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Xiang H, Zhang T, Song W, Yang D, Zhu X. Adrenalectomy for primary aldosteronism and its related surgical characteristics. Front Endocrinol (Lausanne) 2024; 15:1416287. [PMID: 38966219 PMCID: PMC11222333 DOI: 10.3389/fendo.2024.1416287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 06/06/2024] [Indexed: 07/06/2024] Open
Abstract
Primary aldosteronism (PA) is a common cause of secondary hypertension. Adrenalectomy is an effective treatment for unilateral PA, particularly aldosterone-producing adenoma (APA), resulting in improvements in biochemical parameters and blood pressure in the vast majority of patients. The article provides a comprehensive overview of PA, focusing on the outcomes of adrenalectomy for PA and the factors that may suggest prognostic implications. Analysis of the outcome of different PA patients undergoing adrenalectomy in terms of preoperative factors, vascular and adipose conditions, type of pathology, and somatic variants. In addition, it is recommended to use the histopathology of primary aldosteronism (HISTALDO) consensus to classify the patient's pathological type, with classical and nonclassical pathological types showing a different prognosis and possibly being associated with an unresected contralateral adrenal gland. The primary aldosteronism surgical outcome (PASO) consensus sets uniform standards for postoperative outcomes in unilateral PA, but its setting of thresholds remains controversial. Partial adrenalectomy shows similar surgical results and fewer postoperative complications than total adrenalectomy, but there is a risk of missing the true source of abnormal aldosterone secretion. Steroid profiling and functional imaging techniques offer alternative options to adrenal vein sampling (AVS) for unilateral and bilateral judgments in patients with PA. A combination of factors is needed to predict the prognosis of PA patients undergoing adrenalectomy in order to manage patient expectations of the outcome of the procedure and to closely monitor blood pressure and biochemical parameters in patients who suggest a poorer prognosis.
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Affiliation(s)
- Hao Xiang
- Department of Urology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Tingting Zhang
- Department of Neurology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Wei Song
- Department of Hypertension, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Deyong Yang
- Department of Urology, First Affiliated Hospital of Dalian Medical University, Dalian, China
- Department of Surgery, Healinghands Clinic, Dalian, Liaoning, China
| | - Xinqing Zhu
- Department of Urology, First Affiliated Hospital of Dalian Medical University, Dalian, China
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Alesina PF, Kniazeva P, Pinto G, Pontin A, Walz MK. Long-term outcome of retroperitoneoscopic partial versus total adrenalectomy in patients with Cushing's syndrome. World J Surg 2024; 48:121-129. [PMID: 38651548 DOI: 10.1002/wjs.12023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 10/31/2023] [Indexed: 04/25/2024]
Abstract
BACKGROUND We analyze the long-term outcome of surgery for Cushing's syndrome (CS) and the influence of the extent of surgical resection on the duration of postoperative cortisone substitution. METHODS One-hundred forty-one patients (129 female, 12 males; mean age: 45.7 ± 12.8 years) operated between January 2000 to June 2020 were included in the analysis. Patients suffered from manifest (124) or subclinical (17) CS due to benign unilateral adrenal neoplasia. All tumors were removed by the posterior retroperitoneoscopic approach. 105 patients had total (TA) and 36 partial (PA) adrenalectomies. All patients were discharged with ongoing corticosteroid supplementation therapy. RESULTS Follow-up data could be obtained for 83 patients. Twenty-four (1 male, 23 females; mean age 42.3 years) underwent PA and 59 TA (6 males, 53 females; mean age 44.6 years). Mean follow-up time was 107 ± 68 months (range: 6-243 months). The median duration of postoperative corticosteroid therapy was 9.5 months after PA and 11 months after TA (p = 0.1). Significantly, more patients after total adrenalectomy required corticosteroid therapy for more than 24 months (25% vs. 4%; p = 0.03). Recurrent ipsilateral disease occurred in one case after partial adrenalectomy and was treated by completion adrenalectomy. A case of contralateral recurrence associated with subclinical Cushing's syndrome was observed after total adrenalectomy. CONCLUSIONS The risk of local recurrence after partial adrenalectomy in CS is low. Cortical-sparing surgery may shorten corticosteroid supplementation therapy after surgery.
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Affiliation(s)
- P F Alesina
- Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Essen, Germany
| | - P Kniazeva
- Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Essen, Germany
| | - G Pinto
- Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Essen, Germany
| | - A Pontin
- Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Essen, Germany
| | - M K Walz
- Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Essen, Germany
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Birtwistle L, Leong D, Aniss A, Glover A, Sidhu S, Papachristos A, Sywak M. Minimally invasive adrenalectomy: a cohort study of surgical approach and outcomes. ANZ J Surg 2023; 93:2222-2228. [PMID: 37132079 DOI: 10.1111/ans.18443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 03/18/2023] [Accepted: 03/20/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND In the context of minimally invasive adrenal surgery, there remains debate about whether the transperitoneal adrenalectomy (TPA) and posterior retroperitoneoscopic adrenalectomy (PRA) approach have equivalent indications. This study aims to examine complication and conversion rates associated with three surgical approaches for adrenal tumours over the last 17 years in a specialized endocrine surgical unit. METHODS All adrenalectomy cases performed in the period 2005-2021 were identified within a prospectively maintained surgical database. A retrospective cohort study was undertaken with patients divided into two cohorts (2005-2013 and 2014-2021). Surgical approach (open adrenalectomy (OA), TPA, PRA), tumour size, histopathology, complication and conversion rates were compared. RESULTS During the study period, 596 patients underwent adrenalectomy with 31 and 40 cases each year per cohort. The dominant surgical approach per cohort significantly changed from TPA (79% versus 17%) to PRA (8% versus 69%, P < 0.001), whilst the frequency of OA remained stable (13% versus 15%). TPA removed larger tumours (3.0 ± 2.9 cm) than PRA (2.8 ± 2.2 cm, P = 0.02), with the median size increasing from 3.0 ± 2.5 to 4.5 ± 3.5 cm per cohort (P < 0.001). The maximum tumour sizes treated by TPA and PRA were 15 and 12 cm, respectively. Adrenocortical adenoma was the commonest pathology treated by either laparoscopic technique. Complication rates were greatest for OA (30.1%) with no significant difference between minimally invasive approaches (TPA 7.3%, PRA 8.3%, P = 0.7). Both laparoscopic techniques had equivalent conversion rates (3.6%). PRA was preferably converted to TPA (2.8%) over OA (0.8%). CONCLUSION This study demonstrates the transition from TPA to PRA, offering similarly low complication and conversion rates.
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Affiliation(s)
- Lucy Birtwistle
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, 2006, Australia
| | - David Leong
- Endocrine Surgery Unit, University of Sydney, Sydney, New South Wales, 2065, Australia
| | - Ahmad Aniss
- Endocrine Surgery Unit, University of Sydney, Sydney, New South Wales, 2065, Australia
| | - Anthony Glover
- Endocrine Surgery Unit, University of Sydney, Sydney, New South Wales, 2065, Australia
| | - Stan Sidhu
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, 2006, Australia
- Endocrine Surgery Unit, University of Sydney, Sydney, New South Wales, 2065, Australia
| | - Alexander Papachristos
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, 2006, Australia
- Endocrine Surgery Unit, University of Sydney, Sydney, New South Wales, 2065, Australia
| | - Mark Sywak
- Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, 2006, Australia
- Endocrine Surgery Unit, University of Sydney, Sydney, New South Wales, 2065, Australia
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Dogrul AB, Cennet O, Dincer AH. Minimally invasive techniques in benign and malignant adrenal tumors. World J Clin Cases 2022; 10:12812-12821. [PMID: 36569018 PMCID: PMC9782958 DOI: 10.12998/wjcc.v10.i35.12812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/04/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022] Open
Abstract
Minimally invasive adrenalectomy has become the main treatment modality for most adrenal lesions. Both laparoscopic transabdominal and retroperitoneoscopic approaches are safe and feasible options, each with respective advantages, including better surgical outcomes, fewer complications, and faster recovery over open adrenalectomy. While open surgery remains a valid modality in treatment of adrenocortical cancer in the presence of some findings such as invasion, robotic platforms, and minimally invasive surgery have gained popularity as technology continues to evolve. Organ preservation during adrenalectomy is feasible in some conditions to prevent adrenal insufficiency. Ablative technologies are increasingly utilized in benign and malignant tumors, including the adrenal gland, with various outcomes. A multidisciplinary team, an experienced surgeon, and a high-volume center are recommended for any surgical approaches and management of adrenal lesions. This review article evaluated recent findings and current evidence on minimally invasive adrenalectomy.
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Affiliation(s)
- Ahmet Bulent Dogrul
- Department of General Surgery, Hacettepe University Faculty of Medicine, Hacettepe University, Ankara 06100, Turkey
| | - Omer Cennet
- Department of General Surgery, Hacettepe University Faculty of Medicine, Hacettepe University, Ankara 06100, Turkey
| | - Anıl Hilmi Dincer
- Department of General Surgery, Hacettepe University Faculty of Medicine, Hacettepe University, Ankara 06100, Turkey
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Vatansever S, Nordenström E, Raffaelli M, Brunaud L, Makay Ö. Robot-assisted versus conventional laparoscopic adrenalectomy: Results from the EUROCRINE Surgical Registry. Surgery 2022; 171:1224-1230. [PMID: 35027208 DOI: 10.1016/j.surg.2021.12.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 11/01/2021] [Accepted: 12/08/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Adrenalectomy is routinely performed via the minimally invasive approach. Safety of adrenalectomy using the robot-assisted technique has been widely demonstrated by several series, but the literature is scarce regarding the comparison of conventional laparoscopic versus robot-assisted approach. We decided to carry out a multicenter study to compare clinical and surgical outcomes between laparoscopic and robotic adrenalectomy. METHODS This is a retrospective case-control study, including data from centers affiliated to the Surgical Registry EUROCRINE. Patients undergoing laparoscopic surgery for adrenal tumors and registered between 2015 and 2018 were included. Robot-assisted versus laparoscopic adrenalectomy was compared. All comparisons were carried out in terms of complication rate, conversion rate and duration of stay. RESULTS A total of 1,005 patients from 46 clinics underwent robotic or conventional laparoscopic adrenalectomy. Median age was 55 (interquartile range: 45-65) years. Robotic adrenalectomy was performed in 189 (18.8%) patients. According to Clavien-Dindo classification, complication rate was lower in the robotic surgery group (1.6% vs 16.5%, P < .001). Laparoscopic surgery and active hormonal status were significantly correlated with complications, both in univariate and multivariate analysis. There was no significant difference between laparoscopic and robotic surgery groups, in terms of conversion rate (2.1% vs 0.5%, respectively, P = .147). Duration of stay was shorter in the robotic adrenalectomy group (82.1% vs 28.8%, P < .001). CONCLUSION Analysis of the EUROCRINE database supports that robotic adrenalectomy resulted in a lower complication rate and shorter duration of stay, compared with laparoscopic adrenalectomy. Granular data to support this is warranted.
