Prospective randomized comparison of laparoscopic versus open adrenalectomy for sporadic pheochromocytoma

Background  Laparoscopic adrenalectomy for pheochromocytoma remains subject of debate, owing to the systemic consequences of pneumoperitoneum in patients with catecholamine-secreting tumors. Methods  A prospective randomized study was conducted (2000–2006), evaluating cardiovascular instability during open (n = 9, group A) or laparoscopic (n = 13, group B) adrenalectomy for pheochromocytoma. Haemodynamic parameters were recorded by invasive monitoring. Results  Haemodynamic instability was observed in 3/9 (group A) and 6/13 patients (group B), with a mean of 1.8 and 2.2 hypertensive peaks per patient (p = n.s.). Blood loss (164 ± 94 cc versus 48 ± 36 cc, p < 0.05) and operative time (180 ± 40 versus 158 ± 45 min, p = n.s.) favored laparoscopic procedures. Postoperative morbidity and mortality were nil. Hospital stay was shorter in group B (p < 0.05). Long-term follow-up was always normal. Conclusions  Laparoscopic approach for pheochromocytoma can be as safe as open surgery; intraoperative haemodynamic instability, although usually controlled with success, remains a source of concern.     

Robot-assisted laparoscopic partial nephrectomy.

The indications for nephron-sparing surgery and for minimally invasive surgery are continually expanding. Nephron-sparing surgery, also known as partial nephrectomy, presents a challenge to the minimally invasive surgeon. Herein, we describe our technique of robot-assisted laparoscopic partial nephrectomy. This approach may have potential advantages of including easier excision and suturing. Moderate training is required.     

腹腔镜肾上腺嗜铬细胞瘤切除术七例报告

目的探讨腹腔镜手术治疗肾上腺嗜铬细胞瘤的可行性及安全性。方法2003年10月至2007年4月，我院行腹腔镜肾上腺嗜铬细胞瘤切除术7例，肿瘤最大径为3．0～6．5cm，平均5．0cm。6例患者术前均有不同程度的高血压。术前常规行降压、扩容处理。采用后腹腔镜入路6例，经腹入路1例，术中术后严密监测血压变化并给予相应处理。结果5例腹腔镜手术成功，2例中转开放手术。手术时间为70-360min，平均163min，术中出血50-600ml，平均300ml。7例患者术中均出现血压波动，无围手术期患者死亡。病理报告证实为嗜铬细胞瘤。随访7～49个月，5例患者术后2个月内血压恢复正常，1例仍需服用降压药物。结论腹腔镜肾上腺嗜铬细胞瘤切除术可行，疗效确切，充分的术前准备和熟练的腹腔镜操作技术是手术安全的保证。     

后腹腔镜单侧肾上腺全切除术和部分切除术对患者反应速度影响的研究

目的 探讨经后腹腔腹腔镜单侧肾上腺全切除及部分切除术后对机体反应速度的影响.方法 收集2015年8月至2017年5月我院收治的醛固酮瘤患者56例,其中女34例,男22例,年龄21~60岁;34例行单侧肾上腺全切术,22例行单侧肾上腺部分切除术.采取直尺垂直下降法测量并比较患者术前与术后3 d、术后1个月、术后3个月的反应速度.结果 56例患者术后随访均无肿瘤复发,56例患者术后3个月内反应速度均较术前慢(P<0.05),但术后3个月开始单侧肾上腺部分切除组反应速度较单侧肾上腺全切组快,两组差异有统计学意义(P<0.05).结论 单侧肾上腺切除术后对患者反应速度有影响,且单侧肾上腺全切较肾上腺部分切除影响大.但由于本研究病例数较少、随访时间较短,具体影响程度及机制有待进一步随访研究.     

