73 96
Priority
Focus
–
Editorial
Referring
to
the
article
published
on
pp.
66–72
of
this
issue
Maximally
Invasive Ablation Versus Minimally
Invasive
Partial
Nephrectomy
Jed-Sian
Cheng
* ,Michael
L.
Blute
Massachusetts
General Hospital,
Boston, MA, USA
Renal
preservation
techniques
have
become
prevalent
and
favored
in managing
incidental
small
renal masses
(SRMs).
Currently,
the
minimally
invasive
partial
nephrectomy
(MIPN)
is
a
standard
for
the
treatment
of
SRMs.
The
comparison
of MIPN
and
laparoscopic
renal
cryoablation
(LRC)
in
this article by
Fossati
et al
is not
the most practical
[1].
The
development
of
percutaneous
ablation
techniques
such
as
radiofrequency
ablation
(RFA)
and
cryoablation
have mostly
supplanted
the use of LRC. The authors alluded
to
the
fact
that
LRC
patients
tended
to
be
older
and
sicker
and
thus selected
for ablation. Would
it then not make sense
to
perform
a
less
invasive
procedure
on
these
sicker
patients?
A
percutaneous
ablation
would
bypass
the
need
for
general
anesthesia
and
the need
to
insufflate
the
abdomen
with
pneumoperitoneum.
If
one
were
to
go
through
the
trouble of
laparoscopic dissection of
the kidney
for an SRM,
it would not
take much
time
to perform an MIPN.
In
fact,
the
operative
times
in
this
study were
essentially
equivalent.
More
surprisingly,
the
blood
loss was
significantly
greater
in
the
LRC
group
[1].
It
is
hard
to
determine whether
these
are
just
compar-
isons
because
a
number
of
factors
have
not
been
well
evaluated. Nephrometry
scoring
[2]and PADUA
scoring
[3]are necessary
to determine
the
relative difficulty
of
a
renal
mass
for
an
intervention.
Not
having
these
complexity
scores
represents
a
significant
knowledge
gap;
they might
have
provided
more
insight
into
the
interventions
de-
scribed. Moreover,
inclusion
of
the
learning
curve
of
the
surgeons
and
for
which
procedures
(laparoscopic
partial
nephrectomy,
robotic partial nephrectomy, or LRC) was not
well detailed and could have affected many of
the measured
outcomes. Selection bias has not been well accounted
for
in
this
study
and
makes
interpretation
of
the
final
results
somewhat
difficult.
An
interesting
finding
is
the
decrease
in
renal
function,
which was
significantly
different
at
the
6-mo
interval
but
not
so
after 3 yr.
Figure 2b
[1]suggests
that
there
seems
to
be a
recovery of glomerular
filtration
rate
(GFR)
in
the MIPN
group
compared with
the
LRC
group. This
could be
a
result
of compensatory
renal
recovery,
treatment effect, or patient
selection.
Ischemia
time
for
the MIPN was not
reported and
may
have
played
a
role
in
the
initial
loss
and
recovery
of
GFR.
For LRC
to
improve on MIPN,
it needs
to be
superior, and
a
significant
disadvantage
to
the
procedure
includes
the
possibility
of
nondiagnostic
pathology
in
10%
of
the
patients.
In
recent
years,
percutaneous
renal
biopsies
have
increased
in accuracy and diagnostic rate
[4,5] .Biopsy
in
the
preoperative
period
should
be
considered,
especially
in
patients
with
increased
age
and
comorbidities,
and
thus
would
reduce
the
risk
of
benign
disease
undergoing
therapy.
In
summary,
this paper
[1]is
a
comparison of MIPN
to
a
maximally
invasive
cryoablation
technique.
In
a
world
of
minimally
invasive
approaches
to
treating
patients,
espe-
cially morbid
and
elderly
patients,
it
is
unclear
that
LRC
is
going
to
emerge
as
a preferred
option.
Studies have
shown
the
efficacy
of
percutaneous
RFA
[6]and
cryoablation
[7].
Better
studies
are
needed
comparing
percutaneous
ablation
with
MIPN.
For
healthy
patients,
we
would
advocate
for
surgical
resection.
In
elderly
and
comorbid
patients, we
advocate
for
percutaneous
biopsy
and
percu-
taneous
ablation.
Conflicts
of
interest:
The
authors
have
nothing
to
disclose.
E U R O P E A N U R O L O G Y F O C U S 1 ( 2 0 1 5 ) 7 3 – 7 4ava il abl e
at
www.sc iencedirect.comjourna l
homepage:
www.europeanurology.comDOI
of
original
article:
http://dx.doi.org/10.1016/j.euf.2015.02.002.
* Corresponding
author. Department
of Urology, Massachusetts General Hospital,
55
Fruit
Street, GRB
1102,
Boston, MA
02114, USA.
address:
jec870@mail.harvard.edu(J.-S.
Cheng).
http://dx.doi.org/10.1016/j.euf.2015.06.0062405-4569/
#
2015
European
Association
of Urology.
Published
by
Elsevier
B.V.
All
rights
reserved.