Laparoscopic lateral adrenalectomy versus open posterior adrenalectomy for the treatment of benign adrenal tumors

Long-term results of laparoscopic adrenalectomy for primary aldosteronism

BACKGROUND

The management of primary aldosteronism is currently achieved by both medical and surgical treatment. Laparoscopy has in recent years unquestionably become the gold standard in adrenal surgery for benign lesions. This study aims to evaluate our clinical results among patients who underwent laparoscopic adrenalectomy (LA) for primary aldosteronism.

METHODS

From January 1994 to January 2006, amid LA series, 59 primary aldosteronism patients were treated in our institution. Patients were 33 males and 26 females with mean age 49.3 yr (19-78). The mean body mass index was 25.9 kg/m2 (20.5-33.3). The mean size of lesion was 2.9 cm (1-5.5). Clinical symptoms were as follows: hypertension and symptomatic/asymptomatic hypokalemia (54), hypokalemia (5).

RESULTS

Thirty-five left and 24 right LA were performed. On the left side, 22 procedures were carried out by anterior approach, 9 by anterior submesocolic route, and 4 by means of flank approach. All right procedures were completed by the anterior supine approach. The mean operative time was 103.5 min for left and 92.8 min for right adrenalectomy. There was one major complication, a colonic post-operative fistula, regarding a left adrenalectomy case. The mean post-operative hospital stay was 3 days (1-9). The cure rate of hypertension and hypokalemia was similar to the current literature results.

CONCLUSIONS

LA is a safe and effective option in the treatment of primary aldosteronism. Appropriate selection of patients, larger adrenal masses and duration of symptoms are determining factors in the success rate of hypertension management.

Flank approach versus anterior sub-mesocolic access in left laparoscopic adrenalectomy: a prospective randomized study

BACKGROUND

Laparoscopy is commonly recognized as the gold standard in adrenal surgery. The most used surgical access is at present the so-called flank approach. The aim of this study was to compare the flank approach and the anterior sub-mesocolic access carrying out left laparoscopic adrenalectomy (LA).

METHODS

From January 2003 to January 2006 50 eligible left LAs were randomized to the flank (n = 25, group A) or sub-mesocolic transperitoneal approach (n = 25, group B). The two groups were similar concerning patient and lesion features. Comparing the two approaches, the main parameters analyzed, adjusted for tumor size and histology, were operating time (OpT), complication rate, and hospital stay.

RESULTS

There were no converted procedures. Mean overall OpT was 76.4 min (54-96 min) versus 65.6 min (45-95 min) in group A and B, respectively (p = 0.001), while the OpT required to tie the adrenal vein was 42.8 min (26-55 min) and 24.5 min (16-41 min) (p = 0.000). Oral feeding resumed within 12-24 h in both groups. Mean hospital stay was 3 and 2.4 days in groups A and B, respectively (p = 0.04). Mean tumor size was similar in group A and B: 3.6 cm (1.5-6.5 cm) and 3.8 cm (2-6 cm), respectively. Definitive histology in groups A and B were: Cushing adenoma (6 and 4), Conn adenoma (5 and 6), pheochromocytoma (4 and 9), and incidentaloma (8 and 5, respectively). A myelolipoma and an adrenogenital adenoma were observed in group A and one carcinoma was observed in group B.

CONCLUSIONS

Sub-mesocolic approach provides a statistically significant shorter OpT and hospital stay. Identification and early closure of the adrenal vein by means of a really minimal dissection and no-touch gland technique resulted in the main benefits of this approach.

Trends in adrenalectomy rates, indications, and physician volume: A statewide analysis of 1816 adrenalectomies

BACKGROUND

Adrenalectomy rates seem to be increasing in Florida, possibly due to increased availability of laparoscopic adrenalectomy, identification of incidentalomas, and access to care for minorities. We hypothesized that the rate of adrenalectomies in Florida increased from 1998-2005 while characteristics of patients, diagnoses, operations, and operating physicians changed over this period.

