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. 2022 Oct 26;93(5):e2022220. doi: 10.23750/abm.v93i5.12827

Percutaneous Radiofrequency Ablation (RFA) in renal cancer. How to manage challenging masses. A narrative review

Francesco Ziglioli 1,✉, Massimo De Filippo 2, Domenico Maria Cavalieri 2, Francesco Pagnini 2, Davide Campobasso 1, Giulio Guarino 1, Umberto Maestroni 1
PMCID: PMC9686170  PMID: 36300239

Abstract

Background and aim:

In the last decades, the refinements in the imaging techniques led to an increased number of detected renal tumors. If radical and partial nephrectomy remain the gold standard for the treatment of renal cancer, Radio-Frequency Ablation (RFA) has emerged as a therapeutic option for renal masses. Even if this technique is minimally-invasive, it requires a proper preoperative anatomic study and in some cases RFA treatment is technically challenging. To date, there is no standardization for studying challenging cases before treatment and to plan a safe and effective procedure when intervening organs are in the trajectory of the needle. In this study we searched the literature focusing on the challenging cases and strategy applied to manage the treatment safely and effectively.

Materials and methods:

MedLine and Embase via Ovid database were searched, using the following key words: Percutaneous RFA, radiofrequency, renal ablation, kidney ablation, renal thermoablation, kidney thermoablation, hydrodissection, heat sink. The difficulties found in the literature while performing the ablation procedure were grouped and a categorization of the strategies applied to perform a safe and effective procedure was proposed, in the aim to standardize the approach for treatment of challenging cases. Literature was analyzed according with selection criteria agreed by the Authors.

Results:

The literature review showed four groups of lesions requiring an experienced approach. Group 1: Lesions close to the bowel. Group 2: Lesions close to the urinary tract. Group 3: Lesions close to intervening organs. Group 4: Lesions close to large vessels (heat-sink phenomenon).

Conclusion:

When planning a RFA treatment, a standardized approach to challenging masses is possible. This review make the treatment of these masses more systematic and safe. (www.actabiomedica.it)

Keywords: radiofrequency, RFA, renal cancer, thermoablation

Appendix - Supplementary Material
Click here for additional data file. (8.4MB, pdf)

Figure S1.

Figure S1.

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RCC (arrow) close to ascending colon.

Figure S2.

Figure S2.

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The distance between the two organs (arrow) is significantly increased thanks to the injection of 100 cc of glucose solution.

Figure S3.

Figure S3.

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Axial plane image shows the absence of contrast enhancement in the treated area, demonstrating successful ablation.

Figure S4.

Figure S4.

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Sagittal image shows RFA probe in place, close to the the upper calyx (arrow) of the kidney.

Figure S5.

Figure S5.

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Axial pane image shows low density area (arrow) corresponding to the treated zone.

Figure S6.

Figure S6.

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Lateral caudo-cranial approach allows a good probe positioning (coronal and axial plane).

Figure S7.

Figure S7.

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Absence of contrast enhancement in the treated area, showing successful ablation.

Figure S8.

Figure S8.

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Abscence of contrast enhancement in the treated area, showing successful ablation.

Introduction

Due to the increased detection of tumors by ultrasound (US) and computed tomography (CT), the number of incidentally diagnosed Renal Cell Carcinomas (RCCs) has increased (1-4). These tumors are usually smaller and of lower stage (5).

For many years, radical nephrectomy has been considered the best therapeutic approach for patients with RCC confined to the kidney. Today, partial nephrectomy (PN) with the preservation of renal parenchyma is considered the gold standard for the treatment of small and localized RCCs. This technique has become more and more widespread over the last 10 years as it has proved to give similar oncologic results to radical nephrectomy in 5-year follow-up (6,7).

However, even if there is a low risk of mortality for young patients who undergo surgical resection, it is still responsible for morbidities (8,9).

The detection of an increasing number of RCC, and in some cases the old age of patients and their comorbidities, as well as previous renal failure, multiple RCC, hereditary RCC have led to the development of minimally invasive ablative techniques as an alternative to surgery in order to preserve renal function as much as possible.

