Laparoscopic adrenalectomy for hemorrahagic adrenal pseudocyst discovered during pregnancy: report of a case

Pseudocysts of the Adrenal Gland: A Systematic Review of Existing Scientific Literature From 2000 to 2023

Adrenal masses are abnormal growths in the adrenal gland, comprising entities such as pheochromocytomas, adrenal adenomas, adrenocortical carcinomas, and adrenal cysts. Pseudocysts are predominant among adrenal cysts. Due to its infrequent presentation, there are no specific guidelines present in the current literature to steer its management. In such circumstances, a systematic review of the existing literature is imperative to develop comprehensive insights and evidence-based protocols. We aimed to comprehensively analyze the clinico-radiological characteristics and management outcomes of adrenal gland pseudocysts. Human adrenal gland pseudocysts identified through imaging and histopathology, as retrieved from the PubMed search engine, were included in the study. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Joanna Briggs Institute (JBI) Critical Appraisal Checklist were used to stratify searched studies published between 2000 and 2023. A total of 39 studies were finally included, of which 36 were case reports and three case series, containing 45 patients in total. Data for clinical, radiological, histopathological, and outcome variables were collected, and descriptive analysis was carried out. All cases presented were adults with a clear female predominance of 66.67%. About 26.67% presented with no palpable mass or clinical symptoms, while 28.89% presented with vague abdominal pain. The most prevalent computed tomography (CT) finding was a cystic lesion with calcification and/or hemorrhage and/or necrosis, occurring in 17.78% of cases. Following this, a cystic lesion with only calcification was observed in 13.33% of cases, and a well-defined cystic mass/lesion was found in 11.11% of cases. The most important indication for surgery was compression effect in 44.44%, increasing size in 20.00%, and suspicion of malignancy in another 20.00% of cases. About 64.44% underwent open surgery, while 35.55% underwent minimally invasive surgery. Most patients, 95.55% of the total, had an uneventful postoperative course without any complications. Adrenal gland pseudocyst, though rare and incidental, warrants consideration in differential diagnosis as it presents with vague symptoms and sometimes no symptoms at all. Our review of existing literature highlights the importance of surgical intervention for symptomatic or potentially malignant cysts, with en bloc adrenalectomy being the preferred approach.

Adrenal Hemorrhage: A Review

Importance

Adrenal hemorrhage in pregnancy is rare. The prevalence of pregnant patients whose pregnancies are complicated by preeclampsia or eclampsia is hypothesized to be slightly higher than the 0.4% to 1.1% occurrence rate in the nonpregnant population. However, the mortality rate of adrenal hemorrhage is reportedly as high as 15%. Therefore, it is critical for obstetric providers to have basic knowledge on the presentation, diagnosis, and management of adrenal hemorrhage in the pregnant population so that prompt diagnosis can be made.

Objective

This review highlights incidence, pathophysiology, risk factors, diagnosis, management, and complications of adrenal hemorrhage in the peripartum period.

Evidence Acquisition

A literature search was undertaken by our research university librarian using the search engines of PubMed, CINAHL, and EMBASE (Medline items removed). The search terms used included "adrenal hemorrhage" OR "adrenal gland hemorrhage" AND "pregnancy" OR "maternal." The search was limited to articles in English, and the years searched were from January 1, 2015 to December 31, 2021.

Results

There were 130 abstracts identified, and 30 of the articles were ultimately used as the basis for this review. Presenting signs and symptoms of adrenal hemorrhage were typically abdominal, back, and flank pain. Diagnosis was typically made with ultrasound and computed tomography or magnetic resonance imaging without contrast for confirmation. Management options include conservative management versus surgical management with adrenalectomy or interventional radiology embolization in the unstable patient. For patients with evidence of adrenal insufficiency, steroid replacement was used. Most patients with adrenal hemorrhage in the literature had unilateral adrenal hemorrhage; however, several cases of bilateral adrenal hemorrhage have been reported. Patients with bilateral adrenal hemorrhage were more likely to require steroids for adrenal insufficiency. There are no known contraindications to vaginal delivery in this group of patients, and patients who were managed conservatively were often able to continue the pregnancy to term.