后腹腔镜下肾上腺嗜铬细胞瘤切除术37例疗效观察

目的探讨后腹腔镜下肾上腺嗜铬细胞瘤切除术的安全性及治疗效果。方法行后腹腔镜肾上腺嗜铬细胞瘤切除术37例病例资料。肿瘤位于左侧14例,右侧22例,双侧1例。肿瘤直径0.8-8.9cm,平均4.1±2.2cm。4例（13.2％）血压正常,33例（86.8％）血压升高,以头晕、头痛、心悸、恶心、呕吐、腹痛等为主要临床表现,典型三征症患者5例。术前将红细胞比容控制在45％以下,心率90次/min,血压在正常范围后,连续监测3d血压无明显波动后在全身麻醉下行后腹腔镜下肾上腺嗜铬细胞瘤切除术。结果36例手术成功,1例中转开放手术。手术时间143±16min,术中估计出血量96±34ml。术后住院时间5±2d。术中术后未发生重大并发症,肿瘤局部无复发。结论后腹腔镜下肾上腺嗜铬细胞瘤手术具有微创、出血少、恢复快等优点,充分的术前准备、正确的术中操作是取得手术成功、减少术后并发症的关键。     

Robot-assisted vs laparoscopic adrenalectomy: a prospective randomized controlled trial

Background The aim of this study was to assess the benefits and disadvantages of robot-assisted laparoscopic surgery for disorders of the adrenal gland in terms of feasibility, safety, and length of hospitalization.Methods Twenty consecutive patients with benign lesions of adrenal gland were randomized into two groups: Patients in the laparoscopic group underwent traditional laparoscopic adrenalectomy (LAP), whereas those in the robotic group underwent robot-assisted adrenalectomy (ROBOT) using the da Vinci robotic system.Results There was no significant difference between the groups in terms of age, sex, body mass index, and size or locations of lesions. Operative times were significant longer in the ROBOT group (total operative time, 169.2 min [range, 136–215] vs 115.3 min (range, 95–155) p < 0.001. Skin-to-skin time was 107 m (range, 77–154) vs 82.1 min (range, 55–120) (p < 0.001). There were no conversions to open surgery. However, conversion to standard laparoscopic surgery was necessary in four of 10 ROBOT patients (40%; left, one right). Perioperative morbidity was higher in the ROBOT group (20% vs 0%). There was no difference in length of hospital stay. In the following ROBOT group, hospital stay was 5.7 days (range, 4–9) vs 5.4 days (range, 4–8) in the LAP group (p = NS). The total cost of the ROBOT procedure ($3,467) was significantly higher than that for LAP ($2,737) (p < 0.01).Conclusion Laparoscopic adrenalectomy is superior to robot-assisted adrenalectomy in terms of feasibility, morbidity, and cost.     

Retroperitoneoscopic adrenalectomy for pheochromocytoma: comparison with open surgery.

OBJECTIVES: To evaluate the feasibility of the retroperitoneoscopic approach to adrenalectomy for pheochromocytoma and to compare it with the open retroperitoneal approach. METHODS: Twelve retroperitoneoscopic adrenalectomies for pheochromocytomas were performed in 10 patients at our center between January 1996 and January 2001. Two patients underwent simultaneous bilateral surgeries. These were retrospectively compared with open adrenalectomy for pheochromocytoma through the extraperitoneal flank approach in 6 patients with 7 adrenalectomies, conducted during the same period. RESULTS: Retroperitoneoscopic adrenalectomy could be successfully performed in 11 cases with 1 conversion to open surgery. Mean operative time was 151 minutes (range, 90 to 200 min). This was comparable to the time for the open surgery group, 169 minutes (range, 85 to 270 min). However, the mean blood loss of 140 mL (range, 30 to 300 mL), hospital stay of 4.4 days, and analgesia doses required (3.3) were significantly lower than those for the open surgery group (592 mL, 9.8 days, and 8.1 doses, respectively). No significant intraoperative hypertensive crises occurred in either group. CONCLUSIONS: Retroperitoneoscopy is a safe and feasible option for adrenalectomy for pheochromocytoma. It requires shorter operative time, less postoperative analgesia, a shorter hospitalization, and blood loss is less. Although retroperitoneoscopy is widely practiced for other adrenal tumors, it should now also be considered for pheochromocytomas.     

