title: Surgical Salvage of Thermal Ablation Failures for Renal Cell Carcinoma.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  Patients with thermal ablation refractory tumors requiring surgical salvage from 1997 to 2013 were identified and retrospectively reviewed.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Juan A
authors.initials: JA
authors.lastname: Jiménez
authors.affiliation: Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Zhiling
authors.initials: Z
authors.lastname: Zhang
authors.affiliation: Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Juping
authors.initials: J
authors.lastname: Zhao
authors.affiliation: Department of Urology, University Hospitals Case Medical Center, Cleveland, Ohio.
authors.forename: Robert
authors.initials: R
authors.lastname: Abouassaly
authors.affiliation: Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Amr
authors.initials: A
authors.lastname: Fergany
authors.affiliation: Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Michael
authors.initials: M
authors.lastname: Gong
authors.affiliation: Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Jihad
authors.initials: J
authors.lastname: Kaouk
authors.affiliation: Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Venkatesh
authors.initials: V
authors.lastname: Krishnamurthi
authors.affiliation: Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Robert
authors.initials: R
authors.lastname: Stein
authors.affiliation: Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Andrew
authors.initials: A
authors.lastname: Stephenson
authors.affiliation: Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: campbes3@ccf.org.
authors.forename: Steven C
authors.initials: SC
authors.lastname: Campbell
mesh_terms: D000368:Aged; D002292:Carcinoma, Renal Cell / Q000601:surgery* / Q000628:therapy; D017115:Catheter Ablation; D003452:Cryosurgery; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000601:surgery* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy; D012189:Retrospective Studies; D016879:Salvage Therapy; D017211:Treatment Failure
keywords: ablation techniques; carcinoma; cryosurgery; local; neoplasm recurrence; nephrectomy; renal cell