Conclusions

Early recognition and management are integral in decreasing the morbidity and mortality associated with adrenal hemorrhage.

Relevance Statement

This is an evidence-based review of adrenal hemorrhage in pregnancy and how to diagnose and manage a pregnancy complicated by adrenal hemorrhage.

Robotic-assisted left adrenal cystic mass excision in a pregnant patient

A symptomatic adrenal mass diagnosed during pregnancy is a rare clinical scenario. Two primary considerations are the timing of intervention and determining the appropriate surgical approach. Here, we present the case of a young female patient with flank pain, whom on diagnostic imaging, was found to have a large cystic adrenal mass. She was taken for a robotic-assisted resection of her left-sided adrenal mass during the second trimester of pregnancy. Preoperative and postoperative assessment demonstrated a viable intrauterine pregnancy. She tolerated the procedure well and was discharged 5 days later with resolution of her symptoms on follow-up. As one of only three reported cases of robotic adrenal surgery during pregnancy, we demonstrate that a robotic-assisted surgical approach is a viable and durable surgical option under the given clinical circumstances.

A successful pregnancy in a patient with secondary hypertension caused by adrenal adenoma: a case report

Background

Secondary hypertension is a rare complication in pregnancy that causes poor outcomes, such as preeclampsia, premature delivery, intrauterine growth retardation, stillbirths, spontaneous abortion or intrauterine death. Cushing’s disease caused by an adrenal adenoma is rare during pregnancy and may be overlooked by obstetricians and physicians, but can lead to hypertension, diabetes mellitus and an increased risk of fetal and maternal morbidity. Approximately 200 cases have been reported in the literature. Here, we report the successful management of a pregnant patient with Cushing’s syndrome due to an adrenal adenoma.

Case presentation

The 35-year-old Chinese female had no individual or family medical history of hypertension, and did not exhibit chronic kidney disease, diabetes mellitus, autoimmune and common endocrine diseases. Her blood pressure was elevated from the 16th week of gestation and was not controlled by 30 mg nifedipine twice a day. Examination in our department revealed her 24 h urinary free cortisol (24 h UFC) level was 1684.3 μg/24 h (normal range: 20.26–127.55 μg/24 h) and plasma adrenocorticotropic hormone was < 1.00 ng/L in three independent measurements (normal range: 5–78 ng/L). Ultrasonography demonstrated a mass (2.9 cm × 2.8 cm) in the right side of the adrenal gland. Magnetic resonance imaging without contrast showed a 3.2 cm diameter mass in the right-side of the adrenal gland. Other medical tests were normal. Laparoscopic adrenalectomy was performed at the 26th week of gestation by a urological surgeon in the West China Hospital. Histopathology revealed an adrenocortical adenoma. After surgery, the patient accepted glucocorticoid replacement therapy. The remaining trimester continued without complication and her blood pressure was normal at the 32nd week of gestation without antihypertensive therapy. The patient gave birth to a healthy boy at the 40th week of gestation.

Conclusions

Cushing’s syndrome caused by adrenal adenoma is rare during pregnancy. This unique case suggested that analysis of the UFC level and circadian rhythm of plasma cortisol provides a suitable strategy to diagnose Cushing’s syndrome during pregnancy. Laparoscopic surgical resection in the second trimester provides a reasonable approach to treat pregnant patients exhibiting Cushing’s syndrome caused by an adrenal adenoma.

Adrenal cysts - optimal laparoscopic treatment

Introduction

Adrenal cysts develop in up to about 0.2% of the overall population. They may account for up to 11% of all pathologies of adrenal glands.

Aim

Is laparoscopic resection of adrenal cysts a method for the treatment of these pathologies?

