Laparoscopic adrenalectomy: the initial 3 cases

Comparison of robotic and laparoscopic lateral transperitoneal adrenalectomies

Purpose

This study aimed to compare the intraoperative and postoperative outcomes between robotic and laparoscopic transperitoneal adrenalectomies.

Methods

In this retrospective study, 93 patients underwent adrenalectomy using 2 surgical modalities: 45 patients underwent adrenalectomy using the da Vinci Xi system (robotic group), and 48 patients using laparoscopic devices (laparoscopic group). We compared the operation time, intraoperative bleeding, and hospital stay according to the surgical modality and tumor characteristics.

Results

There were no significant differences in the operative time (P = 0.827), hospital stay (P = 0.177), and intraoperative bleeding (P = 0.174) between the groups. However, the robotic group showed a lower coefficient of variation in total operative time than that of the laparoscopic group (100.6 ± 23.3 minutes vs. 101.9±32.7 minutes, 0.230 vs. 0.321). When divided into 2 subgroups based on the tumor size (<3 cm and ≥3 cm), the robotic group with a tumor sized >3 cm had a shorter operative time than that of the laparoscopic group (P = 0.032). The robotic group also had fewer cases of intraoperative bleeding (P = 0.034).

Conclusions

Compared to the laparoscopic transperitoneal adrenalectomy, the robotic one achieved a lower deviation in total operative time and showed less bleeding and a shorter operative time, especially for tumors sized >3 cm.

The Impact of Obesity on Mortality and Complications in Posterior Retroperitoneoscopic Adrenalectomy

Background Obesity is a global epidemic. It influences surgical technique, ergonomics, safety, and outcomes. However, there is a paucity of evidence of obesity-related impact in posterior retroperitoneoscopic adrenalectomy (PRA). This study compared perioperative outcomes of obese and non-obese participants undergoing PRA. Methodology  This is a multi-center retrospective cohort study of elective PRA from March 2014 to December 2022. Patient demographics, surgical techniques, clinicopathological parameters, and outcomes, including overall complication rate, were analyzed using SPSS version 27 (IBM Corp., Armonk, NY, USA). Results Seventy-five patients underwent a PRA, of which 97.3% were completed retroperitoneoscopically. The overall complication rate was (9.3%), and on subgroup analysis, the obese cohort had a lower percentage complication profile at 6.5%. Male participants comprised 52%, with a median age of 55 (IQR=19). The median BMI was 29.0 (IQR=8), of which 41% were obese, and 40% were overweight. Univariate analysis showed that being obese was not significantly associated with a higher complication rate (p=0.471). In addition, there was no significant increase in conversion (p=0.508), bleeding/transfusion (p=0.508), surgical site infection (SSI; p=1.000), incisional hernia (p=1.000), ICU or high dependency unit admission (p=0.292) and any-cause mortality (p=1.000). No sentinel deaths directly related to PRA were recorded. Procedure duration was longer in obese (117 mins) vs. non-obese participants (88.9 mins, p=0.022). However, there was no significant difference in the length-of-hospital stay (p=0.592). The cohort conversion rate was (2.7%), and tumor size was associated with a higher conversion rate (35.4 vs. 62.5mm, p=0.040). Conclusion Posterior retroperitoneoscopic adrenalectomy can be a safe procedure in obese populations, and obesity does not increase perioperative morbidity or mortality.

Laparoscopic Adrenalectomy Is Beneficial for the Health-Related Quality of Life of Older Patients with Primary Aldosteronism

OBJECTIVE

Laparoscopic adrenalectomy (LADX) improves hypertension in patients with primary aldosteronism (PA). However, the antihypertensive impact of LADX appears restricted in older patients with PA. In this study, we evaluated the impact of LADX in older patients focusing on the health-related quality of life (HRQoL).

METHODS

A total of 156 patients with PA who underwent LADX in a single institution were enrolled in this prospective cohort study. The patients were divided into 2 groups, with a boundary of 60 years. The HRQoL was evaluated using the Medical Outcomes Study's 36-Item Short-Form Health Survey version 2 (SF-36v2) questionnaire before and after LADX. Demographics, clinical features, antihypertensive drugs before and after surgery, and perioperative evaluation were recorded. We compared all scale scores and summed scores between groups. Multivariate regression models were used to determine the associations between various covariables and the HRQoL.

RESULTS

In the older PA patients, most subscales of HRQoL at baseline were lower than the national standard values. The antihypertensive drug-free rate by LADX was only 21% in older patients, compared to 58% in younger patients. However, a significant improvement in mental HRQoL was observed after LADX (p = 0.002). The much preoperative antihypertensive drugs, lower preoperative potassium level, and smaller degree of comorbidities were predictors of improved mental HRQoL by LADX on multivariate analyses.

CONCLUSION

The older PA patients showed lower mental HRQOL than the national standard populations. Although antihypertensive effects were limited for these patients, LADX was beneficial as PA treatment via improvement of mental HRQoL.

Survey of senior resident training in urologic laparoscopy, robotics and endourology surgery in Canada

INTRODUCTION

We determined the status of Canadian training during senior residency in laparoscopic, robotic and endourologic surgery.

METHODS

Fifty-six residents in their final year of urology residency training were surveyed in person in 2007 or 2008.

