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© 2023 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

SIUJ.ORG SIUJ  •  Volume 4, Number 3  •  May 2023

Key Words Competing Interests Article Information

Cryoablation, kidney tumor, renal cell 
carcinoma, partial nephrectomy

None declared. Received on December 21, 2022 
Accepted on January 31, 2023 
This article has been peer reviewed.

Soc Int Urol J. 2022;4(3):211–222

DOI: 10.48083/IMBM6087

Role of Cryoablation for the Treatment of cT1b 
Kidney Lesions: Outcomes of a Systematic Review
Adnan El-Achkar,1 Mustafa Khader,2 Ala’a Farkouh,2 Joelle Hassanieh,1 Bhaskar Somani,3  
Mohammed Shahait2

1 Department of Surgery, Division of Urology, American University of Beirut Medical center, Beirut, Lebanon  
2 Department of Surgery, King Hussein Cancer Center, Amman, Jordan 
3 Department of Urology, University Hospital Southampton, Southampton, United Kingdom

Abstract

Introduction The American Urological Association (AUA) and the European Association of Urology (EAU) 
currently recommend partial nephrectomy (PN) over ablation for cT1b lesions. However, recent series have shown 
comparable outcomes for cryoablation (CA) when compared to PN, making it an appealing alternative for a select 
group of patients. The objective of this manuscript is to assess treatment outcomes and complications of CA for cT1b 
lesions.

Methods Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a 
comprehensive search was done on MEDLINE and Cochrane Library electronic databases identifying studies that 
reported on outcomes and complications of CA for kidney tumors. Inclusion criteria included cT1b lesions between 4 
cm and 7 cm, excluding treatment of other sizes.

Results A total of 347 patients with cT1b lesions identified on imaging underwent percutaneous or laparoscopic 
CA. The average age was > 65 years, the median size of lesions and RENAL score ranged between 4.3–4.8 cm and 
8–9, respectively. The majority of patients had a Charlson comorbidity index (CCI) of 2, and median follow-up 
ranged between 13 months and 95 months. Across all the series, primary and secondary success rates were between 
84%–98% and 92%–98%, respectively. The local recurrence ranged from 2.8% to 27%. For patients with documented 
RCC on biopsy, the 5-year overall survival (OS), cancer-specific survival (CSS), recurrence-free survival (RFS), and 
metastasis-free survival (MFS) ranged from 56%–91%, 85%–100%, 70%–96.4%, and 90%–96%, respectively. The 
major complication rate (Clavien-Dindo III-V) was low, at 6.2%.

Conclusion With promising survival outcomes and low complication rates perioperatively, CA is acceptable in a 
select group of patients with T1b renal tumors, including those who are older, have multiple comorbidities, or have 
relative or absolute contraindication to surgery.

Introduction

The increased use of medical imaging over the past decades, especially computerized tomography (CT) scans, has 
increased the detection of renal masses including renal cell carcinoma (RCC)[1]. Partial nephrectomy remains the 
gold standard for treatment of cT1 lesions[2]. The currently available treatment modalities for cT1 tumors include 
radical nephrectomy, partial nephrectomy, and ablative therapy.

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Abbreviations 
AUA American Urological Association
CA cryoablation
CCI Charlson comorbidity index
CSS cancer-specific survival
EAU European Association of Urology
MFS metastasis-free survival
NOS Newcastle Ottawa scale
OS overall survival
PN partial nephrectomy
PRISMA  Preferred Reporting Items for Systematic Reviews and 

Meta-Analyses
RCC renal cell carcinoma
RCT randomized controlled trial
RFS recurrence-free survival

While the use of ablative therapy such as CA has 
become more widely accepted and is endorsed in treat-
ment guidelines with comparable outcomes to partial 
nephrectomy (PN) for tumors classified as cT1a (less 
than 4 cm)[3,4], the data on its efficacy and long-term 
outcomes remains controversial for tumors classified as 
cT1b (between 4 cm and 7 cm)[5–8]. Radical or partial 
nephrectomy is the preferred treatment modality for 
cT1b lesions[8]. Nevertheless, for patients with cT1b 
tumors with multiple comorbidities, those who are unfit 
for general anesthesia, or those who have concomitant 
underlying chronic kidney disease, secondary therapies 
such as cryoablation could prove useful in the urologist 
armamentarium. For this reason, practitioners have 
recently extended the use of CA to a select group of 
patients with cT1b lesions.

Generally, cryoablation for large tumors whether 
performed percutaneously or laparoscopically has been 
associated with higher risk for recurrence and complica-
tions[9,10]. Recent data for cT1b tumors is clinically prom-
ising; however, most of the series are single-center series 
with a limited number of patients, making it difficult to 
appreciate CA efficacy in this select group of patients. The 
goal of this paper is to compile the data on cryoablation 
therapy for cT1b tumors. Specifically, we report outcomes 
such as primary success, need for repeat ablation, local 
recurrence, complications, and survival data.

Methods
This systematic review was conducted according to the 
recommended Preferred Reporting Items for Systematic 
Reviews and Meta-Analyses (PRISMA) check list 
guidelines[11] (online Supplementary Tables 1 and 2). A 
computer-assisted systematic literature search of the 

MEDLINE and Cochrane Library electronic databases 
was performed (latest search February 23, 2022) to 
identify eligible studies reporting on the outcomes and 
complications following cryoablation of kidney tumors. 
The key word combinations used were as follows: 
([“Cryotherapy” {MeSH Terms} OR [“Cryosurgery”{MeSH 
Terms} OR “Cryoablation* OR Cr yosurger y* OR 
Cryotherapy ”{All Fields including title abstract and 
keywords}]) AND (“Kidney neoplasms ”[MeSH Terms] 
OR “Kidney NEXT [cancer* OR tumor*])”(All Fields 
including title, abstract, keywords) OR “ Renal NEXT 
(cancer* OR tumor*)”(All Fields including title, abstract, 
key words). The latter was specifically used in the 
Cochrane Library. Google Scholar was additionally 
checked for the most relevant articles.

Study selection and risk of bias
Duplicates were filtered by Endnote X9. Following 
the exclusion of ineligible articles by title and abstract 
revision, relevant articles underwent full-text review. The 
exclusion criteria were set on the following bases: articles 
not published in English, articles entailing basic science 
research and conducted on non-human species, letters 
to the editor, case reports, series with heterogeneous 
cohort encompassing lesions sizes of < 4 cm and > 7 cm, 
series lacking required data to be extracted, and lastly 
series with fewer than 5 treated patients.

Study selection was performed separately by 2 review-
ers (J.H. and A.E.) and disagreement was resolved with 
the input of a third author (M.S.). The same was done 
for data extraction. Eligibility assessment was based 
on the title or abstract and on full-text review if appro-
priate. Articles were eligible for this systematic review 
if they documented either in the title or abstract the 
sequel of the cryoablation of kidney tumors. Article 
inclusion criteria involved the following: original 
research, randomized controlled trials (RCTs) or obser-
vational studies, published in the past 20 years, system-
atic reviews, and cohort studies with a minimum of 
5 patients. The authors included clinical cT1b lesions, 
which might also encompass benign lesions as well such 
as oncocytoma.

