Posterior Retroperitoneoscopic Adrenalectomy for Clinical and Subclinical Cushing’s Syndrome

Background  

Because of co-morbidity, adrenalectomy for adrenal Cushing’s syndrome may be associated with an increased complication rate and long operating times. In the present study we report our experience with the posterior retroperitoneoscopic adrenalectomy in a large group of patients with clinical or subclinical Cushing’s syndrome.     

Adrenalectomy for bilateral and recurrent pheochromocytoma: increased intraoperative risk?

Adrenalectomy for pheochromocytoma is per se associated with a specific intraoperative cardiovascular risk caused by catecholamine secretion during manipulation of the tumor. Bilateral or multiple, and recurrent chromaffine tumors are special subentities with a potentially more intensified and longer surgical preparation. The aim of our study was to examine these effects on hemodynamic changes compared with those observed for primary, solitary tumors. Of the 82 studied interventions between February 1992 and May 2005, 58 were seen to involve primary, unilateral tumors, 17 involved bilateral (1 trilateral) findings, and there were 7 cases of recurrency. The hemodynamic changes related to primary, solitary pheochromocytomas revealed a higher frequency of intraoperative blood pressure crises (37%) compared with the comparative groups (11.8% in bilateral and 0% in recurrent tumors), as well as higher maximum pCO2 values noted. The intraoperative blood loss was more pronounced in interventions involving recurrencies. Aside from an appropriate preliminary therapy using an alpha-blocker and the careful surgical preparation of the adrenal gland, the different hemodynamic changes possibly may be related to the presence of smaller tumors in bilateral pheochromocytoma, as well as being based upon the already existent ligature of the draining vein in the event of recurrent procedures. The extent to which the adrenergic effect of the increased maximum pCO2 value plays a role on the development of higher maximum blood pressure values and more frequent intraoperative blood pressure crises continues to remain unclear.     

Laparoscopic Adrenalectomy—Is It Any Different in Phaeochromocytoma and Non-Phaeochromocytoma?

BACKGROUND: Laparoscopic adrenalectomy (LA) for phaeochromocytoma is a feasible, safe and effective treatment. The effects of associated catecholamine release render LA more challenging, although with comparable morbidity to LA for other diseases of the adrenal gland. METHODS: Data from case records of 44 patients who underwent LAs between May 2002 and May 2006 were analysed retrospectively. The patients were divided into a phaeochromocytoma group (Group I) and a non-phaeochromocytoma group (Group II). The aim of this study was to assess the operative course and outcome of LA in the two groups. RESULTS: The mean operating time and blood loss were slightly higher in LA for phaeochromocytomas compared to LA for other pathologies, but these differences were not statistically significant. The mean hospital stay was 3.84 days in both groups. The phaeochromocytoma group had a slightly higher complication rate of 21% compared to 12%. None of the procedures needed open conversion. A terminal hand assist was employed in two patients in Group I and one patient in Group II. Two patients with bilateral phaeochromocytoma had single stage bilateral LA. CONCLUSION: LA is feasible and effective in phaeochromocytoma. It is associated with a slightly longer operating time, more blood loss and complications when compared with non-phaeochromocytoma masses. LA can be done in a single operation for bilateral masses. Terminal hand assist is a viable and effective option for very large masses.     

Retroperitoneoscopic Adrenalectomy in Conn’s Syndrome Caused by Adrenal Adenomas or Nodular Hyperplasia

Background In patients with primary hyperaldosteronism, solitary adrenal adenomas are an indication for surgical intervention. In contrast, adrenal hyperplasia is almost exclusively treated by drugs. Patients and methods In a prospective clinical study 183 patients (81 men, 102 women; age 49.6 ± 12.8 years) with Conn’s syndrome were operated on using the posterior retroperitoneoscopic approach. Tumor size ranged from 0.2 to 5.0 cm (mean 1.5 ± 0.8 cm). Final histology described a solitary adenoma in 127 patients and adrenal hyperplasia in 56 patients. Partial adrenalectomies were performed in 47 operations. Results The perioperative complication rate was 4%, mortality zero. In none of the cases was conversion to open surgery necessary. The mean operating time was 58 ± 32 minutes (range 20–230 minutes) and was associated with sex (p < 0.001) but not with the extent of resection (partial vs. total, p = 0.51) or with tumor size (≤1.5 vs. >1.5 cm; p = 0.43) or tumor site (p = 0.77). Median blood loss was 15 ml. Median duration of postoperative hospitalization was 4 days. After a mean follow-up of nearly 5 years, 96% of patients are normokalemic, 30% of patients are cured (normotensive without medication), and 87% showed an improvement of hypertension (normotensive without or with reduced medication). Cure of hypertension depended on the patient’s age (p < 0.001) and sex (p < 0.001), duration of hypertension (p < 0.05), and histomorphology (p < 0.001). Improvement of hypertension was not associated with any of these factors. Conclusions Retroperitoneoscopic removal of adrenal glands in patients with Conn’s syndrome is a safe, rapidly performed surgical procedure and can thus be considered as first choice option for treatment of both solitary adrenal adenomas and hyperplasia presenting with a clinically predominating nodule.     