RESULTS

All residents completed the survey. Most residents (85.7%) train at centres performing more than 50 laparoscopic procedures yearly and almost all (96.4%) believe laparoscopic radical nephrectomy is the gold standard. About 82% of residents participated in a laparoscopic partial nephrectomy in 2008, compared to 64.7% in 2007. Of the respondents, 66% have participated in a laparoscopic prostatectomy and 54% believe the procedure has promising potential. Exposure and training in robotic-assisted laparoscopic procedures seem to be increasing as 35.7% of 2008 residents have access to a surgical robot and 7% consider themselves trained in robotic-assisted procedures. Most residents (71.4%) train at centres that perform percutaneous ablation. However, 65% state the procedure is performed solely by radiologists. Percutaneous nephrolithotomy is widely performed (98.2%), but only 37.5% of residents report training in obtaining primary percutaneous renal access. Despite only 12.5% of residents ranking their laparoscopic experience as below average or poor, an increasing proportion of graduating residents are pursuing fellowships in minimally-invasive urology.

CONCLUSION

Laparoscopic nephrectomy is commonly performed and is considered the standard of care by Canadian urology residents. Robotic-assisted surgery is becoming more common but will require continued evaluation by educators who will ultimately define its role in the urological residency training curriculum. Minimally-invasive surgical fellowships remain popular, as Canadian residents do not feel adequately trained in certain advanced procedures. Urologists must strive to learn and adapt to new technologies or risk losing them to other specialties.

Aldosteronomas--state of the art

Primary aldosteronism (PA) is the most common cause of secondary hypertension in nonsmokers. Widespread screening of unselected hypertensives has identified PA in as many as 15% of patients. With such screening efforts using the PAC/PRA ratio and PAC, the widespread prevalence of the disease has become apparent while the relative percentage of APA has decreased. PA is confirmed by demonstrating lack of aldosterone suppressibility with sodium loading. Subtype evaluation is best achieved with high resolution CT scanning and AVS in the appropriate setting. In patients with PA and a unilateral source of aldosterone excess, laparoscopic adrenalectomy is the treatment of choice with excellent outcomes and low morbidity as compared with older open approaches. Patients with IHA, or those not amenable or agreeable to surgery, are best managed with a MR antagonist.

Adrenal surgery in the pediatric population

Adrenal tumors in children may be benign or malignant. In addition, both benign and malignant tumors may be hormonally active, leading to hypertension, metabolic crises, and endocrinopathies. These tumors may be found incidentally or secondary to signs and symptoms of the aforementioned disorders. Both a metabolic and a radiographic work-up are required before treatment of an adrenal tumor. The primary therapy for most adrenal lesions is surgical, though some are treated medically or require chemotherapy before excision. Laparoscopy has become the surgical approach of choice in both adult and pediatric patients with localized disease. Open surgical approaches remain necessary in patients with extensive locally invasive or metastatic disease.

Laparoscopic adrenalectomy: Comparison of lateral transperitoneal and lateral retroperitoneal approaches

Laparoscopic adrenalectomy has become the method of choice of removal of most of adrenal lesions. This study investigated and compared the results of 2 different approaches of laparoscopic adrenalectomy, through retrospective review of 40 patients. Within this study period between 1995 and 2004, there were 20 lateral retroperitoneal and 20 lateral transperitoneal laparoscopic adrenalectomies performed. There was no significant difference in demographic variables between the 2 groups. Operative time, days to diet and ambulation, hospital stay, rate of conversion and complication did not differ significantly between the 2 approaches. No recurrence was detected upon mean follow-up period of 15.9 months. Learning curves showed gradual decrease in operation time in both approaches, reflecting maturation of techniques. In conclusion, both lateral transperitoneal and lateral retroperitoneal laparoscopic adrenalectomy are safe and effective. There is no difference in outcome between 2 approaches.

Retroperitoneoscopic adrenalectomy for adrenal tumors via a single large port

BACKGROUND AND PURPOSE

Laparoscopic adrenalectomy is generally performed with carbon dioxide insufflation of the cavity and requires multiple trocars. This study reports the outcomes of retroperitoneoscopic adrenalectomy (RA) for adrenal tumors via a single port using a large cylinder without carbon dioxide insufflation.

PATIENTS AND METHODS

Fifty-four patients with adrenal tumors were treated using RA via a single large port. The average tumor size was 2.6 cm. For surgery, patients were placed in the lateral decubitus position with slight flexion, and a 4.5-cm skin incision was performed below the 12th rib in the midaxillary line. The retroperitoneal space was dissected using index fingers and a balloon dilator. A rectoscope tube with a 4-cm diameter was inserted, and the adrenal glands were removed endoscopically via the single large port without carbon dioxide insufflation.

RESULTS

This procedure was completed in 53 patients (98.1%). The average duration of surgery was 203 minutes, and the mean estimated blood loss was 252 mL. Four patients (7.4%) required blood transfusion. Postoperative major complications, including fulminant hepatitis and pulmonary thrombosis, were observed in two patients (3.7%), and the patient with hepatic disease died on the 14th postoperative day. The mortality rate after surgery thus was 1.9%. However, no local tumor recurrence or hormonal relapse has occurred at a median follow-up of 34 months.

CONCLUSIONS

This procedure appears to be effective and relatively minimally invasive. However, it is limited by the narrow working space and restriction of the manipulation of instruments.