The database searches yielded 1018 articles. Using 
the aforementioned inclusion and exclusion criteria and 
following abstract review, a total of 904 articles were 
excluded. The 144 remaining papers were analyzed by 2 
independent researchers using an inclusion criterion of 
only cT1b tumors (size of the tumor between 4 cm and 
7 cm) and all other sizes were excluded. This led to the 
exclusion of 120 articles after full-text screen. Articles 
with the same set of patients were excluded. Finally, 14 
articles were excluded during data extraction due to 
inadequate data for the review, therefore, yielding 10 
papers for this review (Figure 1).

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PubMed, MEDLINE (OVID), Cochrane Library
1964–2021

1018 citation(s)

1018 non-duplicate
citations screened

Inclusion criteria percutaneous or laparoscopic cryoablation
nephrectomy and radioablation were excluded

Criteria applied

144 articles retrieved

10 articles included

904 articles excluded
after title/abstract screen

120 articles excluded
after full text screen

14 articles excluded
during data extraction

Inclusion criteria applied was cT1b lesions (size 4–7 cm)
Exclusion criteria applied tumor size less than 4 cm or more than 7 cm

Primary success was defined as no contrast enhance-
ment observed in imaging at the 3-month follow-up 
examination after cryoablation session. Persistence 
was defined as persistent positive enhancement on CT 
scan at 3-month follow-up. If there was a contrast-en-
hancing lesion at 3 months, usually a repeat cryoabla-
tion was done, and it was not considered recurrence but 
rather incomplete treatment or early post-treatment 
changes. Secondary success was defined as no contrast 
enhancement after repeat cryoablation at 3 months. 
Local recurrence or progression was defined as new 
contrast enhancement within the ablation zone on CT 
after local eradication of all tumor cells using imaging 
criteria[12]. Deaths from non-RCC causes were censored 
in the assessment of cancer-specific survival (CSS). CSS, 
metastasis-free survival (MFS) and recurrence-free 
survival (RFS) were assessed only for patients with 
proven RCC. 

The Newcastle Ottawa scale (NOS) was used to assess 
the quality of the cohort studies included. As for the 
case series, the proposed tool of Murad et al. (2018) was 

used[13]. The rating was done by 2 authors (A.E. and 
M.S.). Final decision was reached following consensus 
with the third author (J.H.). A score of 7 of 9 and 5 of 
6 was considered indicative of a high-quality study for 
each tool, respectively. For the item assessing adequate 
long-term follow-up for NOS, a cut-off of 60 months was 
set a priori and adequacy of follow-up to 50% in the first 
4 years. For the Murad et al. (2018) tool, items 5 and 6 
were removed, as they are relevant to cases of adverse 
drug events. An adequate long-term follow-up for case 
series was a cut-off of 3 years[13].

Results
After reviewing the literature using the PRISMA 
guidelines, 10 studies were included in this review 
(Figure 1). The sample size ranged from 23 to 52 patients, 
with a total of 347 patients. The average age was between 
67 and 77 years. The median tumor size ranged from 
4.3  cm to 4.8 cm, as only cT1b tumors were assessed, 
with a median renal score of 8 to 9. In 2 of the 10 cohorts, 
patients also had a biopsy taken during the procedure, 

FIGURE 1.

PRISMA diagram: The search strategy and the number of articles included and excluded in the systematic review 

213SIUJ.ORG SIUJ  •  Volume 4, Number 3  •  May 2023

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TABLE 1. 
Patient and tumor demographics in all studies 

Study
Study 

sample 
Inclusion criteria Exclusion criteria

Cryoablation
method

Median tumor size 
(cm) 

Mean 
age

Sex M/F
BMI

Mean ± SD
Or Median (IQR)

CCI/ ECOG/ASA
Tumor complexity: RENAL score 

or descriptive (endophytic, 
exophytic, central, etc.)

Timing of 
Biopsy 

Biopsy results 

Atwell et al. (2015)[42] N = 46 Biopsy-proven RCC None mentioned Pc 4.8 73 28/11 Not mentioned
CCI:

Mean 3 ± 2
Median 2

Central: 34/46
Exophytic: 10/46

Intraparenchymal: 2/46 
Preop 

44 RCC
2 RCC unclassified

Caputo et al. (2017)[21] N = 31 Renal Imaging Not mentioned
25 Lp
6 Pc

4.3 68 25/6 30.6 (26.3–37.4)
Median CCI (IQR) 

6 (5–7)
Median 8 (6–9) Preop

17 CCC
1 pRCC

4 RCC unclassified 

Hebbadj et al. (2018)[6] N = 27 Biopsy-proven RCC Coagulation disorder Pc 4.8 72.3 15/12 Not mentioned n/a Median 8 (7–9)

12/27 
(44.4%) SS

15/27 
(55.6%) 
Preop

25 CCC
1 chromophobe
1 oncocytoma

Hasegawa et al. (2018)[36] N = 23 Biopsy-proven RCC
Hereditary RCC
Multiple tumors

Pc 4.6 66.5 11/12 Not mentioned
ECOG=0 (61%)

ECOG =1–4 (39%)
Central: 1 (4%)

Non-central:22 (96%)
Preop

14 CCC
1 papillary

1 chromophobe

Rembeyo et al. (2020)[43] N = 55
Renal mass on imaging

N0M0

Multiple, bilateral and 
metastatic RCC

ASA > 4 
Pc 4.6 72 37/18 27.0 (24.0-29.0)

CCI:
Low:13

Intermediate:10
High: 32

RENAL:
(4–6)à 12 (21.8%)
 (7–9)à24 (41.6%)

(10–12)à19 (34.6%)

Preop 
44 malignant

39 CCC
2 pRCC

Gunn et al. (2019)[44] N = 37 Biopsy-proven RCC None mentioned Pc 4.73 66.5 22/15 34.8 ± 8.8
CCI mean: 
7.1 ± 2.4

Median 9 (7–10)
23 (62%) 

preop biopsy

12 CCC
5 pRCC

6 RCC unclassified

Grange et al. (2019)
[45]

N = 23 Biopsy-proven RCC None mentioned Pc 4.56 74.9 17/6 Not mentioned
CCI mean: 
4.1 ± 1.9

Mean 8.1 ± 1.8 Preop
17 CCC
4 pRCC

2 chromophobe

Andrews et al. (2019)[17] N = 52 Renal mass on imaging Extrarenal spread Pc 4.8
77 

(69.5–83)
35/11 Not mentioned

CCI median (IQR): 
2 (1–4)

Not mentioned both

35 RCC:
24 CCC
4 pRCC

7 RCC unclassified
16 benign

1 unknown

Bhagavatula et al. (2020)[46] N = 25
Suspicious mass on 

renal imaging
Lack of pathology, multiple 

and prior RCC
Pc

Not mentioned, all tumors 
ablated between 4–7 cm

68
Not 

mentioned
Not mentioned Not mentioned Not mentioned Preop Not specified for cT1b

Shimizu et al. (2021)[47] N = 28
Biopsy-proven RCC/ and 

renal mass image
Metastasis or vascular 

invasion
Pc 4.6 73.9 22/6 Not mentioned

CCI median (IQR): 
6 (2–9)

Median 9 (5–11) Preop

17 CCC
1 papillary
1 unknown
9 no biopsy

BMI: body mass index; CCC: clear cell carcinoma; CCI: Charlson comorbidity index; ECOG: Eastern Cooperative Oncology Group; IQR: interquartile range;  
Lp: laparoscopic; n/a: not assessed; Pc: percutaneous; PN: partial nephrectomy; pRCC: papillary renal cell carcinoma; RCC: renal cell carcinoma;  
RN: radical nephrectomy.

while in the other series this was done preoperatively. 
Additionally, 5 series used embolization concurrently 
or preoperatively with cryoablation, and a total of 
48 patients underwent embolization concomitantly 
during the CA procedure. Of the 10 studies, 7 used 
percutaneous CA, 1 used laparoscopic CA, and 1 used a 
mixture of both methods (Table 1).