For these reasons, in the last decades, percutaneous Radiofrequency Ablation (RFA) of renal tumors has been proposed as a therapeutic option.

Nevertheless, percutaneous treatment may be challenging due to the proximity of the surrounding organs, such as ureter, bowel, liver, and in some cases the lung. Moreover, the proximity of large vessels may decrease the effectiveness of the treatment, due to the so called heat sink phenomenon. Even if some techniques have been proposed in the last years to make the procedure safe and effective even if the bowel or a large vessel are close to the targeted lesion, a systematic approach to challenging procedure is still far away.

This review aims to highlight which masses should be considered “challenging” to treat and to increase the awareness of treating a mass that may require a higher level of expertise in order to make the procedure safe and effective. In addition, we reviewed the literature focusing on the technical aspects of the treatment of challenging masses, aiming to make more systematic the approach to these masses.

Background of RFA for Renal Masses

RCC is the commonest cancer of the kidney, accounting for 2-3% of all cancers, with a higher incidence in Western countries (10,11). Over the last two decades, the incidence of RCC has increased by about 2%, probably due to increased detection rate by US, CT, MRI and renal biopsy (12-16) and the increased risk related to cigarette smoking and obesity (17,18). Reportedly, the accuracy of the imaging techniques has improved also for many other urologic tumors and is may be integrated with confirmation biopsy selected cases (19,20).

For many decades, radical nephrectomy was considered the gold standard treatment for RCC and for a long time it was actually the only curative option.

However, the refinements in surgical techniques together with improvements in imaging modalities, led to the development of nephron-sparing surgery, such as open, laparoscopic and robotic PN (8,21).

The advantages of laparoscopic and robot-assisted approach are well known and consist of shorter hospital stay, reduced morbidity, smaller wound, decreased analgesic requirement, reduced intraoperative blood loss and rapid recovery of patient’s strength.

As for other minimally-invasive techniques for treating other genitourinary cancers (22), there is common agreement in the literature that radical surgery and nephron-sparing surgery are equivalent in terms of both oncologic and functional outcome (23,24).

Despite the number of studies reporting excellent results of the nephron-sparing techniques, investigations into ablative methods have expanded considerably, such as cryoablation and radiofrequency ablation (RFA).

In 1997, Zlotta et al reported the first clinical use of RFA for the treatment of localized renal masses (25). The American Association of Urology (AUA) supports consideration for RFA, stating this technique as a viable option for T1a stage renal malignancies smaller than 4 cm in size (26).

The European Association of Urology shares consideration for RFA, reporting the recommendation to offer RFA to elderly and/or comorbid patients with small renal masses (≤ 4cm) (27).

In more details, Clark TW et al report the standard for percutaneous thermal ablation of renal carcinoma (28), showing that potential conditions of patient for RFA are those who are considered poor surgical candidates, due to impaired renal function, solitary kidney or comorbidities, as well as those with a high risk of RCC recurrence as a consequence of genetic syndromes, including Von Hippel-Lindau and Birt-Hogg-Dubé (29).

Even if the majority of studies on RFA are retrospective, with a small number of patients and in some cases with a short follow-up, almost all reported that the procedure is safe and effective (28-30,31) and found no differences in Recurrence Free Survival (RFS) and Cancer Specific Survival (CSS) between surgery and RFA (13,32-34).

Patients demographics of the cohorts reported in the literature show that the majority of lesions treated with RFA are exophytic. Olweny et al. argue that the decision to treat a patient with RFA or cryoablation (CRA) rather than PN is often made upon “clinical judgement” (35). In retrospective observational studies where RFA is compared to PN, indeed, it is clear that the more a lesion is easy to be reached, the more the patients is likely to be indicated to RFA. This makes it arguable that lesions technically challenging to treat are easily considered unfit for RFA.

As a matter of facts, renal masses centrally located in the kidney, close to the pelvis or the calices require much more experience than small exophytic lesions and their treatment may expose to a number of clinically relevant complications, such as urinary fistula, bleeding, hematoma and infections. However, in our review of the literature we found that, in experienced hands, the treatment of renal masses close to the urinary tract did not show a significantly higher complication rate than the treatment of other masses.