Laparoscopic adrenalectomy for primary and secondary malignant adrenal tumors

Laparoscopic adrenalectomy is unanimously recognized as the gold standard for the treatment of adrenal tumors, but it is not indicated for tumors of any size when invasion of the surrounding tissues is clearly detected by preoperative imaging. Although laparoscopic adrenalectomy for metastatic adrenal malignancy is a feasible procedure, in the case of primary adrenal malignancy, it should be done very carefully. When laparoscopic surgery is performed for adrenal tumors >6 cm or for tumors that are considered potentially malignant after preoperative imaging or endocrine studies, the operation should be performed only by a highly skilled laparoscopic surgeon. It is also important to inform the patient and family that the tumors may be malignant and that conversion to open surgery could be necessary. The surgeon must create a sufficiently wide working space, remove the tumor and surrounding fat en bloc, and never grasp the tumor or adrenal tissue. The ultrasonically activated scalpel or ultrasonic endoaspirator should be carefully handled so that it does not touch the tumor surface because this will create a risk of tumor-cell dissemination. It also is essential not to persist unreasonably with laparoscopic procedures but to switch immediately to open surgery when laparoscopic surgery becomes difficult.

New genetic causes of pheochromocytoma: current concepts and the clinical relevance

Pheochromocytoma and paraganglioma are tumors of the autonomous nervous system mainly occurring in the adrenal medulla, but also in the extraadrenal paraganglias of the abdomen, thorax, neck and skull basis. The etiology comprises germline mutations of now 6 genes. About 10 years known are the RET gene susceptible for multiple endocrine neoplasia type 2, the VHL gene for von Hippel-Lindau Disease, and the NF 1 gene for neurofibromatosis Recklinghausen (neuro- fibromatosis type 1). Since 2000 the genes for succinatedehydrogenase subunits SDHB, SDHC, and SDHD have been identified for paraganglioma syndromes type 4, type 3, and type 1 respectively. Investigations of series of pheochromocytoma patients identified germline mutations in one of the genes SDHB, SDHD, VHL and RET in 24% to 50% of the patients. Multifocal tumors, young age and positive family history, known features associated with inheritence, have not been present in all patients. Therefore, analyses of blood DNA for mutations in these genes are recommended. Positive tests provide the patients and their relatives with essential platforms for clinical care. Experiences in this field of medicine have shown that optimal management of patients with pheochromocytoma-associated syndromes is a high challenge. National registries may be instrumental in order to provide with adequate facilities.

Portless endoscopic adrenalectomy via a single minimal incision using a retroperitoneal approach: experience with initial 30 cases

AIM

To assess the feasibility of portless endoscopic adrenalectomy via a single minimum incision that narrowly permits extraction of the specimen.

METHODS

For 30 cases of adrenal tumor, portless endoscopic surgery through a single flank incision (3-9 cm; mean, 5.6 cm) was performed without gas inflation or trocar port placement. All of the instruments used during surgery were reusable. The cases included primary aldosteronism (12), Cushing's syndrome (6), preclinical Cushing's syndrome (3), pheochromocytoma (1), non-functioning cortical adenoma (6), adrenocortical carcinoma (1) and adrenocortical hemorrhage (1).

RESULTS

Resection of the tumor was successfully completed, without complications, in all of the cases. Operative time was between 83 and 240 min (mean, 147 min). Estimated blood loss was 5-470 mL (mean, 139 mL). None of the patients required blood transfusion. Postoperative course was uneventful. Wound pain was mild and walking and full oral feeding were resumed on the first and second postoperative day, respectively, in the majority of cases.

CONCLUSIONS

Adrenal tumors are good candidates for portless endoscopic surgery, which is safe, cost-effective, minimally invasive and matches favorably with laparoscopic surgery.

Computed tomography-guided percutaneous acetic acid injection therapy for functioning adrenocortical adenoma

We reported the outcomes of computed tomography (CT)-guided percutaneous acetic acid injection therapy for functioning adrenocortical adenomas. With the patient in a prone position, the puncture needle was inserted vertically downward into the adenoma with frequent CT scanning. After confirmation by pilot injection with contrast medium, a small aliquot of 40-50% acetic acid was injected and repeated. Between 1997 and 2002, 18 sessions of CT-guided injection therapy, including one session of ethanol injection, were performed on 10 patients (five patients with primary aldosteronism and five patients with Cushing's or subclinical Cushing's syndrome) without any complications except transient upper abdominal pain during the acetic acid injection. The follow-up period ranged from 5-69 months. The treatment resulted in almost an extirpation of the adrenocortical hyperfunction in seven patients after one or two sessions. CT-guided percutaneous acetic acid injection might be a simple, cost-effective, and far less invasive treatment for small functioning adrenocortical adenomas.

Laparoscopic adrenalectomy for pheochromocytoma: a literature review

Laparoscopic adrenalectomy has become the standard treatment for benign adrenal tumors, providing minimal invasiveness and early recovery. In the case of pheochromocytomas, special attention should be paid perioperatively to prevent excessive hypertension or hypotension. The protocol should include sufficient preoperative medication with alpha 1 blockers, early ligation of the adrenal vein, and minimal handling of the tumor itself. A literature review of 227 laparoscopic adrenalectomies for pheochromocytomas revealed that the perioperative data, including the operative time, blood loss, and hemodynamic status, were similar or slightly better in the laparoscopic procedures as compared to the open procedures, although the convalescence period was significantly shorter in the laparoscopic surgery. The majority of surgeons prefer the transperitoneal approach for pheochromocytomas, although some authors use the retroperitoneal approach successfully. A comparison of the perioperative data from laparoscopic surgeries for pheochromocytomas versus those for other adrenal tumors showed that the former had slightly higher demands to complete the procedure safely. In the treatment of familial pheochromocytoma due to multiple endocrine neoplasia type 2 or von Hippel-Lindau disease, a cortical-sparing adrenalectomy can be safely performed laparoscopically. In conclusion, laparoscopic adrenalectomy is the standard for small pheochromocytomas, with a high success rate when the procedure is performed by experienced surgeons.

