Ipsilateral adrenalectomy at the time of radical nephrectomy impacts overall survival

Laparoscopic Radical Nephrectomy

In addition to its established advantages, laparoscopic radical nephrectomy (RN) poses a unique set of challenges over traditional open surgery. In this study, we discuss preoperative considerations and detailed steps for laparoscopic RN. We review the transabdominal approach in detail, including patient positioning, equipment, and port placement in addition to the surgical steps. Intraoperative decisions such as adrenal management, renal preservation, and tumor identification are reviewed. Common complications of laparoscopic renal surgery are also summarized.

Adrenalectomy During Radical Nephrectomy- Incidence and Oncologic Outcomes From the Canadian Kidney Cancer Information System (CKCis) -A Modern Era, Nationwide, Multicenter Cohort

OBJECTIVE

To characterize proportion of patients receiving adrenalectomy, adrenal involvement prevalence and oncologic outcomes of routine adrenalectomy in contemporary practice. Ipsilateral adrenalectomy was once standard during radical nephrectomy. However, benefit of routine adrenalectomy has been questioned because adrenal involvement of renal cell carcinoma (RCC) is low.

METHODS

All patients receiving radical nephrectomy in the Canadian Kidney Cancer information system, a collaborative prospective cohort populated by 14 major Canadian centers, between January 2011 to February 2020 were included. Patients were excluded if they had non-RCC histology, multiple tumors, contralateral tumors, metastatic disease or previous history of RCC. Patient demographic, clinical, and surgical information were summarized and compared. Cox-proportional hazards was used for multivariable analysis.

RESULTS

During study period, 2759 patients received radical nephrectomy, of these, 831(30.1%) had concomitant adrenalectomy. Pathological adrenal involvement was identified in 102 (3.7%overall; 12.3%of adrenalectomy). Median follow-up was 21.6months (Interquartile range 7.0-46.5). Patients with adrenalectomy had higher venous tumor thrombus (30.3% vs 9.6%; P <.0001), higher T stage (71.1% vs 43.4% pT3/4; P <.0001), lymph node metastases (17.6% vs 10.7%; P = .0035), Fuhrman grades (71.4% of Fuhrman grades 3/4 vs 56.2%; P <.0001) and increased proportion of clear cell histology (79.3% vs 74.5%; P = .0074) compared to the no adrenalectomy group. Adrenalectomy patients had higher risk of recurrence (HR 1.23; 95% CI 1.04-1.47; P = .019) and no difference in survival (HR 1.09, 95% CI 0.86-1.38, P = .48).

CONCLUSION

Adrenalectomy is not associated with better oncological outcome of recurrence/survival. Adrenalectomy should be reserved for patients with radiographic adrenal involvement and/or intra-operative adrenal involvement.

Identifying tumor-related risk factors for simultaneous adrenalectomy in patients with cT1-cT2 kidney cancer during robotic assisted laparoscopic radical nephrectomy

BACKGROUND

In some cases, preservation of adrenal gland could be at risk in patients with cT1 and cT2 RCC. The aim of this study was to evaluate tumor-related factors that can potentially increase the risk of simultaneous adrenalectomy during robotic-assisted laparoscopic radical nephrectomy (RALRN) in patients with cT1-cT2 disease and the impact of performing such procedure on recurrence-free survival (RFS) and complication rates.

METHODS

We used a multi-institutional kidney cancer database where we identified patients who underwent RALRN with or without adrenalectomy. We evaluated the tumor-related characteristics that could potentially increase the risk of adrenal gland resection of these patients. We also reported RFS at 12-24 months of follow-up, which was compared with an inverse probability of treatment weighted (IPTW) multivariable cox proportional hazards regression model and postoperative complications, which was compared with an IPTW multivariable logistic regression model.

RESULTS

Tumor size, cT stage, pT stage, histologic subtype, sarcomatoid differentiation, BMI, lymph node involvement, metastatic disease, Fuhrman grade do not increase the risk of simultaneous adrenalectomy during RALRN. Moreover, RALRN with adrenalectomy had no significant benefit in RFS. No differences in post-operative complications were noted.

CONCLUSIONS

Our evaluated tumor-related characteristics did not show to impact the incidence of simultaneous adrenalectomy. Adrenal gland resection T does not provide significant benefit in recurrence-free survival. We consider that RALRN with adrenalectomy should be reserved only for patients with adrenal compromise as stated previously regardless that it has shown to be a safe procedure.

Predictive Ability of Preoperative CT Scan in Determining Whether the Adrenal Gland is Spared at Radical Nephrectomy

INTRODUCTION

The aim of this study was to assess whether preoperative multiple detector computed tomography (MDCT) accurately predicts adrenal involvement for patients undergoing non-adrenal sparing radical nephrectomy for renal cell carcinoma.

METHODS AND MATERIALS

A retrospective observational study based on a composite patient population of two university teaching hospitals who underwent radical nephrectomy. Sensitivity, specificity, overall accuracy, positive and negative predictive values and likelihood ratios were calculated from radiological reports.

RESULTS

Total 579 patients underwent radical nephrectomy, of which 199 (34.4%) patients underwent a non-adrenal sparing radical nephrectomy, in which 128 (64.3%) were male and 118 (59.3%) were left side tumors. Mean tumor size was 8.2 cm (range 1.4-20cm). MDCT was found to have a sensitivity of 100% and specificity of 95.2% for identifying adrenal invasion. Total 179 patients (89.9%) had a radiographically normal ipsilateral adrenal gland, of which none were found to have adrenal involvement. Therefore, the negative predictive value of preoperative cross-sectional imaging for identification of adrenal involvement was 100%.

