PSAT017 A Case of Aldosterone- and Cortisol Co-secreting Adrenal Corticol Neoplasm with Lipomatous and Myeiolipomatous Metaplasia

Background

Adrenal lipomatous tumors are uncommon fatty tumors of theadrenal glands with myelolipoma being the most common histologic feature.Adrenal myelolipoma is a benign adrenal cortical neoplasm composed of fat andmyeloid tissue, commonly diagnosed if fat composition of tumor is more than 50% on cross-sectional imaging studies. The myelolipomatous metaplasia is asecondary degenerative change in primary adrenal tumor, usually seen in benignadrenocortical adenomas and rarely in adrenocortical carcinomas and corticalneoplasms of uncertain malignant potential. Adrenocortical neoplasms areclassified as benign or malignant based on modified Weiss score, when the criteriaare not clear, the tumor is classified as a neoplasm of uncertain malignant lesion.As adrenal lipomatous tumors are usually benign and non-functional, patients withthese tumors often do not undergo hormonal evaluation.

Clinical Case

A 58-year-old female with a history of hypertension diagnosed atage 35 years, on five antihypertensive agents and a history of intermittentspontaneous hypokalemia, was found to have a 6 cm left adrenal myelolipoma onnon-contrast computed tomography of the abdomen performed when she presentedfor left flank pain due to nephrolithiasis. The biochemical evaluation showedpotassium of 2.8 meq/l, plasma aldosterone of 65.9 ng/dl with plasma renin activityof 0.1 ng/ml/hr. An overnight 1 mg dexamethasone suppression test showed nonsuppressible serum cortisol of 10.8 μg/dl. DHEAS, and ACTH were measured at24.5 μg/dl and <5 pg/ml, respectively. Left adrenalectomy was performed and onthe following day, morning serum cortisol was 2.3 μg/dl with aldosterone of 6.2ng/dl and plasma renin activity of 4.2 ng/ml/hr. Expectedly patient beganexperiencing nausea, and postural dizziness. Patient systolic blood pressure was inlow100 mmHg. Thus, hydrocortisone therapy was initiated. Immediatelypostoperatively and thereafter, her blood pressure was controlled with noantihypertensive agent, and morning cortisol measured without hydrocortisone for∼36 h remained low at 1.2 μg/dL. Pathology showed adrenal cortical neoplasm ofuncertain malignant potential with associated lipomatous and myelolipomatousmetaplasia without atypical mitoses, or lymphovascular invasion, or necrosis, orcapsular invasion, with negative surgical margins. Although mitotic activity in thetumor is lacking, the tumor was designated uncertain malignant potential due to thelarge size (7 cm), and lack of clear cells < 25% according to modified Weiss score.

Conclusion

We report a rare case of aldosterone and cortisol co-secreting adrenalcortical neoplasm of uncertain malignant potential with lipomatous andmyelolipomatous metaplasia. While the majority of cases of myelolipoma arebenign and non-functioning, this case emphasizes the importance of looking forsymptoms and signs pointing to adrenal hyperfunction, thorough hormonal andmorphologic evaluation and, definitive treatment is curative unilateraladrenalectomy.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Urine versus stent cultures and clinical UTIs

PURPOSE

Current American Urological Association guidelines recommend pre-operative antimicrobial therapy based on prior urine cultures (UC); however, the role of stent culture (SC) in urologic practice is unclear. We examined whether UC and SC differed at the time of stent removal, as well as the association, microbiology, and timing of subsequent UTIs as related to SC.

METHODS

This was a retrospective review of 159 patients with ureteral stents for indications of urolithiasis, benign stricture, malignant obstruction, and kidney transplant. UC and SC were analyzed at the time of stent removal. Patients were followed for 12 months after stent removal for development, concordance, and timing of clinical UTIs.