METHODS

Prospectively-collected, mandatory-reported, hospital discharge data for all inpatient adrenalectomies undertaken in Florida from 1998-2005 were obtained along with Florida census and physician certification and education data. Characteristics of adrenalectomy patients, diagnoses, operations, and physicians were analyzed.

RESULTS

1816 adrenalectomies were available for analysis. Yearly rates of adrenalectomy nearly doubled from 1.20 to 2.26 per 100,000 Florida residents (P = .0024). Overall, patient characteristics such as demographics, indications and comorbidities did not change, whereas hospital charges increased and length-of-stay (LOS) significantly decreased (P = .0031 and P < .0001, respectively). There was a non-significant trend toward a yearly increase in physician volume and an inverse relationship between physician volume categories and mean LOS (P < .0001).

CONCLUSIONS

The rate of adrenalectomies is increasing in Florida. This increase was not associated with distinct trends in patient characteristics, although a significant decrease in LOS was identified. As these trends continue and adrenalectomy is applied more liberally, indications for adrenalectomy may need to be re-evaluated.

Prediction of successful outcome in patients with primary aldosteronism

Primary aldosteronism is one of the most common causes of secondary hypertension. In recent years the prevalence has risen dramatically, from 1% to 14% of all hypertensive patients. This has been largely attributed to an increase in diagnosis. Primary aldosteronism is characterized by hypertension with or without hypokalemia and a high plasma aldosterone concentration (PAC) with a concurrent low plasma renin activity (PRA). The most common subtypes of primary aldosteronism are aldosterone-producing adenoma (42%) and bilateral idiopathic hyperaldosteronism (58%). Other less common subtypes (<1%) are glucocorticoid-remediable aldosteronism, and unilateral primary hyperplasia. Current treatment for primary aldosteronism relies on accurate subtype distinction and assessment of unilateral versus bilateral disease. Bilateral idiopathic hyperaldosteronism is best managed pharmacologically and improves with the use of aldosterone receptor antagonists. Combined treatment with sodium-channel blockers and calcium-channel blockers has also shown satisfactory results. Glucocorticoid-remediable aldosteronism responds well to treatment with low-dose glucocorticoids. Aldosterone producing adenoma and unilateral adrenal hyperplasia are appropriately treated with laparoscopic adrenalectomy. Following adrenalectomy blood pressure improves in 98% of these patients, but only about 33% require no further antihypertensive medication. Identifying the subgroups that will most benefit from adrenalectomy is paramount to formulating individual treatment strategies. In the past, treatment focused mainly on the correction of hypertension and electrolyte disturbances. Now, with accumulating evidence of the detrimental effects of aldosterone to the myocardium, vascular endothelium and kidneys, treatment also focuses on normalizing aldosterone levels or blocking aldosterone action at the receptor level. Therefore, it is essential to accurately identify the specific subtype of primary aldosteronism in order to select optimal treatment and to achieve successful patient outcomes.

Carcinoembryonic antigen-producing adrenal adenoma resected using combined lateral and anterior transperitoneal laparoscopic surgery

A 74-year-old woman presented with symptoms consistent with hyperadrenocorticism and hyperca-techolaminism. She had a cushingoid appearance and her cortisol level was elevated. Her serum dopamine and noradrenalin levels were also elevated. Computed tomography detected a left adrenal mass measuring 3.5 cm multiply 3.0 cm in diameter. Metaiodobenzylguanidine scintigraphy was negative. Unexpectedly, the serum Serum carcinoembryonic antigen (CEA) level was elevated. Fluorodeoxyglucose positron emission tomography showed increased uptake in the adrenal tumor only, with a maximum standardized uptake value of 2.8. Selective venography and blood sampling revealed that the concentrations of cortisol, catecholamines and CEA were significantly elevated in the vein draining the tumor. A diagnosis of CEA-producing benign adenoma was made. After preoperative management, we performed a combined lateral and anterior transperitoneal laparoscopic adrenectomy. Her vital signs remained stable during surgery. Histopathological examination revealed a benign adenoma. Her cortisol, catecholamine and CEA levels normalized immediately after surgery. We present, to the best of our knowledge, the first case of CEA-producing adrenal adenoma, along with a review of the relevant literature, and discuss our laparoscopic surgery techniques.

