Laparoscopic partial adrenalectomy for aldosterone-producing adenomas with needlescopic instruments

Minilaparoscopy in urology: Systematic review

CONTEXT

There has been a boom in recent years in urological procedures using minilaparoscopy (ML).

OBJECTIVE

To conduct a systematic review of the published evidence on ML and its current role in urology.

ACQUISITION OF EVIDENCE

We performed a search on MedLine spanning October 1983 to December 2016 according to PRISMA criteria. A total of 6 comparative articles and 13 series were selected for this manuscript.

SUMMARY OF THE EVIDENCE

Only 1 study was randomised, 4 studies were prospective and comparative, and most were case series in which the operations were performed with 3-mm instruments. The most common procedures were adrenalectomy, followed by nephrectomy, living donor and pyeloplasty. Other minor conditions were also operated on, including cyst decortications, pyelolithotomies, lymphadenectomies, varicocelectomies and orchiectomies.

DISCUSSION

There have been significant technical improvements in recent years in the materials of ML. Most procedures were for reconstructive surgery and by transperitoneal approach, with a gradually increasing number of cases of oncologic surgery. Only 36.8% of the series assessed the cosmetic results with validated questionnaires, and 68.4% of the studies used the visual analogue scale to measure pain during the postoperative period.

CONCLUSIONS

The level of evidence of most published studies is low. ML is a reproducible technique for urological surgery and is safe even for operations on large surgical masses. The procedure's cosmetic and pain results after surgery are superior to those of conventional laparoscopy, although these conclusions should be taken with caution given the limitations of the current studies.

Laparoendoscopic single-site (LESS) retroperitoneal partial adrenalectomy using a custom-made single-access platform and standard laparoscopic instruments: technical considerations and surgical outcomes

BACKGROUND

We previously reported our initial experience with laparoendoscopic single-site (LESS) retroperitoneal partial adrenalectomy using a custom-made single-port device and conventional straight laparoscopic instruments.

METHODS

Between December 2010 and February 2012, LESS retroperitoneal partial adrenalectomies were performed in 11 patients. Six patients had aldosterone-producing adenomas (APAs) and five patients had nonfunctioning tumors. A single-port access was created with an Alexis wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA) through an incision of 2-3 cm beneath the tip of the 12th rib. All procedures were performed with straight laparoscopic instruments.

RESULTS

All LESS procedures were successfully completed without conversion to traditional laparoscopic conversion. The tumors ranged from 1 cm to 4.7 cm (mean, 2.3 cm). The operative time was 71-257 minutes (mean, 121 minutes). Most patients (n = 8) had minimal blood loss; the other three patients had a blood loss of 150 mL, 100 mL, and 100 mL. The mean hospital stay was 3 days (range, 1-6 days). There were no perioperative or postoperative complications. Pathological examinations revealed negative surgical margins in all specimens. All patients with Conn's syndrome had an improvement in blood pressure and normalization of plasma renin activity and serum aldosterone levels; all patients were free of potassium supplementation.

CONCLUSION

Our results clearly demonstrate that LESS retroperitoneal partial adrenalectomy can be performed safely and effectively using a custom-made single-access platform and standard laparoscopic instruments.

Robot-assisted laparoscopic partial adrenalectomy for pheochromocytoma: the National Cancer Institute technique

BACKGROUND

Partial adrenalectomy has recently been advocated to preserve unaffected adrenal tissue during resection of pheochromocytoma.

OBJECTIVE

To describe a robot-assisted laparoscopic partial adrenalectomy (RALPA) technique and to report on early functional and oncologic outcomes.

DESIGN, SETTING, AND PARTICIPANTS

From 2007 to 2010, 15 RALPA were performed on 12 consecutive patients with pheochromocytoma. Follow-up data of >1 yr are available on 11 procedures. Median follow-up for the entire cohort was 17.3 mo (range: 6-45).

SURGICAL PROCEDURE

Positioning and port placement is designed for adequate reach and visualization of the upper retroperitoneum. The plane between the adrenal cortex and pheochromocytoma pseudocapsule is identified visually and with laparoscopic ultrasound. The tumor is dissected away from normal adrenal cortex, preserving normal adrenal tissue.

MEASUREMENTS

Preoperative, perioperative, pathologic, and functional outcomes data were analyzed.

RESULTS AND LIMITATIONS

Fourteen of 15 cases were completed robotically. Among 15 procedures, 4 were performed on a solitary adrenal gland. Four cases required resection of multiple tumors (up to six) with two performed in a solitary gland. The mean age of the patients was 30 yr, and the mean body mass index was 27. The mean operative time was 163 min, the median estimated blood loss was 161 ml, and the median tumor size was 2.7 cm (range: 1.3-5.5). There was one conversion to an open procedure in a patient requiring reoperation on a solitary adrenal gland. One patient who underwent RALPA on a solitary adrenal gland required postoperative steroid supplementation at last follow-up. At a median follow-up of 17.3 mo (range: 6-45), there were no recurrences or metastatic events. Study limitations include small sample size and short follow-up.

CONCLUSIONS

RALPA for the treatment of pheochromocytoma is feasible and safe and provides encouraging functional and oncologic outcomes, even in patients with a solitary adrenal lesion or multiple ipsilateral lesions.

Robot-assisted laparoscopic partial adrenalectomy: initial experience

OBJECTIVES

To evaluate the feasibility of performing robot-assisted laparoscopic partial adrenalectomy (RALPA) in patients seen at the National Cancer Institute and report the results of our initial experience.

