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- •Foreword
- •Preface
- •Contents
- •Contributors
- •Imaging
- •Personal Preference
- •Introduction
- •Traditional Radical Therapies
- •Active Surveillance
- •Why Consider Focal Therapy?
- •Cancer Treatment Needs
- •Functional Outcomes
- •Conclusion
- •Introduction
- •Focal Therapy Candidates
- •The Index Lesion Theory
- •Further Prospective
- •Conclusions
- •References
- •Introduction
- •Renal Mass Biopsy
- •Approach
- •Cryoablation
- •Treatment Temperature
- •Radiofrequency Ablation
- •Treatment Temperature
- •Intraoperative Monitoring
- •Cryoablation
- •Radiofrequency Ablation
- •Recommended Imaging Follow-Up Protocol
- •Emerging New Ablative Modalities
- •Microwave Ablation
- •Irreversible Electroporation
- •Radiation Therapy
- •Oncological Outcomes
- •Local Recurrence-Free Survival
- •Overall Survival
- •Cryoablation Versus Radiofrequency Ablation
- •Complications
- •Conclusion
- •References
- •Introduction
- •Informed Consent
- •Why Focal Therapy?
- •References
- •References
- •Introduction
- •Conclusions
- •References
- •Introduction
- •Conclusions
- •References
- •Introduction
- •Prostate MRI
- •Robotic Surgery
- •Conclusion
- •References
- •Introduction
- •References
- •Introduction
- •Conclusions
- •References
- •Decipher
- •Oncotype DX
- •Prolaris
- •Limitations
- •Conclusion
- •References
- •Background
- •Androgen Manipulation
- •Conclusion
- •References
- •Introduction
- •Genomic Biomarkers
- •Genomic Heterogeneity
- •Targeted Biopsy Outcomes
- •Outcomes After Active Surveillance
- •Outcomes After Radical Prostatectomy
- •Conclusions
- •References
- •Introduction
- •Early Prostate MRI Consensus Meetings
- •PI-RADS v2
- •PI-RADS v2.1
- •PI-RADS Vs. Likert Score
- •MRI-Targeted Biopsies
- •Reporting Cancer Recurrence
- •MRI After Focal Therapy
- •Conclusion
- •References
- •MR Segmentation
- •US Segmentation
- •MR-US Registration/Fusion
- •Conclusion
- •References
- •Introduction
- •Ultrasound Elastography
- •Strain Elastography
- •Shear Wave Elastography
- •Patient Factors During FB
- •Discussion
- •Learning Curve
- •Core Number Optimization
- •Transrectal Versus Transperineal
- •Future Directions
- •Acoustic Radiation Force Impulse (ARFI) Imaging
- •Quantitative Ultrasound
- •Micro-Ultrasound
- •Multiparametric Ultrasound
- •Conclusions
- •References
- •Multi-Parametric Magnetic Resonance Imaging
- •References
- •Introduction
- •Cognitive Fusion
- •In-Bore MRI-Guided Biopsy
- •Software-Based Image Coregistration
- •Registration Algorithms
- •Biopsy Needle Tracking
- •Biopsy Approach
- •Commercial Systems
- •Electromagnetic Tracking
- •Mechanical Position Encoders
- •Image-Based Tracking
- •Discussion
- •Conclusion
- •References
- •Introduction
- •Complications
- •Urinary Retention
- •Bleeding
- •Conclusion
- •References
- •Introduction
- •Institutional Examples
- •Setting
- •Results
- •Discussion
- •Summary
- •References
- •Introduction
- •PET-Guided Targeted Prostate Biopsy
- •Gallium-68 (68Ga)-Radiolabeled PSMA Ligands
- •Fluorine-18 (18F)-Radiolabeled PSMA Ligands
- •Gastrin-Releasing Peptide Receptor (GRPR)
- •Future Outlook
- •Conclusion
- •References
- •Introduction
- •Approach
- •Sampling
- •Core Length
- •Histologic Submission
- •BxChip™
- •Reporting Results
- •References
- •Introduction
- •Location: Treatment Factors
- •References
- •Introduction
- •Focal Therapy Nomenclature