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Affiliation(s)
- Safa Vatansever
- Department of General Surgery, Division of Endocrine Surgery, Ege University Hospital, Izmir, Turkey
| | - Erik Nordenström
- Department of Surgery, Division of Endocrine and Sarcoma Surgery, Lund University, Lund, Sweden
| | - Marco Raffaelli
- Division of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Laurent Brunaud
- Université de Lorraine, Département de Chirurgie Viscérale, Métabolique et Cancérologique (CVMC), CHRU Nancy, Hopital de Brabois, Vandoeuvre-les-Nancy, France
| | - Özer Makay
- Department of General Surgery, Division of Endocrine Surgery, Ege University Hospital, Izmir, Turkey.
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Sun S, Wang J, Yang B, Wang Y, Yao W, Yue P, Niu X, Feng A, Zhang L, Yan L, Cheng W, Zhang Y. A nomogram for evaluation and analysis of difficulty in retroperitoneal laparoscopic adrenalectomy: A single-center study with prospective validation using LASSO-logistic regression. Front Endocrinol (Lausanne) 2022; 13:1004112. [PMID: 36506074 PMCID: PMC9732249 DOI: 10.3389/fendo.2022.1004112] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 11/15/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND While it is known that inaccurate evaluation for retroperitoneal laparoscopic adrenalectomy (RPLA) can affect the surgical results of patients, no stable and effective prediction model for the procedure exists. In this study, we aimed to develop a computed tomography (CT) -based radiological-clinical prediction model for evaluating the surgical difficulty of RPLA. METHOD Data from 398 patients with adrenal tumors treated by RPLA in a single center from August 2014 to December 2020 were retrospectively analyzed and divided into sets. The influencing factors were selected by least absolute shrinkage and selection operator regression model (LASSO). Additionally, the nomogram was constructed. A receiver operating characteristic curve was used to analyze the prediction efficiency of the nomogram. The C-index and bootstrap self-sampling methods were used to verify the discrimination and consistency of the nomogram. RESULT The following 11 independent influencing factors were selected by LASSO: body mass index, diabetes mellitus, scoliosis, hyperlipidemia, history of operation, tumor diameter, distance from adrenal tumor to upper pole of kidney, retro renal fat area, hyperaldosteronism, pheochromocytoma and paraganglioma, and myelolipoma. The area under the curve (AUC) of the training set was 0.787, and 0.844 in the internal validation set. Decision curve analyses indicated the model to be useful. An additional 117 patients were recruited for prospective validation, and AUC was 0.848. CONCLUSION This study developed a radiological-clinical prediction model proposed for predicting the difficulty of RPLA procedures. This model was suitable, accessible, and helpful for individualized surgical preparation and reduced operational risk. Thus, this model could contribute to more patients' benefit in circumventing surgical difficulties because of accurate predictive abilities.
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Affiliation(s)
- Shiwei Sun
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, China
| | - Jinyao Wang
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bin Yang
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yue Wang
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, China
| | - Wei Yao
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, China
| | - Peng Yue
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, China
| | - Xiangnan Niu
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Anhao Feng
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, China
| | - Lele Zhang
- Department of Urology, Tangdu Hospital, Air Force Medical University, Xi’an, China
| | - Liang Yan
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Cheng
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yangang Zhang
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, China
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Yangang Zhang,
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Lase I, Grönberg M, Norlén O, Stålberg P, Welin S, Janson ET. Adrenalectomy in ectopic Cushing's syndrome: A retrospective cohort study from a tertiary care centre. J Neuroendocrinol 2021; 33:e13030. [PMID: 34448524 DOI: 10.1111/jne.13030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 08/06/2021] [Accepted: 08/10/2021] [Indexed: 11/27/2022]
Abstract
Neuroendocrine neoplasms (NENs) causing ectopic Cushing's syndrome (ECS) are rare and challenging to treat. In this retrospective cohort study, we aimed to evaluate different approaches for bilateral adrenalectomy (BA) as a treatment option in ECS. Fifty-three patients with ECS caused by a NEN (35 females/18 men; mean ± SD age: 53 ± 15 years) were identified from medical records. Epidemiological and clinical parameters, survival, indications for surgery and timing, as well as duration of surgery, complications and surgical techniques, were collected and further analysed. The primary tumour location was thorax (n = 30), pancreas (n = 14) or unknown (n = 9). BA was performed in 37 patients. Median time from diagnosis of ECS to BA was 2 months (range 1-10 months). Thirty-two patients received different steroidogenesis inhibitors before BA to control hypercortisolaemia. ECS resolved completely after surgery in 33 patients and severe peri- or postoperative complications were detected in 12 patients. There were fewer severe complications in the endoscopic group compared to open surgery (p = .030). Posterior retroperitoneoscopic BA performed simultaneously by a two surgeon approach had the shortest operating time (p = .001). Despite the frequent use of adrenolytic treatment, BA was necessary in a majority of patients to gain control over ECS. Complication rate was high, probably as a result of the combination of metastatic disease and metabolic disorders caused by high cortisol levels. The two surgeon approach BA may be considered as the method of choice in ECS compared to other BA approaches as a result of fewer complications and a shorter operating time.
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Affiliation(s)
- Ieva Lase
- Department of Medical Sciences, Endocrine Oncology Unit, Uppsala University, Uppsala, Sweden
| | - Malin Grönberg
- Department of Medical Sciences, Endocrine Oncology Unit, Uppsala University, Uppsala, Sweden
| | - Olov Norlén
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Peter Stålberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Staffan Welin
- Department of Medical Sciences, Endocrine Oncology Unit, Uppsala University, Uppsala, Sweden
| | - Eva Tiensuu Janson
- Department of Medical Sciences, Endocrine Oncology Unit, Uppsala University, Uppsala, Sweden
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Abstract
Since the introduction of minimally invasive surgery, laparoscopic adrenalectomy has become the main treatment option for adrenal masses. Various studies have reported that laparoscopic adrenalectomy showed fewer postoperative complications and faster recovery than conventional open adrenalectomy. Laparoscopic adrenalectomy can be performed through either the transperitoneal approach or the retroperitoneoscopic approach, which are widely used in most adrenal surgical procedures. Furthermore, with the development of minimally invasive surgery, organ-sparing adrenalectomy has recently emerged as a way to conserve functional adrenal gland tissue. According to recent data, organ-sparing adrenalectomy shows promising surgical, functional, and oncological outcomes including less intraoperative blood loss, maintenance of adrenal function, and low recurrence. Partial adrenalectomy was initially proposed for bilateral adrenal tumors in patients with hereditary disease to avoid chronic adrenal insufficiency. However, it has also gained popularity for the treatment of unilateral adrenal disease involving a small adrenal tumor because even patients with a unilateral adrenal gland may develop adrenal insufficiency in stressful situations. Therefore, partial adrenalectomy has become increasingly common to avoid lifelong steroid replacement and recurrence in most cases, especially in bilateral adrenal disease. This review article evaluates the current evidence on minimally invasive adrenalectomy and organ-preserving partial adrenalectomy.
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Affiliation(s)
- JungHak Kwak
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul,
Korea
| | - Kyu Eun Lee
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul,
Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul,
Korea
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Safety of outpatient adrenalectomy across 3 minimally invasive approaches at 2 academic medical centers. Surgery 2020; 169:145-149. [PMID: 32409169 DOI: 10.1016/j.surg.2020.03.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 03/17/2020] [Accepted: 03/24/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Outpatient adrenalectomy has the potential to decrease costs, improve inpatient capacity, and decrease patient exposure to hospital-acquired conditions. Still, the practice has yet to be widely adopted and current studies demonstrating the safety of outpatient adrenalectomy are limited by sample size, extensive exclusion criteria, and no comparison to inpatient cases. We aimed to study the characteristics and safety of outpatient adrenalectomy using the largest such sample to date across 2 academic medical centers and 3 minimally invasive approaches. METHODS All minimally invasive adrenalectomies were identified, starting from the time outpatient adrenalectomy was initiated at each institution. Cases involving removal of other organs, bilateral adrenalectomies, and cases in which a patient was admitted to the hospital before the day of surgery were excluded. Patient, tumor, and case characteristics were compared between outpatient and inpatient cases, and multivariable regression analysis was used to assess odds of 30-day readmission and/or complication. RESULTS Of 203 patients undergoing minimally invasive adrenalectomy, 49% (n = 99) were performed on an outpatient basis. Outpatient disposition was more likely in the setting of lower estimated blood loss, case completion before 3 pm, and for surgery performed in the setting of nodule/mass and primary hyperaldosteronism versus Cushing's syndrome, pheochromocytoma, and metastasis (P < .05). There were no significant differences in patient age, body mass index, American Society of Anesthesiologists class, procedure performed, or total time under anesthesia between inpatient and outpatient cases. On adjusted analysis, outpatient adrenalectomy was not associated with increased 30-day readmission rate (odds ratio 0.23 [confidence interval 0.04-1.26] P = .09) or 30-day complication rate (odds ratio 0.21 [confidence interval 0.06-0.81] P = .02). CONCLUSION Outpatient adrenalectomy can be performed safely without increased risk of 30-day complications or readmission in appropriately selected candidates.
