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Data supporting minimally invasive management for small renal masses has matured over the last decade. The outpatient procedures such as the one described in the present issue of BJUI by the Breen et al. [1] have limited morbidity and allow urologists to lower the threshold to treat patients presenting with localised disease. The authors present a contemporary cohort of patients undergoing percutaneous cryoablation of a renal mass. They report an overall technical treatment success rate of 97.6% with a medically significant complication rate of 4.6%, and a single recurrence noted at 12-months follow-up. This experience reflects the low incidence of complications and durable intermediate oncological outcomes currently reported in the literature [2]. As safety and efficacy become less of a concern, a question remains – which patients require treatment?

Many small renal lesions have low lethal or metastatic potential. One approach would be to adopt the paradigm of our dermatology colleagues… remove everything. They perform a minimally invasive excision under local anaesthesia with a low incidence of complications. On pathology, 22% of index skin lesions referred for biopsy result in ‘malignant’ pathology, with only 5.7% being melanoma [3]. The remainder, although largely basal and squamous cell carcinomas, go on to treatment despite low metastatic potential of 0.1% and 4%, respectively. Principles of management are similar in that treatment often requires surgical intervention (Mohs, excision, curettage, cryosurgery) with a negative margin, resulting in a high rate of cure. The perceived limited morbidity of treatment is acceptable to the general public and has afforded the dermatologists the option to treat all patients and as such the treatment of non-melanoma skin cancers increased by nearly 77% between 1992 and 2006. However, with new economic paradigms it will be interesting to see if over treating 75% of individuals in this arena is sustainable.

The treatment of T1a RCC presents a more problematic management dilemma. Despite 10-year cause-specific survival exceeding 97% and low rates of complications, selecting patients that will benefit from these statistics remains a challenge. Ultimately, although every patient can be treated successfully, a risk-based stratification is sorely needed. Growth rates and renal biopsy are examples of current methods being evaluated to standardised criteria for guiding intervention [4, 5]. Unfortunately, no schema has shown to be 100% foolproof in limiting treatment or identifying patients who will benefit most. As such, we are at a time in urological history where we continue to over treat… but it is acceptable when done in a minimally invasive manner. And although it does cost a bit, it only hurts a little.

Conflict of Interest

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None declared.

References

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