Active surveillance, radiofrequency ablation, or cryoablation for the nonsurgical management of a small renal mass: a cost-utility analysis.

BACKGROUND: Patients with a cortical small (≤4 cm) renal mass often are not candidates for or choose not to undergo surgery. The optimal management strategy for such patients is unclear. METHODS: A decision-analytic Markov model was developed from the perspective of a third party payer to compare the quality-adjusted life expectancy and lifetime costs for 67-year-old patients with a small renal mass undergoing premanagement decision biopsy, immediate percutaneous radiofrequency ablation or percutaneous cryoablation (without premanagement biopsy), or active surveillance with serial imaging and subsequent ablation if needed. RESULTS: The dominant strategy (most effective and least costly) was active surveillance with subsequent cryoablation if needed. On a quality-adjusted and discounted basis, immediate cryoablation resulted in a similar life expectancy (3 days fewer) but cost $3,010 more. This result was sensitive to the relative rate of progression to metastatic disease. Strategies that employed radiofrequency ablation had decreased quality-adjusted life expectancies (82-87 days fewer than the dominant strategy) and higher costs ($3,231-$6,398 more). CONCLUSIONS: Active surveillance with delayed percutaneous cryoablation, if needed, may be a safe and cost-effective alternative to immediate cryoablation. The uncertainty in the relative long-term rate of progression to metastatic disease in patients managed with active surveillance versus immediate cryoablation needs to be weighed against the higher cost of immediate cryoablation. A randomized trial is needed directly to evaluate the nonsurgical management of patients with a small renal mass, and could be limited to the most promising strategies identified in this analysis.

Volume Reduction in Enlarged Kidneys in Autosomal Dominant Polycystic Kidney Disease (ADPKD) Prior to Renal Transplant with Transcatheter Arterial Embolization (TAE): A Systematic Review and Meta-Analysis.

PURPOSE: Symptomatically enlarged kidneys observed in autosomal dominant polycystic kidney disease (ADPKD) patients can lead to compression symptoms and contraindications to renal transplantation. Surgical nephrectomy can be utilized to increase space in the abdomen prior to renal transplantation; however, not all individuals are appropriate candidates for this procedure. Transcatheter arterial embolization (TAE) of the renal arteries can provide a noninvasive way to reduce renal volume in ADPKD. MATERIALS AND METHODS: We performed a systematic literature review on the usage of TAE to reduce renal volume prior to kidney transplantation and to relief compression symptoms in ADPKD. PubMed, Web of Science, and Cochrane Library were searched for articles focused on the usage of TAE to reduce renal volume in symptomatic enlarged kidneys. Renal volume data were compiled, and meta-analysis was performed with three or more studies. RESULTS: Six papers satisfied the inclusion and exclusion criteria. Significant renal volume reduction was observed by 12 months in all studies. Success of TAE was measured with three clinical outcomes: removal of contraindication for renal transplant, relief of compression symptoms, and pulmonary function test. Proportionality meta-analysis of three studies measuring relief of compression symptoms showed no significant differences in heterogeneity (p = 0.4543). CONCLUSION: Current studies conclude that TAE is an effective and minimally invasive option for reduction in renal volume in order to optimize patient outcome for renal transplantation and for relief of compression symptoms. Further prospective studies involving increased sample size and multiple centers should be pursued to establish evidence-based guidelines.