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Figure 1. Cryoablation - mechanism of action.

ESTABLISHED INDICATIONS
When determining the management approach for patients diagnosed with SRM, the patient’s values/goals,
life expectancy, and potential treatment benefits must all be considered and balanced. There is currently no
universal agreement on the ideal patient and tumor selection standards for the implementation of CA. The
current guidelines for the management of renal cancer from the American Urological Association (AUA)
include consideration of CA for RCC tumors < 3 cm, as well as select oligometastatic RCC and recurrent
[16]
RCC tumors . The National Comprehensive Network (NCCN) guidelines for kidney cancer management
include consideration of CA for RCC tumors ≤ 4 cm, as well as select oligometastatic renal tumors and
[17]
recurrent renal tumors . The European Association of Urology (EAU) recommends consideration of CA
for patients with SRM who are frail and/or have comorbidities but recommends against routine use of CA
[18]
for renal masses > 4 cm, tumors located near the renal hilum or the proximal ureter . The Society of
Interventional Radiology (SIR) recommends consideration of CA for patients with clinically localized renal
cell cancer with a maximum diameter of ≤ 4 cm (cT1a), and in select patients with clinically localized renal
cell cancer with a maximum diameter > 4 cm but ≤ 7 cm (cT1b) . There is limited strength of evidence to
[19]
compare treatments for SRM, resulting in these differences in recommendations and the need for an
individualized approach to patient care.

CONTRAINDICATIONS
The only absolute contraindication to CA is untreatable coagulopathy . Relative contraindications for CA
[20]
include younger age for patients who are healthy enough to be good candidates for PN, larger tumors such
as those > 3 cm, SRM located near the hilum or proximal ureter, intrarenal SRM, small cystic SRM that
would be good candidates for active surveillance or patients who have very short life expectancy where
expectant management would be preferred .
[21]
IMPLICATIONS OF TUMOR LOCATION AND APPROACH
Open CA, LCA, and PCA are all viable treatment options for renal masses. PCA is typically used for
posterior and lateral tumors, whereas open CA and LCA are preferred for anterior tumors where the