Experience of retroperitoneoscopic adrenalectomy in 195 patients with primary aldosteronism

Lateral retroperitoneoscopic adrenalectomy: advantages and drawbacks

Lateral retroperitoneoscopic adrenalectomy (LRA) is performed mostly by urologists. It is gaining popularity among general surgeons because of the direct access to the adrenal gland. However, the management of large tumors remains controversial. We report our experience and discuss the advantages and the drawbacks of this approach. Between December 2011 and April 2015, 89 consecutive patients underwent LRA for adrenal tumors. Conversion to open surgery, operative time, blood loss, hospital stay, intra-operative complications, early and late postoperative complications, and mortality were analyzed. The entire group was divided into patients with large tumors (> 5 cm) and patients with small tumors (≤ 5 cm), which were further compared. The conversion rate was 1.1%. The mean operative time was 107.4 ± 27.95 min, the mean blood loss 33.15 ± 25.45 ml. The mean hospital stay was 4.7 ± 2.05 days. Most of the complications were minor. There was zero mortality. Concerning the size of the tumor, we found statistically significant difference in operative time (p = 0.001), hospital stay (p = 0.020), incidence of early postoperative complications (p = 0.049), and conversion rate to open surgery (p = 0.037). LRA is a feasible, effective and safe procedure that offers additional advantages over the standard transabdominal approach because of its direct access to the adrenal gland. However, malignancy, large tumor size, bilateral pathology, and concomitant intra-abdominal pathology may represent a potential setback for this approach.

Comparison of Technical Details and Short-term Outcomes of Single-incision Versus Multiport Laparoscopic Adrenalectomy

To date, the single-incision laparoscopic surgery (SILS) technique has been applied to a wide range of general surgical procedures; however, there are still scant data and debates on adrenal procedures. The aim of this study was to compare surgical outcomes of single-incision versus laparoscopic multiport adrenalectomy. The patients were divided into 2 study groups on the basis of the surgical approach: SILS (group 1) and multiport laparoscopic surgery (group 2). Patient demographics and their perioperative and postoperative results were evaluated retrospectively from the medical records. A total of 80 patients were included in the study. There were 44 patients in group 1 and 36 patients in group 2. The average operative time, estimated blood loss, and tumor size were similar between the study groups. There were no mortalities in both groups and the mean duration of hospital stay was 3 days for both groups. Without using any single-incision access trocars and articulated instrumentation, we achieved the same surgical outcomes in our SILS adrenalectomy series compared with conventional multiport laparoscopy series in terms of postoperative short-term outcomes and cost-effectivity.

Evaluating the learning curve for retroperitoneoscopic adrenalectomy in a high-volume center for laparoscopic adrenal surgery

Background

Laparoscopic adrenalectomy is an effective method for benign adrenal tumor removal. In the literature, both lateral transperitoneal (TLA) and posterior retroperitoneoscopic (RPA) approaches are described. Since 2007, the number of patients increased significantly in our center. Therefore, RPA was introduced in 2011 because of its potential advantages in operating and recovery times. The learning curve of RPA is now evaluated.

Methods

All data of patients undergoing laparoscopic adrenalectomy from 2007 until 2014 were prospectively collected. Patients were eligible for RPA with a tumor <7 cm, with BMI < 35 kg/m², and with low suspicion of malignancy. The learning curve of RPA was measured by operating time. Furthermore, blood loss, preoperative complications and hospital stay were analyzed. Descriptive statistics were performed using SPSS 20.0.

Results

In the study period, 290 patients underwent surgery, of whom 113 underwent RPA. After starting with RPA, operating times decreased significantly (median 100 min in the first 20 patients to 60 min after 40 patients, p < 0.05). There was a significant difference in operating times (median 108 vs. 62 min, p < 0.05) and hospital stay (median 4 vs. 3 days, p < 0.05) in unilateral surgery in favor of RPA, compared to TLA. Also in bilateral surgery, operating times were significantly shorter (median 236 vs. 117 min, p < 0.05). In both groups, few major complications occurred.

Conclusion

After the introduction of RPA, a short learning curve was seen for a single surgeon with extensive experience in laparoscopic adrenal surgery. Compared to TLA, RPA has significant advantages in operating times and hospital stay. Therefore, RPA may be the preferred approach for patients with BMI < 35 kg/m² and small benign adrenal tumors (<7 cm).