- •Nerve-Sparing (Unilateral or Bilateral)
- •Hemi-Ablation
- •Anterior Hockey-Stick Ablation (Anterior Three-Fourth)
- •Posterior Hockey-Stick Ablation (Posterior Three-Fourth)
- •Targeted Focal Therapy
- •Quadrant (Zonal) Ablation
- •Conclusions
- •References
- •Introduction
- •Cryotherapy
- •Irreversible Electroporation (IRE)
- •Transurethral Ultrasound Ablation (TULSA)
- •High-Intensity Focused Ultrasound (HIFU)
- •Surgery (Partial Prostatectomy)
- •Evolving Frontiers
- •Conclusion
- •References
- •Background
- •Procedure Selection
- •Patients’ Selection
- •Anesthesia
- •Perioperative Protocols
- •Procedure
- •Postoperative Period
- •Outcomes
- •Procedure Feasibility
- •Adverse Events
- •Outcomes
- •Conclusion
- •References
- •Clinical Background
- •Radiotherapy Techniques
- •Clinical Evidence About High-Dose Rate Interventional Radiotherapy (HDR IRT)
- •Clinical Evidence About Low-Dose Rate Interventional Radiotherapy (LDR IRT)
- •Clinical Evidence About Focal External Beam Radiotherapy (ERT)
- •Discussion
- •References
- •28: Focal Cryotherapy
- •Introduction
- •Focal Cryotherapy Procedure
- •Contemporary Focal Cryotherapy Series
- •Primary Focal Cryoablation
- •Salvage Focal Cryotherapy
- •Surveillance
- •Future Developments
- •Imaging
- •Cryotechnology
- •Immune Enhancer
- •References
- •Background
- •Energy Principles: Basic Science
- •Conclusion
- •References
- •Introduction
- •Early Studies
- •Phase 1 Clinical Trial (“Subtotal” Ablation)
- •Phase II (“TACT”) Clinical Trial (“Whole Gland” Ablation)
- •Patient Selection
- •Preoperative Imaging Planning
- •Intraoperative Considerations
- •Follow-Up Routine Post-Focal TULSA
- •Summary
- •References
- •Vapor 1 Study Results
- •References
- •Introduction
- •Robotic HIFU
- •Safety Features
- •Robotic HIFU Procedure
- •Intraoperative Monitoring
- •Built-in Contrast-Enhanced Transrectal Ultrasound
- •Postoperative Care
- •Follow-up
- •Oncologic Outcomes
- •Functional Outcomes
- •Complications
- •Conclusions
- •References
- •Indications
- •Contraindications
- •Preprocedure Workup
- •Technique
- •Outcomes
- •Complications
- •Controversies
- •Conclusion
- •References
- •Introduction
- •Posttreatment MRI Findings
- •High-Intensity Focused Ultrasound (HIFU)
- •Focal Laser Ablation (FLA)
- •Irreversible Electroporation (IRE)
- •Focal Cryotherapy (FC)
- •Photodynamic Therapy (PDT)
- •Future Perspectives
- •Conclusion
- •References
- •Introduction
- •Oncological Outcomes
- •Biochemical Recurrence
- •Functional Outcomes
- •Perioperative Complications
- •Urinary
- •Sexual
- •Bowel
- •Decision Regret
- •Conclusion
- •References
- •36: Assessing Functional Outcomes After Focal Therapy
- •High-Intensity Focused Ultrasound (HIFU)
- •Cryotherapy
- •Irreversible Electroporation (IRE)
- •Focal Brachytherapy
- •Focal Laser Ablation (FLA)
- •Photodynamic Therapy (PDT)
- •Microwave Ablation
- •Partial Prostatectomy
- •Bipolar Radiofrequency Ablation (bRFA)
- •Prostatic Artery Embolization (PAE)
- •Urinary Function
- •IPSS
- •EPIC
- •ICIQ-SF
- •Erectile Function
- •IIEF
- •EPIC
- •Safety Outcomes
- •Clavien-Dindo
- •CTCAE
- •Physical/Mental Outcomes
- •SF-12
- •Monitoring Patients After Focal Therapy
- •References
- •Introduction
- •PSA Nadir
- •PSA Density
- •Other Molecular Biomarkers
- •Follow-Up Protocols After FT
- •References
- •Introduction
- •Postbrachytherapy Treatment Changes
- •Post High-Intensity Focused Ultrasound (HIFU) Treatment Changes