Perioperative results of 214 laparoscopic adrenalectomies by anterior transperitoneal approach

BACKGROUND

The present study attempts to evaluate the perioperative results of the anterior approached laparoscopic adrenalectomy (LA) in a large cohort of patients, and report the advantages and disadvantages of this route.

METHODS

204 patients, 125 female and 79 male with a mean age 52.8 years (range, 19-75 years), underwent LA by the anterior transperitoneal approach from 1994 to 2005 in our institution. There were 100 right and 114 left LAs. Ten patients underwent bilateral LA. Associated surgical procedures were performed in 17 cases. During the same period 47 LAs had been performed by different approaches (flank and submesocolic).

RESULTS

Mean operative time was 80 minutes for right (40-150), 109 minutes for left (64-300) and 194 minutes for bilateral adrenalectomy. Intraoperative major complications were observed in six patients. Mortality occurred in one diabetic patient who was converted to open surgery because of a colonic perforation and subsequently developed a Candida sepsis in the postoperative course. The mean size of lesion removed was 6.2 cm (1.5-12 cm). Oral intake started within 24 hours and the mean hospital stay was 2.5 days (1-8 days). Histology results were as follows: nonsecreting adenoma 65, Cushing's adenoma 58, Conn's adenoma 53, pheochromocytoma 24, metastases 9, myelolipoma 3, adrenogenital syndrome 1, carcinoma 1.

CONCLUSIONS

LA by anterior transperitoneal approach is safe and effective in our experience, despite the inherent limitation that this was not a prospective randomized study. The main advantage of this route is early ligature of the adrenal vein on both sides, enabling the performance of associated surgical procedures and bilateral adrenalectomy.

Intraoperative haemodynamic stability in patients with phaeochromocytoma--minimally invasive vs conventional open surgery

OBJECTIVE

There is conflicting evidence, whether or not minimally invasive adrenalectomy (MA) is associated with an increased perioperative cardiovascular instability in phaeochromocytomas compared to conventional open adrenalectomy (CA).

DESIGN AND PATIENTS

In a retrospective analysis of 49 patients with phaeochromocytoma we compared 27 cases of MA to 22 cases of CA by assessing intraoperative haemodynamic parameters and perioperative complications. Patients undergoing MA for adrenocortical adenomas (aldosteronomas n = 15, inactive adenomas n = 13) served as controls. Additionally, we investigated the effect of phenoxybenzamine (POB) pretreatment on intraoperative cardiovascular stability in 42 patients (ranked by maximum daily POB-dose) by comparing the highest (n = 10) with the lowest (n = 10) POB dose quartile (0.32 +/- 0.2 and 2.17 +/- 0.6 mg/kg/day, P < 0.001).

RESULTS

In phaeochromocytomas we found no significant difference in intraoperative haemodynamic parameters or complications when comparing MA with CA. In comparison to adrenocortical adenomas, MA in phaeochromocytomas was associated with a significantly higher maximum systolic BP (188 +/- 29 vs 154 +/- 22 mmHg, P < 0.001), more frequent hypertensive episodes (1[0-4]vs 0[0-1], P < 0.001), more episodes of systolic BP > 200 mmHg (0[0-4]vs 0[0-1], P = 0.03) and a higher demand for intraoperative fluids (3194 ml vs 1750 ml, P < 0.001). Most haemodynamic parameters did not differ significantly between high-dose POB pretreatment and low-dose POB pretreatment, but high-dose POB pretreatment was associated with a significantly higher intraoperative heart rate (120 +/- 19.5 vs 94 +/- 15.2 min(-1), P < 0.01).

CONCLUSION

There is no significant difference in haemodynamic stability between MA and CA in phaeochromocytomas, but it is significantly inferior when compared to MA for cortical adenomas. We could not detect a beneficial effect of high-dose compared to low-dose POB pretreatment on intraoperative cardiovascular stability.