Retroperitoneoscopic Adrenalectomy in Obese Patients: Is It Suitable?

BACKGROUND

The aim of this study was to evaluate the suitability of posterior retroperitoneoscopic adrenalectomy for patients with morbid obesity.

METHODS

This retrospective clinical cohort study included patients who underwent elective posterior retroperitoneoscopic adrenalectomy. Intraoperative (operative time, blood loss, intraoperative complications, conversion rate) and postoperative (hospital stay, morbidity, mortality) parameters were compared between the two study subgroups: obese (body mass index [BMI] ≥30 kg/m(2)) and non-obese patients (BMI <30 kg/m(2)).

RESULTS

A total of 137 subsequent patients were enrolled in the study (41 obese and 96 non-obese patients). Mean tumour size was 5.2 ± 2.2 cm; aldosteronism and incidentaloma were the most frequent indications. Operative time was significantly longer (87 vs. 65 min; P = 0.0006) in obese patients. There was no difference in operative blood loss. One conversion was necessary. Overall, the 30-day postoperative morbidity was significantly higher in obese patients (26.8 vs. 11.5 %; P = 0.025). The hospital stay was significantly longer in obese patients (3.1 vs. 2.5 days; P = 0.003).

CONCLUSIONS

Dorsal retroperitoneoscopic adrenalectomy can be safely performed in morbidly obese patients, maintaining the advantages of minimally invasive surgery. Avoiding an abdominal approach is beneficial for patients. There is a more favourable postoperative course, shorter hospital stay, better cosmetic outcome and quicker recovery with dorsal retroperitoneoscopic adrenalectomy. The prolonged operative time, longer hospital stay and higher risk of postoperative complications that occurred in obese patients were acceptable in light of the generally higher risk associated with surgeries performed in obese patients.

Systematic review of surgery and outcomes in patients with primary aldosteronism

BACKGROUND

Primary aldosteronism (PA) is the most common cause of secondary hypertension. The main aims of this paper were to review outcome after surgical versus medical treatment of PA and partial versus total adrenalectomy in patients with PA.

METHODS

Relevant medical literature from PubMed, the Cochrane Library and Embase OvidSP from 1985 to June 2014 was reviewed.

RESULTS

Of 2036 records, 43 articles were included in the final analysis. Twenty-one addressed surgical versus medical treatment of PA, four considered partial versus total adrenalectomy for unilateral PA, and 18 series reported on surgical outcomes. Owing to the heterogeneity of protocols and reported outcomes, only a qualitative analysis was performed. In six studies, surgical and medical treatment had comparable outcomes concerning blood pressure, whereas six showed better outcome after surgery. No differences were seen in cardiovascular complications, but surgery was associated with the use of fewer antihypertensive medications after surgery, improved quality of life, and (possibly) lower all-cause mortality compared with medical treatment. Randomized studies indicate a role for partial adrenalectomy in PA, but the high rate of multiple adenomas or adenoma combined with hyperplasia in localized disease is disconcerting. Surgery for unilateral dominant PA normalized BP in a mean of 42 (range 20-72) per cent and the biochemical profile in 96-100 per cent of patients. The mean complication rate in 1056 patients was 4·7 per cent.

CONCLUSION

Recommendations for treatment of PA are hampered by the lack of randomized trials, but support surgical resection of unilateral disease. Partial adrenalectomy may be an option in selected patients.

Laparoscopic adrenalectomy in a patient with situs inversus

This study emphasizes the importance of careful preoperative imaging and select port positions appropriate for the targeted organ in patients with situs inversus undergoing laparoscopic surgery.

Background:

Situs inversus is a relatively rare congenital disease. A patient with a right adrenal tumor complicated by total situs inversus was treated by laparoscopy.

Case Discussion:

The patient was a 45-y-old male with lower limb weakness. He had been diagnosed with situs inversus during a general health check-up as an infant. His blood pressure was 230/160 mm Hg, and the serum potassium level was 2.0 mEq/L. Abdominal ultrasonography and magnetic resonance imaging showed a mass of about 2cm in diameter in contact with the right adrenal gland. Total situs inversus was simultaneously confirmed. The plasma aldosterone concentration was elevated to 442pg/mL, and renin activity was suppressed, at 0.3ng/mL/hr.