- •Post Cryotherapy Treatment Changes
- •Post Laser Ablation Changes
- •Post Photodynamic Therapy Changes
- •Post Irreversible Electroporation Changes
- •Interstitial Microwave Thermal Therapy
- •Radiofrequency Ablation
- •References
- •39: Salvage Treatment Following Focal Therapy
- •Introduction
- •Salvage Treatment Modalities
- •Repeat Ablation
- •Salvage Radical Treatment
- •Salvage Radical Prostatectomy
- •Salvage Radiotherapy
- •References
- •Introduction
- •Ensuring Appropriate Quality
- •Conclusion
- •References
- •Patient Selection
- •Posttreatment Follow-Up
- •Conclusions
- •References
- •Index

2 The Story ofBreast andProstate Cancer: Parallels andCommon Controversies
21
Conclusions
Thanks to large, well-designed randomized clinical trials and an understanding of the underlying
biology of the tumor progression, the standard of
care for BCa has shifted over the past 50years
from RM to multidisciplinary therapy, including
focal surgical resection and systematic therapy.
To date, most newly diagnosed BCa are treated
with this multidisciplinary approach to achieve
excellent long-term oncologic outcomes while
maintaining a good quality of life. The side
effects of radical therapies, the biomolecular similarity to BCa, and the low tumor aggressiveness
are leading the urologic scientic community to
adopt FTs for PCa. However, the future of PCa
FT will depend on the results of long-term oncologic outcomes and the results of randomized trials comparing its efcacy with that of
conventional therapies. We should learn from the
work of the breast colleagues that a better understanding of the disease biology will lead to effective combinations of local and systemic therapies
for PCa, and this will be the key to preventing,
detecting, and treating the recurrence in FT. A
comprehensive, biological- based, and multimodal approach to PCa management will help to
improve PFS and patient quality of life.
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Focal Ablative Therapy
forLocalized Kidney Cancer
MohannadA.Awad, YuzhiWang, CraigG.Rogers,
PilarLaguna, andJereyA.Cadeddu
3
Introduction
Kidney cancer is the sixth and ninth most common cancer in the United States for men and
women, respectively. It accounts for approximately 81,800 new cases and 14,980 deaths per
year [1]. The incidence of kidney cancer has been
rising due to the increasing use of cross-sectional
imaging. Along with that, there has been a downstaging of newly detected kidney masses with
more than 70% being small and organ-conned.
As a result, there has been a paradigm shift in the
management of kidney cancer over the last two
decades, with an emphasis on minimally invasive
M. A. Awad
Department of Urology, University of Texas
Southwestern Medical Center, Dallas, TX, USA
Department of Surgery, King Abdulaziz University,
Rabigh, Saudi Arabia
e-mail: mohannad.awad@utsouthwestern.edu
Y. Wang · C. G. Rogers
Vattikuti Urology Institute, Henry Ford Health,
Detroit, MI, USA
e-mail: Crogers2@hfhs.org
P. Laguna
Department of Urology, Medipol University,
Istanbul, Turkey
J. A. Cadeddu (*)
Department of Urology, University of Texas
Southwestern Medical Center, Dallas, TX, USA
Department of Radiology, University of Texas
Southwestern Medical Center, Dallas, TX, USA
e-mail: Jeffrey.cadeddu@utsouthwestern.edu
treatment with nephron preservation and lower
morbidity while maintaining cancer-specic survival (CSS) [2].
