Open adrenalectomy in the era of laparoscopic surgery: a review

Progress in treatment and follow-up of pheochromocytoma

Pheochromocytoma (PHEO) is an uncommon neuroendocrine tumor originating from the chromaffin cells of the adrenal medulla. These tumors are capable of producing and releasing substantial amounts of catecholamine (CA) hormones. Individuals with PHEO often experience transient blood pressure fluctuations, headaches, and palpitations, among other symptoms. In extreme cases, they may develop severe complications, including cardiovascular and cerebrovascular incidents, myocardial disorders, and gastrointestinal issues. At the advanced stage, PHEO can affect multiple organs, potentially leading to pheochromocytoma crisis. However, the clinical manifestations of pheochromocytoma may be diverse. Some patients have no typical triad of headache, palpitations, and sweating, and are not accompanied by obvious clinical symptoms or signs. There are only abnormalities in imaging and biochemical indicators, which will pose a challenge for early diagnosis. The primary treatment options for PHEO encompass surgical and non-surgical approaches. In contrast to many other adrenal pathologies, there is currently no consensus on the optimal surgical versus non-surgical management of PHEO. Laparoscopic surgery, as opposed to traditional open surgery, offers numerous benefits. However, whether retroperitoneal or transperitoneal laparoscopic adrenalectomy remains controversial. Da Vinci robot-assisted adrenalectomy has the advantages of highly precise operation and excellent hemostasis capabilities. The day surgery management model for adrenalectomy procedures has proven to be both safe and feasible. However, current research on its long - term effectiveness and wide - scale application still has limitations. Additionally, the application of the Senhance robot in urology, particularly in adrenalectomy, has seen relatively little investigation thus far. In terms of non-surgical treatment for pheochromocytoma, chemotherapy, radionuclide therapy, targeted therapy and immunotherapy, as well as radiofrequency ablation and microwave ablation chemotherapy have all advanced significantly. This article aims to review the latest advancements in the treatment of pheochromocytoma.

Estimation of physiologic ability and surgical stress (E-PASS) predicts postoperative complications after adrenalectomy

The Estimation of Physiologic Ability and Surgical Stress (E-PASS) score, initially developed for gastrointestinal surgery, is a validated system used to predict postoperative complications by evaluating preoperative and intraoperative factors. This study aims to assess the effectiveness of the E-PASS score in predicting postoperative complications following adrenalectomy. In this single-center retrospective study, we analyzed data from 202 patients who underwent adrenalectomy by a single surgeon between January 2017 and March 2024. 182 patients with complete data and who met the study criteria were included in the study. Demographic, clinical, intraoperative, and postoperative data were collected and analyzed, including preoperative complaints, ASA classification, ECOG performance status, presence of systemic diseases, type of surgery, and intraoperative details, such as blood loss and complications. Postoperative complications were classified using the Clavien-Dindo Classification. The mean age of the patients was 48.7 ± 13.6 years. The mean BMI was 24.1 kg/m2. Postoperative complications were observed in 26.4% of patients, categorized as Grade 1 (54.1%), Grade 2 (25%), Grade 3 (16.7%), and Grade 4 (4.2%). Multivariate logistic regression identified higher BMI (OR = 1.394) and an E-PASS CRS score > - 0.0677 (OR = 6.17) as independent risk factors for complications. ROC curve analysis determined this CRS score cut-off with an AUC of 0.866 (CI 0.808-0.923; p < 0.001). The E-PASS scoring system effectively predicts postoperative complications in adrenalectomy. Its integration into clinical practice can enhance the identification of high-risk patients, optimize perioperative management, and potentially reduce adverse outcomes.