Another circumstance that may make the percutaneous RFA challenging is the presence of large vessels close to the renal mass. As it is reported in the literature, tumors close to large vessels will suffer a heat sink, as regional vascular flow reduces the extent of the heat-induced damage (3).

Last but not least, percutaneous access to the renal mass may be complicated by the liver or the lung in the trajectory of the needle. In such cases, a modified patient decubitus and/or a modified percutaneous access may make the procedure feasible and effective avoiding to damage the intervening organs and tissues.

In conclusion, RFA of renal tumors seems to be safe and effective with a few tricks in most technically challenging cases, such as lesions located close to urinary tract, large vessels and bowel or lesions difficult to reach due to intervening organs.

Materials and Methods

Literature search and selection. We reviewed the literature focusing on the technical aspects of RFA for renal masses. The literature search was restricted to those cases requiring additional technical expertise in order to avoid complications and perform the treatment effectively and safely.

MedLine and Embase via Ovid database were searched, using the following key words: Percutaneous RFA, radiofrequency, renal ablation, kidney ablation, renal thermoablation, kidney thermoablation, hydrodissection, heat sink.

Selection criteria were: English language, articles published between 2001 and 2020, case series or case reports that included the treatment of masses presenting as technically difficult to treat and requiring the application of a dedicated approach, such as specific techniques; note of caution during treatment; unconventional radiologic study prior to or during the treatment; prolonged treatment due to the anatomic feature of the mass. All studies that did not meet the inclusion criteria were excluded.

All the articles were grouped into different groups by typology of difficulties encountered at the time of the procedure. We did not define any category before the literature search, as this would preclude the possibility to report groups of “challenging” procedure not expected before starting to search the literature. The design of the study was intended to report, analyze and discuss all the difficulties reported on the percutaneous ablation of renal masses. At the end of the process of literature search and selection and the analysis of the articles, the categories were defined by similarity of the difficulties reported by the Authors.

Results

Our review of the literature found 4 groups of potential “challenges”. Group 1: lesions close to the bowel; Group 2: lesions close to the urinary tract (pelvis, calices, ureter); Group 3: lesions difficult to reach due to intervening organs (liver, lung and genito-femoral nerve); Group 4: lesions close to large vessels.

Discussion

Group 1: Lesions Close to The Bowel

The proximity of the bowel to the renal mass may increase the complexity of the ablation procedure. Inadvertent thermal damage to the bowel may have detrimental effects, such as perforation, fistulas or abscesses (36).

In the first reports of RFA procedure, a distance between bowel and renal tumor ≤ 3 cm was considered a contraindication. Nevertheless, early attempts to increase the distance between bowel and kidney are reported in the literature consisting in changing patient position (37).

As of today, adjusting patient position in considered a non-invasive method to prevent complications. Even if this technique is still recommended, whenever possible, because it is easy and costless and may help increase the distance from the bowel due to gravity (38), specialized bowel displacement techniques enable to make the ablation procedure safe and effective.

The most common invasive method to displace the bowel is hydrodissection (39,40). This technique consists in infusing sterile water or 5% dextrose solution into the tissue between the kidney and the bowel under CT guidance (Figure 1, S1-S3) (40,41).

Figure 1.

Figure 1.

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Hydrodissection needle placed between the colon and the kidney (arrow).

The evaluation of prior cross-sectional imaging is fundamental, but the operator has to be aware of the change of position of the bowel from supine decubitus, in which CT is performed, to prone or lateral one, in which the patient is positioned during radiofrequency ablation (39).

The precise knowledge of local anatomy is of the utmost importance, as the effectiveness of the dissection depends on the exact plane in which the needle tip is inserted (42). In order to achieve a real time monitoring of the dissected area, the injection of non-ionic contrast medium may be considered (43). At this regard, CIRSE Guidelines recommend a contrast/fluid dilution ratio of 1:50 (44). Hydrodissection, including the use of contrast medium, is reported not to affect the oncological outcome of the radiofrequency ablation, according with Khan F, et al. (45).