Historically, the standard treatment for renal
cell carcinoma (RCC), including small renal
masses (SRM), was radical nephrectomy.
However, partial nephrectomy (PN) has gradually emerged as a viable alternative option for
SRM, given that it provides comparable oncological outcomes (>95% CSS) with radical
nephrectomy and is associated with improved
renal function preservation, superior cardiac outcomes, and similar overall survival [3, 4]. As a
result of the excellent outcomes of PN, it is considered the gold standard for SRM by most urological guidelines including the American
Urological Association (AUA) [5]. Nevertheless,
irrespective of the surgical approach (open, laparoscopic, robotic), PN is underused due to the
higher technical demands and comparative risks
with the procedure [6]. Therefore, to broaden
minimally invasive management options for
SRM, energy-based focal or thermal ablation
(TA) systems, including cryoablation (CA) and
radiofrequency ablation (RFA) were introduced
in the 1990s.
Focal ablative therapies for SRM offer several
advantages compared with surgery. First, these
procedures are less technically demanding compared to open, laparoscopic, or robotic
PN. Consequently, these procedures are associated with shorter recovery and fewer complica-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
T. J. Polascik et al. (eds.), Imaging and Focal Therapy of Early Prostate Cancer,
https://doi.org/10.1007/978-3-031-66754-1_3
25

26
M. A. Awad et al.
tions [4, 7]. Second, ablation therapies have
minimal impact on post-ablation renal function.
This impact was found to be similar or better
when compared to PN [8]. Considering these
advantages, these minimally invasive therapies
are well indicated for patients with SRM who are
poor surgical candidates or at risk for renal insufciency. However, given the excellent long-term
published results with the growing experience,
these indications have been expanded to include
healthy patients with SRM [9]. As a result,
European and American urological associations
both include focal ablative therapy as a viable
alternative therapeutic option to surgery for SRM
<3cm [5, 10].
Role, Indications,
andContraindications
Studies suggest that around 20% of solid renal
tumors are benign at the time of surgery with
most small RCCs being low-grade histology [11,
12]. Given the knowledge that some of the SRMs
are benign or indolent, there recently has been
greater utility of active surveillance (AS) and
non-surgical therapies. While PN is still a nephron-sparing surgery for small tumors, TA has a
role in patients who are poor surgical candidates
due to age and multiple comorbidities, are at risk
for renal insufciency, or have solitary, bilateral,
and hereditary renal tumors. The current 2021
AUA and the 2023 National Comprehensive
Cancer Network (NCCN) guidelines state that
TA is an alternative treatment for cT1RMs<3cm.
Although there are multiple modalities of TA,
only CA and RFA are recommended by the
AUA. Patients undergoing TA should be counseled on the small risk of tumor persistence and
the possibility of salvage treatment to achieve an
outcome similar to conventional surgery [5,
13–15]. Absolute contraindications include
uncorrected coagulopathy and acute illness.
Relative contraindications include several tumor
characteristics that predict a lower chance of success with TA.Larger renal masses are less favorable for TA due to a higher likelihood of residual
tumors after treatment. Anterior and hilar tumors
are more likely to be in proximity to the bowel
and vessels, making these tumors more difcult
to access [16].
Renal Mass Biopsy
Renal mass biopsy (RMB) has emerged as a
diagnostic tool to characterize renal masses
(RMs) and guide treatment decision-making for
physicians and patients. In the setting of focal
therapy, the AUA, EAU, and NCCN guidelines
all state that RMB should be performed prior to
or at the time of TA to provide pathological diagnosis and guidance [5, 10, 13, 14].
RMB has been controversial in the past, with
criticisms regarding diagnostic accuracy, patient
safety, and tumor seeding along the biopsy tract.
Early biopsies had a high nondiagnostic rate of
31% [17]. However, recent literature indicates
that RMB is a safe and relatively accurate procedure with a diagnostic rate of around 90%.