Benefits of Laparoscopic Adrenalectomy: A 10-year Single Institution Experience

INTRODUCTION

We aimed to compare the outcomes of laparoscopic and open adrenalectomies and to assess the impact of the availability of advanced laparoscopy on adrenal surgery at our institution.

MATERIALS AND METHODS

A retrospective analysis of data of all patients who underwent adrenalectomy at the University of Massachusetts Medical Center over a 10-year period.

RESULTS

Sixty-four consecutive patients underwent adrenalectomy during the study periods. There were 19 open (OA) and 45 laparoscopic (LA) adrenalectomies performed. There was no significant difference between the average size of adrenal masses removed for the LA and the OA groups [4.3 vs. 5.5 cm, respectively (P=0.23)]. LA proved superior to OA, resulting in shorter operative times (171 vs. 229 min, P=0.02), less blood loss (96 vs. 371 mL, P<0.01), shorter time to regular diet (1.9 vs. 4.4 d, P<0.001), and shorter hospital stay (2.5 vs. 5.8 d, P=0.02). In addition, the average annual number of adrenalectomies increased significantly since the establishment of our advanced laparoscopic program (10.0 vs. 2.0, P=0.02).

CONCLUSIONS

LA offers superior results when compared to OA in terms of operative time, blood loss, return of bowel function, duration of hospital stay, and functional recovery. The availability of advanced laparoscopy has resulted in a significant increase in the number of adrenalectomies performed at our institution without a shift in surgical indications.

Safety and efficacy of endoscopic retroperitoneal adrenalectomy

Background

Minimally invasive adrenalectomy has replaced open surgery in the treatment of benign adrenal tumours. Transperitoneal and retroperitoneal approaches have been advocated. However, long-term outcome data are rare.

Methods

Over a period of 8 years, 123 patients underwent surgery for benign adrenal lesions using the endoscopic retroperitoneal approach. Data were analysed retrospectively by review of medical charts. Long-term results were obtained by sending questionnaires to patients and contacting their primary physicians.

Results

One hundred and twenty-three patients underwent 126 endoscopic retroperitoneal adrenalectomies. Mean operating time for unilateral adrenalectomy was 115 min, whereas that for bilateral adrenalectomy was 208 min. The conversion rate was 4·8 per cent. Complications occurred after 15·9 per cent of adrenalectomies. One patient died during the postoperative period. Long-term results were obtained in 80 patients (74·8 per cent). Nine patients (11 per cent) reported chronic incisional pain and six patients (8 per cent) had chronic abdominal pain. Addisonian crisis after bilateral adrenalectomy occurred in three patients. Most patients (86 per cent) were satisfied with the cosmetic results.

Conclusion

Endoscopic retroperitoneal adrenalectomy is a safe and effective procedure. Long-term outcome is acceptable and the procedure has excellent cosmetic results.

Clinical Management of Large Adrenal Cystic Lesions

The widespread use of ultrasonography and computed tomography has resulted in an increased diagnosis of large sized adrenal cysts with diameters of more than 5 cm. Most of these adrenal cystic lesions are clinically silent and are therefore often diagnosed incidentally. Since up to 7% of adrenal cysts are malignant, a careful hormonal, morpho-functional and instrumental evaluation is mandatory. In particular, functioning adrenal carcinomas or pheochromocytomas have to be ruled out. Fine needle aspiration cytology as well as examination of a punch biopsy specimen of the cystic wall are of limited value, as there is considerable overlap in cytologic and histologic features of benign and malignant adrenal cystic lesions. Immediate surgical excision is indicated in the presence of symptoms, suspicion of malignancy, increase in the size or detection of a functioning adrenal cyst. En bloc adrenalectomy, preferably by a laparoscopic approach, has become the treatment of choice.

Laparoscopic adrenalectomy, an initial experience of fifteen cases

BACKGROUND

Laparoscopic adrenalectomy is an attractive alternative to open surgery, but making the transition can be difficult.

AIM

To evaluate the initial experience of a general surgical team at a single institution at making the transition.

METHODS

The details of 15 patients undergoing laparoscopic adrenalectomy were prospectively recorded over a 21-month period.