Outcomes and Follow-Up Trends in Adrenal Leiomyosarcoma: A Comprehensive Literature Review and Case Report

Background: Leiomyosarcoma (LMS) originating from the adrenal gland is exceedingly rare, constituting a minute fraction of soft tissue sarcomas. Due to its rarity, with less than 50 documented cases in English medical literature, the diagnosis and management of adrenal LMS remain challenging. The aim of this study was to perform a review of the literature, in order to evaluate the prognosis of these rare cancers and report our specific case. Methods: A systematic review of the literature was conducted using PubMed, Web of Science, Google Scholar, and Scopus databases, up to December 2020. The search utilized MeSH terms such as "Adrenal Gland Neoplasms," "Leiomyosarcoma," "Adrenalectomy," and "Smooth Muscle Tumor." The inclusion criteria focused on studies reporting patients with a histopathological diagnosis of adrenal leiomyosarcoma. The PRISMA guidelines were followed to ensure a comprehensive analysis. Results: Out of 63 identified studies, 43 met the inclusion criteria and were reviewed. These studies highlighted the rarity and aggressive behavior of adrenal leiomyosarcoma. Surgical excision remains the cornerstone of treatment, often complemented by adjuvant therapies. The reviewed case involved a 52-year-old woman who underwent a right laparoscopic adrenalectomy for a 9 × 7 × 6 cm grade 3 leiomyosarcoma. Despite subsequent adjuvant chemotherapy, hepatic metastases were detected, illustrating the aggressive nature of the disease. The literature underscores the importance of histopathological analysis and long-term surveillance for managing disease progression. Conclusions: Optimal management of adrenal leiomyosarcoma requires a multidisciplinary approach and meticulous follow-up. The rarity of the disease poses challenges for standardizing treatment, but surgical excision and tailored adjuvant therapies show promise. Further research is essential to refine treatment strategies and improve prognosis for this rare malignancy.

Safety and surgical outcomes of robotic adrenalectomy from a 15-year experience at a single institution

Robotic adrenalectomy (RA) has gained significant popularity in the management of adrenal gland diseases. We report our experience at a single tertiary institution and evaluate the safety and surgical outcomes of RA. The data of 122 consecutive patients who underwent RA from October 2009 to December 2022 at Korea University Anam Hospital (Seoul, Korea) were reviewed. There were no perioperative complications. Clinicopathological features and surgical outcomes were retrospectively analyzed through complete chart reviews. Noteworthy findings include the influence of sex, tumor size, and body mass index on operation time, with the female and small tumor groups exhibiting shorter operation times (P = 0.018 and P = 0.009, respectively). Pheochromocytoma was identified as a significant independent risk factor for a longer operation time in the multivariate analysis [odds ratio (OR), 3.709; 95% confidence interval (CI), 1.127-12.205; P = 0.031]. A temporal analysis revealed a decreasing trend in mean operation times across consecutive groups, reflecting a learning curve associated with RA adoption. RA is a safe and effective operative technique alternative to laparoscopic adrenalectomy that has favorable surgical outcomes and enhances the convenience of the operation.

[Are there still indications for open adrenalectomy?]

Despite the triumph of minimally invasive techniques in adrenal surgery, the indications for open adrenalectomy are indispensable in the canon of treatment options and must remain part of the repertoire of visceral surgery. Open adrenalectomy is indicated for advanced adrenal carcinoma (ENSAT stage III). In addition to the frequent local infiltration of these carcinomas which makes the en bloc resection of adjacent organs necessary, thromboses in the renal vein or the vena cava or multiple lymph node metastases can also necessitate an open procedure; however, open adrenalectomy is justified and must also be discussed for adrenocortical carcinoma ENSAT stages I-II (tumor size ≤ 5 cm or > 5 cm, NO). Furthermore, highly suspicious large adrenal tumors (6-8 cm, Hounsfield units > 20) without preoperative evidence of malignancy and other adrenal pathologies, such as neuroblastomas, large pheochromocytomas and also schwannomas can be an indication for open adrenalectomy.

Robot assisted laparoscopic adrenalectomy: Should this be the new standard?

Introduction:

Minimal invasive surgeries (MIS) for large size adrenal tumors are still debatable. The objective is to evaluate the contemporary peri- and post-operative outcomes of patients undergoing (open = OA, laparoscopic = LA, and robotic = RA) adrenalectomies in three institutions.

Materials and methods:

Retrospectively gathered peri- and post-operative data of 235 patients, underwent adrenalectomy at three Institutions over a 7-year period (2013–2020) were analyzed. All patients underwent thorough radiological and endocrine workup.