The primary and secondary success rate was high at 
84%–98% and 92%–100%, respectively. Most cohorts 
had a median of 5 probes to ablate the tumor. The 
median follow-up time ranged from 13 months to 
95 months. During follow-up for patients with biop-
sy-proven RCC, the local recurrence ranged from  
2.8% to 27%. The 5-year OS, CSS, RFS/progression- 

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free survival (PFS), and MFS ranged from 56%–91%, 
85%–100%, 70%–96.4%, and 90%–96%, respectively 
(Table 2).

Nine studies reported complications using the Clavien-
Dindo classification system. A total of 74 (23%) compli-
cations were reported, with a higher complication rate of 

grade III–IV noted in 6.2%. The majority of complica-
tions (73%) were grade I–II, with 20.2% grade III, and 
6.75% grade IV. No grade V complications were encoun-
tered (Table 3).

Nine studies included were considered high quality, 
with a mean NOS score of 7.8 (standard deviation [SD], 

TABLE 1. 
Patient and tumor demographics in all studies 

Study
Study 

sample 
Inclusion criteria Exclusion criteria

Cryoablation
method

Median tumor size 
(cm) 

Mean 
age

Sex M/F
BMI

Mean ± SD
Or Median (IQR)

CCI/ ECOG/ASA
Tumor complexity: RENAL score 

or descriptive (endophytic, 
exophytic, central, etc.)

Timing of 
Biopsy 

Biopsy results 

Atwell et al. (2015)[42] N = 46 Biopsy-proven RCC None mentioned Pc 4.8 73 28/11 Not mentioned
CCI:

Mean 3 ± 2
Median 2

Central: 34/46
Exophytic: 10/46

Intraparenchymal: 2/46 
Preop 

44 RCC
2 RCC unclassified

Caputo et al. (2017)[21] N = 31 Renal Imaging Not mentioned
25 Lp
6 Pc

4.3 68 25/6 30.6 (26.3–37.4)
Median CCI (IQR) 

6 (5–7)
Median 8 (6–9) Preop

17 CCC
1 pRCC

4 RCC unclassified 

Hebbadj et al. (2018)[6] N = 27 Biopsy-proven RCC Coagulation disorder Pc 4.8 72.3 15/12 Not mentioned n/a Median 8 (7–9)

12/27 
(44.4%) SS

15/27 
(55.6%) 
Preop

25 CCC
1 chromophobe
1 oncocytoma

Hasegawa et al. (2018)[36] N = 23 Biopsy-proven RCC
Hereditary RCC
Multiple tumors

Pc 4.6 66.5 11/12 Not mentioned
ECOG=0 (61%)

ECOG =1–4 (39%)
Central: 1 (4%)

Non-central:22 (96%)
Preop

14 CCC
1 papillary

1 chromophobe

Rembeyo et al. (2020)[43] N = 55
Renal mass on imaging

N0M0

Multiple, bilateral and 
metastatic RCC

ASA > 4 
Pc 4.6 72 37/18 27.0 (24.0-29.0)

CCI:
Low:13

Intermediate:10
High: 32

RENAL:
(4–6)à 12 (21.8%)
 (7–9)à24 (41.6%)

(10–12)à19 (34.6%)

Preop 
44 malignant

39 CCC
2 pRCC

Gunn et al. (2019)[44] N = 37 Biopsy-proven RCC None mentioned Pc 4.73 66.5 22/15 34.8 ± 8.8
CCI mean: 
7.1 ± 2.4

Median 9 (7–10)
23 (62%) 

preop biopsy

12 CCC
5 pRCC

6 RCC unclassified

Grange et al. (2019)
[45]

N = 23 Biopsy-proven RCC None mentioned Pc 4.56 74.9 17/6 Not mentioned
CCI mean: 
4.1 ± 1.9

Mean 8.1 ± 1.8 Preop
17 CCC
4 pRCC

2 chromophobe

Andrews et al. (2019)[17] N = 52 Renal mass on imaging Extrarenal spread Pc 4.8
77 

(69.5–83)
35/11 Not mentioned

CCI median (IQR): 
2 (1–4)

Not mentioned both

35 RCC:
24 CCC
4 pRCC

7 RCC unclassified
16 benign

1 unknown

Bhagavatula et al. (2020)[46] N = 25
Suspicious mass on 

renal imaging
Lack of pathology, multiple 

and prior RCC
Pc

Not mentioned, all tumors 
ablated between 4–7 cm

68
Not 

mentioned
Not mentioned Not mentioned Not mentioned Preop Not specified for cT1b

Shimizu et al. (2021)[47] N = 28
Biopsy-proven RCC/ and 

renal mass image
Metastasis or vascular 

invasion
Pc 4.6 73.9 22/6 Not mentioned

CCI median (IQR): 
6 (2–9)

Median 9 (5–11) Preop

17 CCC
1 papillary
1 unknown
9 no biopsy

BMI: body mass index; CCC: clear cell carcinoma; CCI: Charlson comorbidity index; ECOG: Eastern Cooperative Oncology Group; IQR: interquartile range;  
Lp: laparoscopic; n/a: not assessed; Pc: percutaneous; PN: partial nephrectomy; pRCC: papillary renal cell carcinoma; RCC: renal cell carcinoma;  
RN: radical nephrectomy.