后腹腔镜下肾上腺嗜铬细胞瘤切除术56例体会

目的探讨后腹腔镜下手术治疗肾上腺嗜铬细胞瘤的有效性和安全性。方法行后腹腔镜肾上腺嗜铬细胞瘤切除术56例。肿瘤位于左侧24例、右侧30例、双侧2例。肿瘤直径1．5～10．0cm，平均（4．5±2.0）cm。主要临床表现为高血压者45例；无高血压者5例，主诉心悸、恶心、呕吐、腹痛、消瘦等；无症状经体检发现者6例。56例均行内分泌常规检查和影像学检查。术前常规行扩容、降压及对症处理，术中术后严密监测血压变化并给予相应处理。结果55例手术成功，1例中转开放手术。手术时间（52±22）min，术中估计出血量（74±34）ml．术后住院时间（5±1）d。术中术后未发生重大并发症。术中血压波动≥20rnmHg（1mmHg=0．133kPa）21例。病理报告均为嗜铬细胞瘤。随访5～36个月，36例患者术后2个月内血压恢复正常，9例仍需口服降压药物。肿瘤局部无复发。结论后腹腔镜下肾上腺嗜铬细胞瘤手术具有微创、出血少、恢复快等优点，充分的术前准备、正确的术中操作是手术安全的保证。     

Laparoscopic adrenalectomy for pheochromocytoma

Background Laparoscopic adrenalectomy is a safe and effective treatment for most surgical diseases of the adrenal gland. However it has been suggested that catecholamine effects associated with pheochromocytoma render the laparoscopic approach a more challenging and a more morbid procedure. The purpose of this study was to compare the operative characteristics and outcomes of laparoscopic adrenalectomy for pheochromocytoma to those of aldosteronoma and incidentaloma.Method Patient records and operative reports were retrospectively reviewed for demographics, diagnoses, operative management, and outcomes for patients undergoing laparoscopic adrenalectomy between June 1994 and July 2002 at two academic medical centers. A total of 74 patients were included and analyzed by diagnosis. Differences were considered statistically significant at p < 0.05.Results Twenty-eight patients with pheochromocytoma, 27 with aldosteronoma, and 19 with incidentally discovered nonfunctioning adrenal masses underwent laparascopic adrenalectomy. Patients undergoing resection for pheochromocytoma trended toward more operative blood loss (150 ml) compared to aldosteronoma (88 ml) and incidentaloma (75 ml). Eight patients were converted to an open procedure for a 10.8% conversion rate. The mean operative time was 171 min and there was a 10.8% perioperative complication rate. The mean hospital stay was 3.4 days. These results were not statistically significant between diagnostic groups.Conclusion Despite concern about increased operative times and morbidity associated with pheochromocytoma, our experience supports that laparoscopic adrenalectomy may be performed as safely as, and achieve outcomes similar to, those for other diseases.Paper presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Los Angeles, California, USA, March 2003     

Robot-assisted Laparoscopic Adrenalectomy: Step-by-Step Technique and Comparative Outcomes

Background

Recent evidence supports the use of robotic surgery for the minimally invasive surgical management of adrenal masses.

Objective

To describe a contemporary step-by-step technique of robotic adrenalectomy (RA), to provide tips and tricks to help ensure a safe and effective implementation of the procedure, and to compare its outcomes with those of laparoscopic adrenalectomy (LA).

Design, setting, and participants

We retrospectively reviewed the medical charts of consecutive patients who underwent RA performed by a single surgeon between April 2010 and October 2013. LA cases performed by the same surgeon between January 2004 and May 2010 were considered the control group.

Surgical procedure

The main steps of our current surgical technique for RA are described in this video tutorial: patient positioning, port placement, and robot docking; exposure of the adrenal gland; identification and control of the adrenal vein; circumferential dissection of the adrenal gland; and specimen retrieval and closure.

Outcome measurements and statistical analysis

Demographic parameters and main surgical outcomes were assessed.

Results and limitations

A total of 76 cases (RA: 30; LA: 46) were included in the analysis. Median tumor size on computed tomography (CT) was significantly larger in the LA group (3 cm [interquartile range (IQR): 3] vs 4 cm [IQR: 3]; p = 0.002). A significantly lower median estimated blood loss was recorded for the robotic group (50 ml [IQR: 50] vs 100 ml [IQR: 288]; p = 0.02). The RA group presented five minor complications (16.7%) and one major (Clavien 3b) complication (3.3%), whereas four minor complications (8.7%) and one major (Clavien 3b) complication (2.3%) were observed in the LA group. No significant difference was noted between groups in terms of malignant histology (p = 0.66) and positive margin rate (p = 0.60). Distribution of pheochromocytomas in the LA group was significantly higher than in the RA group (43.5% vs 16.7%; p = 0.02).

