Expert Point of View: Alessandro Volpe, MD


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Partial nephrectomy remains the gold standard for patients with solitary renal masses and a long life expectancy. Ablation may be a rational initial choice for patients with a short life expectancy.
— Alessandro Volpe, MD

Formal discussant of this abstract, Alessandro Volpe, MD, of the University of Eastern Piedmont Hospital, Maggiore Della Carita Hospital, Novara, Italy, commented that nephron-sparing surgery is recommended for clinical stage T1 tumors; however, when compared with ablation, the advantages of nephron-sparing surgery disappear in older patients.

“Ablation can be offered to patients with kidney masses and older patients,” explained Dr. Volpe. “In younger patients, ablation has theoretical advantages, including less morbidity and a nephron-sparing approach.”

Study Strengths and Limitations

According to Dr. Volpe, the strengths of the study are that this is a relatively large series of healthy patients and that the researchers used a multidisciplinary approach with standardized technique to determine the ice ball with intraprocedural imaging.

The limitations Dr. Volpe mentioned were that the data were a from a single institution and were analyzed retrospectively. Also, use of general anesthesia limits the minimal invasiveness of the procedure, he said. Another limitation of this study is that only 63% of patients had biopsy-proven renal cell carcinoma, indicated Dr. Volpe. Although there was only one local recurrence, follow-up of 22 months is relatively short, he added.

“The lack of tumor histology is a problem, and this may dilute the results. It is possible that many of these masses were benign tumors. The follow-up is too short for local control outcomes, and the study did not stratify outcomes by tumor size. We need information on which patients can derive the most benefit from this approach,” Dr. Volpe stated.

Literature Comparison

Some studies have shown longer-term outcomes with cryoablation, Dr. Volpe continued. One study, by Thompson et al, showed lower overall survival with cryoablation vs partial nephrectomy but similar metastases-free survival.1 In addition, a systematic review of observational studies showed a 5 times higher risk of local disease progression and a 1.86 greater risk of metastatic disease progression with cryoablation vs partial nephrectomy in small renal masses.2

“The current series reported by Dr. Zaid conflicts with results of other studies,” acknowledged Dr. Volpe, “so we can’t recommend cryoablation as a standard.” The adoption of cryoablation has been slow in Europe, but there is a trend toward its increasing use in the United States in younger patients and academic centers.

“Partial nephrectomy remains the gold standard for patients with solitary renal masses and a long life expectancy. Ablation may be a rational initial choice for patients with a short life expectancy,” he stated. “The urologic community should foster clinical trials of ablation vs partial nephrectomy,” concluded Dr. Volpe. ■

Disclosure: Dr. Volpe reported no potential conflicts of interest.

References

1. Thompson RH, Atwell T, Schmit G, et al: Comparison of partial nephrectomy and percutaneous ablation for cT1 renal masses. Eur Urol 67:252-259, 2015.

2. Klatte T, Grubmüller B, Waldert M, et al: Laparoscopic cryoablation versus partial nephrectomy for the treatment of small renal masses: Systematic review and cumulative analysis of observational studies. Eur Urol 60:435-443, 2011.


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