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TABLE 2. 
Outcomes of cryoablation including need for embolization, repeat cryotherapy, recurrence, metastasis,  
and salvage treatment 

Study
Primary 
Success

Secondary 
success rate

Number of intraop 
embolization done

Number of 
probes used 

Repeat cryoablation vs. 
other modality (after 
technique failures)

Median follow-up
(months)

Local 
recurrences

Type of salvage  
treatment

Progression 
to metastasis

Death OS CSS
RFS/
PFS

MFS

Atwell et al. (2015)[42] 45/46 (98%) 98% 7 Not mentioned 1 RN 24 1/36 (2.8%) 1 RN 2/36 (6%) 2
5-yr
94%

5y
94%

5-yr
96.4%

5-yr
94%

Caputo et al. (2017)[21] 27/31 (87%) 93.5% 0 Median 2
2 rCA

2 observed
13 5 (16%)

1 RN,
2 rCA

Not assessed
1 CRD

5 all-cause 
mortality

5-yr 
60%

5-yr
85%

5-yr
70%

–

Hebbadj et al. (2018)[6] 3/27 (88%) 92.5% 0
Mean (range)

5.3 (3–9)
1 PN, 1 rCA 20.0 3 (11.1%)

1 PN
2 active surveillance

1 1 CRD
3-yr
96%

3-yr 
95.7%

3-yr
97%

3-yr
96%

Hasegawa et al. (2018)[36] 1/23 (96%) 100%
13/23 patients (56.5%)

(Preop)
Median (range)

4 (3–5)
1 rCA 23.0 2 (9%) Active surveillance 2/21 (9%)

3 All-cause 
mortality

5-yr 
82%

5-yr 
100%

5-yr
91%

5-yr
91%

Rembeyo et al. (2020)[43] 9/55 (84%) 98% 0 Mean 5 9 rCA 19.9 12 (27%)

[total 12]
5 rCA

2 monitoring
1 PN
2 RN

0
2 CRD

1 all-cause 
mortality

2-yr
93%

2-yr
95%

2-yr
72%

2-yr
93%

Gunn et al. (2019)[44] 4/37 (88%) 92% 3 (preop)
Median (range)

3 (1–7)
4 rCA 25.1 8 (21.6%)

1 chemo, 1 RN after 
second cryotherapy 

attempt
Not assessed 1

3-yr 
77.6%

3-yr 
100%

3-yr
62.6%

–

Grange at al. (2019)[45] 3/23 (86.3%) 100% 0
Mean ± SD

4.9 ± 1.3
3 rCA 13.9 2 (8.7%) 1 RN 1/23 (4%) 1 CRD -

2-yr
85.7%

2-yr
81.8%

–

Andrews et al. (2019)[17] Not assessed Not assessed 7 Not mentioned - 72 3/48 (6.3%) - 2/35 (6%) 2
5-yr 
56%

5-yr 91%
5-yr

92.7%
5-yr
90%

Bhagavatula et al. (2020)[46] 2/25 (92%) 99% - Range (1–7) 2 rCA 95 2 (8%) 2 rCA - 1
5-yr
91%

5-yr
95%

5-yr
85%

5-yr
96%

Shimizu et al. (2021)[47] 1/28 (96.4%) 100% 18 5.0 ± 1.5 1 rCA 42 2 (7.1%) 2 rCA 2/18 (11%) 3 deaths
5-yr 

79.1%
5-yr
96%

5-yr
92.7%

5-yr
93%

CRD: cancer-related death; CSS: cancer-specific survival; MFS: metastasis-free survival; n/a: not assessed; OS: overall survival;  
PFS: progression-free survival; PN: partial nephrectomy; rCA: repeat cryoablation; RN: radical nephrectomy.

1.3) for the cohort arm. One cohort study was considered 
fair, and all the case series were of high quality. There were 
no RCTs on the subject. (Supplemental Tables 1 and 2).

Discussion
There are multiple treatment options available for cT1b 
renal tumors including radical nephrectomy, partial 
nephrectomy, cryoablation, radiofrequency ablation, 
or active surveillance. The selection of a personalized 
treatment option is based on many variables including but 
not limited to patient characteristics, patient preference, 

and aggressiveness of the tumor at hand. The European 
Association of Urology (EAU), American Urological 
Association (AUA), and National Comprehensive 
Ca ncer Net work (NCCN) g u ideli nes cu rrent ly 
recommend partial nephrectomy for cT1b tumors when 
PN is deemed feasible by the surgeon[14–16]. CA is 
proposed as an alternative to PN in cT1a patients with 
comparable outcomes. However, its role in cT1b remains 
controversial. Historically, it has been considered only 
in patients with contraindications to surgery, those who 
are unfit for surgery, or those who refuse surgery[17]. 
In this systematic review, we reported the patient and 

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tumor characteristics of laparoscopic or percutaneous 
(image-guided) CA for such tumors, and the outcomes 
and complications of each series.

Our review consists of 10 cohorts where the authors 
recruited a total of 347 patients who underwent CA for 
their cT1b renal tumor. It is important to highlight that 
the demographic of the cohorts consists of an older and 
more comorbid group of patients. The average age ranges 
from 66.5 years to 75 years. The majority of patients had 
a Charlson comorbidity index (CCI) of ≥ 2. On the other 
hand, a large series on patients undergoing PN for cT1b 

kidney tumors showed that patients had an average age 
of 59 years, and the majority had a CCI of 0–1[18,19]. 
Despite being an older and a more comorbid cohort, the 
5-year OS, CSS, and RFS across all the cohorts ranged 
from 56%–91%, 85%–100%, 70%–96.4%, respectively. 
Only a few patients (28/295; 9.5%) required repeated 
cryotherapy for recurrence at 3 months for incomplete 
treatment or technical failure, or for an unspecified 
reason. 23 of the 28 patients had repeat cryoablation, 
with an excellent primary and secondary success rate of 
> 90% and > 95%, respectively. In addition, the risk for 
metastasis was low, with 5-year MFS ranging from 90% 

TABLE 2. 
Outcomes of cryoablation including need for embolization, repeat cryotherapy, recurrence, metastasis,  
and salvage treatment 

Study
Primary 
Success

Secondary 
success rate

Number of intraop 
embolization done

Number of 
probes used 

Repeat cryoablation vs. 
other modality (after 
technique failures)

Median follow-up
(months)

Local 
recurrences

Type of salvage  
treatment

Progression 
to metastasis

Death OS CSS
RFS/
PFS

MFS

Atwell et al. (2015)[42] 45/46 (98%) 98% 7 Not mentioned 1 RN 24 1/36 (2.8%) 1 RN 2/36 (6%) 2
5-yr
94%

5y
94%

5-yr
96.4%

5-yr
94%

Caputo et al. (2017)[21] 27/31 (87%) 93.5% 0 Median 2
2 rCA

2 observed
13 5 (16%)

1 RN,
2 rCA

Not assessed
1 CRD

5 all-cause 
mortality

5-yr 
60%

5-yr
85%

5-yr
70%

–

Hebbadj et al. (2018)[6] 3/27 (88%) 92.5% 0
Mean (range)

5.3 (3–9)
1 PN, 1 rCA 20.0 3 (11.1%)

1 PN
2 active surveillance

1 1 CRD
3-yr
96%

3-yr 
95.7%

3-yr
97%

3-yr
96%

Hasegawa et al. (2018)[36] 1/23 (96%) 100%
13/23 patients (56.5%)

(Preop)
Median (range)

4 (3–5)
1 rCA 23.0 2 (9%) Active surveillance 2/21 (9%)

3 All-cause 
mortality

5-yr 
82%

5-yr 
100%

5-yr
91%

5-yr
91%

Rembeyo et al. (2020)[43] 9/55 (84%) 98% 0 Mean 5 9 rCA 19.9 12 (27%)

[total 12]
5 rCA

2 monitoring
1 PN
2 RN

0
2 CRD

1 all-cause 
mortality

2-yr
93%

2-yr
95%

2-yr
72%

2-yr
93%

Gunn et al. (2019)[44] 4/37 (88%) 92% 3 (preop)
Median (range)

