Surgical outcomes of laparoscopic adrenalectomy for primary hyperaldosteronism: 20 years of experience in a single institution

Single-Port Robotic Posterior Retroperitoneoscopic Adrenalectomy: Current Perspectives, Technical Considerations, and Future Directions

Single-port (SP) robotic posterior retroperitoneoscopic adrenalectomy (SP-PRA) represents a State-of-the-Art innovation in endocrine surgery, offering a minimally invasive approach for adrenal gland resection with significant improvements in surgical precision, cosmetic outcomes, and patient quality of life. The SP robotic system facilitates surgery through a single incision in the back, avoiding the transperitoneal cavity and enabling direct retroperitoneal access to the adrenal gland. This review explores the evolution, techniques, and clinical outcomes of SP-PRA, emphasizing its advantages over traditional multi-port and laparoscopic methods. Enhanced visualization and precise articulation of the SP robotic system minimize trauma to surrounding tissues, leading to fewer complications and faster recovery times. Initial studies suggest superior patient satisfaction due to hidden incisions and excellent postoperative outcomes. However, challenges such as a steep learning curve, high costs, and limited long-term data remain. This review highlights the need for continued research and innovation to optimize the adoption of SP-PRA and expand its indications.

Outcomes following laparoscopic adrenalectomy: Experience of more than two decades at a tertiary care centre

INTRODUCTION

Laparoscopic transperitoneal adrenalectomy was first described by Gagner M et al . Here, we present our experience of more than two decades of laparoscopic adrenalectomy performed in a single surgical unit at a tertiary care centre.

PATIENTS AND METHODS

A prospectively collected database of patients undergoing laparoscopic adrenalectomy from December 1994 to May 2020 was analysed retrospectively. The demographic profile, details of clinical workup and laboratory parameters were recorded in a pre-structured pro forma. Functional workup and anatomical imaging were performed for all the patients. Patients were taken up for surgery after adequate pre-operative optimisation using a multidisciplinary approach. All the patients were operated by a single surgical team of experienced laparoscopic surgeons.

RESULTS

A total of 158 patients underwent laparoscopic transperitoneal adrenalectomy. The majority patients were females (64.5%). The median tumour size was 5 cm (range, 1-18 cm). The diagnosis in the majority of the patients was pheochromocytoma (56.3%). The mean operative time was 80 min (range: 45-210 min). The most common complication was bleeding in 6 (3.7%) patients, which required laparotomy. The median duration of post-operative hospital stay was 3 days (range: 1-13). There was no 30-day mortality. The mean follow-up period was 15 months (range: 6-72 months), during which two patients developed local recurrence.

CONCLUSION

The advantages of laparoscopic surgery are well established and have been extensively explored for the management of adrenal lesions. A multidisciplinary approach to management, consisting of endocrinologists, surgeons and anaesthesiologists is preferred. Pre-operative evaluation, optimisation and accurate selection of patients are crucial for successful laparoscopic adrenalectomy.

What We Know about and What Is New in Primary Aldosteronism

Primary aldosteronism (PA), a significant and curable cause of secondary hypertension, is seen in 5-10% of hypertensive patients, with its prevalence contingent upon the severity of the hypertension. The principal aetiologies of PA include bilateral idiopathic hypertrophy (BIH) and aldosterone-producing adenomas (APAs), while the less frequent causes include unilateral hyperplasia, familial hyperaldosteronism (FH) types I-IV, aldosterone-producing carcinoma, and ectopic aldosterone synthesis. This condition, characterised by excessive aldosterone secretion, leads to augmented sodium and water reabsorption alongside potassium loss, culminating in distinct clinical hallmarks: elevated aldosterone levels, suppressed renin levels, and hypertension. Notably, hypokalaemia is present in only 28% of patients with PA and is not a primary indicator. The association of PA with an escalated cardiovascular risk profile, independent of blood pressure levels, is notable. Patients with PA exhibit a heightened incidence of cardiovascular events compared to counterparts with essential hypertension, matched for age, sex, and blood pressure levels. Despite its prevalence, PA remains frequently undiagnosed, underscoring the imperative for enhanced screening protocols. The diagnostic process for PA entails a tripartite assessment: the aldosterone/renin ratio (ARR) as the initial screening tool, followed by confirmatory and subtyping tests. A positive ARR necessitates confirmatory testing to rule out false positives. Subtyping, achieved through computed tomography and adrenal vein sampling, aims to distinguish between unilateral and bilateral PA forms, guiding targeted therapeutic strategies. New radionuclide imaging may facilitate and accelerate such subtyping and localisation. For unilateral adrenal adenoma or hyperplasia, surgical intervention is optimal, whereas bilateral idiopathic hyperplasia warrants treatment with mineralocorticoid antagonists (MRAs). This review amalgamates established and emerging insights into the management of primary aldosteronism.