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Zhao J, Ma W, Xie J, Dai J, Huang X, Fang C, He W, Sun F. Laparoscopic Treatment of Large Adrenal Tumor is Safe and Effective? A Single Center Experiences. J INVEST SURG 2020; 34:957-962. [PMID: 32036714 DOI: 10.1080/08941939.2020.1719243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND The comparisons between open surgery and minimally invasive surgery for treatment of large adrenal tumor (LAT) are still lacking. In this study, we attempted to explore the safety and effectiveness of laparoscopic treatment of LAT by comparing the outcomes between open adrenalectomy (OA) and laparoscopic adrenalectomy (LA). METHODS From 2003 to 2018, 78 LAT patients underwent tumor resection by OA or LA method at a single academic institution. Data were retrospectively collected and analyzed. RESULTS The median largest diameter of LAT was 10.0 (IQR 9.0-13.4) cm. The median operation time in OA group was 215 (IQR 180-240) min versus 180 (IQR 135-245) min in LA group (P = 0.042). The median blood loss in OA group was 1000 (IQR 625-1500) ml versus 200 (IQR 100-700) ml in LA group (P < 0.001). The median Clavien-Dindo score in OA group was 2 (IQR 2-4) versus 0 (IQR 0-4) in LA group (P = 0.035). On univariate and multivariate analysis, the largest diameter of tumor was significantly associated with operation time, blood loss, and recovery time (P < 0.05). CONCLUSIONS Laparoscopic treatment of LAT was found to be safe and feasible in experienced hands and can replace open surgeries in most cases.
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Affiliation(s)
- Juping Zhao
- Department of Urology, Shanghai JiaoTong University School of Medicine, Ruijin Hospital, Shanghai, China
| | - Wenming Ma
- Department of Urology, Shanghai JiaoTong University School of Medicine, Ruijin Hospital, Shanghai, China
| | - Jialing Xie
- Department of Pathology, Shanghai JiaoTong University School of Medicine, Ruijin Hospital, Shanghai, China
| | - Jun Dai
- Department of Urology, Shanghai JiaoTong University School of Medicine, Ruijin Hospital, Shanghai, China
| | - Xin Huang
- Department of Urology, Shanghai JiaoTong University School of Medicine, Ruijin Hospital, Shanghai, China
| | - Chen Fang
- Department of Urology, Shanghai JiaoTong University School of Medicine, Ruijin Hospital, Shanghai, China
| | - Wei He
- Department of Urology, Shanghai JiaoTong University School of Medicine, Ruijin Hospital, Shanghai, China
| | - Fukang Sun
- Department of Urology, Shanghai JiaoTong University School of Medicine, Ruijin Hospital, Shanghai, China
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Vidal O, Saavedra-Perez D, Martos JM, de la Quintana A, Rodriguez JI, Villar J, Ortega J, Moral A, Duran M, Valentini M, Fernandez-Cruz L. Risk factors for open conversion of lateral transperitoneal laparoscopic adrenalectomy: retrospective cohort study of the Spanish Adrenal Surgery Group (SASG). Surg Endosc 2019; 34:3690-3695. [DOI: 10.1007/s00464-019-07264-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 11/12/2019] [Indexed: 10/25/2022]
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12
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Feng Z, Feng MP, Feng DP, Solórzano CC. Robotic-assisted adrenalectomy using da Vinci Xi vs. Si: are there differences? J Robot Surg 2019; 14:349-355. [PMID: 31273609 DOI: 10.1007/s11701-019-00995-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 07/02/2019] [Indexed: 02/07/2023]
Abstract
Da Vinci Xi, the fourth generation platform, was released in 2014 and introduced as the successor to the Si platform for minimal invasive surgery. We reviewed our experience with robotic-assisted adrenalectomy and compared peri-operative outcomes using the da Vinci robot model Xi vs. Si. Since June of 2014, 85 consecutive patients underwent robotic-assisted adrenalectomy by a high-volume adrenal surgeon at our institution. Patients were divided into two groups: Xi group (n = 25) and Si group (n = 60). The average anesthesia time was 145.8 min for the Xi group and 170.4 min for the Si group (p = 0.001). The mean procedure time for the Xi group (skin to skin) was 92.1 min and for the Si group it was 122.5 min (p = 0.001). The average docking time for the Xi group was 18.2 min and for the Si group 20.3 min (p = 0.04). The average consumables fees for the Xi group were $1246 and for the Si group $1106 (p = 0.04). The calculated relative costs for the Xi group were $3375 and for the Si group $3527 (p = 0.03). The average post-operative hospital stay for the Xi group was 1.6 days and for the Si group 1.7 days (p = 0.18). Robotic-assisted adrenalectomy using the da Vinci Xi system is effective and efficient. This study shows that outcomes were similar between Xi and Si groups.
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Affiliation(s)
- Zuliang Feng
- Department of Perioperative Services, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Michael P Feng
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David P Feng
- Department of Urology Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carmen C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Alesina PF. Retroperitoneal adrenalectomy-learning curve, practical tips and tricks, what limits its wider uptake. Gland Surg 2019; 8:S36-S40. [PMID: 31404183 DOI: 10.21037/gs.2019.03.11] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The minimally invasive retroperitoneal approach to the adrenal surgery has been described in the early 90s following the first description of laparoscopic adrenalectomy. Although the advantages of the technique compared to laparoscopic surgery have been demonstrated in many studies, it remained for a long period confined to few centers. The operation has been standardized over the years into a safe and reproducible procedure that finally gained worldwide acceptance in the last 10 years. The present paper summarizes the surgical steps of the procedure focusing on the recent technical developments. Retroperitoneoscopic adrenalectomy should be part of the surgical armamentarium of any center dedicated to endocrine surgery.
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Affiliation(s)
- Pier Francesco Alesina
- Department of Surgery and Center of Minimally Invasive Surgery, Kliniken Essen-Mitte, Essen, Germany
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14
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Ashitate Y, Levitz A, Park MH, Hyun H, Venugopal V, Park G, El Fakhri G, Henary M, Gioux S, Frangioni JV, Choi HS. Endocrine-specific NIR fluorophores for adrenal gland targeting. Chem Commun (Camb) 2018; 52:10305-8. [PMID: 27476533 DOI: 10.1039/c6cc03845j] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The adrenal glands (AGs) are relatively small yet require definitive identification during their resection, or more commonly their avoidance. To enable image-guided surgery involving the AGs, we have developed novel near-infrared (NIR) fluorophores that target the AGs after a single intravenous injection, which provided dual-NIR image-guided resection or avoidance of the AGs during both open and minimally-invasive surgery.
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Affiliation(s)
- Yoshitomo Ashitate
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA and Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo 060-8638, Japan
| | - Andrew Levitz
- Department of Chemistry, Georgia State University, Atlanta, GA 30303, USA.
| | - Min Ho Park
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA and Department of Surgery, Chonnam National University Medical School, Gwangju 501-746, South Korea
| | - Hoon Hyun
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA and Department of Biomedical Sciences, Chonnam National University Medical School, Gwangju 501-746, South Korea
| | - Vivek Venugopal
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - GwangLi Park
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA and Gordon Center for Medical Imaging, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
| | - Georges El Fakhri
- Gordon Center for Medical Imaging, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
| | - Maged Henary
- Department of Chemistry, Georgia State University, Atlanta, GA 30303, USA.
| | - Sylvain Gioux
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA and ICube Laboratory, University of Strasbourg, Illkirch cedex 67412, France
| | - John V Frangioni
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA and Curadel, LLC, 377 Plantation Street, Worcester, MA 01605, USA
| | - Hak Soo Choi
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA and Gordon Center for Medical Imaging, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
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15
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Robotic retroperitoneoscopic adrenalectomy: useful modifications of the described posterior approach. J Robot Surg 2017; 11:409-414. [PMID: 28044246 DOI: 10.1007/s11701-016-0671-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 12/24/2016] [Indexed: 10/20/2022]
Abstract
Herein we describe a technique modification of the robotic posterior retroperitoneoscopic adrenalectomy (RPRA). Three patients presented to our clinic with adrenal lesions. The average BMI and tumor size was 29.3 kg/m2 and 4.6 cm, respectively. All had prior major abdominal procedures. Long robotic trocars were used. A 5-mm assistant port was added and the number of robotic instrument use was minimized. The average total operation time was 136 min, average docking time was 14.7 min and the average console time was 108.7 min. Blood loss was minimal and there were no complications. In patients with prior history of extensive abdominal procedures, RPRA is safe and effective when performed by surgeons with PRA and robotic experience. Long robotic trocars effectively minimized external robotic arm collisions. Adding a 5-mm assistant trocar maximized the first assistant and console surgeon abilities. Limiting the number of robotic instruments and energy devices contained cost.
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16
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Vrielink OM, Wevers KP, Kist JW, Borel Rinkes IHM, Hemmer PHJ, Vriens MR, de Vries J, Kruijff S. Laparoscopic anterior versus endoscopic posterior approach for adrenalectomy: a shift to a new golden standard? Langenbecks Arch Surg 2016; 402:767-773. [PMID: 27888343 PMCID: PMC5506107 DOI: 10.1007/s00423-016-1533-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 10/31/2016] [Indexed: 11/26/2022]
Abstract
Purpose There has been an increased utilization of the posterior retroperitoneal approach (PRA) for adrenalectomy alongside the “classic” laparoscopic transabdominal technique (LTA). The aim of this study was to compare both procedures based on outcome variables at various ranges of tumor size. Methods A retrospective analysis was performed on 204 laparoscopic transabdominal (UMC Groningen) and 57 retroperitoneal (UMC Utrecht) adrenalectomies between 1998 and 2013. We applied a univariate and multivariate regression analysis. Mann-Whitney and chi-squared tests were used to compare outcome variables between both approaches. Results Both mean operation time and median blood loss were significantly lower in the PRA group with 102.1 (SD 33.5) vs. 173.3 (SD 59.1) minutes (p < 0.001) and 0 (0–200) vs. 50 (0–1000) milliliters (p < 0.001), respectively. The shorter operation time in PRA was independent of tumor size. Complication rates were higher in the LTA (19.1%) compared to PRA (8.8%). There was no significant difference in recovery time between both approaches. Conclusions Application of the PRA decreases operation time, blood loss, and complication rates compared to LTA. This might encourage institutions that use the LTA to start using PRA in patients with adrenal tumors, independent of tumor size.