Results:

Two hundred and thirty five patients who underwent adrenalectomy (OA ( n = 29), LA ( n = 146), and RA ( n = 60)) were assessed. OA ( n = 29) versus Minimally invasive surgery ( n = 206) showed significant differences (median, p value) in larger tumour size, cm (9.4 vs 5, ( p = 0.0001)), longer operative time, mins (240 vs 100, ( p = 0.0001)), longer hospital stay, days (8 vs 3,( p = .0001)), Higher readmission rates (14% vs 1.9%), higher blood loss, ml (400 vs 100, ( p = 0.0001)) requiring blood transfusion (14% vs 4.3%) ( p = 0.03), higher intraoperative complication (21% vs 6%) ( p = 0.0004), and post op complications (17% vs 5.3%) ( p = 0.01). Amongst the MIS (RA vs LA), RA appeared be have better outcomes in terms of shorter operative time, less blood loss and less intra operative complications with a p value <0.05. These results were consistent for the assessment of patients who had ⩾6 cm tumor size. The postoperative complication rates were lowest with RA (3.3%) compared to OA (17%) and LA (6.1%).

Conclusions:

Contemporary practice of adrenalectomy shows that robotic adrenalectomy is safe and effective irrespective of the tumor size.

Laparoscopic adrenalectomy: comparison of outcomes between posterior retroperitoneoscopic and transperitoneal adrenalectomy with 10 years' experience

Background

Laparoscopic adrenalectomy is widely used for treating various adrenal tumors. Posterior retroperitoneoscopic adrenalectomy was introduced after transperitoneal laparoscopic adrenalectomy. The comparability and superiority of posterior retroperitoneoscopic adrenalectomy have been widely investigated. We aimed to compare the outcomes of posterior retroperitoneoscopic adrenalectomy and transperitoneal laparoscopic adrenalectomy using 10 years' data. The changes in outcomes over time were also analyzed.

Methods

This was a retrospective observational study. A total of 505 patients who underwent laparoscopic adrenalectomy between 2009 and 2018 were included. The patients were divided into two groups: transperitoneal (n=114) and retroperitoneal (n=391) groups. Patients who underwent posterior retroperitoneoscopic adrenalectomy were further classified into sub-groups (sub-group 1: 2009-2012; sub-group 2: 2013-2015; and sub-group 3: 2016-2018) based on time periods. Clinicopathological factors and postoperative outcomes were retrospectively reviewed and analyzed.

Results

The retroperitoneal group showed significantly shorter operation time, diet initiation time, and hospital stay compared to the transperitoneal group (P=0.000, 0.000 and 0.000, respectively). Analgesics were used less frequently in the retroperitoneal group than in the transperitoneal group (P=0.048). In the retroperitoneal group, the time to postoperative diet initiation shortened over time (P=0.000).

Conclusions

Posterior retroperitoneoscopic adrenalectomy is a favorable surgical method that results in patient outcomes that are comparable to those of conventional transperitoneal laparoscopic adrenalectomy, without compromising patient safety.

Risk Predictors of Prolonged Hypotension After Open Surgery for Pheochromocytomas and Paragangliomas

BACKGROUND

Prolonged hypotension is a common complication after surgery for pheochromocytomas and paragangliomas (PPGLs). It places patients at an increased risk of major morbidities and even death. The objective of the study was to investigate the risk predictors of prolonged hypotension in patients undergoing open surgery for PPGLs.

METHODS

The present study adopted a retrospective, single-center design. Patients who underwent open surgery for PPGLs were enrolled from January 1, 2002, to December 31, 2018, at Peking University First Hospital. Perioperative variables were screened from patients' electronic medical records. Prolonged hypotension was defined as hypotension that required continuous catecholamine support for at least 30 min to maintain a systolic blood pressure of > 90 mmHg after surgery.