3 (1–7)
4 rCA 25.1 8 (21.6%)

1 chemo, 1 RN after 
second cryotherapy 

attempt
Not assessed 1

3-yr 
77.6%

3-yr 
100%

3-yr
62.6%

–

Grange at al. (2019)[45] 3/23 (86.3%) 100% 0
Mean ± SD

4.9 ± 1.3
3 rCA 13.9 2 (8.7%) 1 RN 1/23 (4%) 1 CRD -

2-yr
85.7%

2-yr
81.8%

–

Andrews et al. (2019)[17] Not assessed Not assessed 7 Not mentioned - 72 3/48 (6.3%) - 2/35 (6%) 2
5-yr 
56%

5-yr 91%
5-yr

92.7%
5-yr
90%

Bhagavatula et al. (2020)[46] 2/25 (92%) 99% - Range (1–7) 2 rCA 95 2 (8%) 2 rCA - 1
5-yr
91%

5-yr
95%

5-yr
85%

5-yr
96%

Shimizu et al. (2021)[47] 1/28 (96.4%) 100% 18 5.0 ± 1.5 1 rCA 42 2 (7.1%) 2 rCA 2/18 (11%) 3 deaths
5-yr 

79.1%
5-yr
96%

5-yr
92.7%

5-yr
93%

CRD: cancer-related death; CSS: cancer-specific survival; MFS: metastasis-free survival; n/a: not assessed; OS: overall survival;  
PFS: progression-free survival; PN: partial nephrectomy; rCA: repeat cryoablation; RN: radical nephrectomy.

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to 96%. The data at hand shows that cryotherapy may be 
a valid alternative to partial or radical nephrectomy for 
a select group of patients with encouraging oncological 
outcomes.

Only small, single-center retrospective studies have 
been published in the literature that compare the effi-
cacy of ablation therapies (cryoablation or radiofre-
quency) compared to their surgical counterparts (partial 
nephrectomy or radical nephrectomy) in this group of 
patients (cT1b)[20]. Caputo et al. published a matched 
analysis of 62 patients comparing partial nephrec-
tomy to cryoablation in the treatment of T1b tumors 
and they found no significant difference in both over-
all mortality (P  =  0.155) or cancer-specific mortality 
(P = 0.48) between the 2 studied samples[21]. In another 
cohort, Thompson et al. compared long-term outcomes 
of cryoablation to partial nephrectomy in T1b tumors. 
Those authors retrospectively followed 376 patients from 
the Mayo Clinic Tumor Registry, 14% (N = 52) under-
went cryoablation and 86% (N = 324) underwent partial 
nephrectomy. The median follow-up in that study was 6 
years and 8.7 years, respectively, for each of the 2 groups. 
The authors found no significant difference between 
both groups in relation to local recurrence, metastases, 
and death of patients from their tumor. In addition, 
5-year cancer-free survival was 91% for the cryotherapy 
group and 98% for the partial nephrectomy group[5,17]. 
While some found comparable survival data between 
both techniques, others have found a higher odds of 

survival when comparing CA to PN after propensity 
matching (hazard ratio [HR], 2.74; 95% CI 1.611–4.66; 
P < 0.001). However, this study didn’t account for tumor 
complexity using nephrometry score and had a clear 
selection bias between those treated with PN and those 
with cryoablation.

Two of the major concerns for cryoablation remain 
the local tumor control rate and the local recurrence 
rate[6,22]. One series by Gunn et al. had the highest 
recurrence rate at 21%; however, this cohort had the high-
est mean body mass index (BMI) (34.8 ± 8.8), mean CCI 
(7.1 ± 2.4), and median RENAL score 9 (range, 7–10) of all 
the patients[23]. Higher BMI and higher tumor complex-
ity are additional predictors of recurrence, as seen by 
Caputo et al., who found significant differences in the rate 
of local recurrence at 1-year follow-up (P = 0.019), with 
recurrence rates significantly higher for the cryoablation 
group compared to PN. Predictor of recurrence included 
tumor size, BMI > 30, and endophytic lesions[24]. 
While tumor complexity is a clear predictor of recur-
rence[25–28], the effect of BMI on recurrence and success 
remains controversial, with some series showing no effect 
of BMI or obesity on survival and recurrence[29,30]. 
Across all series, only 12.1% of the subjects (N = 42) 
experienced local tumor recurrence, with progression 
to metastasis only ranging from 4% to 11%. It is import-
ant to note that these comparative series have short-
term follow-up, with a median follow-up time between  
13 months and 31.6 months. Recent data after long-term 

TABLE 3. 
Complications using the Clavien-Dindo classification system across all studies*

Study
Number of 

complications
Grade I Grade II Grade III Grade IV Grade V

Atwell et al. (2015)[42] 8 1 3 3 1 0

Caputo et al. (2017)[21] 7 1 5 0 1 0

Hebbadj et al. (2018)[6] 13 9 1 2 1 0

Hasegawa et al. (2018)[36] 2 0 0 2 0 0

Rembeyo et al. (2020)[43] 13 12 1 0 0 0

Gunn et al. (2019)[44] 17 11 1 4 1 0

Grange et al. (2019)[45] 5 4 1 0 0 0

Andrews et al. (2019)[17] 8 1 3 3 1 0

Bhagavatula et al. (2020)[46] _ _ _ _ _ 0

Shimizu et al. (2021)[47] 1 0 0 1 0 0

TOTAL 74 39 15 15 5 0

*Not considering hematuria for > 24 hours as a complication and allowing 2 asymptomatic hematomas.

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follow-up have shown no difference in 5-year local recur-
rence-free survival between cryoablation and PN (91.6% 
vs. 92.7%; HR, 1.46; P  =  0.6)[17]. One reason could be  
the late recurrence of patients who underwent PN.

With regard to postoperative complications, grade III 
and above complications were low, at 6.2% across all the 
series. When comparing CA to PN, Caputo et al. (2017) 
showed a higher incidence of postoperative compli-
cations with PN (PN 42% vs. CA 23%; P = 0.10)[21]. A 
recent systematic review showed a significant increase in 
postoperative complication of PN compared to CA (OR, 
2.97; 95% CI, 2.13–4.14; P < 0.001)[29]. Cryoablation can 
be performed either laparoscopically or percutaneously, 
and this review included both these techniques. The 
majority of the procedures were done percutaneously; 
however, some institutions do still use the laparoscopic 
approach[21,31]. Multiple studies have been published 
comparing outcomes of both techniques. While some 
series have shown similar complication rates, and simi-
lar OS, CSS, and RFS between percutaneous and laparo-
scopic cryoablation[24], a meta-analysis has shown that 
percutaneous cryoablation (PCA) had shorter hospital 
stay and laparoscopic cryoablation (LCA) had lower 
incidence of perirenal hematoma. PCA is favored for 
older patients and those with posterior tumors[32].