Conclusions

The standardization of each surgical step optimizes the RA procedure. The robotic approach can be applied for a wide range of adrenal indications, recapitulating the safety and effectiveness of open surgery and potentially improving the outcomes of standard laparoscopy.

Patient summary

In this report we detail our surgical technique for robotic removal of adrenal masses. This procedure has been standardized and can be offered to patients, with excellent outcomes.     

腹膜后腹腔镜肾上腺嗜铬细胞瘤切除术与开放手术患者血压变化的对比研究

目的:对比分析腹膜后腹腔镜与开放肾上腺嗜铬细胞瘤切除术中患者血压的变化,评价腹膜后腹腔镜手术切除肾上腺嗜铬细胞瘤的安全价值.方法:回顾性分析2008年9月至2011年2月为26例患者行单侧腹膜后腹腔镜肾上腺嗜铬细胞瘤手术(腹腔镜组)和19例单侧开放性肾上腺嗜铬细胞瘤手术(开放组)的临床资料,对比两组患者术中血压的变化(...     

腹腔镜下经肠系膜途径左侧肾上腺巨大嗜铬细胞瘤切除术五例报告

目的探讨腹腔镜下经肠系膜途径切除左侧肾上腺巨大嗜铬细胞瘤的可行性和安全性。 方法选取2017年8月至2018年10月我院左侧肾上腺巨大嗜铬细胞瘤5例患者,肿瘤直径6.5～10.5 cm,平均8.2 cm,3例有阵发性高血压,2例无明显自觉症状。采用经腹腹腔镜经肠系膜入路,于结肠脾曲内侧肠系膜根部肿瘤隆起处纵向切开系膜及后腹膜,显露游离并切除肿瘤,注意避免损伤肠管和肠系膜血管。 结果手术均取得成功,手术时间95～180 min,平均155 min;术中出血量为50～300 ml,平均为180 ml;术后重症监护室监护1～2 d,术后第2～3天患者即可下地活动,术后1～3 d肠道功能恢复,2～4 d拔除引流管,术后8～12 d出院,平均9.5 d,术后随访4～18个月,3例术前有高血压者术后阵发性高血压等症状缓解,无并发症发生。 结论对于左侧肾上腺巨大嗜铬细胞瘤,经腹腹腔镜经肠系膜入路肾上腺嗜铬细胞瘤切除术是可行和安全有效的。     

后腹腔镜手术治疗嗜铬细胞瘤

目的探讨后腹腔镜手术治疗嗜铬细胞瘤的适应证及手术安全性. 方法采用后腹腔镜手术治疗肾上腺嗜铬细胞瘤患者15例(双侧2例),腹主动脉旁嗜铬细胞瘤1例.对照组为开放手术治疗的肾上腺嗜铬细胞瘤16例,腹主动脉旁嗜铬细胞瘤1例.结果后腹腔镜手术组16例患者行后腹腔镜手术18例次,17例次取得成功,1例因术中出血改行开放手术.肿瘤最大径2.0～6.5(3.8±1.6)cm.手术时间45～150(85±31)min,出血量10～100(32±22)ml.术后吗啡用量0～40(12.5±7.8)mg;术后恢复进食时间1～3(1.8±0.7)d;下床活动时间2～3(2.3±0.5)d;术后住院时间4～9(6.5±1.3)d.开放手术组肿瘤最大径1.5～6.0(4.3±1.3)cm.手术时间90～240(155±39)min,出血量50～600(273±105)ml,9例输血.术后吗啡用量10～120(61±24)mg;术后恢复进食时间2～4(2.9±0.5)d;术后下床活动时间3～6(4.8±0.7)d;术后住院时间8～11(8.8±0.9)d.结论对于有一定腹腔镜手术经验者,后腹腔镜手术并不增加嗜铬细胞瘤手术的危险性,且具有手术时间短、出血少、创伤小、疼痛轻、康复快等优点.该法有望成为治疗肾上腺嗜铬细胞瘤的首选手术方法.     