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Affiliation(s)
- O M Vrielink
- Department of Surgical Oncology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands
| | - K P Wevers
- Department of Surgical Oncology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands
| | - J W Kist
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - I H M Borel Rinkes
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - P H J Hemmer
- Department of Surgical Oncology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands
| | - M R Vriens
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J de Vries
- Department of Surgical Oncology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands
| | - S Kruijff
- Department of Surgical Oncology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands.
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17
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Iacobone M, Citton M, Viel G, Rossi GP, Nitti D. Approach to the surgical management of primary aldosteronism. Gland Surg 2015; 4:69-81. [PMID: 25713782 DOI: 10.3978/j.issn.2227-684x.2015.01.05] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 01/15/2015] [Indexed: 11/14/2022]
Abstract
Primary aldosteronism (PA) is the most common cause of endocrine hypertension; it has been reported in more than 11% of referred hypertensive patients. PA may be caused by unilateral adrenal involvement [aldosterone producing adenoma (APA) or unilateral adrenal hyperplasia (UAH)], and bilateral disease (idiopathic adrenal hyperplasia). Only patients with unilateral adrenal hypersecretion may be cured by unilateral adrenalectomy, while patients with bilateral and non-surgically correctable PA are usually treated by mineralocorticoid receptor antagonists; thus the distinction between unilateral and bilateral aldosterone hypersecretion is crucial. Most experts agree that the referral diagnostic test for lateralization of aldosterone hypersecretion should be adrenal venous sampling (AVS) because the interpretation of other imaging techniques [computed tomography (CT), magnetic resonance imaging (MRI) and scintigraphy] may lead to inappropriate treatment. Adrenalectomy represents the elective treatment in unilateral PA variants. Laparoscopic surgery, using transperitoneal or retroperitoneal approaches, is the preferred strategy. Otherwise, the indications to laparoscopic unilateral total or partial adrenalectomy in patients with unilateral PA remain controversial. Adrenalectomy is highly successful in curing the PA, with correction of hypokalemia in virtually all patients, cure of hypertension in about 30-60% of cases, and a marked improvement of blood pressure values in the remaining patients. Interestingly, in several papers the outcomes of surgery focus only on blood pressure changes and the normalization of serum potassium levels is often used as a surrogate of PA recovery. However, the goal of surgery is the normalization of aldosterone, because chronically elevated levels of this hormone can lead to cardiovascular complications, independently from blood pressure levels. Thus, we strongly advocate the need of considering the postoperative normalization of aldosterone-renin ratio (ARR) as the main endpoint for determining outcomes of PA.
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Affiliation(s)
- Maurizio Iacobone
- 1 Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, 2 Internal Medicine 4, Department of Medicine-DIMED, University of Padua, Padova, Italy
| | - Marilisa Citton
- 1 Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, 2 Internal Medicine 4, Department of Medicine-DIMED, University of Padua, Padova, Italy
| | - Giovanni Viel
- 1 Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, 2 Internal Medicine 4, Department of Medicine-DIMED, University of Padua, Padova, Italy
| | - Gian Paolo Rossi
- 1 Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, 2 Internal Medicine 4, Department of Medicine-DIMED, University of Padua, Padova, Italy
| | - Donato Nitti
- 1 Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, 2 Internal Medicine 4, Department of Medicine-DIMED, University of Padua, Padova, Italy
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18
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Vidal Ó, Astudillo E, Valentini M, Ginestà C, García-Valdecasas JC, Fernandez-Cruz L. Single-incision transperitoneal laparoscopic left adrenalectomy. World J Surg 2012; 36:1395-9. [PMID: 22392358 DOI: 10.1007/s00268-012-1555-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Laparoscopic adrenalectomy via three or four trocars is a well-established procedure. This report describes the initial experience with single-incision laparoscopic surgery (SILS) using the transperitoneal approach for left adrenalectomy. METHODS Between April 2010 and August 2011, all consecutive patients with adrenal masses, including Conn's syndrome, Cushing's adenoma, and nonfunctional adrenal tumors, who agreed to undergo SILS adrenalectomy were included in a prospective study. The left 2.5-cm subcostal incision was the sole point of entry. Data of patients who underwent SILS adrenalectomy were compared with those from an uncontrolled group of patients who underwent conventional laparoscopic adrenalectomy during the same study period. RESULTS There were 20 patients in each study group (20 men, 20 women; mean age [SD] = 50 [6.5] years). SILS was successfully performed and none of the patients required conversion to an open procedure. In one case of SILS procedure, an additional lateral 5-mm port was needed for retraction of the kidney. The mean (SD) duration of the operation was 95 (20) min in the SILS group and 80 (8) min in the conventional laparoscopic adrenalectomy group (p = 0.052). There were no intraoperative or postoperative complications. There were no differences between the two study groups with respect to postoperative pain, number of patients who resumed oral intake within the first 24 h, final pathologic diagnosis, and length of hospital stay. CONCLUSION SILS left adrenalectomy is a technically feasible and safe procedure in carefully selected patients. The definitive clinical, aesthetic and functional advantages of this technique require further analysis.
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Affiliation(s)
- Óscar Vidal
- General and Endocrine Surgery Unit, Department of General and Digestive Surgery, Digestive Diseases and Metabolism Institute, Hospital Clínic i Provincial, Universitat de Barcelona, CIRBERHED, IDIBAPS, Villarroel 170, 08036 Barcelona, Spain.
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Beiša V, Kildušis E, Strupas K. Single access retroperitoneoscopic adrenalectomy: initial experience. Wideochir Inne Tech Maloinwazyjne 2012; 7:45-9. [PMID: 23256000 PMCID: PMC3516963 DOI: 10.5114/wiitm.2011.25640] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Revised: 07/23/2011] [Accepted: 09/13/2011] [Indexed: 11/17/2022] Open
Abstract
Today, endoscopic adrenalectomy has become a gold standard in endocrine surgery. To minimize the morbidity and improve cosmesis, single access retroperitoneoscopic adrenalectomy (SARA) has been developed as an alternative to traditional multiport laparoscopy and single port access (SPA) surgery, potentially exploiting even more the already proven benefits of minimally invasive surgery. We applied the SARA technique to adrenalectomy using the posterior retroperitoneal approach. The aim is to highlight the current situation regarding the feasibility and safety of single access retroperitoneoscopic adrenalectomy and to present our initial experience. Between October 2010 and February 2011, a 74-year-old woman (body mass index (BMI) - 31 kg/m(2)) with pheochromocytoma (1.2 cm in size) and 3 women, aged 45, 46 and 66 years (BMI - 27, 32, 33 kg/m(2)), respectively, and all diagnosed with Conn's adenoma (from 1.2 cm to 2.0 cm in size), underwent single access retroperitoneoscopic adrenalectomies. Operations were performed using conventional laparoscopic (STORZ) equipment. No conversions to the open or conventional retroperitoneal approach were necessary. There were no perioperative or postoperative complications. Operating time ranged from 60 min to 80 min. All patients left the hospital 2 days after surgery. The single access retroperitoneoscopic technique has been successfully applied to adrenalectomy as an available alternative to multiport laparoendoscopic adrenalectomy and single port access surgery. Exposure, visualization and dissection are the same as in retroperitoneal endoscopic adrenalectomy. The SARA surgery offers patient benefits such as faster convalescence, decreased postoperative scarring, better cosmetic effect and financial benefit.
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Affiliation(s)
- Virgilijus Beiša
- Vilnius University Hospital Santariskiu Clinics, Center of Abdominal Surgery, Lithuania
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Al-Zahrani HM. Laparoscopic adrenalectomy: An update. Arab J Urol 2012; 10:56-65. [PMID: 26558005 PMCID: PMC4442880 DOI: 10.1016/j.aju.2011.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2011] [Revised: 11/21/2011] [Accepted: 11/25/2011] [Indexed: 12/26/2022] Open
Abstract
Objective To review the current role and outcome of laparoscopic adrenalectomy (LA) in the management of adrenal tumours. Methods A Medline search using the keywords (adrenalectomy, laparoscopy, adrenal masses/tumours) was done for reports published between 1990 and 2011. Key articles were used to find more relevant references on the evaluation and laparoscopic management of adrenal masses. Results The hormonal evaluation is not standardised, but initial screening tests are recommended and followed with confirmatory ones when positive, equivocal or the clinical presentation suggest adrenal hyperfunction. The imaging studies had, and continued to, advance, especially computed tomography (CT), magnetic resonance imaging and positron-emission tomography/CT. These advances have increased the accuracy of the diagnosis of adrenal masses, with a reported high sensitivity and specificity of 95–100%. The introduction of laparoscopy has resulted in more adrenal lesions being removed, especially incidental lesions smaller than the 5–6 cm that was previously the indication for surgical excision. The technique has developed and larger lesions of >6 cm are now considered for LA in the proper setting. The transperitoneal and retroperitoneal approaches are currently widely practised, with minor differences in the outcome. The reported outcome, although mostly retrospective, is excellent and with fewer complications. The role of LA for adrenal malignancy should be considered cautiously. Preoperative imaging signs of invasion into surrounding structures should be considered a contraindication for LA. Conclusion LA is the standard procedure for most adrenal lesions of appropriate size and no signs of surrounding tissue invasion, giving an excellent outcome.