Laparoscopic adrenalectomy for pheochromocytoma

We reviewed 10 cases of laparoscopic adrenalectomy for pheochromocytoma and compared the results with those of a recent series of 11 patients who underwent open adrenalectomy. Of the 10 cases, the tumor was removed successfully in all cases except in one case with laparoscopy that required open laparotomy. A pair of laparoscopic coagulating scissors was utilized in all except the initial two cases. In the laparoscopy group (excluding the initial two cases and the case that required conversion to open surgery), mean operative time and blood loss were 145 min and 55 ml, respectively. No significant difference was observed in mean operative time between the laparoscopy group and the open surgery group (165 min for open surgery). Mean blood loss of the laparoscopy group was significantly less than that of the open surgery group (330 ml for open surgery, P = 0.01). Mean intervals to first ambulation and oral intake, and postoperative hospital stay of the laparoscopy group, tended to be less than those of the open surgery group, although no statistical significance was observed (2.3 versus 3.2 d, 2.9 versus 3.6 d, and 12 versus 14 d, respectively). We conclude that laparoscopic adrenalectomy for pheochromocytoma is equally effective and less invasive than open adrenalectomy and should be considered the therapy of choice even for pheochromocytoma.

Laparoscopic adrenalectomy: current status with a review of Japanese literature

A decade has elapsed since laparoscopic adrenalectomy was first performed in 1992. Accumulated experiences of laparoscopic adrenalectomy have shown superior results to treat small functional benign tumors and make the indication expand to large tumors, pheochromocytomas and localized malignant tumors. Following the initially established transperitoneal approach, which includes anterior and lateral approaches, the retroperitoneal lateral flank and posterior lumber approaches have been performed. Each approach has advantages and disadvantages. The transperitoneal approach supplies a large operative field, many anatomical landmarks and easy handling. But it causes post-operative irritability and it is very difficult to perform after previous upper abdominal surgery. The retroperitoneal approach can be performed even after previous abdominal surgery and patients may be more comfortable after the operation. However, the narrow working space and the lack of anatomical landmarks may increase the rate of intra-operative complications and the rate of conversion to open surgery. Although there is no clear preference between transperitoneal and retroperitoneal approaches, the transperitoneal approach is commonly employed and the transperitoneal anterior approach seems to be the easiest one for right adrenal tumors and the transperitoneal lateral approach for left adrenal tumors. The shorter convalescence with laparoscopic adrenalectomy as compared with open adrenalectomy has been accepted and lower morbidity from laparoscopic adrenalectomy has been achieved. The operative time has been shortened to the level of open adrenalectomy. Less blood loss, less pain and better cosmesis are absolute advantages for the patients. Laparoscopic adrenalectomy is now the gold standard for the treatment of adrenal tumors.

Laparoscopic surgery for malignant adrenal tumors

This paper outlines the indications and techniques of laparoscopic surgery for malignant adrenal tumors. Laparoscopic surgery is not indicated for adrenal tumors of any size when invasion of the surrounding tissues is clearly detected by preoperative imaging. When laparoscopic surgery is performed for a tumor without invasion that has a maximum diameter of more than 6 cm or a tumor that is considered potentially malignant from preoperative imaging or endocrine studies, it is important to inform the patient and family that the tumor may be malignant and that conversion to open surgery may be necessary. The transperitoneal approach is appropriate for primary adrenal malignancies. For metastatic cancer, the transperitoneal approach is suitable for radical surgery and the extraperitoneal approach for histological diagnosis by partial resection or tumor biopsy. In either case, it is important for the surgeon to have a sufficiently wide working space, to remove the tumor and surrounding fat en bloc, to never grasp the tumor or adrenal tissue, and to carefully handle the ultrasonically activated scalpel or ultrasonic aspirator so that it does not touch the tumor surface due to the risk of tumor cell dissemination. It is also essential not to unreasonably persist with laparoscopic procedures, but to immediately switch to open surgery when laparoscopic surgery becomes difficult.

Japanese experience with radical prostatectomy

Laparoscopic prostatectomy has become an established treatment option for localized prostate cancer in France, where open prostatectomy is now the gold standard. The main purposes of treatment for prostate cancer are cancer control and preservation of urinary continence and sexual function. To become a standard treatment option for organ-confined prostate cancer, laparoscopic prostatectomy has to show equal or better clinical outcome in these areas than its open counterpart. Many institutes in other countries are now trying to perform this surgery. There are, however, some negative reports, mainly because of the difficulty of the procedure. In Japan, more than 250 patients have undergone this surgery. It seems that satisfactory results in terms of positive surgical margin rate, bleeding volume, recovery from surgery, and urinary continence have been obtained so far. We need longer follow-up to assess recurrence rate and sexual function. The main obstacles for this surgery are the long operative time and the difficulty of the procedures. Although it will take time until laparoscopic prostatectomy becomes an approved treatment modality, we are gradually conquering these problems. In this paper, we review the current situation facing laparoscopic prostatectomy in Japan.