Through a systematic review, Patel and col-
leagues found that 19% of the biopsies had
benign pathology and 14% were undiagnostic.
However, repeat RMB led to the diagnosis in
80% of patients with an initial undiagnostic
biopsy. Overall, the reported sensitivity, specicity, PPV, and NPV were 98%, 96%, 99%, and
69%, respectively. Reported complications were

3 Focal Ablative Therapy forLocalized Kidney Cancer
27
rare, but included hematoma, pain at the biopsy
site, gross hematuria, pneumothorax, and hemorrhage [18]. Another meta-analysis done by
Marconi etal. showed a median diagnostic rate
of 92%. There was good agreement between
tumor histology from RMB and surgical pathology with a median concordance rate of 90%.
There was a fair agreement between tumor grade
from RMB and surgical pathology, with a median
concordance rate of 87% for the 4-tiered Fuhrman
grading system. The sensitivity and specicity
for core needle biopsy were 99% for both, respectively [19]. Jeon and colleagues found an initial
and overall diagnostic rate of 89% and 91% for
RMBs at two large tertiary centers.
Tumor seeding is a rare occurrence. From
2013 to 2019 worldwide, there have been 12
cases of seeding associated with core needle
biopsy, calculated to be approximately 1 case per
3000 patients. Papillary histology, the use of a
needle larger than 20 g, and the absence of a
coaxial sheath were associated with tumor seeding [20]. The incidence of seeding remains low
and should not discourage the use of RMB.
Approach
TA therapies have traditionally been administered through the open, laparoscopic, and percutaneous routes. However, open and laparoscopic
techniques have been rendered obsolete in current practice [21, 22]. Percutaneous TA can be
performed under conscious sedation with local
anesthesia and general anesthesia as an outpatient or a short-stay procedure. Ablations can be
guided using ultrasound, magnetic resonance
(MRI), and most commonly computed tomography (CT) imaging [16]. Patient positioning and
direction of approach highly depend on the location and size of the tumor. It is also important to
consider the proximity of the SRM to nearby anatomical structures such as the bowel, renal vessels, ureter, ilioinguinal and genitofemoral
nerves, and psoas muscle. Therefore, potential
TA-induced complications include bowel injury,
ureteropelvic junction obstruction, and neuromuscular injury. Prior to the use of bowel displacement techniques, TA was contraindicated in
patients with bowel within 1–3cm of the target
lesion.
Hydrodissection is now the most common
bowel displacement technique used to protect
the bowel and other surrounding structures during TA.Specically, it can be utilized for anterior lesions to displace the colon for RMs
located in the posterior lower poles or adjacent
to the small bowel. It can also reduce the heat
sink effect by increasing the distance of vessels
from the tumor ablation site. Hydrodissection is
done through ultrasound, CT, or MRI-guided
instillation of uid into tissue between the kidney and surrounding structure. Typically, the
site is infused with 135–150cc of sterile water,
normal (0.9%) saline, 5% dextrose in water, or
0.5% lidocaine, which allows for up to 2.5cm of
extra bowel separation (Figs.3.1a, b, c). There
is caution associated with the use of saline with
radiofrequency ablation due to its high electrical
conductivity. Failure to separate organs can be a
result of uid spillage or difculty instilling
uid secondary to abdominal adhesions. In such
cases, needle repositioning or other bowel separation techniques can be utilized. These techniques include gas insufation, balloon
interposition, and electrode torquing [23–26].
TA can proceed when there is sufcient bowel
separation.

28
M. A. Awad et al.
a
b
c
Fig. 3.1 (a) A complex right renal mass (red arrow) with
adjacent bowel (green arrow). (b) The placement of the
RFA probes in the renal tumor and the spinal needle in the
small space between the tumor and the bowel.
Hydrodissection is then done with saline prior to ablation.
