Microwave ablation of the T1a small renal mass: expanding beyond 3 cm.

PURPOSE: To compare the oncological and renal function outcomes for patients receiving microwave ablation (MWA) in tumors < 3 and 3-4 cm. METHODS: Retrospective analysis of a prospectively maintained database identified patients with < 3 or 3-4 cm renal cancers undergoing MWA. Radiographic follow-up occurred at approximately 6 months post-procedure and annually thereafter. Serum creatinine and estimated glomerular filtration rate (eGFR) were calculated before and 6-months post-MWA. Local recurrence-free survival (LRFS) was estimated using the Kaplan-Meier method. Tumor size was evaluated as a prognostic factor using Cox proportional-hazards regression. Predictors for change in eGFR and chronic kidney disease (CKD) stage were modeled using linear and ordinal logistic regression. RESULTS: A total of 126 patients fit the inclusion criteria. Overall recurrences were 2/62 (3.2%) and 6/64 (9.4%) for < 3 versus 3-4 cm. Both recurrences in the < 3 cm group were local, 4/6 in the 3-4 cm group were local and 2/6 were metastatic without local progression. For < 3 versus 3-4 cm, cumulative LRFS at 36 months was 94.6% versus 91.4%. Tumor size was not a significant prognostic factor for LRFS. Renal function did not change significantly after MWA. Patient comorbidities and RENAL nephrometry score significantly affected change in CKD. CONCLUSION: With comparable oncological outcomes, complication rates, and renal function preservation, MWA is a promising management strategy for renal masses of 3-4 cm in select patients. Our findings suggest that current AUA guidelines, which recommend thermal ablation for tumors < 3 cm, may need review to include T1a tumors for MWA, regardless of size.

Recurrent Anterior Urethral Stricture: Challenges and Solutions.

Recurrent male anterior urethral stricture disease is a complex surgical challenge that should be managed by reconstructive urologists with experience in stricture management. Diagnosis of recurrence requires both anatomic narrowing and patient symptoms identified on validated questionnaires, with limited role for intervention in asymptomatic treatment "failures". Endoscopic management has a very specific role in recurrence, and the choice of technique for urethroplasty depends on pre-operative urethrography and cystoscopy. Surgical success depends on addressing patient concerns, complete stricture excision, tissue quality optimization, and the use of multi-stage repair when indicated. Augmentation with genital skin flaps and/or grafts is often required, with buccal mucosa as the ideal graft source if local tissue is compromised. Salvage options including urinary diversion and perineal urethrostomy must also be considered in debilitated patients with severe disease or repeated treatment failures. Unique patient populations including patients with hypospadias and lichen sclerosis are among the highest risk for repeated recurrence and require special care in surgical technique, graft selection, and post-operative management.

Thermal ablation of the small renal mass: a critical analysis of current literature.

INTRODUCTION: Thermal ablation is increasingly utilized as a management strategy for small renal masses (<4 cm). Partial nephrectomy is recognized as the gold standard; thermal ablation has been reserved for older patients with comorbidities due to concern for local tumor recurrence. As long-term data regarding the safety and efficacy of ablative techniques accumulate with encouraging results, clinicians are widening the utility in select patient populations. This review summarizes the currently available technologies in terms of procedural differences, oncologic outcomes, renal function, and complication rates. EVIDENCE ACQUISITION: A structured literature review was conducted using PubMed and Web of Science, using the keywords: "renal cell carcinoma," "ablation techniques," "cryosurgery," "radiofrequency ablation," "microwave ablation," "outcomes assessment," "post-operative complication," and "hospital costs." Articles were reviewed to summarize oncologic outcomes, complications, and impact on renal function of cryoablation, radiofrequency ablation, and microwave ablation. EVIDENCE SYNTHESIS: Thermal ablation is a safe and effective management option for small renal masses in select patients, particularly in those with multiple tumors and/or those unable or unwilling to undergo more invasive surgery. Slightly higher rates of local recurrence rates (~1-10%) with thermal ablation are offset by lower complication rates and reduced morbidity, and equivalent or better renal function outcomes compared to surgery. CONCLUSIONS: The established modalities of cryo-, radiofrequency, and microwave ablation offer equivalent outcomes with similar complication rates; technique choice is primarily based on tumor characteristics and operator preference. Better quality evidence comparing thermal ablation with surgical nephron-sparing intervention is needed to make informed conclusions on efficacy.