腹腔镜切除5～10 cm肾上腺嗜铬细胞瘤的安全性分析

目的 探讨5～10 cm肾上腺嗜铬细胞瘤腹腔镜切除术的安全性. 方法 2001年1月至2007年6月在北京大学第一医院泌尿外科行肾上腺嗜铬细胞瘤切除的连续79例患者中肿瘤最大径5～10 cm者共41例,回顾分析其临床资料.腹腔镜组11例(其中2例中转开放,数据分析时排除在外),开放手术组30例.应用t检验、Mann-Whitney U检验对两组患者的临床资料及围手术期数据进行分析. 结果 两组患者年龄、肿瘤最大径、术前最高收缩压及舒张压、术前心率、血儿茶酚胺水平的差异均无统计学意义(P>0.05).腹腔镜组均经腹膜后途径.开放手术组经腹腔途径11例,经腹膜后途径19例.两组患者手术时间分别为(132±54)min和(178±64)min;术中出血量分别为100 ml(0～800 m1)和450 ml(0～9500 ml);术后住院时间分别为(7±2)d和(9±4)d,差异均有统计学意义(P<0.05).腹腔镜组术中均未输血,开放手术组术中输血量的中位值为225 ml(0～3800 ml).2组患者术中最高血压、最低血压、最快心率、最慢心率、收缩压增加基础血压30%的次数、收缩压≥200 mm Hg(1 mm Hg=0.133 kPa)次数、收缩压≤90 mm Hg次数、心率≥110次/min次数、心率≤50次/min次数的差异均无统计学意义(P>0.05).两组患者引流量、拔管时间、住ICU时间、术后开始进食时间、住院费用差异均无统计学意义(P>0.05). 结论 腹腔镜切除5～10 cm肾上腺嗜铬细胞瘤的手术时间、术中出血量、术中输血量、术后住院日较开放手术有优势,且术中血压、心率波动等指标不高于开放手术.因此,5～10 cm的肾上腺嗜铬细胞瘤不是腹腔镜的绝对禁忌,经验丰富的术者可以考虑开展腹腔镜手术切除较大肾上腺嗜铬细胞瘤.     

Robot-assisted laparoscopic adrenalectomy: preliminary UK results

OBJECTIVE: To describe the results of our first two cases of laparoscopic adrenalectomy using the da Vinci surgical system (Intuitive Surgical, Inc., Mountain View, CA, USA). PATIENTS AND METHODS: Amongst 75 robot-assisted procedures performed at our institution, two patients underwent robot-assisted laparoscopic adrenalectomy. The set-up time, procedure time, hospital stay, complications and outcomes were recorded. RESULTS: Both operations were completed successfully using the robot; the mean (range) set-up time was 31 (25-37) min and mean procedure time 118.5 (107-130) min. One patient had a postoperative pulmonary embolus and was discharged 5 days after surgery; the second patient was discharged after 3 days. There were no intraoperative complications; both patients were well at the 1-year follow-up. CONCLUSIONS: Robot-assisted laparoscopic adrenalectomy is technically feasible and can be conducted efficiently and safely with the da Vinci surgical system.     

后腹腔镜手术治疗肾上腺嗜铬细胞瘤9例报告

目的探讨后腹腔镜肾上腺嗜铬细胞瘤切除术的可行性及疗效. 方法回顾性分析2002年10月～2004年11月9例后腹腔镜肾上腺嗜铬细胞瘤切除术的临床资料. 结果 9例手术均获成功,无严重并发症.术中3例出现血压骤升,幅度超过30 mm Hg,调整操作强度及阻断中央静脉后好转.手术时间90～210 min,平均150 min.术中出血量30～150 ml,平均50 ml,均未输血.术后住院4～9 d,平均5 d.术后病理检查证实均为肾上腺嗜铬细胞瘤.9例随访3～24个月,平均11个月,临床症状消失,B超或CT检查未见肿瘤复发. 结论后腹腔镜肾上腺嗜铬细胞瘤切除术可行,损伤小,手术时间短,出血少,术后恢复快,并发症少,疗效好,临床应用前景广泛.