RESULTS

In 159 patients, 15% had positive UC and 45% had positive SC. Of patients who had positive SC, 66% had negative UC. All patients with positive UC had identical micro-organisms on SC; however, 33% of these had SC with additional micro-organisms. Relative to those with both negative UC and SC, patients with negative UC and positive SC had a 5.7 odds, and those with both positive UC and SC had a 13.6 odds of developing a clinical UTI within 12 months. Concordance of SC and future UTI was highest in those with post-operative sepsis, and those with Candida species on SC.

CONCLUSIONS

SC was a unique risk factor for development of UTI within 12 months of stent removal. Clinicians should consider SC results when empirically treating those with post-operative sepsis or those with UTI after Candida on SC.

Comparison of the Comprehensive Complication Index and Clavien-Dindo systems in predicting perioperative outcomes following radical nephroureterectomy

Background

Complications can occur following radical nephroureterectomy (RNU) in 20–40% of patients. The Comprehensive Complication Index (CCI) is an alternative grading system to the Clavien-Dindo (CD) grading system that aggregates all complications experienced by a patient on a continuous (as opposed to categorical) scale. We investigate whether the cumulative nature of CCI renders it superior to CD in predicting perioperative course after RNU.

Methods

The records of 596 patents who underwent RNU at 7 academic medical centers from 2005 to 2015 were reviewed. Complications occurring within 30 days of RNU were annotated using both the CD and CCI classification systems. Logistic regression was used to determine associations between CD and CCI with perioperative covariates as well as measures of convalescence [hospital length of stay (LOS) and readmission].

Results

A total of 377 men and 219 women with a median age of 71, BMI of 27, and Charlson comorbidity score of 4 were included. Over half underwent a minimally invasive RNU. Median LOS following RNU was 6.0 days (range, 1–37 days) and readmission within 30-days occurred in 45 (8%) patients. Overall, 136 patients (23%) experienced a post-operative complication with 91 having a single complication and 45 with multiple (range, 2–6); 44 (7%) patients had Clavien III or greater complications, and the median CCI for those patients experiencing a complication was 20.9 (range, 8.7–100). Both the upper quartile of CCI (≥75th %) and major CD complications were associated with higher baseline Charlson score, ECOG ≥2, and CKD stage ≥ III (all P<0.05). However, only the upper quartile of CCI was associated with LOS (8.9 vs. 5.4 days, P<0.01) and hospital readmission (OR 3.2, 95% CI: 1.9–5.6, P=0.02) after RNU.

Conclusions

The CD and CCI classification systems both are associated with similar baseline and perioperative characteristics for RNU patients. However, the cumulative nature of the CCI allows for superior prediction of postoperative course after RNU including LOS and readmission.

Robotic partial nephrectomy using robotic bulldog clamps

Robotically applying bulldog clamps was found to be a safe and feasible method of hilar occlusion during robotic partial nephrectomy.

Background and Objectives:

The need for a skilled assistant to perform hilar clamping during robotic partial nephrectomy is a potential limitation of the technique. We describe our experience using robotic bulldog clamps applied by the console surgeon for hilar clamping.

Methods:

A total of 60 consecutive patients underwent robotic partial nephrectomy, 30 using laparoscopic bulldog clamps applied by the assistant and 30 using robotic bulldog clamps applied with the robotic Prograsp instrument. Perioperative outcomes were compared between groups.

Results:

All 30 patients underwent successful hilar clamping during robotic partial nephrectomy using robotic bulldog clamps with no intraoperative complications and without the need for readjustment/reclamping. Robotic bulldog clamps provided adequate ischemia even for tumors >4 cm, hilar, endophytic, multiple tumors, and multiple renal arteries. Both groups had similar baseline characteristics. Perioperative outcomes with robotic bulldog clamps were at least comparable to the laparoscopic bulldog group, with a trend to lower console time, warm ischemia time, and estimated blood loss.

Conclusions:

Use of robotically applied bulldog clamps is a safe and feasible method of hilar occlusion during robotic partial nephrectomy; they perform at least as well as laparoscopic bulldog clamps while allowing the console surgeon greater autonomy and precision for hilar clamping.