One final aspect of CA to be raised is the timing of 
renal mass biopsy (RMB), and whether to do it concom-
itantly or in a separate session prior to ablation. Each 
institution has a different protocol, hence some of the 
series had RMB before the procedure while others 
concomitantly during the ablation procedure. The EAU 
guidelines recommend a percutaneous renal biopsy 
done prior to ablation therapy rather than concomi-
tantly because biopsy reduces the number of unneces-
sary ablations of benign lesions, where historically 32% 
to 45 % of patients undergoing ablation therapy had 
benign lesions[33–35]. In addition, oncological outcome 
of patients might differ based on the RCC subtypes 
detected on biopsy, which will help in better patient 
counseling and on the best treatment course[36].

Comparing the 2 ablative methods (cryoablation 
vs. radiofrequency), the literature is especially lacking 
in studies for cT1b lesions. Only one published study, 
performed by Hasegawa et al., compared the efficacy 
of the 2 ablative methods in 46 patients with T1b stage 
RCC. Those authors found that the 5-year OS rates were 
similar between cryoablation and radiofrequency abla-
tion (82% vs. 78%, respectively; P = 0.82), and the 5-year 
RCC-related survival rate was 100% for both groups[37]. 
Cryoablation is preferentially used in centrally located 
lesions, for tumors between 3 cm and 7 cm, and for those 
near the ureter[34,38]. For now, radiofrequency abla-
tion remains reserved for tumors smaller than 3 cm[38]. 
The EAU guideline panel proposal still limits ablative 

therapy to lesions between 3 cm and 7 cm in patients 
where surgery is not feasible or contraindicated[40].

Long-term oncological effectiveness about cryoabla-
tions remains hard to ascertain, as these series are not 
without limitations. These series are mostly retrospec-
tive, observational studies with short-term follow-up. No 
prospective RCT exists that compares outcomes of PN 
to CA for cT1b kidney tumor. Even matching was poor 
in some comparative series that compared CA and PN. 
Moreover, these series have small sample sizes, and the 
authors fail to mention the reason for cryoablations or 
the criteria used to treat these patients with CA, both 
of which are causes of a selection bias. In addition, the 
median lesion size ranges from 4.3 cm to 4.8 cm. While 
this size range falls within the range of cT1b tumors (4 
cm to 7 cm), it targets a subset of patients within that 
group, and these findings may not be generalizable to the 
larger population of cT1b. Currently, there is no consen-
sus on the number and size of probes that are used in 
the ablative techniques, and this causes some variabil-
ity between treating centers. Lastly, some centers elected 
to do preoperative or intraoperative embolization of 
tumor prior to cryoablation. Embolization can decrease 
complications such as hemorrhage and renal collecting 
system injury in large tumors without affecting renal 
function. However, its definitive effect on recurrence 
rate and survival remains to be determined[41,42].

Conclusion
While partial nephrectomy remains the preferred 
method to treat cT1b kidney tumors, cryoablation is a 
feasible alternative with good survival and recurrence-
free survival outcomes. Cryoablation for T1b tumors 
might be considered in a select group of patients—those 
who are older, have multiple comorbidities, or cannot 
tolerate surgery. It can also serve as a suitable alternative 
for patients who refuse surgery.

Acknowledgments
Availability of data and material
All data generated or analyzed during this study 
are included in this article and its supplementary 
material files. Further enquiries can be directed to the 
corresponding author.

Authors contributions
M. Shahait and A. El-Achkar conceived the study and 
its design; A. Farkouh, J. Hassanieh, A. El-Achkar, and 
M. Khader performed data collection; A. El-Achkar, 
M. Khader, and A. Farkouh performed data analysis 
and interpreted the results; A. El-Achkar, M. Khader, 
and M. Shahait prepared the manuscript draft; and all 
the authors reviewed the results and approved the final 
version of the manuscript.

219SIUJ.ORG SIUJ  •  Volume 4, Number 3  •  May 2023

Role of Cryoablation for the Treatment of cT1b Kidney Lesions: Outcomes of a Systematic Review

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References

1. Moskowitz D, Chang J, Ziogas A, Anton-Culver H, Clayman RV. 
Treatment for T1a renal cancer substratified by size: “less is more”.  
J Urol.2016;196(4):1000–1007. doi: 10.1016/j.juro.2016.04.063. PMID: 
27113965; PMCID: PMC7802797.

2. Van Poppel H, Da Pozzo L, Albrecht W, Matveev V, Bono A, Borkowski 
A, et al. A prospective, randomised EORTC intergroup phase 3 study 
comparing the oncologic outcome of elective nephron-sparing 
surgery and radical nephrectomy for low-stage renal cell carcinoma.  
Eur Urol.2011;59(4):543–552. doi: 10.1016/j.eururo.2010.12.013. PMID: 
21186077.

3. Pickersgill NA, Vetter JM, Kim EH, Cope SJ, Du K, Venkatesh 
R, et al. Ten-year experience with percutaneous cr yoablation 
of renal tumors: tumor size predicts disease progression.  
J Endourol.2020;34(12):1211–1217. doi: 10.1089/end.2019.0882. PMID: 
32292059.

4. Morkos J, Porosnicu Rodriguez KA, Zhou A, Kolarich AR, Frangakis 
C, Rodriguez R, et al. Percutaneous cryoablation for stage 1 renal 
cell carcinoma: outcomes from a 10-year prospective study and 
comparison with matched cohorts from the National Cancer Database. 
Radiology.2020;296(2):452–459. doi: 10.1148/radiol.2020192325. 
PMID: 32515677.

5. Thompson RH, Atwell T, Schmit G, Lohse CM, Kurup AN, Weisbrod A, 
et al. Comparison of partial nephrectomy and percutaneous ablation 
for cT1 renal masses. Eur Urol.2015;67(2):252–259. doi: 10.1016/j.
eururo.2014.07.021. PMID: 25108580.

6. Hebbadj S, Cazzato RL, Garnon J, Shaygi B, Buy X, Tsoumakidou G, et al. 
Safety considerations and local tumor control following percutaneous 
image-guided cryoablation of T1b renal tumors. Cardiovasc Intervent 
Radiol.2018;41(3):449–458. doi: 10.1007/s00270-017-1820-0. PMID: 
29075877.

7. Pecoraro A, Palumbo C, Knipper S, Mistretta FA, Tian Z, Shariat SF, 
et al. Cryoablation predisposes to higher cancer specific mortality 
relative to partial nephrectomy in patients with nonmetastatic 
pT1b kidney cancer. J Urol.2019;202(6):1120–1126. doi: 10.1097/
JU.0000000000000460. PMID: 31347950.

8. Abu-Ghanem Y, Fernández-Pello S, Bex A, Ljungberg B, Albiges L, 
Dabestani S, et al. Limitations of available studies prevent reliable 
comparison between tumour ablation and partial nephrectomy for 
patients with localised renal masses: a systematic review from the 
European Association of Urology Renal Cell Cancer Guideline Panel. 
Eur Urol Oncol.2020;3(4):433–452. doi: 10.1016/j.euo.2020.02.001. 
PMID: 32245655.

9. Lehman DS, Hruby GW, Phillips CK, McKiernan JM, Benson MC, 
Landman J. First prize (tie): laparoscopic renal cr yoablation: 
efficacy and complications for larger renal masses. J Endourol. 
2008;22(6):1123–1127. doi: 10.1089/end.2008.0077. PMID: 18484888.