RESULTS

A total of 162 patients were included in the study. Fifty-two patients (31.1%) had prolonged hypotension with a median vasopressor support duration of 14 h (IQR = 4-30 h). Body mass index <24 kg/m² (OR = 3.015, 95% CI 1.217-7.467; P = 0.017), larger tumor size (OR = 1.146, 95% CI 1.014-1.295; P = 0.029), and higher plasma norepinephrine concentration (OR = 1.053, 95% CI 1.019-1.087; P = 0.002) were associated with prolonged hypotension. Patients with prolonged hypotension had a higher incidence of complication, were more frequently admitted to the intensive care unit, underwent mechanical ventilation for a longer duration, and had a longer postoperative hospital stay when compared to those without.

CONCLUSION

Body mass index < 24 kg/m², larger tumor size, and higher plasma norepinephrine concentration are independent risk predictors of prolonged hypotension in patients undergoing open surgery for PPGLs.

The Evolving Role of Metastasectomy for Patients with Metastatic Renal Cell Carcinoma

Surgical metastasectomy continues to be utilized for patients with solitary or low-volume metastatic renal cell carcinoma (mRCC). Although few high-quality data are available to evaluate outcomes, local treatment is recommended when feasible because it may allow a subset of patients to delay or avoid systemic treatments. With the development of improved mRCC therapies, utilization of metastasectomy has increased because most patients have incomplete responses to systemic treatment of their metastases. This review discusses the rationale and history of metastasectomy, trends in utilization, prognostic factors for patient selection, site-specific considerations, alternatives for nonsurgical local treatment, and risk of morbidity associated with metastasectomy.

SURGICAL MANAGEMENT OF THE ADRENAL GLAND TUMORS - SINGLE CENTER EXPERIENCE

Context

Incidentally discovered solid adrenal tumors must be evaluated from two points of view: the risk of malignancy and the secretory feature.

Objective

Our aim was to evaluate the surgical technique option in relation with clinical and histopathologic features.

Design

We performed a retrospective study that included patients with adrenal gland tumors.

Subjects and methods

All patients were operated between 2012 and 2019 by the same surgical team in a single center.

Results

The batch included 102 patients with adrenal tumors operated through open surgery (OS, n=41) and laparoscopic surgery (LS, n=61). Tumor localization was especially on the right adrenal gland (n=52, 50.98%). Primary origin of the adrenal gland tumors was in 82 cases (80.39%) and a metastatic origin in 16 cases. Average dimension for surgical resected tumors was 4.02 cm (0.9-12 cm) for the LS group as compared to 7.22 cm (1.3-19 cm) for OS group with a predominant type of surgery represented by adrenalectomy and a conversion rate of 2.94%. The hospital stay was 7.22 days (5-12 days) in the LS group versus 12.72 days (6-57 days) in OS group with significant differences (p<0.01). Also, the postoperative recovery was significantly different (6.5 days versus 2.62 days, p<0.01).

Conclusion

Laparoscopic approach represents the gold standard in adrenal gland tumors less than five centimeters in size. Adrenalectomy is mostly performed by LS and adenoma is the most frequent histopathologic type, while pheochromocytoma is operated through OS. LS has a significantly reduced hospitalization and postoperative stay compared to OS.

Clinical analysis of adrenal lesions larger than 5 cm in diameter (an analysis of 251 cases)

Background

To describe the pathological distribution, imaging manifestations, and surgical managements and prognosis of large adrenal tumors (LATs) ≥ 5 cm

Methods

A total of 251 patients with LATs were analyzed on the basis of pathological or clinical diagnosis. Regarding surgery, open adrenalectomy was performed on 89 patients, and laparoscopic adrenalectomy was performed on 89 patients. Thirty-two patients with bilateral tumors were analyzed in terms of clinical characteristics. The survival rate was determined for 43 patients with adrenal metastases and 29 patients with primary adrenal malignancies. The CT characteristics including tumor diameter, shape, edge, heterogeneity, necrosis, calcification, pre-contrast attenuation, and contrast attenuation were analyzed for 117 patients.

