed surgical approach ( P = 0.007), length of stay ( P < 0.001), and OR time ( P < 0.001) to be significant predictors of total cost. However, tumor size ( P = 0.175), and Charlson comorbidity index ( P = 0.078) were not statistically significant. Conclusions Six-month cost of nephron-sparing surgery is lowest with radio frequency ablation (RFA) by either laparoscopic or computed tomography (CT)-guided approach compared to RLPN and OPN. As oncologic and safety outcomes improve and become comparable in all nephron-sparing surgery (NSS) approaches, cost of each procedure will start to play a stronger role in the clinical and healthcare policy setting.
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