Of note, the RFA probe is placed and the umbrella tines
Principles ofAblation
Cryoablation
Background andMechanism ofAction
Although the theory of cryotherapy has existed
for millennia, the modern cryoprobe was rst
developed in 1963 with pressurized liquid nitrogen [27]. In 1995, Uchida and colleagues rst
described the use of CA for renal cell carcinoma
[28]. Currently, standard cryoprobes use argon
gas to generate a cooling effect based on the
Joule–Thomson principle, which states that low
temperatures occur with the rapid expansion of
deployed rst, followed by the spinal needle placement.
Then, hydrodissection is performed followed by removing
the spinal needle prior to ablation. (c) Post-ablation image
of the mass and the hydrodissection plane that was made
between the mass and the bowel
high-pressured gas. As argon gas ows through
the cryoprobe, it expands and can generate temperatures as low as −185.7°C within the target
tissue, inducing iceball formation around the target tissue [29, 30].
There are multiple mechanisms that explain
cell death during the freezing and thawing process of CA. Freezing temperatures cause direct
cellular injury through physical damage to cell
membranes and organelles. This is due to changes
in lipid properties with extreme shifts in temperatures, increasing uidity and permeability across
membranes. Freezing intracellular and extracellular liquids also change solute concentrations.

3 Focal Ablative Therapy forLocalized Kidney Cancer
29
Intracellularly, the cell experiences dehydration
from freezing, resulting in high solute concentrations and further protein denaturation.
Extracellular freezing similarly results in the
depletion of free water, which contributes to the
osmotic gradient to enhance cell dehydration.
The opposite extreme occurs with thawing. As
the ice melts, solute concentrations quickly
decrease, leading to a rapid ow of uid into
cells. This causes cellular edema and subsequent
membrane rupture. Vascular injury mechanisms
are described through multiple aspects. Freezing
leads to stasis in affected vessels, causing ischemia and necrosis in the associated region.
Physical distension in vessels can result in tears
in the endothelial wall. On the other hand, thawing introduces reperfusion injury to the affected
area. Both freezing and thawing can cause platelet aggregation, coagulation, and thrombosis.
Lastly, immunological mechanisms have not
been fully characterized but are thought to play a
role in cell death after CA.The immune system
becomes sensitized to the target tissue, thus
destroying any surviving cells in the area [31–33].
Overall, cell death occurs from apoptosis and
necrosis from the multiple mechanisms stated
above. Over several months, inammatory cells
in the necrotic tissue slowly create a brous collagen scar [34].
Treatment Temperature
The temperature within the iceball is not consistent, with the coldest temperatures adjacent to the
probe and the warmest temperatures at the edge of
the ball. Previous studies show that temperatures
below −20 °C are lethal for normal renal parenchyma. However, many authors theorize that
malignant cells, in general, are more cryo-resistant due to their brous nature and may require
lower temperatures for cellular death [29].
Therefore, it is recommended to achieve temperatures around −40 °C during freezing cycles to
ensure lethality [30, 32, 34, 35]. Tissue near the
edge of the iceball can range from 0 to −20°C,
which does not ensure lethality (Fig.3.2) [34].
Necrosis Zone
Indeterminate Zone
Viable Zone
Fig. 3.2 Iceball ablation zones: The central/necrosis
zone is characterized by uniform ablation and temperatures
<−40°C.Surrounding the central zone is the indeterminate
zone, which has areas of cell death intermixed with viable
cells and temperatures between −40 and −20 °C. The
outermost zone is comprised of mostly viable cells with
little to no necrosis and temperatures >−20°C
Freeze-Thaw Cycles andDuration
ofTreatment
Multiple freeze-thaw cycles can promote more
desirable results by affecting a larger area.