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21
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Dalvi AN, Thapar PM, Vijay Kumar K, Kamble RS, Rege SA, Deshpande AA, Shah NS, Menon PS. Laparoscopic adrenalectomy: Gaining experience by graded approach. J Minim Access Surg 2011; 2:59-66. [PMID: 21170236 PMCID: PMC2997274 DOI: 10.4103/0972-9941.26649] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2006] [Accepted: 06/10/2006] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Laparoscopic adrenalectomy (LA) has become a gold standard in management of most of the adrenal disorders. Though report on the first laparoscopic adrenalectomy dates back to 1992, there is no series of LA reported from India. Starting Feb 2001, a graded approach to LA was undertaken in our center. Till March 2006, a total of 34 laparoscopic adrenalectomies were performed with success. MATERIALS AND METHODS The endocrinology department primarily evaluated all patients. Patients were divided into Group A - unilateral LA and Group B - bilateral LA (BLA). The indications in Group A were pheochromocytoma (n=7), Conn's syndrome (n=3), Cushing's adenoma (n=2), incidentaloma (n=2); and in Group B, Cushing's disease (CD) following failed trans-sphenoid pituitary surgery (n = 8); ectopic ACTH- producing Cushing's syndrome (n=1) and congenital adrenal hyperplasia (CAH) (n=1). The lateral transabdominal route was used. RESULTS The age group varied from 12-54 years, with mean age of 28.21 years. Average duration of surgery in Group A was 166.43 min (40-270 min) and 190 min (150-310 min) in Group B. Average blood loss was 136.93 cc (20-400 cc) in Group A and 92.5 cc (40-260 cc) in Group B. There was one conversion in each group. Mean duration of surgical stay was 1.8 days (1-3 days) in Group A and 2.6 days (2-4 days) in Group B. All the patients in both groups were cured of their illness. Three patients in Group B developed Nelson's syndrome. The mean follow up was of 24.16 months (4-61 months). CONCLUSION LA though technically demanding, is feasible and safe. Graded approach to LA is the key to success.
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Affiliation(s)
- Abhay N Dalvi
- Department of General Surgery, Seth G S Medical College & KEM Hospital, Mumbai - 400 012, India
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22
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Walz MK, Groeben H, Alesina PF. Single-access retroperitoneoscopic adrenalectomy (SARA) versus conventional retroperitoneoscopic adrenalectomy (CORA): a case-control study. World J Surg 2010; 34:1386-90. [PMID: 20213204 DOI: 10.1007/s00268-010-0494-4] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Stimulated by the concept of Natural Orifice Transluminal Endoscopic Surgery (NOTES), minimizing the access even further has become a new trend in minimally invasive surgery. We compare our recently described new method of endoscopic single-access adrenalectomy with the conventional retroperitoneoscopic approach in a matched-pairs study. METHODS Fifty single-access retroperitoneoscopic adrenalectomies (SARA) were performed in 47 selected patients suffering from Conn's adenomas (n = 20), pheochromocytomas (n = 15), Cushing's adenomas (n = 6), and other diseases (n = 6). For SARA, a single 2-cm skin incision beneath the 12th rib was used. Following creation of the retroperitoneal space with the rigid endoscope, dissection was carried out single-handed. Another 47 patients served as control group; they were treated by the traditional retroperitoneoscopic three-port approach (CORA). Patients were matched with respect to gender, body mass index, diagnoses, tumor size, and tumor site. RESULTS Mortality was zero and no major complications occurred in both groups. SARA was completed in 41 cases (86%). The overall complication rate was 8.5% in SARA and 6.4% in CORA. Operative time was longer for SARA (56 +/- 28 min) than for CORA (40 +/- 12 min) (P < 0.05). Postoperatively, pain medication was administered in 47% of SARA patients and in 75% of CORA patients (P = 0.01). Mean hospital stay was 2.4 +/- 0.7 days (SARA) and 3.1 +/- 1.2 days (CORA) (P < 0.01). CONCLUSIONS Because feasibility and safety of SARA could be demonstrated in a large group of selected patients, this surgical technique may represent a new milestone in minimally invasive endocrine surgery.
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Affiliation(s)
- Martin K Walz
- Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Akademisches Lehrkrankenhaus der Universität Duisburg-Essen, Henricistrasse 92, 45136, Essen, Germany.
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Ludwig AT, Wagner KR, Lowry PS, Papaconstantinou HT, Lairmore TC. Robot-Assisted Posterior Retroperitoneoscopic Adrenalectomy. J Endourol 2010; 24:1307-14. [DOI: 10.1089/end.2010.0152] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Aaron T. Ludwig
- Division of Urology, Department of Surgery, Scott and White Memorial Clinic and Hospital, Texas A&M University System Health Science Center College of Medicine, Temple, Texas
| | - Kristofer R. Wagner
- Division of Urology, Department of Surgery, Scott and White Memorial Clinic and Hospital, Texas A&M University System Health Science Center College of Medicine, Temple, Texas
| | - Patrick S. Lowry
- Division of Urology, Department of Surgery, Scott and White Memorial Clinic and Hospital, Texas A&M University System Health Science Center College of Medicine, Temple, Texas
| | - Harry T. Papaconstantinou
- Division of Surgical Oncology, Department of Surgery, Scott and White Memorial Clinic and Hospital, Texas A&M University System Health Science Center College of Medicine, Temple, Texas
| | - Terry C. Lairmore
- Division of Surgical Oncology, Department of Surgery, Scott and White Memorial Clinic and Hospital, Texas A&M University System Health Science Center College of Medicine, Temple, Texas
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Allemann P, Perretta S, Asakuma M, Dallemagne B, Marescaux J. NOTES new frontier: Natural orifice approach to retroperitoneal disease. World J Gastrointest Surg 2010; 2:157-64. [PMID: 21160866 PMCID: PMC2999234 DOI: 10.4240/wjgs.v2.i5.157] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2009] [Revised: 02/06/2010] [Accepted: 02/13/2010] [Indexed: 02/06/2023] Open
Abstract
AIM: To develop a pure transvaginal access to the retroperitoneum, that is simple, reproducible and uses endoscopic material available on the market.
METHODS: From February 2008 to April 2009, 31 pigs were operated on, with 17 as an acute experiment and 14 with a survival protocol. The animals were placed in a supine position and a 12-mm double-channel endoscope (Karl Storz™, Tuttlingen) was used for vision and dissection. During the same time period, the access experiment was reproduced on 3 human cadavers using material similar to that used in the animal model.
RESULTS: In the animal model, 37 interventions were done on the kidney, adrenal gland and pancreas. The mean time to fashion the access was 10 min (range 5 to 20 min). No intraoperative death was observed. Two major (5%) intraoperative complications occurred: one hemorrhage on the aorta and one tearing of the right renal vein. Peritoneal laceration was encountered in 5 cases without impairing the planned task. In the survival group, good clinical outcome was observed at a mean follow-up of 3 wk (range 2 to 6 wk). In the 3 cadavers, access was performed correctly. The mean time to fashion the access was 52 min (range 40 to 60 min). All the anatomical landmarks described in the pig model were clearly identified in the same sequence.
CONCLUSION: A retroperitoneal natural orifice translumenal surgical transvaginal approach is feasible in both animal and human models and allows performance of a large panel of interventions.
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Affiliation(s)
- Pierre Allemann
- Pierre Allemann, Silvana Perretta, Mitsuhiro Asakuma, Bernard Dallemagne, Jacques Marescaux, IRCAD/EITS Institute, Strasbourg University Hospital, 1, place de l'hôpital, 67000 Strasbourg, France
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Matsuda T, Terachi T, Yoshida O. Laparoscopic adrenalectomy: The surgical technique and initial results of 13 cases. ACTA ACUST UNITED AC 2009. [DOI: 10.3109/13645709309152951] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Giacchetti G, Ronconi V, Rilli S, Guerrieri M, Turchi F, Boscaro M. Small tumor size as favorable prognostic factor after adrenalectomy in Conn's adenoma. Eur J Endocrinol 2009; 160:639-46. [PMID: 19131503 DOI: 10.1530/eje-08-0902] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Primary aldosteronism (PA) due to aldosterone-producing adenoma (APA) is the most common curable form of secondary hypertension. DESIGN In order to evaluate blood pressure outcome after adrenalectomy for APA and to identify new favorable prognostic factors, data from 42 consecutive APA patients who underwent adrenalectomy were collected from 2005 to 2007. METHODS Renin-angiotensin-aldosterone system (upright and postsaline infusion test), serum and urinary electrolytes, office and ambulatory blood pressure monitoring were evaluated at baseline and after a follow-up of 2.7+/-2.2 years. Drug history and adenoma size at morphological evaluation were also collected. RESULTS Multiple regression analysis showed that, before surgery, patients with a small adenoma (diameter <20 mm) displayed higher postsaline aldosterone values (P=0.0001), and lower serum potassium levels (P=0.020), than patients with adenoma >20 mm. Before surgery, mineralocorticoid receptor (MR) antagonists were used in patients with small APA in greater percentage than patients with bigger adenomas (64 vs 30% respectively, P=0.037). At follow-up, blood pressure normalized in 63% of the subjects. Recovered patients had a shorter duration of hypertension (P=0.038), and a smaller adenoma size (P=0.035). Receiver operating characteristic curves showed that a duration of hypertension <or=6 years and an APA size <20 mm were the best predictors of blood pressure normalization. Patients with APA <20 mm showed the complete restoration of blood pressure circadian rhythm. CONCLUSIONS The presence of APA <20 mm, duration of hypertension equal or less than 6 years, and preoperative MR antagonists use are favorable prognostic factors for hypertension recovery after adrenalectomy.
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Affiliation(s)
- Gilberta Giacchetti
- Division of Endocrinology, Azienda Ospedaliero-Universitaria, Ospedali Riuniti Umberto I-GM Lancisi-G Salesi, Università Politecnica delle Marche, Ancona, Italy.
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Walz MK, Alesina PF. Single access retroperitoneoscopic adrenalectomy (SARA)--one step beyond in endocrine surgery. Langenbecks Arch Surg 2008; 394:447-50. [PMID: 18784938 DOI: 10.1007/s00423-008-0418-z] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2008] [Accepted: 08/26/2008] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Today, endoscopic adrenalectomy has become a gold standard in endocrine surgery. METHOD AND RESULTS To minimize the morbidity and improve cosmesis, a single access retroperitoneoscopic adrenalectomy (SARA) has been developed. Patients were placed in prone position. Through a single 1.5 cm skin incision at the tip of the 12th rib the creation of the retroperitoneal space and the dissection of the adrenal gland were performed. SARA was used in five patients with adrenal tumors (size: 1-4 cm; four right, one left). Operating time ranged from 35 to 70 min, mean blood loss was <10 ml. No perioperative or postoperative complications were noticed. Mean hospital stay was 2 days. CONCLUSIONS SARA is feasible and represents a new horizon in endocrine surgery.