10. Par vinian A, Kurup AN, At well TD, Schmit GD, Schmit z JJ, 
Morris JM. Percutaneous cryoablation of large tumors: safety, 
feasibilit y, and technical considerations. Cardiovasc Intervent 
Radiol.2022;45(1):69–79. doi: 10.1007/s00270-021-03025-7. PMID: 
34859309.

11. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow 
CD, et al. The PRISMA 2020 statement: an updated guideline for 
reporting systematic reviews. BMJ.2021;372:n71. doi: 10.1136/bmj.
n71. PMID: 33782057; PMCID: PMC8005924.

12. Ahmed M, Solbiati L, Brace CL, Breen DJ, Callstrom MR, Charboneau 
JW, et al.; International Working Group on Image-guided Tumor 
Ablation; Interventional Oncology Sans Frontières Expert Panel; 
Technology Assessment Committee of the Society of Interventional 
Radiology; Standard of Practice Committee of the Cardiovascular and 
Interventional Radiological Society of Europe. Image-guided tumor 
ablation: standardization of terminology and reporting criteria–a 
10-year update. Radiology.2014;273(1):241–260. doi: 10.1148/
radiol.14132958. PMID: 24927329; PMCID: PMC4263618.

13. Murad MH, Sultan S, Haffar S, Bazerbachi F. Methodological quality 
and synthesis of case series and case reports. BMJ Evid Based 
Med.2018;23(2):60–63. doi: 10.1136/bmjebm-2017-110853. PMID: 
29420178; PMCID: PMC6234235.

14. Ljungberg B, Bensalah K, Canfield S, Dabestani S, Hofmann F, Hora 
M, et al. EAU guidelines on renal cell carcinoma: 2014 update. Eur 
Urol.2015;67(5):913–924. doi: 10.1016/j.eururo.2015.01.005. PMID: 
25616710.

15. Campbell SC, Clark PE, Chang SS, Karam JA, Souter L, Uzzo RG. Renal 
mass and localized renal cancer: evaluation, management, and follow-
up: AUA Guideline: Part I. J Urol.2021;206(2):199–208. doi: 10.1097/
JU.0000000000001911. PMID: 34115547.

16. Motzer RJ, Jonasch E, Agarwal N, Alva A, Baine M, Beckermann K, et 
al. Kidney Cancer, Version 3.2022, NCCN Clinical Practice Guidelines 
in Oncology. J Natl Compr Canc Netw.2022;20(1):71–90. doi: 10.6004/
jnccn.2022.0001. PMID: 34991070.

17. Andrews JR, Atwell T, Schmit G, Lohse CM, Kurup AN, Weisbrod 
A, et al. Oncologic outcomes following partial nephrectomy and 
percutaneous ablation for cT1 renal masses. Eur Urol.2019;76(2):244–
251. doi: 10.1016/j.eururo.2019.04.026. PMID: 31060824.

18. Weight C J, Larson BT, Gao T, Campbell SC, Lane BR, Kaouk 
JH, et al. Elective partial nephrectomy in patients with clinical 
T1b renal tumors is associated with improved overall survival. 
Urology.2010;76(3):631– 637. doi: 10.1016/j.urology.2009.11.087. 
PMID: 20451967.

19. Zhang M, Zhao Z, Duan X, Deng T, Cai C, Wu W, et al. Partial versus 
radical nephrectomy for T1b-2N0M0 renal tumors: a propensity 
score matching study based on the SEER database. PLoS One. 
2018;13(2):e0193530. doi: 10.1371/journal.pone.0193530. PMID: 
29489911; PMCID: PMC5830994.

20. Morris CS, Baerlocher MO, Dariushnia SR, McLoney ED, Abi-Jaoudeh 
N, Nelson K, et al. Society of Interventional Radiology Position 
Statement on the Role of Percutaneous Ablation in Renal Cell 
Carcinoma: Endorsed by the Canadian Association for Interventional 
Radiology and the Society of Interventional Oncology. J Vasc Interv 
Radiol.2020;31(2):189.e3–194.e3. doi: 10.1016/j.jvir.2019.11.001. 
PMID: 31917025.

220 SIUJ  •  Volume 4, Number 3  •  May 2023 SIUJ.ORG

REVIEW

http://SIUJ.org


21. Caputo PA, Zargar H, Ramirez D, Andrade HS, Akca O, Gao T, et al. 
Cryoablation versus partial nephrectomy for clinical T1b renal tumors: 
a matched group comparative analysis. Eur Urol.2017;71(1):111–117. 
doi: 10.1016/j.eururo.2016.08.039. PMID: 27568064.

22. Sundelin MO, Lagerveld B, Ismail M, Keeley F X Jr, Nielsen TK. 
Repeated cryoablation as treatment modality after failure of primary 
renal cr yoablation: a European registr y for renal cr yoablation 
multinational analysis. J Endourol.2019;33(11):909–913. doi: 10.1089/
end.2019.0444. PMID: 31507206.

23. Gunn AJ, Joe WB, Salei A, El Khudari H, Mahmoud KH, Bready E, 
et al. Percutaneous cryoablation of stage T1b renal cell carcinoma: 
safety, technical results, and clinical outcomes. Cardiovasc Intervent 
Radiol.2019;42(7):970–978. doi: 10.1007/s00270-019-02226-5. PMID: 
31044292; PMCID: PMC8983093.

24. Kim EH, Tanagho YS, Bhayani SB, Saad NE, Figenshau RS. 1200 
Outcomes of laparoscopic and percutaneous cryoablation for renal 
masses. J Urol.2013;189(4S):e492. doi: 10.1016/j.juro.2013.02.2554.

25. Asayama Y, Nishie A, Ushijima Y, Okamoto D, Morita K, Takao S, et al. 
Usefulness of a pretreatment CT-based modified RENAL nephrometry 
score in predicting renal function after cryotherapy for T1a renal mass. 
Cardiovasc Intervent Radiol.2019;42(8):1128–1134. doi: 10.1007/
s00270-019-02238-1. PMID: 31073824.

26. Bhindi B, Thompson RH, Mason RJ, Haddad MM, Geske JR, Kurup AN, 
et al. Comprehensive assessment of renal tumour complexity in a large 
percutaneous cryoablation cohort. BJU Int.2017;119(6):905–912. doi: 
10.1111/bju.13841. PMID: 28296030.

27. Camacho JC, Kokabi N, Xing M, Master VA, Pattaras JG, Mittal PK, et 
al. R.E.N.A.L. (Radius, exophytic/endophytic, nearness to collecting 
system or sinus, anterior/posterior, and location relative to polar lines) 
nephrometry score predicts early tumor recurrence and complications 
after percutaneous ablative therapies for renal cell carcinoma: a 5-year 
experience. J Vasc Interv Radiol.2015;26(5):686–693. doi: 10.1016/j.
jvir.2015.01.008. PMID: 25769213.

28. Schmit GD, Thompson RH, Boorjian SA, McDonald RJ, Kurup AN, 
Weisbrod AJ, et al. Percutaneous renal cryoablation in obese and 
morbidly obese patients. Urology.2013;82(3):636–641. doi: 10.1016/j.
urology.2013.05.025. PMID: 23890665.