Current CA practices conduct two freeze-thaw
cycles with a freeze duration of 8–10 minutes
[30, 32, 34, 35]. Passive thawing allows the iceball to melt naturally after the freezing cycle,
which can be time consuming. Active thawing
uses helium gas to create a warming effect, again
through the Joule–Thomson principle, which
expedites the process [36]. There is no current
data to suggest the superiority of either thawing
method. The heat sink effect can also raise the
temperature of nearby vessels [32]. Lethal temperatures in the iceball are present until 3 mm
from the margin [29]. To ensure no surviving
tumor cells, the visualized edge of the iceball
should be at least 5–6mm beyond the edge of the
target lesion. Size and shape of the iceball can be
altered by different probes. Thinner probes result
in a smaller ablation zone, while thicker and multiple probes result in larger ablation zones [32,
33]. In the case of multiple probes, each probe
should be positioned around 1cm from the lesion
edge and 2cm from other probes [29].

30
M. A. Awad et al.
Radiofrequency Ablation
Background andMechanism ofAction
RFA uses radiofrequency energy to heat tissue to
the point of causing cellular death. In 1981,
d’Arsonval described the ability of radiofrequency waves to heat live tissue [37]. Initially,
the technology was not clearly understood, and
the energy was not effectively controlled till
Cushing and Bovie developed the electrocautery
knife. They described the ability to cauterize or
cut tissue using electrocautery energy, leading
the way to the development of the modern-day
electrocautery probe. The electrocautery probe
desiccates tissue at the point of contact when the
alternating current passes through the patient and
eventually dissipates in a remotely placed
grounding pad on the patient [38].
In 1990, two individual groups of researchers
published the development of probes for percutaneous ablation. These probes consisted of a layer
of insulation down to an exposed metal tip. This
allows for the needle to be passed percutaneously
to the deeper target tissue. Adjusting the length of
the exposed, uninsulated portion of the needle,
allows for the control of the amount of tissue
being destructed along the central axis of the
lesion [39, 40]. RFA uses monopolar alternating
electric current which is delivered at a frequency
of 450–1200kHz directly into the target tissue,
causing vibration of ions with tissue, resulting in
molecular friction and heat production. The
increase in temperature within the target tissue
results in cell membrane disintegration and cellular protein denaturation [41, 42].
Variation inRadiofrequency Ablation
Equipment
There are two main types of monitoring systems
while performing RFA: temperature based and
impedance based. These systems are essential to
ensure effective treatment and patient safety.
Temperature-based systems measure the temperature at the electrode tip, while impedance- based
systems measure tissue impendence at the tissue
probe interface. Temperature-based systems provide accurate measurements of the temperature at
the electrode tip but do not measure the tempera-
ture of the surrounding parenchyma. On the other
hand, impendence- based systems offer real-time
feedback on tissue changes during the procedure
and provide insights into the overall tissue
response. There is currently no clear evidence
supporting superiority of either monitoring system. The choice of either system depends on various factors, including the clinical situation, tissue
type, and the preference of the clinician.
The initial RFA probes were designed as single-electrode monopolar probes controlled by
changing the exposed uninsulated tip. These
probes were limited in their ability to treat
tumors larger than 2cm, requiring additional or
overlapping treatment regions [43]. To address
this issue, LeVeen (1997) introduced an insulated
monopolar probe that featured 12 deployable
tines functioning as radiofrequency antennas.
These tines are deployed in an umbrella shape,
allowing for a wider current dispersion and the
creation of a spherical lesion (Boston Scientic,
MA). When high impedance occurs at one prong,
the current is redirected to other areas of lower
impedance [44]. Another monopolar probe system is the starburst-shaped RITA device ®
(AngioDynamics, Queensbury, NY). It uses
embedded thermistors in ve of its nine tines to
modulate energy based on the average temperature of the electrodes. A different monopolar
impedance-based system by Covidien (Boulder,
CO) uses a single 17-gauge (cool tip) electrode
cooled internally with saline to prevent charring
of tissue near the probe. Comparative studies in
porcine liver showed larger ablation zones with
the “cool tip” system, more spherical ablation
volumes with the 12-tine electrodes, and better
reproducibility with the 9-tine electrodes [45].
Clinical validation studies have also indicated
improved necrosis, lesion accuracy, and treatment outcomes with multi-tine electrodes
[46–48].