Although the rationale of hydrodissection is to increase the distance between organs, this technique also helps reduce the heat sink effect, thanks to the displacement of vessels from the ablation area (44).

Technical failure of hydrodissection in separating organs is not frequent, and it may occur in case of adhesions, generally related to previous surgery or when the injected fluid disperses from the site of injection (39).

Another technique that can be used for bowel displacement is probe traction and/or torqueing. The probe may be employed as a lever against the skin entry site or may be rotated to move vulnerable organs away from the ablation area (44,46,47). Straight probes can be used as a lever only, while probes with expandable electrodes can be used for torqueing, as they are fixed inside the lesion. Probe traction and torqueing are described not only for kidney, but also for lung and liver.

Reportedly, however, the efficacy of this technique is limited. Ginat DT, et al. reported that this technique allow only 8mm displacement in renal tumor RFA, but in other series only a 3-4mm displacement was obtained (39). Probe traction/torqueing is less effective in patients with little perirenal fatty tissue, as in this case there is limited excursion (48).

However, it is intuitive that this displacement technique carries the risk of potentially injuring the renal pedicle when performed forcefully, although major complications are not reported in the literature to our knowledge (39).

We reported probe traction/torqueing following hydrodissection, because it can be considered a complementary displacement technique, able to increase the efficacy of other methods.

Group 2: Lesions Close to The Urinary Tract

A damage to the ureter during the ablation procedure may have detrimental effects, like stricture formation and loss or renal function (48,49). The incidence of ureter complication is reported to be 1-2% (50,51). For this reason, all renal tumors close to the ureter, as well the pelvis and the calices, must be considered at risk when planning RFA treatment (Figure 2, S4, S5).

Figure 2.

Figure 2.

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RCC (arrow head) close to the renal pelvis (arrow).

Unfortunately, patient position does not affect the position of the urinary tract. This led to the development of specific techniques to protect the urinary tract.

Among these, one of the most used is the pyeloperfusion. According with CIRSE Guidelines, pyeloperfusion is recommended in medial/inferior renal tumors < 1.5cm from the ureter or the uretero-pelvic junction (44).

Originally reported as a technique able to preserve renal parenchyma by achieving hypothermia during surgical procedures (52), pyeloperfusion showed to be of help in protecting the ureter during RFA (53,54). This technique consists in the placement of an externalized 5- to 7-French ureteral stent and irrigation during the procedure (44). The ureteral stent is generally removed at the end of the procedure, but is may be left in place for a few days or exchanged for and internal ureteral catheter (double-J) for a few weeks in case of challenging procedure of suspect of ureteric damage (40).

The safety of pyeloperfusion and its efficacy in reducing potential complications related to the RFA procedure have been reported by many authors (54-56).

Theoretically, cooled irrigation may result in a heat-sink effect, thus reducing the effectiveness of thermal ablation. In favor of pyeloperfusion, however, it is well known the study of Margulis, showing that pyeloperfusion did not reduce the ablation volume in in vivo models [57].

Also, data reported in the literature suggest that pyeloperfusion does not affect the oncological outcome of the RFA procedure (56,58).

Group 3: Lesions Close to Intervening Organs

Lesions located in the upper pole of the kidney may be close to the lung or to the liver (Figure 3, S6, S7). Park BK et al. argues that the injury to these organs comes from inappropriate manipulation of the probe (59). The obliquity of the trajectory of the probe is fundamental to avoid damage to these organs, as a vertical direction is reported to be one of the most frequent causes of pneumothorax (48), a complication with an incidence or 2% in the literature (51).

Figure 3.

Figure 3.

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Axial plane image shows the RCC (arrow) close to the liver and on the same level of the right lower lobe of the lung.

A mass located in the anterior part of the right kidney may require a transhepatic approach, that in selected cases has to be considered as one of the possible options, as it might be safer than passing the needle through a large portion of renal parenchyma (60).