CONCLUSION

Cross- sectional MDCT imaging accurately predicts adrenal involvement and the decision to remove or spare the adrenal gland should be made preoperative planning regardless of tumour size or location at the time of multi-disciplinary discussion unless there is intraoperative evidence of adrenal invasion.

The Role of Adrenalectomy in Renal Cancer

CONTEXT

Since the 1960s, routine ipsilateral adrenalectomy (IA) has been considered an integral step in the removal of renal tumors as a part of a radical nephrectomy. However, recent data from the past decade have narrowed the indications for adrenalectomy and called into question the need for adrenalectomy at all in the treatment of renal cell carcinoma (RCC).

OBJECTIVE

We sought to identify the role of adrenalectomy in the treatment of RCC. Specifically, we wanted to answer the following questions: What is the incidence of ipsilateral adrenal involvement by cancer? How reliable is preoperative imaging? What is the rate of ipsilateral and contralateral metachronous recurrence? And finally, what are the potential noncancer sequelae from unnecessary removal of the adrenal gland?

EVIDENCE ACQUISITION

A systematic literature search of Embase, PubMed, Cochrane, and Ovid Medline was performed to identify studies evaluating the role of adrenalectomy during RCC surgery. Only articles published in English from the years 2000-2015 were included. Case reports, articles about primary adrenal tumors, letters to the editor, and surgical technique papers were excluded.

EVIDENCE SYNTHESIS

We found little evidence to suggest that routine IA is associated with a higher risk of short-term surgical or medical complications. We did not find evidence that IA is associated with improved cancer control. Tomographic preoperative imaging of the adrenal gland demonstrating no cancer involvement is rarely wrong (<1% of the time), and the few adrenal lesions missed on imaging can often be identified intraoperatively. Some evidence indicates that IA may be associated with worse long-term survival. Adrenalectomy rates have been decreasing in recent years, reflecting a changing practice pattern.

CONCLUSIONS

IA at the time of kidney surgery for a renal mass should be performed only if radiographic or intraoperative evidence indicates adrenal gland involvement.

PATIENT SUMMARY

We sought to define the role of adrenalectomy in patients with kidney cancer. Although there are not high-quality studies to answer this question definitively, we conclude that the adrenal gland should be spared unless there is clinical evidence of adrenal involvement.

Comparative effectiveness of adrenal sparing radical nephrectomy and non-adrenal sparing radical nephrectomy in clear cell renal cell carcinoma: Observational study of survival outcomes

INTRODUCTION

We compare the survival outcomes of patients with clear cell renal cell carcinoma (RCC) treated with adrenal sparing radical nephrectomy (ASRN) and non-adrenal sparing radical nephrectomy (NASRN).

METHODS

We conducted an observational study based on a composite patient population from two university teaching hospitals who underwent RN for RCC between January 2000 and December 2012. Only patients with pathologically confirmed RCC were included. We excluded patients undergoing cytoreductive nephrectomy, with loco-regional lymph node involvement. In total, 579 patients (ASRN = 380 and NASRN = 199) met our study criteria. Patients were categorized by risk groups (all stage, early stage and locally advanced RCC). Overall survival (OS) and cancer-specific survival (CSS) were analyzed for risk groups. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression.

RESULTS

The median follow-up was 41 months (range: 12-157). There were significant benefits in OS (ASRN 79.5% vs. NASRN 63.3%; p = 0.001) and CSS (84.3% vs. 74.9%; p = 0.001), with any differences favouring ASRN in all stage. On multivariate analysis, there was a trend towards worse OS (hazard ratio [HR] 1.759, 95% confidence interval [CI] 0.943-2.309, p = 0.089) and CSS (HR 1.797, 95% CI 0.967-3.337, p = 0.064) in patients with NASRN (although not statistically significant). Of these patients, only 11 (1.9%) had adrenal involvement.

CONCLUSIONS

The inherent limitations in our study include the impracticality of conducting a prospective randomized trial in this scenario. Our observational study with a 13-year follow-up suggests ASRN leads to better survival than NASRN. ASRN should be considered the gold standard in treating patients with RCC, unless it is contraindicated.

Indications for adrenalectomy during radical nephrectomy for renal cancer

Objectives

To determine if the selection criteria for ipsilateral adrenalectomy during laparoscopic radical nephrectomy (RN) can be further restricted, with the goal of sparing more patients unnecessary adrenalectomy while preserving the removal of adrenal glands containing malignancy, as recent evidence suggests that adrenalectomy in association with RN for renal cancer can be limited to patients with abnormalities on adrenal imaging or large upper-pole renal tumours.

Patients and methods

The cohort consisted of two data sets, each from one institution, i.e., a training set and a validation set. All patients underwent RN for radiographically localised disease. Removal of the adrenal gland was based on the surgeon’s preference, related to the presence of a suspect adrenal lesion on preoperative imaging, suspicion for involvement of the adrenal gland intraoperatively, location of the tumour, size of the tumour and local tumour stage.

Results

Of 159 patients in the training cohort, three (2%) had metastatic renal cancer in the ipsilateral adrenal gland. All three patients had tumours of >7 cm and either an abnormal radiographic appearance of the adrenal gland or suspect intraoperative findings. In the validation cohort of 74 patients, seven (10%) had adrenal metastasis, of which one had a tumour of <7 cm and the indication for adrenalectomy was the high intraoperative suspicion.

Conclusion

We recommend performing ipsilateral adrenalectomy in association with RN for renal cancer when there is either abnormal radiographic appearance of the adrenal gland or suspect intraoperative findings, with no regard for primary tumour size.