Radiofrequency ablation technology can be
classied into “dry” and “wet’ RFA. In “dry”
RFA, tissue desiccation leads to charring and
increased impedance, limiting the ablation zone
size to less than four centimeters with a single
electrode. In contrast, “wet” RFA probes deliver
a constant saline infusion into the tissue and

3 Focal Ablative Therapy forLocalized Kidney Cancer
31
around the probe to lower the temperature at the
probe tip. This mitigates charring, prevents a
temperature rise in impedance, and allows for
larger ablation zones [45, 49]. Additionally, the
infusion of hypertonic saline creates a virtual
“liquid electrode” beyond the metal electrode,
effectively increasing the total electrode surface
area [50]. While “wet” RFA tends to create larger
lesions, it may result in less control over the exact
size of the ablation, potentially leading to overtreatment of the target area and ablating the adjacent normal parenchyma [51].
Treatment Temperature
The effectiveness of RFA in ablating target tissue
depends on factors such as power delivery, maximum temperature achieved, and duration of the
ablation [52]. When alternating radiofrequency
current is applied, it generates cellular agitation
and localized heating due to tissue impedance.
When the electrical impedance remains low, outward spherical tissue damage emanates from the
treatment probe. If the current is delivered too
rapidly, tissue charring can occur at the probetissue interface, resulting in increased impedance
and halted heating [53, 54]. To avoid incomplete
or nonuniform ablation, temperatures during
RFA are generally maintained at or below
105°C.It is also important to reach a minimum
target temperature that induces cellular death. In
studies using human prostate tissue, irreversible
cell injury was achieved at temperatures of 45°C
for 60minutes, 55°C for 5min, and 70°C for
1min [55]. Similarly, short exposures to temperatures above 70 °C were found to be lethal to
human RCC invitro [56]. Modern temperaturebased RFA generators are programmed to reach a
target temperature of 90–105 °C, with a minimum of 70 °C uniformly reached during the
treatment cycle to ensure successful ablation.
Impedance- based systems typically start at
40–80W and increase gradually at 10W/min to
a maximum of 130–200W until an impedance of
200–500 ohms is reached. Optimizing the power
delivery, temperature control, and impedance
monitoring in RFA procedures is essential to
achieve effective tissue ablation while avoiding
charring and incomplete treatment.
The success of RFA in reaching the target
temperature during treatment depends not only
on the proven energy delivery but also on the
surrounding treatment environment. When the
target zone is highly vascularized or located
near large blood vessels, thermal energy tends
to be dispersed to the cooler blood within these
vessels, resulting in a heat sink effect. This phenomenon can spare tumor cells near blood vessels and lead to treatment failures [57].
Experimental studies have shown that temporary renal ischemia, achieved through vascular
clamping, can increase the size of the treatment
lesion and accelerate the time to reach the target
temperature [58]. However, due to the risks of
arterial thrombosis and ischemia-reperfusion
injury to normal tissue, renal hilar occlusion is
not currently recommended. Instead, some
authors suggest selective arterial embolization
as a means to reduce the circulatory head sink
during RFA procedures [59]. This approach has
been successfully employed by the authors for
central or large tumors (>4cm) to minimize the
impact of blood ow on the efcacy of the
treatment.
While single-cycle RFA has been shown to
induce cellular death, studies using CA in animals have demonstrated enhanced cell death with
multiple treatment cycles. Consequently, when
utilizing a temperature-based system for RFA,
we recommend performing two separate RFA
cycles with a minimum cool-down period of
30seconds between them [60].
Intraoperative Monitoring
While various imaging modalities such as ultrasonography, MRI, and CT can be used to guide
the placement of RFA probes, there is currently
no reliable radiographic method to assess the
treatment zone [61, 62]. Unlike cryoablation,
where the expanding iceball visually indicates
the treatment zone, RFA relies on probe placement, accurate positioning, and measurement of
electrical impedance or temperature to dene the
treatment area. An alternative approach involves
placing nonconducting temperature probes
around the tumor’s periphery or deep margin to
independently monitor real-time treatment tem-
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