Discussion:

These findings indicated a diagnosis of primary aldosteronism due to an adrenal tumor, and the right adrenal tumor was resected laparoscopically. The right adrenal gland was approached and resected from the lateral side of the spleen, which was located on the right side because of situs inversus. The resected specimen was 4.5cm×1.6cm, and no intraoperative complications occurred. The histopathological examination showed the tumor to be an aldosterone-producing adrenocortical adenoma.

Laparoscopic adrenalectomy in pheochromocytoma: retroperitoneal approach versus transperitoneal approach

OBJECTIVES

The aim of this study was to evaluate outcomes of transperitoneal and retroperitoneal approaches in laparoscopic adrenalectomy (LA) for pheochromocytoma.

METHODS

We retrospectively compared the results of transperitoneal LA (TLA) with that of retroperitoneal LA (RLA) in 99 patients with unilateral pheochromocytoma (<6 cm in diameter). Age of patients ranged from 20 to 63 years (42 men and 57 women; 56 in right and 43 in left). The mean operation time, blood loss, mean hospital stay after operation, fluctuation range of blood pressure, blood pressure after operation, complication, mortalities, and recurrences were considered.

RESULTS

There were significant differences between RLA and TLA in terms of duration of surgery 84 ± 17 minutes versus 117 ± 24 minutes (p < 0.05), intraoperative blood loss 200 ± 22.5 ml versus 340 ± 41.7 ml (p < 0.05), mean hospital stay after operation 4.8 ± 1.6 days versus 7.8 ± 2.2 days (p < 0.05), and complication 12.5% versus 6.7% (p < 0.05). There was no significant difference between RLA and TLA in terms of fluctuation range of blood pressure (p > 0.05) and blood pressure after operation (p > 0.05). There were no mortalities or recurrences of tumors in all patients during follow-up.

CONCLUSIONS

Compared with TLA, RLA is safer, more quick, and effective for patients with unilateral pheochromocytoma (< 6 cm in diameter).

Retroperitoneoscopic adrenalectomy for pheochromocytoma in a morbidly obese

Laparoscopy has become a standard approach for adrenal surgery. Additionally, retroperitoneoscopic techniques have also shown to be effective for adrenal removal. It is known that laparoscopic techniques in the morbidly obese may be challenging; therefore, alternative approaches such as the retroperitoneoscopic may prove to be of value in the morbidly obese.

Posterior retroperitoneoscopic adrenalectomy: preferred technique for removal of benign tumors and isolated metastases

OBJECTIVE

Posterior retroperitoneoscopic adrenalectomy (PRA) is a minimally invasive approach to removal of the adrenal gland. This anatomically direct approach, popularized by Walz, minimizes dissection and affords early access to the adrenal vein. We report the largest experience to date of PRA in the United States.

METHODS

The prospective endocrine surgery database at a tertiary care center was used to capture all patients who underwent PRA between October 2005 and February 2008. All PRA procedures were performed using a 3-trocar technique with the patient in a prone jackknife position.

RESULTS

Sixty-eight PRAs were performed in 62 patients; there were 6 conversions (3 video-assisted and 3 open). Indications for adrenalectomy were functional tumors in 43 patients (20 pheochromocytomas, 13 Cushing disease or syndrome, and 10 others), nonfunctional cortical adenomas in 4, and isolated adrenal metastases in 15. Mean tumor size was 3.4 cm. Complications occurred in 11 patients (16%), with no perioperative deaths. In 34 (55%) patients, there was a relative contraindication to an anterior approach. Additionally, 20 patients (38%) had a body mass index greater than 30. Median operating time was 121 minutes.

CONCLUSION

PRA is safe, avoids intra-abdominal adjacent organ mobilization, is unaffected by the presence of intra-abdominal adhesions, and is possible in obese patients. PRA may be the preferred technique for removing benign adrenal tumors and isolated metastases.

Updates in endourology

Rapid urologic innovations in minimally invasive treatment are creating exciting new horizons in endourology. However, these new concepts are blurring the traditional boundary between endourology and oncology. Organ-sparing surgery, laparoscopy, robotics systems, and image-guided ablation techniques enable surgeons to develop specifically tailored treatments for patients. We examine recent developments and future prospects for how new technology will continue to advance the field of endourology.