RESULTS

Fifteen glands were removed from fifteen patients. Nine of these were left-sided. The mean gland size was 3.4 cm. Pathology included six non-functioning adenomas, four Conn's syndrome, two Cushing's syndrome and three phaeochromocytomas. Mean operating time was 74 minutes (range 31-172 minutes), with one conversion to open procedure. There were no morbidities and no mortality.

CONCLUSION

Our initial experience demonstrates this approach to be the ideal technique for removal of benign adrenal tumours with significant advantages for the patient.

Long-term remission rates after pituitary surgery for Cushing's disease: the need for long-term surveillance

OBJECTIVE

There have been a few reports on long-term remission rates after apparent early remission following pituitary surgery in the management of Cushing's disease. An undetectable postoperative serum cortisol has been regarded as the result most likely to predict long-term remission. Our objective was to assess the relapse rates in patients who underwent transsphenoidal surgery in order to determine whether undetectable cortisol following surgery was predictive of long-term remission and whether it was possible to have long-term remission when early morning cortisol was measurable but not grossly elevated. Endocrinological factors associated with late relapse were also studied.

PATIENTS

We reviewed the long-term outcome in 63 patients who had pituitary surgery for the treatment of Cushing's disease between 1979 and 2000.

MEASUREMENTS

Case notes were reviewed and the current clinical and biochemical status assessed. Our usual practice was that early after the operation, an 08:00 h serum cortisol was measured 24 h after the last dose of hydrocortisone. This was followed by a formal low-dose dexamethasone suppression test. Current clinical status and recent 24-h urinary free cortisol values were used as an index of activity of the Cushing's disease. If there was evidence suggesting relapse, a low-dose dexamethasone suppression test was performed. In many patients, sequential collections of early morning urine specimens for urinary cortisol to creatinine ratio were also performed in an attempt to diagnose cyclical and intermittent forms of recurrent hypercortisolism. We did this if there was conflicting endocrine data, or if patients were slow to lose abnormal clinical features.

RESULTS

Mean age at diagnosis was 40.3 years (range 14-70 years). Mean follow-up up time was 9.6 years (range 1-21 years). Forty-five patients (9 males/36 females) achieved apparent remission immediately after surgery and were subsequently studied long term. Of these 45 patients, four have subsequently died while in remission from hypercortisolism. Ten of the remaining 41 patients have relapsed. Of those 10, six demonstrated definite cyclical cortisol secretion. Two of the 10 had undetectable basal serum cortisol levels in the immediate postoperative period. Thirty-one patients are still alive and in remission. Fourteen (45%) of the 31 who remained in remission had detectable serum cortisol levels (> 50 nmol/l) immediately postoperatively, and remain in remission after a mean of 8.8 years. Our relapse rate was therefore 10/45 (22%), after a mean follow-up time of 9.6 years, with mean time to relapse 5.3 years.

CONCLUSIONS

The overall remission rate of 56% (35/63) at 9.6 years follow-up is disappointing and merits some re-appraisal of the widely accepted principle that pituitary surgery must be the initial treatment of choice in pituitary-dependent Cushing's syndrome. Following pituitary surgery, careful ongoing expert endocrine assessment is mandatory as the incidence of relapse increases with time and also with increasing rigour of the endocrine evaluation. A significant number of our patients were shown to have relapsed with a cyclical form of hypercortisolism.

Systemic inflammatory response syndrome in open versus laparoscopic adrenalectomy

OBJECTIVES

To compare the surgical invasiveness of laparoscopic adrenalectomy with that of open surgery when the invasiveness is evaluated by the incidence of systemic inflammatory response syndrome (SIRS).

METHODS

Patients who underwent open adrenalectomy (35 patients) and those who underwent transperitoneal laparoscopic adrenalectomy (35 patients) were included in this study. We retrospectively investigated the incidence and duration of SIRS in the two groups. Of the 70 patients, 39 had primary aldosteronism and 31 had clinically nonfunctioning adrenal tumors.