29. Zhou W, Herwald SE, Uppot RN, Arellano RS. Impact of body mass 
index on perioperative complications and oncologic outcomes in 
patients undergoing thermal ablation for renal cell carcinoma. J Vasc 
Interv Radiol. 2021;32(1):33–38. doi: 10.1016/j.jvir.2020.07.028. PMID: 
33308948.

30. Deng W, Chen L, Wang Y, Liu X, Wang G, Liu W, et al. Cryoablation 
versus partial nephrectomy for clinical stage T1 renal masses: a 
systematic review and meta-analysis. J Cancer.2019;10(5):1226–1236. 
doi: 10.7150/jca.28881. PMID: 30854132; PMCID: PMC6400682.

31. Ham BK, Kang SG, Choi H, Ko YH, Kang SH, Cheon J. The impact of 
renal tumor size on the efficacy of laparoscopic renal cryoablation. 
Korean J Urol.2010;51(3):171–177. doi: 10.4111/kju.2010.51.3.171. 
PMID: 20414392; PMCID: PMC2855452.

32. Jiang K, Tang K, Guo X, Liu H, Chen H, Chen Z, et al. Laparoscopic 
cr yoablation vs. percutaneous cr yoablation for treatment of 
small renal masses: a systematic review and meta-analysis. 
Oncotarget.2017;8(16):27635–27644. doi: 10.18632/oncotarget.15273. 
PMID: 28199973; PMCID: PMC5432364.

33. Widdershoven CV, Aarts BM, Zondervan PJ, Henderickx MMEL, 
Klompenhouwer EG, van Delden OM, et al. Renal biopsies performed 
before versus during ablation of T1 renal tumors: implications 
for prevention of over treatment and follow-up. Abdom Radiol 
(NY).2021;46(1):373–379. doi: 10.1007/s00261-020-02613-4. PMID: 
32564209; PMCID: PMC7864836.

34. At well TD, Schmit GD, Boorjian SA, Mandrekar J, Kurup AN, 
Weisbrod A J, et al. Percutaneous ablation of renal masses 
measuring 3.0 cm and smaller: comparative local control and 
complications after radiofrequency ablation and cryoablation. AJR 
Am J Roentgenol.2013;200(2):461–466. doi: 10.2214/AJR.12.8618. 
PMID: 23345372.

35. E AU Guidelines. Edn. presented at the E AU Annual Congress 
Amsterdam 2022, ISBN: 97–4-92671-16-5. EAU Guidelines Office, 
A r nhem, T he Netherlands. ht tps://uroweb.org /guidelines/
compilations-of-all-guidelines [cited 2022 20/3/2022]

36. Haddad MM, Schmit GD, Kurup AN, Schmitz JJ, Boorjian SA, Geske 
J, et al. Percutaneous cryoablation of solitary, sporadic renal cell 
carcinoma: outcome analysis based on clear-cell versus papillary 
subtypes. J Vasc Interv Radiol.2018;29(8):1122–1126. doi: 10.1016/j.
jvir.2018.02.029. PMID: 29887184.

37. Hasegawa T, Yamanaka T, Gobara H, Miyazaki M, Takaki H, Sato Y, 
et al. Radiofrequency ablation versus cryoablation for T1b renal cell 
carcinoma: a multi-center study. Jpn J Radiol.2018;36(9):551–558. 
doi: 10.1007/s11604-018-0756-x. PMID: 29968201.

38. Schmit GD, Atwell TD, Leibovich BC, Callstrom MR, Kurup AN, 
Woodrum DA, et al. Percutaneous cryoablation of anterior renal 
masses: technique, efficacy, and safety. AJR Am J Roentgenol. 
2010;195(6):1418–1422. doi: 10.2214/AJR.09.3530. PMID: 21098204.

39. Zondervan PJ, Buijs M, De Bruin DM, van Delden OM, Van Lienden KP. 
Available ablation energies to treat cT1 renal cell cancer: emerging 
technologies. World J Urol.2019;37(3):445–455. doi: 10.1007/s00345-
018-2546-6. PMID: 30448873; PMCID: PMC6424924.

40. Capitanio U, Bedke J, Albiges L, Volpe A, Giles RH, Hora M, et al. A 
renewal of the TNM staging system for patients with renal cancer to 
comply with current decision-making: proposal from the European 
Association of Urology Guidelines Panel. Eur Urol.2023;83(1):3–5. doi: 
10.1016/j.eururo.2022.09.026. PMID: 36253306.

41. Harmon TS, Matteo J, Meyer TE, Kee-Sampson J. Pre-cryoablation 
embolization of renal tumors: decreasing probes and saving loads. 
Cureus. 2018;10 (12):e3676. doi: 10.7759/cureus.3676. PMID: 
30761229; PMCID: PMC6367110.

42. Miller JM, Julien P, Wachsman A, Van Allan RJ, Friedman ML. The role 
of embolization in reducing the complications of cryoablation in renal 
cell carcinoma. Clin Radiol.2014;69(10):1045–1049. doi: 10.1016/j.
crad.2014.05.110. PMID: 25037148.

221SIUJ.ORG SIUJ  •  Volume 4, Number 3  •  May 2023

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43. Atwell TD, Vlaminck JJ, Boorjian SA, Kurup AN, Callstrom MR, 
Weisbrod AJ, et al. Percutaneous cryoablation of stage T1b renal cell 
carcinoma: technique considerations, safety, and local tumor control.  
J Vasc Interv Radiol.2015;26(6):792–799. doi: 10.1016/j.jvir.2015.02.010. 
PMID: 25824313.

44. Rembeyo G, Correas JM, Jantzen R, Audenet F, Dariane C, Delavaud 
C, et al. Percutaneous ablation versus robotic partial nephrectomy in 
the treatment of cT1b renal tumors: oncologic and functional outcomes 
of a propensity score-weighted analysis. Clin Genitourin Cancer. 
2020;18(2):138–147. doi: 10.1016/j.clgc.2019.10.006. PMID: 31982346.

45. Grange R, Tradi F, Izaaryene J, Daidj N, Brunelle S, Walz J, et al. 
Computed tomography-guided percutaneous cryoablation of T1b renal 
tumors: safety, functional and oncological outcomes. Int J Hyperthermia. 
2019;36(1):1065–1071. doi: 10.1080/02656736.2019.1675913. PMID: 
31648584.

46. Bhagavatula SK, Tuncali K, Shyn PB, Levesque VM, Chang SL, 
Silverman SG. Percutaneous CT- and MRI-guided cr yoablation 
of cT1 renal cell carcinoma: intermediate- to long-term outcomes 
in 307 patients. Radiology. 2020;296(3):687– 695. doi: 10.1148/
radiol.2020200149. PMID: 32633677.

47. Shimizu K, Enoki K, Kameoka Y, Motohashi K, Yanagisawa T, Miki 
J, et al. Image-guided percutaneous cr yoablation of T1b renal 
cell carcinomas in patients with comorbidities. Jpn J Radiol. 
2021;39(12):1213–1222. doi: 10.1007/s11604-021-01168-8. PMID: 
34228240.

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