Comparison of 3 surgical approaches to laparoscopic adrenalectomy: a nonrandomized, background matched analysis

PURPOSE

To clarify the characteristics of surgical approaches to laparoscopic adrenalectomy we performed background matched analysis of clinical outcomes of the 3 approaches.

MATERIALS AND METHODS

From February 1992 to July 2000 we performed 118 laparoscopic adrenalectomies in 115 patients with adrenal tumors. For these operations we used the anterior transperitoneal approach in 46 patients, the lateral transperitoneal approach in 32 and the lateral retroperitoneal approach in 40.

RESULTS

To exclude the learning curve effect we eliminated our initial 20 patients treated with the anterior transperitoneal approach. To allow background matching of the 3 groups we also excluded 14 patients with tumors more than 5 cm., 6 who underwent conversion to open surgery and 1 patient who required 5 days of bed rest for retroperitoneal hematoma caused by bleeding from a trocar port. The final analysis included 16, 25 and 36 cases managed via the anterior transperitoneal, lateral transperitoneal and lateral retroperitoneal approach, respectively. Average operative time was significantly shorter for the lateral transperitoneal approach. Postoperative recovery was not significantly different in the lateral transperitoneal and lateral retroperitoneal groups. Postoperative complications included mild paralytic ileus in 2 patients and shoulder tip pain, probably peritoneal irritation due to carbon dioxide insufflation and bowel preparation, in 4 in the transperitoneal groups. Our results imply that the easiest procedure is the lateral transperitoneal approach but the lateral retroperitoneal approach is slightly less invasive.

CONCLUSIONS

Although it is important to remember that this study was not a prospective randomized trial and, thus, had from certain biases, we believe that if a tumor is more than 5 cm. and/or the surgeon is not yet skilled in laparoscopic adrenalectomy, the lateral transperitoneal approach is the most suitable method. If the surgeon has performed at least 20 operations, the adrenal tumor is unilateral and the lesion is less than 5 cm., the lateral retroperitoneal approach seems to be more suitable because of its minimally invasive nature. The lateral retroperitoneal approach is also preferred in patients with a history of upper abdominal surgery. With improvements in technique and new instruments the time required for the lateral retroperitoneal approach has been significantly decreased.

Laparoscopic adrenalectomy: retroperitoneal approach

The most important procedure in retroperitoneoscopic adrenalectomy is en bloc dissection of the perinephric fat, including the upper pole of the kidney and the adrenal gland, from the surrounding muscles (transversus abdominalis, psoas, and diaphragm) just inside Gerota's fascia. It is not recommended that the surgeon directly identify the adrenal gland at the start of the operation. After dividing the perinephric fat between the adrenal gland and kidney, the upper pole of the kidney is exposed, and dissection proceeds along the renal surface. The lateral retroperitoneoscopic approach promises to be a safer and less invasive treatment for patients with small unilateral adrenal tumors. In all cases, careful patient selection and correct choice of the surgical approach based on tumor size, the patient's condition, and the surgeon's skill are vital to avoid complications during laparoscopic adrenalectomy.

Endoscopic retroperitoneal adrenalectomy: lessons learned from 111 consecutive cases

OBJECTIVE

To evaluate the effectiveness of endoscopic retroperitoneal adrenalectomy (ERA).

SUMMARY BACKGROUND DATA

Minimally invasive adrenalectomy has become the procedure of choice for benign adrenal pathology. Although the adrenal glands are located in the retroperitoneum, most surgeons prefer the transperitoneal laparoscopic approach to adrenal tumors.

METHODS

Clinical characteristics and outcomes of 111 ERAs from January 1994 to December 1999 were evaluated.

RESULTS

Ninety-five patients underwent 111 ERAs (79 unilateral, 16 bilateral). Indications were Cushing syndrome (n = 22), Cushing disease (n = 8), ectopic adrenocorticotropic hormone syndrome (n = 6), Conn's adenoma (n = 25), pheochromocytoma (n = 19), incidentaloma (n = 11), and other (n = 4). Tumor size varied from 0.1 to 8 cm. Median age was 50 years. Unilateral ERA required 114 minutes, with median blood loss of 65 mL. Bilateral ERA lasted 214 minutes, with median blood loss of 121 mL. The conversion rate to open surgery was 4.5%. The complication rate was 11%. Median postoperative hospital stay was 2 days for unilateral ERA and 5 days for bilateral ERA. The death rate was 0.9%. At a median follow-up of 14 months, the recurrence rate of disease was 0.9%.

CONCLUSION

For benign adrenal tumors less than 6 cm, ERA is recommended.

Laparoscopic adrenalectomy for benign adrenal tumors

Laparoscopic adrenalectomy has been rapidly accepted for treatment of benign adrenal tumors. To evaluate the advantages of laparoscopic adrenalectomy, we examined 55 patients who underwent laparoscopic adrenalectomy. In all patients, adrenal tumors were successfully removed. The mean operating time was 143 minutes, and the estimated mean blood loss was 49 mL in all patients. The postoperative course was uneventful in all cases. The mean frequency of administration of analgesics was only 2.9 times, and the time elapsed to first walking after surgery was 17 hours. The peak white blood cell count and C-reactive protein values after surgery were 8,266 +/- 1,963/mm3 and 2.5 +/- 1.2 mg/dL, respectively. Of the 55 patients, 44 underwent total adrenalectomy and another 11 underwent partial adrenalectomy, which was introduced in the expectation of preserving normal adrenal cortex; it is therefore indicated in solitary and peripherally located benign tumors. The mean operating time was 154 minutes for the total adrenalectomy, which was longer than that of partial adrenalectomy (92 minutes). The estimated blood loss was 50 mL for the total and 46 mL for the partial adrenalectomy. The postoperative course was uneventful and surgical outcome was excellent in each group. In conclusion, our results are encouraging enough to suggest that laparoscopic adrenalectomy should be a preferential therapeutic option for benign adrenal tumors; also, partial adrenalectomy could be a safe, effective, and less invasive procedure in selected cases.