RESULTS

The incidence of SIRS was 51.4% (18 patients) in the open group and 31.4% (11 patients) in the laparoscopic group (P = 0.14, Fisher's exact probability test). The mean duration of SIRS was 1.9 days in the open group and 1.2 days in the laparoscopic group (P = 0.04, unpaired t test). Surgical site infection, which occurred in 2 patients in the open group (5.7%) and 3 patients (8.5%) in the laparoscopic group, was the only infectious complication. No patient had any severe or life-threatening complications.

CONCLUSIONS

Laparoscopic adrenalectomy seems less invasive than open surgery, when the magnitude of the invasiveness is evaluated by the incidence of SIRS.

Predictors of Duration of Postoperative Hospital Stay in Patients Undergoing Advanced Laparoscopic Surgery

The expansion of the indications for laparoscopic surgery to include high-risk patient, acute and malignant pathology, and more complex procedures may prolong the hospital stay. Cox multiple stepwise regression analysis model was employed to determine independent predictors of prolonged postoperative hospital stay (more than 3 days) following advanced laparoscopic procedures among 10 variables. Some 130 patients had undergone advanced laparoscopic surgical procedures between November 2000 and August 2003. The median postoperative hospital stay was 3 days (interquartile range 2-5), and 81 patients (62.3%) were discharged within 3 days of surgery. The independent predictors of prolonged postoperative hospital stay were ASA score of 3 or 4 (odds ratio [OR] = 4.610, P = 0.0002) and preoperative hospital stay (OR = 0.151 per day, P = 0.001). Independent predictors of duration of preoperative hospital stay were emergency admission to hospital (OR = 9.516, 95% CI 5.770-13.261, P < 0.0001) and an underlying malignant pathology (OR = 7.948, 95% CI 3.623-12.273, P = 0.0004). Advanced laparoscopic surgery is associated with a short postoperative hospital stay in the majority of patients. Prolongation of the postoperative hospital stay (more than 3 days) may be expected if the patient had been in the hospital with an acute or malignant disease for more than 6 days prior to surgery and in patients with high comorbidity. The duration of surgery has no impact on the duration of the postoperative hospital stay.

Simultaneous bilateral laparoscopic adrenalectomy: a surgical option for multiple endocrine neoplasia (MEN 2) patients with bilateral pheochromocytomas

Multiple endocrine neoplasia (MEN 2) is a rare disorder. Of this group, 42% develop a pheochromocytoma of which 60% will have bilateral involvement. Although the benefits of unilateral laparoscopic adrenalectomy have been well documented, fewer cases of simultaneous bilateral laparoscopic adrenalectomy have been reported. We present the cases of three patients with MEN 2 who underwent successful simultaneous bilateral laparoscopic adrenalectomy after their initial presentation with bilateral pheochromocytoma. Although the management of bilateral pheochromocytomas has traditionally been approached via open laparotomy or bilateral posterior incisions, the bilateral laparoscopic approach should be considered a viable alternative for patients requiring surgical intervention. Clinical outcomes and complications are similar to open laparotomy. Simultaneous bilateral laparoscopic adrenalectomy is a safe and effective procedure that results in a more rapid recovery and a shorter hospital stay for patients with bilateral pheochromocytomas originating from MEN 2.

The clinically inapparent adrenal mass: update in diagnosis and management

Clinically inapparent adrenal masses are incidentally detected after imaging studies conducted for reasons other than the evaluation of the adrenal glands. They have frequently been referred to as adrenal incidentalomas. In preparation for a National Institutes of Health State-of-the-Science Conference on this topic, extensive literature research, including Medline, BIOSIS, and Embase between 1966 and July 2002, as well as references of published metaanalyses and selected review articles identified more than 5400 citations. Based on 699 articles that were retrieved for further examination, we provide a comprehensive update of the diagnostic and therapeutic approaches focusing on endocrine and radiological features as well as surgical options. In addition, we present recent developments in the discovery of tumor markers, endocrine testing for subclinical disease including autonomous glucocorticoid hypersecretion and silent pheochromocytoma, novel imaging techniques, and minimally invasive surgery. Based on the statements of the conference, the available literature, and ongoing studies, our aim is to provide practical recommendations for the management of this common entity and to highlight areas for future studies and research.