Laparoscopic adrenalectomy: comparison of outcomes between posterior retroperitoneoscopic and transperitoneal adrenalectomy with 10 years' experience

Background

Laparoscopic adrenalectomy is widely used for treating various adrenal tumors. Posterior retroperitoneoscopic adrenalectomy was introduced after transperitoneal laparoscopic adrenalectomy. The comparability and superiority of posterior retroperitoneoscopic adrenalectomy have been widely investigated. We aimed to compare the outcomes of posterior retroperitoneoscopic adrenalectomy and transperitoneal laparoscopic adrenalectomy using 10 years' data. The changes in outcomes over time were also analyzed.

Methods

This was a retrospective observational study. A total of 505 patients who underwent laparoscopic adrenalectomy between 2009 and 2018 were included. The patients were divided into two groups: transperitoneal (n=114) and retroperitoneal (n=391) groups. Patients who underwent posterior retroperitoneoscopic adrenalectomy were further classified into sub-groups (sub-group 1: 2009-2012; sub-group 2: 2013-2015; and sub-group 3: 2016-2018) based on time periods. Clinicopathological factors and postoperative outcomes were retrospectively reviewed and analyzed.

Results

The retroperitoneal group showed significantly shorter operation time, diet initiation time, and hospital stay compared to the transperitoneal group (P=0.000, 0.000 and 0.000, respectively). Analgesics were used less frequently in the retroperitoneal group than in the transperitoneal group (P=0.048). In the retroperitoneal group, the time to postoperative diet initiation shortened over time (P=0.000).

Conclusions

Posterior retroperitoneoscopic adrenalectomy is a favorable surgical method that results in patient outcomes that are comparable to those of conventional transperitoneal laparoscopic adrenalectomy, without compromising patient safety.

The effect of obesity in laparoscopic transperitoneal adrenalectomy

Objective: Laparoscopic adrenalectomy is the gold standard for the resection of adrenal tumors. However, there are some technical difficulties, which may be due to the fact that adrenalectomy is rarely encountered in general surgery practice and has a high learning curve. In addition to these, obesity is another problem in laparoscopic adrenalectomies. In the present study, it was aimed to evaluate whether obesity affects perioperative and postop- erative complications after laparoscopic adrenalectomy.

Material and Methods: This is a retrospective comparative study carried out between December 2008 and June 2018. A total of 65 patients who un- derwent laparoscopic transperitoneal adrenalectomy were divided into two groups according to their Body Mass Index (BMI). Patients’ demographic data, perioperative and postoperative results were analyzed from hospital medical records.

Results: There were 30 non-obese and 35 obese patients. There was no significant difference between obese and non-obese patients in terms of op- eration time, peroperative complications and length of hospital stay. However, there was a statistically significant difference between the two groups for postoperative complications (p< 0.031). There was conversion to open surgery in four obese patients and in one patient in the non-obese group.

Conclusion: In obese patients, technical difficulties may be encountered during surgery due to increased adipose tissue, and postoperative complica- tion rates may increase. Nevertheless, laparoscopic transperitoneal adrenalectomy can be performed safely paying attention to the management of obesity-related complications.

Surgical treatment outcome of primary aldosteronism assessed using new modified diagnostic tests

PURPOSE

Primary aldosteronism (PA) is the most frequent type of endocrine hypertension. In our previous studies, we introduced two modified diagnostic tests for PA, the post-dexamethasone saline infusion test (DSIT) and the overnight dexamethasone, captopril, and valsartan test (DCVT). In this study, we aimed to validate both tests in respect to the biochemical and clinical response of a cohort of hypertensive patients in pre- and post-surgical setting.

METHODS

We retrospectively studied 41 hypertensive patients (16 males), with a median (IQR, range) age of 50 (16, 35-74) years and positive histology for adrenal adenoma. Preoperatively, all patients had a single adenoma on CT and a diagnosis of PA with either DSIT or DCVT. The defined daily dose (DDD) of hypertensive drugs was assessed pre- and postoperatively. DSIT or DCVT and basal ARR were reassessed postoperatively.

RESULTS

Two of the 41 patients failed to suppress aldosterone post-surgery, leading to a post-adrenalectomy biochemical cure rate of 95%, while blood pressure was improved in 36 patients, leading to a clinical cure rate of 88% as assessed by the DDD methodology.

CONCLUSIONS

The present study was a proof-of-concept process to validate two modified diagnostic tests for PA in clinical practice. These tests, used to diagnose a group of patients with PA, successfully assessed their biochemical cure post-adrenalectomy at rates similar to those reported in the literature.