Bilateral Adrenalectomy for Ectopic Cushing’s Syndrome—Discussions on Technique and Indication

Background Tumors producing adrenocorticotropic hormone (ACTH) or corticotropin releasing hormone (CRH) often remain undiagnosed until severe Cushing’s syndrome appears, and it may be difficult to distinguish from Cushing’s syndrome due to pituitary tumors. Many patients suffer from disease spread, with metastases in the liver or other locations, and the main symptoms may be mineral disturbances, diabetes mellitus, or psychological symptoms from the severe hypercortisolism. Bilateral adrenalectomy may alleviate this situation, but is sometimes a troublesome procedure in these severely ill patients. Methods We have retrospectively investigated 8 patients with ectopic Cushing’s syndrome who have undergone bilateral adrenalectomy at the University Hospital in Uppsala. In addition, another 5 patients who underwent bilateral adrenalectomy for other reasons (recurrent pituitary Mb Cushing or bilateral hyperplasia) were scrutinized for technical considerations. Indications, timing of surgery, and operative procedures were studied to identify signs that may support our approach to management in the future. Results Curative surgery was not possible in any of the cases with ectopic Cushing’s syndrome. Of the 13 operated patients, handport-assisted laparoscopic adrenalectomy was successfully performed bilaterally in 5 patients and unilaterally in combination with contralateral open surgery in 1 patient; conventional open surgery was performed on 7 patients, 3 of which were conversions from intitial handport-assisted procedures. Non-fatal complications occurred in 4 out of 10 patients. Conclusions We conclude that bilateral handport-assisted laparoscopic adrenalectomy is safe, and that all surgical techniques in these severely ill patients may be troublesome and technically demanding. Early surgical intervention may reduce the technical disadvantages. Moreover, bilateral adrenalectomy can substantially reduce the symptoms of Cushing’s syndrome, although effects on mortality are not obvious.     

Outcome of Adrenalectomy for Cushing’s Syndrome: Experience from a Tertiary Care Center

Adrenalectomy continues to play an important role in the management of Cushing’s syndrome (CS). Untreated CS causes considerable physical and mental morbidity and mortality. However, little information is available on the effect of adrenalectomy in ameliorating functional disabilities in CS patients. Our study assesses the long-term outcome of adrenalectomy in patients with CS. This is a retrospective analysis of CS patients managed during 1990–2005 at a tertiary care center. We analyzed the clinical presentation, endocrine evaluation, and surgical management preoperatively and following adrenalectomy. The subjects were 37 patients with CS (age 24.5 ± 15 years, range 1–60 years; male:female 1.0:1.2). There were various etiologies—unilateral adrenocortical adenoma (n = 11), adrenocortical carcinoma (n = 13), pituitary ACTH-secreting adenoma with failed transsphenoidal surgery (n = 4), ectopic unidentified ACTH source (n = 7), bilateral adrenal macronodular hyperplasia (n = 1), primary pigmented nodular adrenal hyperplasia (n = 1) —for which the patients underwent adrenalectomy: unilateral (n = 22), bilateral (n = 13), or adrenonephrectomy (n = 2). Two patients died during the perioperative period owing to chest infection and sepsis. At the median follow-up of 60 months (range 6–144 months), the patients exhibit significant persistence of obesity (41%), proximal muscle weakness (44%), menstrual irregularity (8%), hypertension (31%), and insulin-dependent diabetes (29%). Hirsutism and psychological abnormalities persisted to a lesser extent. All patients had biochemical cure of CS following surgery evidenced by the 8 a.m. basal cortisol ≤ 5 μg/dl. The hypothalamic-pituitary-adrenal axis recovered as shown by normalization of the short synacthen-stimulated cortisol level (peak level ≥ 20 μg/dl) after a median follow-up of 9 months (range 6–18 months). Incomplete clinical recovery following adrenalectomy emphasizes the need of early recognition and prompt treatment of CS. Surgery for adrenocortical adenoma is safe and effective; however, survival of patients with CS due to adrenocortical carcinoma remains poor. Bilateral adrenalectomy provides early control of hypercortisolism in selected cases of unlocalized ectopic ACTH syndrome or failed transsphenoidal surgery. Even though functional recovery is incomplete after adrenalectomy, quality of life improves considerably.     