Laparoscopic adrenalectomy: transperitoneal vs retroperitoneal approaches

PURPOSE

To compare the results between transperitoneal and retroperitoneal approaches.

MATERIALS

Between 17 January 1992 and 31 December 1997, 76 patients (31 men and 45 women, 37 right and 37 left, mean 46.7 years old) with adrenal tumors including 37 primary aldosteronism. 19 Cushing's syndrome, 15 non-functioning adrenal tumors, and five pheochromocytomas, underwent laparoscopic removal operations in one hospital. Fifty-seven open adrenalectomies were also included.

METHODS

Fifty-two patients by transperitoneal laparoscopic approach, and the other 24 patients by retroperitoneal laparoscopic approach were compared.

RESULTS

Mean operative time, operative blood loss, time to oral intake, and ambulation of transperitoneal approach were 203 min, 115.6 mL, 1.9 days, and 1.4 days. In patients operated on by the retroperitoneal approach, these factors were 257 min, 141.6 mL, 1.1 days, and 1.4 days. There was no significant difference in any item between the two groups. In patients operated on by open procedure, these factors were 143 min, 214 mL, 2.5 days, and 2.4 days. Operating time of the open surgery group was significantly shorter than either of the other two groups, and all of the other three items of open surgery group were significantly greater than either of the other two groups. Open surgery was required in two of 76 patients treated by endoscopic procedure due to inadvertent injury of the anomalous adrenal vein during the transperitoneal approach, and pancreatic injury during the retroperitoneal approach. During and after the operation, no significant complication was observed.

CONCLUSION

Both transperitoneal and retroperitoneal laparoscopic adrenalectomies are feasible for adrenal tumors.

Transperitoneal anterior laparoscopic adrenalectomy: the easiest technique

Four laparoscopic methods have been developed to approach the adrenal gland: anterior or lateral transperitoneal approaches, and lateral or posterior retroperitoneal approaches. The advantages and disadvantages of these methods were reviewed during a workshop held by the Japanese Society of Endourology and ESWL in 1997. The transperitoneal anterior approach, when combined with a lateral approach for the left side, is the easiest for small adrenal tumors, and discloses the adrenal vein early in the procedure. For large tumors over 5 cm in diameter, the transperitoneal lateral approach is the most feasible bilaterally. Regardless of the methods of approach, laparoscopic adrenalectomy has already become the standard procedure for adrenal tumors, because it minimizes the operative morbidity and postoperative hospital stay.

Laparoscopic adrenalectomy: posterior approach

Adrenalectomy for benign adrenal diseases is currently performed by transperitoneal laparoscopy. The transperitoneal approach, however, invades the intraperitoneal cavity, and may cause injury to the abdominal organs. The posterior lumbar approach allows direct access to the main adrenal vascular supply before the gland is manipulated. Retroperitoneoscopic adrenalectomy by this approach is technically feasible and most effective as regard to the simplicity of vascular control. The operating time, perioperative morbidity and cost have been reduced with this approach.

Complications of laparoscopic and retroperitoneoscopic adrenalectomies in 370 cases in Japan: a multi-institutional study

A total of 370 laparoscopic adrenalectomies, including 311 transperitoneal (TP) and 59 retroperitoneal (RP) approaches, were performed in nine urologic centers, where the laparoscopic adrenalectomy was first begun independently in Japan, and their affiliated hospitals between January 1992 and September 1996. The clinical diagnoses of those 370 adrenal diseases were primary aldosteronism in 155 patients, Cushing's syndrome in 61. preclinical Cushing's syndrome in 21. pheochromocytoma in 16, nonfunctioning adenoma in 87, complicated cyst in ten, myelolipoma in nine, adrenal cancer in four and other diagnoses in eight (table 1). There was no mortality in this series. Intraoperative complication rate was 33/370 (9%) in total: 26/311(8%) in the TP procedures and 7/59 (12%) in the RP procedures (table 11). Postoperative complication rate was 24/370 (6%) in total: 22/311 (7%) in the TP procedures and 2/59 (3%) in the RP ones (table 111). Conversion rates to open surgery in total, in the TP and in the RP procedures were 13/370 (3.5%), 10/311 (3.2%) and 3/59 (5.1 %). respectively (table IV). Although the RP procedure has a lower morbidity rate compared to the TP procedure, more skill is required to overcome the drawback of the narrow working space and fewer anatomical landmarks.

Surgical management of primary aldosteronism

Adenoma is usually the etiology of primary aldosteronism, and we have also encountered 44 patients with adenoma since 1990. In this study. we examined surgical management of these patients. Conventional open surgery (supracostal flank incision) was performed in ten patients, and laparoscopic surgery in 34 patients. When these two techniques were compared, the time required for laparoscopic surgery was significantly longer, although it tended to be considerably shortened in the last ten patients compared with that in the initial patients. However, regarding all the parameters of recovery in the last ten patients, laparoscopic surgery was superior to open surgery. Laparoscopic surgery seems to be the most appropriate surgery for patients with adrenal adenoma, which comprise the majority of patients with this disease.