Material and methods

In the years 2010-2017, a total of 27 patients underwent surgery due to adrenal cysts; those included 18 (66.7%) women and 9 (33.3%) men aged 29 to 84 years (mean age: 42.7). Cyst diameter ranged from 55 to 130 mm. After exclusion of hormonal hyperactivity, parasitic cysts, or, to the best possible extent, cancer lesions, patients were qualified for adrenal-sparing laparoscopic surgery.

Results

All patients were subjected to laparoscopic surgery. Cystic wall resection was performed in 15 (55.6%) patients while adrenalectomy was performed in the remaining 12 (44.4%) patients. The decision regarding the extent of the surgery was made intraoperatively. Histopathological assessment revealed pathological adrenal lesions in as few as 3 (11.1%) patients, with the rest of the study population, i.e. 24 (88.9%), presenting with normal adrenal tissue.

Conclusions

Laparoscopic resection of adrenal cysts appears to be recommendable as a method for the treatment of these pathologies. It is simpler than adrenalectomy and associated with low risk of any pathological lesion remaining within the adrenal gland following careful intraoperative assessment by an experienced surgeon.

Acute non-traumatic adrenal haemorrhage-management, pathology and clinical outcomes

Background

Acute adrenal haemorrhage is a rare medical emergency. The aim of the series was to study the clinical presentation and management of patients presenting with acute non-traumatic adrenal haemorrhage.

Methods

The records of patients presenting with an acute abdomen secondary to adrenal haemorrhage and treated in a tertiary endocrine surgical unit over a period of 6 years were reviewed.

Results

Of the 11 included patients, there were 4 males and 7 females; the median [range] age at presentation was 58 [27-89] years. All were initially managed conservatively for bleeding, except one who underwent angioembolisation to ensure hemodynamic stability. Two patients underwent percutaneous drainage of persistent collection and suspected sepsis. Biochemical workup showed hyper function with metanephrine excess in 1 patient. Adrenalectomy was performed in 5 patients after a median [range] of 10 [7-11] weeks. Histology showed benign pathology in 2 patients, malignant in 2 patients and necrotic tumour in 1 patient. Two patients died of disseminated metastatic disease at 5 and 2 months after presentation with bleeding. Conservative management in the other 3 patients was successful at a median follow up of 26 [6-66] months.

Conclusions

Acute adrenal haemorrhage is usually associated with an underlying pathology; which may be benign or malignant; functional or non-functional. Initial conservative management is preferred as it allows determination of functional status and elective surgery, if necessary.

Surgical Management of a Giant Adrenal Pseudocyst: A Case Report and Review of the Literature in the Last Decade

Adrenal pseudocysts are rare entities and occurred in the 5th and the 6th decades of life. They are discovered accidentally, while appearing with nonspecific clinical and imaging findings. We report a case of a 28-year-old woman presented in our Emergency Department complaining about upper abdomen pain. Computed tomography revealed a hypodense cystic lesion containing hyperdense material. The size of a mass was 11. 7 × 9.3 × 6.6 cm in diameter close to the pancreas, but the origin was from the left adrenal gland. The mass was excised with surgical laparotomy. Giant adrenal pseudocysts are rare entities. Final diagnosis usually confirmed with the pathology examination. Management of such adrenal lesions depends on the unique characteristics, the surgeon's experience, and local resources.

Management of adrenal tumors in pregnancy

Adrenal diseases, including Cushing syndrome (CS), primary aldosteronism (PA), pheochromocytoma, and adrenocortical carcinoma, are uncommon in pregnancy; a high degree of clinical suspicion must exist. Physiologic changes to the hypothalamus-pituitary-adrenal axis in a normal pregnancy result in increased cortisol, renin, and aldosterone levels, making the diagnosis of CS and PA in pregnancy challenging. However, catecholamines are not altered in pregnancy and allow a laboratory diagnosis of pheochromocytoma that is similar to that of the nonpregnant state. Although adrenal tumors in pregnancy result in significant maternal and fetal morbidity, and sometimes mortality, early diagnosis and appropriate treatment often improve outcomes.