Conversely, pneumothorax may be intentionally created, in order to perform an effective puncture of the lesion. In these cases, the RFA procedure should not be delayed and should be completed in the shorter time possible. A severe pneumothorax may require drainage, whereas a mild pneumothorax can be treated conservatively with bed rest and oxygen therapy (59,61).

Noteworthy, the the genitor-femoral nerve runs along the psoas muscle. A damage to this nerve is reported in 2-6% in the literature and no effective treatment is reported to our best knowledge (44). The course of the genitor-femoral nerve should be considered when planning a RFA procedure. In case of masses ≤ 5mm distant from the psoas muscle, the above mentioned techniques of hydrodissection and probe traction are highly recommended (62,63).

Group 4: Lesions Close to Large Vessels (Heat-Sink Phenomenon)

Another circumstance that may make the percutaneous RFA challenging is the presence of large vessels close to the renal mass (Figure 4, S8). As it is reported in the literature, tumors close to large vessels will suffer a heat sink, as regional vascular flow reduces the extent of the heat-induced damage (3).

Figure 4.

Figure 4.

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Hilar endophytic RCC (arrow head) close to the left renal vein (arrow).

As the larger vessels of the kidney are in hilum, RFA showed limitations for the treatment of centrally located masses in terms of oncologic outcome in mid- to long follow-up.

In order to increase the distance between large vessels and the ablation area and to improve the oncologic results of RFA, some of the techniques described above for other challenging circumstances can be used.

First of all, the probe can be used as a lever, using the site of skin entry as a fulcrum. Probe traction/torqueing is actually the most simple technique to avoid the heat-sink phenomenon, thus assuring the effectiveness of the procedure (44,64).

Another technique that can be used to reduce the effects of the heat-sink phenomenon is the hydrodissection, which can displace large vessels from the ablation area (64).

Cryoablation is supposed to provide better results compared to RFA for centrally located renal masses, which is probably due to the superiority of multiple probes to decrease the effects of the heat-sink phenomenon. For this reason, in the aim to reduce the failure of RFA treatment, cryoablation and RFA would be weighed when planning the treatment of masses close to large vessels (60).

Conclusion

RFA is a minimally invasive treatment, but may result in major complications, that require further treatment. The risk of complications is much higher when the renal mass is difficult to reach due to intervening organs, or when it is close to the bowel. Similarly, the proximity of ureter may increase the risk of major complications. Finally, the heat-sink phenomenon is a cause of failure of the RFA treatment, reportedly.

Unfortunately, no algorithm or flowchart is known to minimize the risk of damaging surrounding organs and tissues in these challenging circumstances and the safety of the procedure is still in the hands of the surgeon, whose experience is crucial.

Our review highlights the characteristics of potentially challenging masses and outlines which technique is the most appropriate to make a safe and effective procedure. This review makes the approach to renal masses more systematic when planning a RFA treatment.

Conflicts of interest:

Each author declares that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangement etc.) that might pose a conflict of interest in connection with the submitted article.

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Associated Data

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Supplementary Materials

Appendix - Supplementary Material
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Figure S1.

Figure S1.

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RCC (arrow) close to ascending colon.

Figure S2.

Figure S2.

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The distance between the two organs (arrow) is significantly increased thanks to the injection of 100 cc of glucose solution.

Figure S3.

Figure S3.

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Axial plane image shows the absence of contrast enhancement in the treated area, demonstrating successful ablation.

Figure S4.

Figure S4.

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Sagittal image shows RFA probe in place, close to the the upper calyx (arrow) of the kidney.

Figure S5.

Figure S5.

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Axial pane image shows low density area (arrow) corresponding to the treated zone.

Figure S6.

Figure S6.

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Lateral caudo-cranial approach allows a good probe positioning (coronal and axial plane).

Figure S7.

Figure S7.

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Absence of contrast enhancement in the treated area, showing successful ablation.

Figure S8.

Figure S8.

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Abscence of contrast enhancement in the treated area, showing successful ablation.

Articles from Acta Bio Medica : Atenei Parmensis are provided here courtesy of Mattioli 1885

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