Laparoscopic adrenalectomy for functioning adrenal tumors: clinical experiences with 38 cases and comparison with open adrenalectomy

We reviewed 38 cases of transperitoneal or retroperitoneal laparoscopic adrenalectomy for unilateral benign functioning adrenal tumors and compared the results with those of a recent series of 36 patients undergoing an open adrenalectomy. The tumors were removed successfully in all but two cases with laparoscopy that required open laparotomy. In the other 36 cases of the laparoscopy group, mean operative time and blood loss were 225 minutes and 138 mL, respectively. Mean operative time was significantly longer for the laparoscopy group (122 minutes for open surgery: P < 0.0001), whereas mean blood loss of the laparoscopy group was almost equal to that of the open surgery group. Mean intervals to first ambulation and oral intake, and postoperative hospital stay of the laparoscopy group were significantly less than those of the open surgery group (1.4 vs 2.0 days: P = 0.014; 1.8 vs 2.9 days: P < 0.0001; and 8.5 vs 12.9 days: P < 0.0001, respectively). We conclude that laparoscopic adrenalectomy is equally effective and less invasive than open adrenalectomy. and that it should be considered as the first-choice therapy for benign adrenal tumors.

Laparoscopic direct supragastric left adrenalectomy

BACKGROUND

In this paper a novel laparoscopic approach to the left adrenal gland by the transabdominal anterior route is presented. This approach avoids an extensive viscera dissection to gain access to the left adrenal gland.

METHODS

The first step of the procedure is the division of the gastrophrenic ligament and the section of 1 or 2 short gastric vessels in order to mobilize the gastric fundus. The gastric fundus is then pulled down, allowing a wide exposure of the left crus of the diaphragm, the perirenal fat, and the superior edge of the pancreatic body. The diaphragmatic-adrenal channel runs on the left crus, crosses the middle adrenal artery, and, usually, joins the left adrenal vein before its junction with the left renal vein. By pulling on the diaphragmatic vein, exposure of the adrenal vein is facilitated. The adrenal vein is then isolated and divided between clips. Using the monopolar electrocautery to control arteries and small veins, the mobilization of the gland is then completed. The adrenal gland is then placed in a plastic bag to prevent cell spillage and removed through an enlarged umbilical incision.

RESULTS

During a 20-month period, 6 consecutive patients with left adrenal gland neoplasms have been operated on with the above mentioned original approach. The diameter of the adrenal mass ranged from 3 cm to 6 cm. No conversion to open surgery or complications have been registered. The mean operative time was 126 minutes. The mean length of hospitalization was 4.1 days (range 3 to 6).

CONCLUSIONS

This approach offers a complete visualization of the left adrenal gland, avoiding mobilization of the spleen, pancreatic tail, and left flexure of the colon, and allows an early and easy control of the left adrenal vein so adrenalectomy can be safely performed.

Laparoscopic adrenalectomy in the elderly

Laparoscopic adrenalectomy has recently been shown to be a safe and effective procedure for treating a variety of benign adrenal tumors. Advanced age, with its concomitant comorbid conditions, has been believed to be associated with more postoperative complications in laparoscopic procedures. The purpose of this study was to evaluate the outcome of laparoscopic adrenalectomy in patients age 65 and older. From June 1992 to February 1998, 14 patients (4 men and 10 women) with a mean age of 69 years underwent 17 laparoscopic adrenalectomies. In 12 procedures, a transperitoneal lateral decubitus flank approach was used. The lesion was a nonfunctioning adenoma in three patients, aldosterone adenoma in four, Cushing's syndrome in four, and pheochromocytoma in one. A retroperitoneal lateral decubitus approach was used in five procedures. The lesion was a nonfunctioning adenoma in one patient, aldosterone adenoma in one, Cushing's adenoma in one, and pheochromocytoma in two. Seventy-eight percent of these patients had comorbid conditions, including hypertension, diabetes, chronic obstructive airway disease, coronary artery disease, and cardiac dysrhythmia. The preoperative physical status was as ASA Class II in 11 patients and ASA III in 3. Two of the 17 laparoscopies were converted to open surgery (11%), in one because of difficulties in dissecting extraperitoneally a mass >8 cm, and in the other because of difficulties in localization of a 3-cm mass. The median surgical time was 95 +/- 33 minutes. The mean analgesia requirements were 3 doses of (range 2-7) ketorolac. There were no deaths. Postoperative morbidity consisted of pulmonary atelectasis in one patient and urinary tract infection in two patients. The median hospital stay was 3 days (range 2-4 days). We conclude that laparoscopic adrenalectomy in the elderly population is safe and offers low morbidity, fast recovery, and a short hospital stay. Age alone should not be a contraindication to treating adrenal tumors laparoscopically.

Changes in urinary output during laparoscopic adrenalectomy

OBJECTIVE

To better understand the physiological effects of pneumoperitoneum, by examining changes in urinary output during gaseous and gasless laparoscopic adrenalectomy.

PATIENTS AND METHODS

Laparoscopic adrenalectomy was performed with gas in six patients and without in three. Urinary output was measured during insufflation and after desufflation.

RESULTS

In all patients who received gas, the urinary output was significantly decreased during insufflation and significantly increased after desufflation. However, there were no changes in urinary output in patients who did not receive gas.