Results

The majority of LATs were still benign, but they had a higher probability to be malignant. Benign LATs made up 68.13% of all cases, mainly adrenal cysts (19.52%), pheochromocytoma (18.73%), benign adenoma (16.73%), and myelolipoma (7.17%). Malignant LATs accounted for 28.69% of cases, mainly including adrenocortical carcinoma (8.76%) and metastases (17.13%). Laparoscopic surgery was found to involve less trauma than open surgery. It was also safer and postoperative recovery was faster, but it had drawbacks and could not completely replace open surgery. CT features had obvious specificity for the diagnosis of benign and malignant tumors. For example, benign adenomas had a smaller pre-contrast (< 10 Hu) whereas malignant adrenal tumors had, on the contrary, higher attenuation. Regarding adrenal malignant carcinoma, adrenal primary malignant tumors showed a better prognosis than adrenal metastases (mean survival of 19.17 months vs 9.49 months). Primary adrenal cortical carcinoma without metastasis had a better prognosis than primary adrenal cortical carcinoma metastasis (mean survival of 23.71 months vs 12.75 months), and adrenal solitary metastasis had a better prognosis than general multiple metastatic carcinoma (mean survival of 14.95 months vs 5.17 months).

Conclusion

LATs were more likely to be benign; however, they still had a high probability of being a malignant tumor. Understanding the clinicopathological characteristics of LATs can facilitate selection of more effective clinical treatment options.

Challenges of training in adrenal surgery

While adrenal tumors are common, adrenalectomy is rather uncommon. This is one reason for the many challenges regarding the training of adrenal surgery. Here we focus on issues that are most pertinent regarding training of the young surgeons performing adrenalectomy. Due to the very limited literature, what is presented is mainly based on personal experience and/or from the literature published for other surgical operations and subspecialties. The discussed challenges include indications for surgery, surgical approaches and extent, and intraoperative complications. With advances in adrenal surgery, we expect some old challenges to be resolved, and some new challenges to arise. These challenges will be faced in order to continue to help our younger trainee acquire the knowledge and skills to best care for our patients with adrenal diseases.

Comparison of retroperitoneal laparoscopic versus open adrenalectomy for large pheochromocytoma: a single-center retrospective study

Background

It remains unclear whether retroperitoneal laparoscopic adrenalectomy (RLA) is safe and effective for the treatment of large pheochromocytoma (PHEO). This retrospective study aimed to identify the advantages and disadvantages of RLA compared to open adrenalectomy (OA).

Methods

This study included 147 patients who underwent RLA (n = 101) or OA (n = 46) for PHEO larger than 5 cm. Groups were balanced by propensity score matching (PSM) into 46 pairs. Perioperative variables and long-term follow-up results were compared between the two groups.

Results

After PSM, patients in the RLA group had a shorter operative time (218 vs. 245 min, P = 0.040), quicker bowel recovery (2 vs. 3 days, P = 0.046), and a shorter hospital stay (8 vs. 9 days, P = 0.010) compared to the OA group. The results of multiple linear regression analyses showed that the operative method (OA vs. RLA) had an influence on the above three postoperative variables (β = 31.84, P = 0.046; β = 0.76, P = 0.044; and β = 1.25, P = 0.025, respectively). There was no significant difference in the proportion of patients with improved blood pressure (82.61% vs. 69.57%, P = 0.143) between the two groups.

Conclusions

Both RLA and OA provide similar perioperative and long-term outcomes for the surgical management of large PHEO. RLA is an efficacious and safe surgical method for patients with PHEO larger than 5 cm in diameter.

Adrenal Surgery for Cushing's Syndrome: An Update

Recent advances in the molecular pathogenesis and the natural history of Cushing's syndrome have improved the understanding of the management of this disease. The long-term efficacy of several cortisol-lowering medical treatments is currently under evaluation. However, adrenalectomy is a safe option for the treatment of patients affected by Cushing's syndrome. Unilateral adrenalectomy is the gold standard for treatment of adrenocortical adenomas associated with hypercortisolism. Bilateral adrenalectomy has been widely used in the past as definitive treatment of bilateral macronodular hyperplasia and persistent or recurrent Cushing's disease. The indication and the potential applications of this technique have been recently critically analyzed.