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Affiliation(s)
- Martin K Walz
- Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Akademisches Lehrkrankenhaus der Universität Duisburg-Essen, Henricistrasse 92, 45136, Essen, Germany.
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Eto M, Harano M, Koga H, Tanaka M, Naito S. Clinical outcomes and learning curve of a laparoscopic adrenalectomy in 103 consecutive cases at a single institute. Int J Urol 2006; 13:671-6. [PMID: 16834640 DOI: 10.1111/j.1442-2042.2006.01383.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We examined the clinical outcomes and the learning curve for a laparoscopic adrenalectomy (LA) in 103 consecutive cases performed by three surgeons at our institute, according to the type of adrenal disorder. PATIENTS AND METHODS One hundred and three patients with adrenal tumors, including 38 cases of primary aldosteronism, 33 cases of Cushing syndrome (including preclinical Cushing syndrome), 15 cases of pheochromocytoma, and nine cases of non-functioning adenoma were evaluated, while focusing on the approaches, intraoperative and postoperative data, and the learning curve of LA, according the type of adrenal disorder. RESULTS There was no significant difference in the operation time, estimated blood loss, incidence of conversion to open surgery and blood transfusion, or postoperative recovery among the patients treated by LA for aldosteronoma, Cushing adenoma, pheochromocytoma, and non-functioning adenoma. In the cases of aldosteronoma and Cushing adenoma, the learning curve for the operation time and blood loss in each operator tended to decrease as the number of operations increased. On the other hand, in the cases treated by LA for pheochromocytoma, no trends in either the operation time or blood loss were observed. However, there has been neither any conversion to open surgery nor blood transfusion in cases treated by LA since 1998 (our 42nd case), even after the changes in the operators. CONCLUSIONS Our results clearly indicate that LA is becoming safer than before, probably due to improvements in the technique, education, and training of surgeons, in addition to the increased number of cases now treated by LA.
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Affiliation(s)
- Masatoshi Eto
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Rocha MF, Tauzin-Fin P, Vasconcelos PL, Ballanger P. Assessment of serum catecholamine concentrations in patients with pheochromocytoma undergoing videolaparoscopic adrenalectomy. Int Braz J Urol 2005; 31:299-307; discussion 307-8. [PMID: 16137397 DOI: 10.1590/s1677-55382005000400002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2005] [Accepted: 06/10/2005] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION We analyzed the changes in serum catecholamine concentrations, i.e. adrenaline and noradrenaline, in response to surgical stress in patients with pheochromocytoma who undergone videolaparoscopic adrenalectomy. MATERIALS AND METHODS Between January 1998 and March 2002, 11 patients underwent 12 videolaparoscopic adrenalectomies. In one case, the adrenalectomy was bilateral. Serum catecholamines were measured at 6 surgical times: T0: control before induction; T1: following the induction, laryngoscopy and intubation sequence; T2: after installing the pneumoperitoneum; T3: during manipulation-exeresis of the pheochromocytoma; T4: following ablation of the pheochromocytoma; T5: in the recovery room following intervention when the patient was extubated and was hemodynamically stable. RESULTS Mean concentrations of serum noradrenaline were significantly different when the T0 and T2 surgical times were compared (T0: 3161 pg/mL; T2: 40440 pg/mL; p < 0.01), T0 and T3 (T0: 3161 pg/mL; T3: 46021 pg/mL; p < 0.001), T1 and T3 (T1: 5531 pg/mL; T3: 46021 pg/mL; p < 0.01), T2 and T4 (T2: 40440 pg/mL; T4: 10773 pg/mL; p < 0.01) and T3 and T5 (T3: 46021 pg/mL; T5: 2549 pg/mL; p < 0.001). Mean concentrations of serum adrenaline were significantly different when the T0 and T3 surgical times were compared (T0: 738 pg/mL; T3: 27561 pg/mL; p < 0.01). CONCLUSION The pneumoperitoneum significantly increases serum noradrenaline concentrations, manipulation of the adrenal gland significantly increases the serum concentrations of noradrenaline and adrenaline, and the pheochromocytoma ablation significantly decreases serum noradrenaline concentrations.
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Affiliation(s)
- Marcos F Rocha
- Department of Urology, Hospital Pellegrin-Tondu, Pellegrin University Hospital Center, Bordeaux, France.
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Neumann HPH, Cybulla M, Shibata H, Oya M, Naruse M, Higashihara E, Terachi T, Ling H, Takami H, Shuin T, Murai M. New genetic causes of pheochromocytoma: current concepts and the clinical relevance. Keio J Med 2005; 54:15-21. [PMID: 15832076 DOI: 10.2302/kjm.54.15] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Pheochromocytoma and paraganglioma are tumors of the autonomous nervous system mainly occurring in the adrenal medulla, but also in the extraadrenal paraganglias of the abdomen, thorax, neck and skull basis. The etiology comprises germline mutations of now 6 genes. About 10 years known are the RET gene susceptible for multiple endocrine neoplasia type 2, the VHL gene for von Hippel-Lindau Disease, and the NF 1 gene for neurofibromatosis Recklinghausen (neuro- fibromatosis type 1). Since 2000 the genes for succinatedehydrogenase subunits SDHB, SDHC, and SDHD have been identified for paraganglioma syndromes type 4, type 3, and type 1 respectively. Investigations of series of pheochromocytoma patients identified germline mutations in one of the genes SDHB, SDHD, VHL and RET in 24% to 50% of the patients. Multifocal tumors, young age and positive family history, known features associated with inheritence, have not been present in all patients. Therefore, analyses of blood DNA for mutations in these genes are recommended. Positive tests provide the patients and their relatives with essential platforms for clinical care. Experiences in this field of medicine have shown that optimal management of patients with pheochromocytoma-associated syndromes is a high challenge. National registries may be instrumental in order to provide with adequate facilities.
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Perretta S, Campagnacci R, Guerrieri M, Paganini AM, De Sanctis A, Sarnari J, Rimini M, Lezoche E. Sub-mesocolic access in laparoscopic left adrenalectomy. Surg Endosc 2005; 19:977-80. [PMID: 15920687 DOI: 10.1007/s00464-004-2233-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2004] [Accepted: 01/17/2005] [Indexed: 01/28/2023]
Abstract
BACKGROUND This article reports an alternative laparoscopic access to left adrenal gland. METHODS From January 1994 to August 2004, 209 laparoscopic adrenalectomies were performed in our Department. Indications were Conn adenoma (55 cases), incidentaloma (64), Cushing adenoma (45), pheochromocytoma (32), adreno-genital syndrome (two), mielolipoma (two), and metastatic mass(nine). Of 209, in 12 cases the left adrenalectomy was performed through a submesocolic access (seven pheochromocytoma, two incidentaloma, two Cushing adenoma, one Conn adenoma,). The identification and closure of the adrenal vein with minimal gland manipulation resulted the main benefit of this approach. Moreover, the adrenalectomy was performed with minimal anatomical dissection. RESULTS No mortality or major complications occurred. During the operation, the blood pressure and cardiac rhythm were significantly more stable, in the group of patients who underwent a left adrenalectomy by the submesocolic approach compared to the anterior or flank lateral transperitoneal group. CONCLUSIONS Left adrenal lesions, as selected cases of pheochromocytoma, can be safely treated by laparoscopic submesocolic access.
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Affiliation(s)
- S Perretta
- Clinica di Chirurgia Generale e Metodologia Chirurgica-Ospedali Riuniti, 60121, Ancona, Italy
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Abstract
INTRODUCTION The laparoscopic approach to the adrenal gland was first reported in 1992. Since then, many publications about this issue have come from Europe, Japan and North America. We reviewed our 10-year experience with laparoscopic adrenal surgery. PATIENTS AND METHODS Laparoscopic adrenalectomy was carried out in 113 patients, 77 females and 36 males, between January 1994 and January 2004. The age ranged from 1 to 76 years (43.1 +/- 16.2 years). Ten (8.8%) patients were 20 years old or younger, 19 (16.8%) patients had unilateral tumor larger than 4 cm, 25 (22.1%) patients had Body Mass Index > or = 30 kg/m2, and 13 (11.5%) had had previous open upper abdominal surgery. The size of the lesion ranged from 1 to 9 cm (3.3 +/- 1.6 cm). One hundred and sixteen operations were performed, of which 109 were unilateral and 7 were bilateral, adding up to a total of 123 adrenalectomies. Among the 116 procedures, the lateral transperitoneal approach was employed in 113 cases, whereas lateral retroperitoneal approach enabled 3 adrenalectomies. RESULTS Unilateral procedures lasted 107 +/- 33.7 min (45-250 min); bilateral procedures lasted 180 +/- 90.6 min (100-345 min); 5 (4.3%) cases were converted to open surgery. Twenty (17.7%) patients suffered complications, being 8 (7.0%) intraoperative and 12 (10.6%) postoperative complications. Six (5.3%) cases were considered major complications. No deaths occurred due to the surgical procedures. Blood transfusion rate was 3.5%. Hospital stay was 5.7 +/- 15.0 days (1-140 days). Follow-up period was 23 +/- 12.8 months (1-60 months) and all these patients were followed for a minimum of 6 months. CONCLUSIONS Laparoscopic adrenalectomy is feasible and has excellent results in selected patients.