CONCLUSION

For the safety of laparoscopic surgery it is important to recognise that oliguria occurs during pneumoperitoneum, although the changes in urinary output caused no complications in renal function.

Laparoscopic adrenalectomy: the retroperitoneal approach

PURPOSE

Retroperitoneal laparoscopy, by providing direct access to the retroperitoneal cavity, is an interesting approach to urological surgery. We report our initial experience with retroperitoneal laparoscopic adrenalectomy.

MATERIALS AND METHODS

Between January 1995 and April 1997, 23 adrenalectomies were performed by retroperitoneal laparoscopy in 10 men and 12 women. The patients were placed in the lateral decubitus position and 5 trocars were used. The retroperitoneal working space was created by digital dissection and was completed by insufflation without balloon dissection. The surgical indications were Conn's adenoma in 12 cases, Cushing's adenoma in 4, bilateral adrenal hyperplasia (Cushing's disease) in 1 (treated in a single procedure), a nonfunctioning adenoma in 2, pheochromocytoma in 2 and adrenal metastasis in 1.

RESULTS

We removed 7 right and 16 left adrenal glands in an average operating time of 97 minutes (range 45 to 160). Average tumor size was 26 mm. (range 10 to 40). Average hospital stay was 3.3 days (range 1 to 10). Blood loss was minimal. Postoperative analgesic requirements were moderate. Conversion to open surgery was not necessary. The morbidity rate was low, with 1 postoperative hematoma and 1 case of persistent fever (greater than 38.5C).

CONCLUSIONS

Retroperitoneal adrenalectomy is a reliable and effective technique. At our institution retroperitoneal laparoscopy is now the standard adrenal surgery procedure for tumors less than 5 cm.

Laparoscopic adrenalectomy: experience with transabdominal and retroperitoneal approaches

OBJECTIVES

To study the patient outcomes of various approaches on 14 consecutive patients who had laparoscopic adrenalectomy surgery between October 1995 and March 1997.

METHODS

The patients comprised 5 men and 9 women (mean age 46.2 years, range 32 to 61) with varying diagnoses. Eleven patients had Conn's syndrome, 1 had Cushing's syndrome, 1 had a nonfunctioning adrenal adenoma, and 1 had an adrenal myelolipoma. The adenomas were confirmed by hormonal assays, biochemical tests, and computed tomography (CT) imaging. Seven adenomas were sited on the right and seven were sited on the left. We used two alternative approaches: a transabdominal approach (8 patients) and a retroperitoneal approach (6 patients).

RESULTS

None of the procedures required conversion to open surgery, nor was there any procedure-related complication. Blood loss was minimal. All the lesions were benign on final histology. The mean operating time was 135 minutes (range 80 to 190). The postoperative period was without significant complications, with patients reporting minimal pain. Patients were able to achieve an early return to oral intake and preoperative activity. The postoperative hospital period ranged from 1 to 10 days.

CONCLUSIONS

We believe laparoscopic adrenalectomy to be a viable option in the removal of benign adrenal lesions. It is a safe technique when performed by experienced practitioners and results in faster recovery. The key advantage to this technique is its minimally invasive approach and decreased hospital costs.

Laparoscopic adrenalectomy: lessons learned from 100 consecutive procedures

One hundred consecutive laparoscopic adrenal procedures for a variety of endocrine disorders were reviewed. There was no mortality, morbidity was 12%, and conversions was 3%. During follow-up, none had recurrence of hormonal excess. Laparoscopic adrenalectomy is the procedure of choice for adrenal removal except in carcinoma or masses > 15 cm.

OBJECTIVE

The authors evaluate the effectiveness of laparoscopic adrenalectomy for a variety of endocrine disorders.

SUMMARY BACKGROUND DATA

Since the first laparoscopic adrenalectomy was performed in 1992, this approach quickly has been adopted, and increasing numbers are being reported. However, the follow-up period has been too short to evaluate the completeness of these operations.

METHODS

One hundred consecutive laparoscopic adrenal procedures from January 1992 until November 1996 were reviewed and followed for adequacy of resection.

RESULTS

Eighty-eight patients underwent 97 adrenalectomies and biopsies. The mean age was 46 years (range, 17-84 years). Indications were pheochromocytomas (n = 25), aldosterone-producing adenomas (n = 21), nonfunctional adenomas (n = 20), cortisol-producing adenomas (n = 13), Cushing's disease (n = 8), and others (n = 13). Fifty-five patients had previous abdominal surgery. Mean operative time was 123 minutes (range, 80-360 minutes), and estimated blood loss was 70 mL (range, 20-1300 mL). There was no mortality, and morbidity was encountered in 12% of patients, including three patients in whom venous thrombosis developed with two sustaining pulmonary emboli. During pheochromocytoma removal, hypertension occurred in 56% of patients and hypotension in 52%. There were three conversions to open surgery. The average length of stay has decreased from 3 days (range, 2-19 days) in the first 3 years to 2.4 days (range, 1-6 days) over the past 16 months. During follow-up (range, 1-44 months), two patients had renovascular hypertension and none had recurrence of hormonal excess.

CONCLUSION

Laparoscopic adrenalectomy is safe, effective, and decreases hospital stay and wound complications. Prior abdominal surgery is not a contraindication. Pheochromocytomas can be resected safely laparoscopically despite blood pressure variations. Venous thrombosis prophylaxis is mandatory. The laparoscopic approach is the procedure of choice for adrenalectomy except in the case of invasive carcinoma or masses > 15 cm.