Trends in Utilization of Adrenalectomy in the United States: Have Indications Changed?

Minimally invasive approaches have dramatically reduced morbidity associated with adrenalectomy. There has been concern that an increased frequency of adrenal imaging along with the advantages of less morbidity could influence the indications for adrenalectomy. We tested the hypothesis that adrenalectomy has become more common over time and that benign diseases have been increasingly represented among procedural indications. The Nationwide Inpatient Sample (NIS) database was utilized to determine the incidence of adrenalectomy and the associated surgical indications in the United States between 1988 and 2000. All discharged patients were identified whose primary ICD-9-CM procedure code was for adrenalectomy, regardless of the specific surgical approach (laparoscopic adrenalectomy was not reliably coded). This subset was then queried for associated ICD-9-CM diagnostic codes. Linear regression and t-tests were utilized to determine the significance of trends. The total number of adrenalectomies increased significantly, from 12.9 per 100,000 discharges in 1988 to 18.5 per 100,000 discharges in 2000 (p = 0.000003). The total number of adrenalectomies with a primary ICD-9-CM code for malignant adrenal neoplasm did not increase significantly: from 1.2 per 100,000 discharges in 1988 to 1.6 per 100,000 discharges in 2000 (p = 0.47). The total number of adrenalectomies with a primary ICD-9-CM diagnostic code for benign adrenal neoplasm increased significantly, from 2.8 per 100,000 discharges in 1988 to 4.8 per 100,000 discharges in 2000 (p = 0.00002). The average percentage of adrenalectomies performed for malignant neoplasm was significantly higher during the period 1988–1993 when compared to 1994–2000 (11% vs. 9%; p = 0.002). The average percentage of adrenalectomies performed for benign neoplasm was significantly lower during 1988–1993 when compared to 1994–2000 (25% vs. 28%; p = 0.015). Adrenalectomy is being performed with increasing frequency. This is associated with an increase in the proportion of adrenalectomies performed for benign neoplasms. Assuming no significant change in disease prevalence during the study period, these data suggest that indications for adrenalectomy may have changed somewhat over that period.This article was presented at the International Association of Endocrine Surgeons meeting, Uppsala, Sweden, June 14–17, 2004.     

Synchronous Bilateral Adrenalectomy for Cushing’s Syndrome: Laparoscopic Versus Posterior Retroperitoneoscopic Versus Robotic Approach

Background

Synchronous endoscopic bilateral adrenalectomy (BilA) can effectively provide definitive cure of hypercortisolism in ACTH-dependent Cushing’s syndrome and in primary adrenal bilateral disease. We compared three different approaches for BilA: transabdominal laparoscopic BilA (TL-BilA), simultaneous posterior retroperitoneoscopic BilA (PR-BilA), and robot-assisted BilA (RA-BilA).

Methods

All patients who underwent BilA between January 1999 and December 2012 at two referral centers (one performing TL-BilA and PR-BilA and one performing RA-BilA) were included. A comparative analysis was performed.

Results

Twenty-nine patients were included: 5 underwent TL-BilA, 11 underwent PR-BilA, and 13 underwent RA-BilA. No significant difference was found concerning age, gender, diagnosis, and previous abdominal surgery. No conversion to open approach was registered. Operative time was significantly shorter for the PR-BilA group than for the TL-BilA and RA-BilA groups (157.4 ± 54.6 vs 256.0 ± 43.4 vs 221.5 ± 42.2 min, respectively) (P < 0.001). No significant difference was found concerning intraoperative and postoperative complications rate and time to first flatus. Drains were used routinely after PR-BilA and TL-BilA and electively in four RA-BilA patients (P < 0.001). Hospital stay was longer in the TL-BilA and PR-BilA groups than in the RA-BilA group (12.0 ± 5.7 vs 10.8 ± 3.7 vs 4.4 ± 1.7 days, respectively) (P < 0.001). No recurrence or disease-related death was registered.

Conclusions

Operative time was significantly shorter in the PR-BilA group, because it eliminates the need to reposition the patient. The number of drains and the length of hospital stay were reduced after RA-BilA, but this was likely related to different management protocols in different settings. Because no significant difference was found in terms of postoperative outcome, none of the three operative approaches can be considered the preferable one.     

Letter to the Editor: Primary Aldosteronism: Does Underlying Pathology Impact Clinical Presentation and Outcomes Following Unilateral Adrenalectomy?

World Journal of Surgery -     

Are Adrenal Lesions of 6 cm or More in Diameter a Contraindication to Laparoscopic Adrenalectomy? A Case–Control Study

World Journal of Surgery - The aim of this case–control study is to compare the surgical outcomes of laparoscopic adrenalectomy (LA) for lesions measuring ≥6&nbsp;cm versus...