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Flávio Rocha M, Faramarzi-Roques R, Tauzin-Fin P, Vallee V, Leitao de Vasconcelos PR, Ballanger P. Laparoscopic surgery for pheochromocytoma. Eur Urol 2004; 45:226-32. [PMID: 14734011 DOI: 10.1016/j.eururo.2003.09.016] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate the feasibility of laparoscopic adrenalectomy for pheochromocytoma. MATERIAL Between January 1998 and March 2002, 12 patients aged from 19 to 76 (average age 54 years) underwent 13 adrenalectomies (7 right and 6 left, 1 bilateral) using laparoscopic surgery. A specific anti-hypertensive preparation was begun prior to the operation. Peaks of blood pressure were treated by bolus Nicardipine and sinus tachycardia by bolus Esmolol. Catecholamines were dosed at different times during the intervention. As far as surgery was concerned, the adrenalectomies were performed 11 times using the transperitoneal route and twice using the retroperitoneal route. The adrenal vein was found and ligatured before manipulation of the adrenal gland. RESULTS Average length of operation was 127 minutes (75 to 195). Average blood loss was 105 ml (0 to 1000). Catecholamines dosed throughout showed a variable increase in plasma rates during peritoneal insufflation and manipulation of the gland. They were responsible for 5 cases of hypertensive bouts and 2 cases of tachycardia which were treated with medication. No surgical conversions were necessary. Average length of hospital stay was 4.18 days (3 to 6); average size of adrenal tumours was 44 mm (30 to 72); average follow-up, 18.4 months. CONCLUSION This study showed the feasibility of adrenalectomy for pheochromocytoma using laparoscopic surgery, subject to specific medical preparation to reduce the consequences of peroperative bouts of hypertension and sinus tachycardia during peritoneal insufflation and manipulation of the adrenal gland despite initial ligature of the main adrenal vein.
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Affiliation(s)
- Marcos Flávio Rocha
- Department of Urology, Hôpital Pellegrin-Tondu, Centre Hospitalier Universitaire Pellegrin, 5 place Amélie Raba-Léon, 33076 Cedex, Bordeaux, France
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Abstract
BACKGROUND AND PURPOSE The laparoscopic approach to the adrenal gland was first reported in 1992. Since then, many publications about this issue have come from Europe, Japan, and North America. We reviewed our 7-year experience with laparoscopic adrenal surgery. This is the first large series presented from Latin America. PATIENTS AND METHODS Laparoscopic adrenalectomy was carried out in 61 female and 33 male patients between January 1994 and February 2001. Their ages ranged from 1 to 72 (42.8 +/- 16.4 years) years. Ten patients (10.6%) were 20 years or younger, 10 (10.6%) had unilateral tumors >4 cm, 22 (23.4%) had a Body Mass Index >/= 30, and 10 (10.6%) had had previous open upper abdominal surgery. The size of the lesion ranged from 1 to 9 cm (2.9 +/- 4 cm). Ninety-seven operations were performed, of which 91 were unilateral and 6 were bilateral, adding up to 103 adrenalectomies. Among the 97 procedures, the lateral transperitoneal approach was employed in 94 cases, whereas a lateral retroperitoneal approach enabled 3 adrenalectomies. RESULTS Unilateral procedures lasted 117 +/- 43.7 minutes (range 45-250 minutes); bilateral procedures lasted 186 +/- 91.6 minutes (range 100-345 minutes). Five operations (5.1%) were converted to open surgery. Twenty patients (21.3%) suffered complications, 8 (8.5%) being intraoperative and 12 (12.8%) postoperative. Six cases (6.4%) were considered major complications. No deaths occurred. The blood transfusion rate was 4.2%. The hospital stay averaged 6.1 +/- 15.3 days (range 1-140 days). The follow-up period was 17 +/- 12.6 months (range 1-60 months). CONCLUSIONS Laparoscopic adrenalectomy is feasible and has excellent results in properly selected patients.
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Affiliation(s)
- Lísias N Castilho
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
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Sung GT, Hsu TH, Gill IS. Retroperitoneoscopic adrenalectomy: lateral approach. J Endourol 2001; 15:505-11; discussion 511-2. [PMID: 11465330 DOI: 10.1089/089277901750299302] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Laparoscopy has become the essential surgical approach to the adrenal gland at many institutions, including ours. At the Cleveland Clinic, laparoscopic adrenalectomy for benign and malignant adrenal neoplasms can be performed by either the transperitoneal or the retroperitoneal approach. Herein, we present our technique of lateral retroperitoneal laparoscopic adrenalectomy.
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Affiliation(s)
- G T Sung
- Section of Laparoscopic and Minimally Invasive Surgery, Cleveland Clinic Foundation, Ohio 44195, USA
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Bonjer HJ, Sorm V, Berends FJ, Kazemier G, Steyerberg EW, de Herder WW, Bruining HA. Endoscopic retroperitoneal adrenalectomy: lessons learned from 111 consecutive cases. Ann Surg 2000; 232:796-803. [PMID: 11088074 PMCID: PMC1421272 DOI: 10.1097/00000658-200012000-00008] [Citation(s) in RCA: 115] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of endoscopic retroperitoneal adrenalectomy (ERA). SUMMARY BACKGROUND DATA Minimally invasive adrenalectomy has become the procedure of choice for benign adrenal pathology. Although the adrenal glands are located in the retroperitoneum, most surgeons prefer the transperitoneal laparoscopic approach to adrenal tumors. METHODS Clinical characteristics and outcomes of 111 ERAs from January 1994 to December 1999 were evaluated. RESULTS Ninety-five patients underwent 111 ERAs (79 unilateral, 16 bilateral). Indications were Cushing syndrome (n = 22), Cushing disease (n = 8), ectopic adrenocorticotropic hormone syndrome (n = 6), Conn's adenoma (n = 25), pheochromocytoma (n = 19), incidentaloma (n = 11), and other (n = 4). Tumor size varied from 0.1 to 8 cm. Median age was 50 years. Unilateral ERA required 114 minutes, with median blood loss of 65 mL. Bilateral ERA lasted 214 minutes, with median blood loss of 121 mL. The conversion rate to open surgery was 4.5%. The complication rate was 11%. Median postoperative hospital stay was 2 days for unilateral ERA and 5 days for bilateral ERA. The death rate was 0.9%. At a median follow-up of 14 months, the recurrence rate of disease was 0.9%. CONCLUSION For benign adrenal tumors less than 6 cm, ERA is recommended.
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Affiliation(s)
- H J Bonjer
- Departments of Surgery and Internal Medicine, University Hospital Dijkzigt, The Netherlands.
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Tanaka M, Tokuda N, Koga H, Kimoto Y, Naito S. Laparoscopic adrenalectomy for pheochromocytoma: comparison with open adrenalectomy and comparison of laparoscopic surgery for pheochromocytoma versus other adrenal tumors. J Endourol 2000; 14:427-31. [PMID: 10958565 DOI: 10.1089/end.2000.14.427] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To compare the efficacy of laparoscopic adrenalectomy for pheochromocytoma with that of conventional open adrenalectomy for pheochromocytoma and laparoscopic surgery for other adrenal tumors. PATIENTS AND METHODS Fifty-four patients with adrenal tumors, including 10 cases of pheochromocytoma, 18 cases of Cushing's syndrome, 20 cases of primary aldosteronism, and 6 cases of nonfunctioning tumors, were evaluated. A historical group of 7 consecutive patients who underwent conventional open adrenalectomy for pheochromocytoma was also studied. RESULTS Laparoscopic adrenalectomy for pheochromocytoma was successful in 9 of the 10 patients. There was no difference in tumor size, operation time, estimated blood loss, or occurrence of hypertensive episodes during surgery between patients treated with laparoscopic procedures and those treated with open surgery. However, the number of days to first postoperative oral feeding and first ambulation, length of hospitalization, and number of patients requiring parenteral analgesics were significantly smaller after laparoscopic surgery than after open surgery. There was no significant difference in operation time, estimated blood loss, incidence of intraoperative complications, or postoperative recovery between patients who underwent laparoscopic adrenalectomy for pheochromocytoma and those who underwent laparoscopic surgery for other adrenal lesions. CONCLUSIONS Laparoscopic adrenalectomy does not increase the specific risks associated with surgery for pheochromocytoma. It is a minimally invasive alternative to conventional open adrenalectomy.
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Affiliation(s)
- M Tanaka
- Department of Urology, Faculty of Medicine, Kyushu University, Fukuoka, Japan.
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Castilho LN, Medeiros PJ, Mitre AI, Dénes FT, Lucon AM, Arap S. Pheochromocytoma treated by laparoscopic surgery. REVISTA DO HOSPITAL DAS CLINICAS 2000; 55:93-100. [PMID: 10983012 DOI: 10.1590/s0041-87812000000300005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the results of the laparoscopic technique in the treatment of adrenal pheochromocytoma. METHOD Ten patients, 7 men and 3 women, between 10 and 67 years of age (mean 48) with pheochromocytoma underwent transperitoneal laparoscopic adrenalectomy and were evaluated retrospectively, based on clinical, laboratory, and pathological diagnosis. In all cases there was a solid unilateral adrenal tumor, 5 on the left side and 5 on the right side, whose greater diameter varied from 7 to 80 mm (mean 32). Nine of the 10 patients were chronically hypertensive or had already had hypertensive crises. One patient was normotensive, but presented metabolic alterations suggestive of adrenergic hyperfunction. RESULTS No deaths occurred in this series. There were two (20%) conversions to open surgery, one due to venous bleeding and one due to the difficulty of dissection behind the vena cava in a patient presenting a partially retro-caval tumor. Surgical time in the 8 non-converted cases ranged from 70 to 215 minutes (mean 136). One patient (10%) received blood transfusion, and another (10%) presented two complications - acute renal failure and a subcutaneous infection. Both had been converted to open surgery. None of the non-converted cases was transfused or presented complications. Hospital discharge occurred between the 2nd and 11th post-operative day (mean 3). The pathological exam of the surgical specimens confirmed the diagnoses of pheochromocytoma in all 10 cases, one of them associated with an aldosterone-producing cortical tumor. CONCLUSIONS Laparoscopic adrenalectomy for selected patients presenting pheochromocytoma is feasible and provides good results.