METHODS

We reviewed the records of patients with adrenal masses who underwent attempted RALPA from July of 2008 until January of 2010. Demographic, perioperative, and pathologic data were collected. The functional and early oncological outcomes were examined by the need for steroid replacement and development of recurrent disease, respectively.

RESULTS

Ten patients underwent a total of 13 attempted RALPAs for removal of 19 adrenal tumors. There was one open conversion with successful completion of partial adrenalectomy. Of the patients, 80% had a known hereditary syndrome predisposing them to adrenal tumors. One patient had bilateral multifocal adrenal masses with unknown germ line genetic alteration and 1 patient had a sporadic adrenal mass. Of the 19 tumors removed, 17 were pheochromocytoma and 2 were adrenal-cortical hyperplasia. Two patients underwent partial adrenalectomy on a solitary adrenal gland, with one subsequently requiring steroid replacement postoperatively. On postoperative imaging, all but one operated adrenal gland demonstrated contrast enhancement. No patient developed local recurrence at a median follow-up of 16.2 months (range, 2-29).

CONCLUSIONS

RALPA appears safe and feasible in our early experience. Only 1 patient in our series required steroid replacement. Local recurrence rates are low but will require longer follow-up.

Initial experience of transumbilical laparoendoscopic single-site surgery of partial adrenalectomy in patient with aldosterone-producing adenoma

BACKGROUND

Laparoscopic single-site surgery has recently emerged in the field of urology and this minimally-invasive surgery has resulted in a further reduction in morbidity compared with traditional laparoscopy. We present our initial experience with laparoendoscopic single-site surgery of partial adrenalectomy (LESS-PA) to treat aldosterone-producing adenomas.

CASE PRESENTATION

A 60-year-old woman was diagnosed with aldosterone-producing macroadenomas in the left adrenal and aldosterone-producing microadenomas in the right adrenal. A two-step operation was planned. The first step involved transumbilical LESS-PA for the left adrenal tumors. A multichannel port was inserted through the center of the umbilicus and the left adrenal gland was approached using bent instruments according to standard traditional laparoscopic procedures. The tumors were resected using an ultrasonic scalpel, and the resected site was coagulated using a vessel sealing instrument and then sealed with fibrin glue. Operative time was 123 minutes and blood loss was minimal. The patient was discharged from hospital within 72 hours. Her right adrenal microadenomas will be treated in the next several months.

CONCLUSIONS

Although our experience is limited, LESS-PA appears to be safe and feasible for treating aldosterone-producing adenomas. More cases and comparisons with the multiport technique are needed before drawing any definite conclusions concerning the technique.

Partial adrenalectomy: underused first line therapy for small adrenal tumors

PURPOSE

Many patients with small adrenal masses undergo total adrenalectomy. We evaluated partial adrenalectomy outcomes by performing a comprehensive literature review.

MATERIALS AND METHODS

We performed a PubMed search of the English language literature using the queries partial adrenalectomy and adrenal sparing surgery, and identified 317 and 155 articles, respectively. We excluded case reports or series with fewer than 5 patients, articles not focused on surgical management and those that did not indicate perioperative outcomes. The remaining articles were cross-referenced by author and institution to eliminate studies with redundant cases. Demographics, diagnosis, tumor characteristics, perioperative and functional outcomes, and recurrence data were collected when available.

RESULTS

A total of 22 articles from a total of 22 first authors met our inclusion criteria, describing outcomes in a total of 417 patients. There has been an increasing trend toward partial adrenalectomy worldwide in the last 20 years. Partial adrenalectomy is most commonly done for Conn's syndrome, followed by pheochromocytoma. Most procedures are laparoscopic with minimal morbidity. The recurrence rate is only 3% and more than 90% of patients remain steroid independent.

CONCLUSIONS

Partial adrenalectomy surgical outcomes and perioperative complications are similar to those reported for total adrenalectomy. When partial adrenalectomy is done for small adrenal lesions, the malignancy rate is negligible, the recurrence rate is low and most patients remain steroid-free at long-term followup. These data strongly support the acceptance of partial adrenalectomy as first line treatment for small adrenal masses.

Single incision laparoscopic sleeve gastrectomy (SILS): a novel technique

BACKGROUND

Laparoscopic sleeve gastrectomy is an emerging bariatric procedure that typically necessitates five to seven small skin incisions to place five to seven trocars. The senior author (Saber) has developed a single umbilical incision approach to laparoscopic sleeve gastrectomy.

METHODS

Seven patients underwent single access transumbilical laparoscopic sleeve gastrectomy between March 2008 and July 2008. The same surgeon performed all surgical interventions. The umbilicus was the sole point of entry for all patients, and the same operative technique and perioperative protocol were used in all patients.

RESULTS

A total of seven single-incision laparoscopic sleeve gastrectomies were performed. The procedure was successfully performed in all patients. Mean operating time was 125 min. None of the patients required conversion to an open procedure. There were no mortalities or postoperative complications noted during the mean follow-up period of 3.4 months.

CONCLUSION

Single-incision transumbilical laparoscopic sleeve gastrectomy is safe, technically feasible, and reproducible.

Adrenal-preserving minimally invasive surgery: update on the current status of laparoscopic partial adrenalectomy

Adrenalectomy is the standard of care for hormonally active adrenal masses. In recent years, minimally invasive laparoscopic excision has become a preferred management option. As with advances in parenchymal-sparing renal surgery, investigators have begun to examine adrenal-sparing procedures to preserve functional adrenal tissue. This article reviews the recent literature and reports on intermediate results with laparoscopic partial adrenalectomy (LPA).