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Affiliation(s)
- L N Castilho
- Division of Urology, Hospital das Clínicas, Faculty of Medicine, University of São Paulo
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Terachi T, Matsuda T, Terai A, Ogawa O, Kakehi Y, Kawakita M, Shichiri Y, Mikami O, Takeuchi H, Okada Y, Yoshida O. Transperitoneal laparoscopic adrenalectomy: experience in 100 patients. J Endourol 1997; 11:361-5. [PMID: 9355955 DOI: 10.1089/end.1997.11.361] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Between July 1992 and October 1996, 100 transperitoneal laparoscopic adrenalectomies were performed on 99 patients at our hospital and affiliated hospitals. The clinical diagnoses were primary aldosteronism (41 patients), Cushing's syndrome (15), pre-Cushing's syndrome (6), pheochromocytoma (7; 8 adrenal glands), adrenal cancer (2), nonfunctioning adenoma (22), myelolipoma (3), and complicated adrenal cyst (3). Ninety-seven glands were removed laparoscopically. The mean operative time was 240 +/- 76 (SD) minutes and the mean blood loss 68 +/- 80 mL for the series. The mean blood was 77 +/- 113 mL when the three operations that were converted to open surgery are included. The mean times for the return to a normal diet and unassisted ambulation were 1.3 +/- 0.6 and 1.4 +/- 0.8 days, respectively. The mean duration of the use of analgesics was 1.5 +/- 1.3 days, including the day of surgery. In contrast, in the latest 10 open adrenalectomies done at Kyoto University Hospital, the mean operative time was 186 +/- 53 minutes and the mean blood loss 220 +/- 170 mL. The mean times for return to a normal diet and for unassisted ambulation and the mean duration of the use of analgesics were 1.9 +/- 0.3, 2.9 +/- 1.1, and 2.9 +/- 1.7 days, respectively. Thirty-six operations, excluding one converted to open surgery, performed at Kyoto University Hospital were selected to look at the learning curve for transperitoneal laparoscopic adrenalectomy and evaluated for operative time and blood loss. The mean operative time and mean blood loss in the first 10 procedures performed at Kyoto University Hospital were 256 +/- 63 minutes and 89 +/- 57 mL; however, these values were reduced to 177 +/- 39 minutes and 48 +/- 32 mL in the next 10 procedures at the same hospital. Laparoscopic adrenalectomy via the transperitoneal anterior approach can be equivalent to open adrenalectomy in efficiency with a shorter convalescence.
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Affiliation(s)
- T Terachi
- Department of Urology, Faculty of Medicine, Kyoto University, Japan
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Gagner M, Pomp A, Heniford BT, Pharand D, Lacroix A. Laparoscopic adrenalectomy: lessons learned from 100 consecutive procedures. Ann Surg 1997; 226:238-46; discussion 246-7. [PMID: 9339930 PMCID: PMC1191015 DOI: 10.1097/00000658-199709000-00003] [Citation(s) in RCA: 407] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
UNLABELLED One hundred consecutive laparoscopic adrenal procedures for a variety of endocrine disorders were reviewed. There was no mortality, morbidity was 12%, and conversions was 3%. During follow-up, none had recurrence of hormonal excess. Laparoscopic adrenalectomy is the procedure of choice for adrenal removal except in carcinoma or masses > 15 cm. OBJECTIVE The authors evaluate the effectiveness of laparoscopic adrenalectomy for a variety of endocrine disorders. SUMMARY BACKGROUND DATA Since the first laparoscopic adrenalectomy was performed in 1992, this approach quickly has been adopted, and increasing numbers are being reported. However, the follow-up period has been too short to evaluate the completeness of these operations. METHODS One hundred consecutive laparoscopic adrenal procedures from January 1992 until November 1996 were reviewed and followed for adequacy of resection. RESULTS Eighty-eight patients underwent 97 adrenalectomies and biopsies. The mean age was 46 years (range, 17-84 years). Indications were pheochromocytomas (n = 25), aldosterone-producing adenomas (n = 21), nonfunctional adenomas (n = 20), cortisol-producing adenomas (n = 13), Cushing's disease (n = 8), and others (n = 13). Fifty-five patients had previous abdominal surgery. Mean operative time was 123 minutes (range, 80-360 minutes), and estimated blood loss was 70 mL (range, 20-1300 mL). There was no mortality, and morbidity was encountered in 12% of patients, including three patients in whom venous thrombosis developed with two sustaining pulmonary emboli. During pheochromocytoma removal, hypertension occurred in 56% of patients and hypotension in 52%. There were three conversions to open surgery. The average length of stay has decreased from 3 days (range, 2-19 days) in the first 3 years to 2.4 days (range, 1-6 days) over the past 16 months. During follow-up (range, 1-44 months), two patients had renovascular hypertension and none had recurrence of hormonal excess. CONCLUSION Laparoscopic adrenalectomy is safe, effective, and decreases hospital stay and wound complications. Prior abdominal surgery is not a contraindication. Pheochromocytomas can be resected safely laparoscopically despite blood pressure variations. Venous thrombosis prophylaxis is mandatory. The laparoscopic approach is the procedure of choice for adrenalectomy except in the case of invasive carcinoma or masses > 15 cm.
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Affiliation(s)
- M Gagner
- Department of General Surgery, The Cleveland Clinic Foundation, Ohio 44195, USA
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Abstract
Laparoscopic adrenalectomy has become a viable option for removal of adrenal pathology and is becoming preferred over the conventional technique. With the conventional technique, many approaches are available, which vary according to pathology, diameter of the adrenal mass, location of the lesion, and patient morphology. Knowledge of anatomy is essential, because careful hemostasis and delicate tissue handling are necessary to make adrenal surgery a success.
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Affiliation(s)
- M Gagner
- Department of General Surgery, Cleveland Clinic Foundation, Ohio, USA
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Abstract
BACKGROUND The anterior transabdominal approach for adrenalectomy is associated with a longer postoperative recovery period than a posterior extraperitoneal adrenalectomy. The posterior approach is useful for patients requiring bilateral adrenalectomy or in those undergoing unilateral adrenalectomy for benign adenomas smaller than 5 cm. Recently transabdominal laparoscopic adrenalectomy has been used in patients with adrenal tumors. Endoscopic retroperitoneal adrenalectomy (ERA) is an alternative method that provides excellent exposure and should be associated with less postoperative morbidity. METHODS Between 1993 and 1994 11 ERAs were performed in eight patients in the Department of Surgery, Istanbul Faculty of Medicine. The patients were placed in the prone semijackknife position on the operating table. After the retroperitoneal space was expanded with a balloon trochar, four 10 mm trochars were placed to perform the procedure. RESULTS Among the eight female patients 23 to 65 years of age (mean, 42 +/- 12.4 years), three had bilateral adrenal hyperplasia caused by Cushing's disease, three patients had functioning adenoma, one patient had nonfunctioning adenoma (three on right and one on left adrenal), and one patient had right adrenal cyst. The mean operation time was 150 minutes (range, 90 to 300 minutes). No changes in PCO2 values have been found during intraoperative blood gas analyses. No intraoperative or postoperative complications occurred. All patients were discharged on the third postoperative day. CONCLUSIONS ERA is a new and safe method of adrenalectomy. It is less invasive than the posterior approach. Patients treated by ERA seem to experience less postoperative pain and discomfort and have a shorter postoperative hospitalization and recovery period.
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Affiliation(s)
- S Mercan
- Department of Surgery, Istanbul Faculty of Medicine, Turkey
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Abstract
Laparoscopic adrenalectomy has been successfully performed and described in humans. Though it is presently not widely employed it offers tremendous potential for adrenal surgery. It remains, however, an advanced technique requiring demonstration and practice. The aim of this study is to develop a porcine model of adrenalectomy for teaching and advancing the technique applicable to human surgery. Five female pigs weighing 10-20 kg underwent bilateral adrenalectomy by the lateral approach using endotracheal intubation. The left adrenal was resected with the pig in the right decubitus position. The animal was repositioned to left decubitus and the right adrenal was resected. In each case four 10-mm trochars were placed over the respective flanks. There was no need to mobilize the colon or liver (in the pig model). The peritoneum over each gland was incised and the gland dissected in a cephalocaudal manner. The vessels were ligated and divided particularly those from the vena cava. Upon completion blood loss (< 100 cc) and operating times (mean 60 min for the left and 90 min for the right) were assessed and the animal was sacrificed. The glands were weighed (mean 1.23 g R and 1.15 g L) and measured. Using this model, experience is gained in positioning the subject as well as trocars, in fine dissection in a lateral orientation, and in techniques of hemostasis. Although porcine and human adrenal anatomy differ in some details the pig constitutes an excellent model for the development of the technical experience required to perform adrenalectomy in humans.
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Affiliation(s)
- A Park
- Department of Surgery, St. Joseph's Hospital, McMaster University, Hamilton, Ontario, Canada
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Gagner M, Lacroix A, Bolte E, Pomp A. Laparoscopic adrenalectomy. The importance of a flank approach in the lateral decubitus position. Surg Endosc 1994; 8:135-8. [PMID: 8165486 DOI: 10.1007/bf00316627] [Citation(s) in RCA: 120] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Adrenalectomy is usually performed via transabdominal or posterior approaches. Unfortunately, both approaches are associated with painful postoperative syndromes. Recently, laparoscopic surgery was applied to organ removal. During a period of 12 months, we performed a series of successful laparoscopic adrenalectomies (10 of the right and 11 of the left gland). The pathologies were medullary cyst (1), angiomyolipoma (1), DHEAS hyperplasia (1), primary aldosteronism (2), Cushing's adenoma (3), pheochromocytoma (4), Cushing's syndrome (4), and nonfunctional adenoma (5). A flank approach was taken with four 11-mm trocars. Electrocautery and blunt forceps were used for dissection. The vessels were secured with medium-large titanium clips, and the adrenal was removed in a sterile plastic bag. The average operating time was 2.3 h, and median postoperative stay was 4 days. Two patients required blood transfusion of 2 units postoperatively. We believe this technique is adequate for the surgical removal of adrenal tissue, resulting in less postoperative pain and in rapid recovery. It may also change the surgical management of asymptomatic adrenal lesions.
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Affiliation(s)
- M Gagner
- Department of Surgery, Hôtel-Dieu de Montréal Hospital, University of Montréal, Quebec, Canada
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