腹腔镜肾上腺切除术和开放肾上腺切除术治疗肾上腺巨大良性肿瘤的比较

目的：了解腹腔镜肾上腺切除术（1aparoscopicadrenalectomy,LA）和开放肾上腺切除术（openadre—nalectomy,OA）治疗肾上腺巨大（〉6cm）良性肿瘤的差别。方法：分析2009年1月～2011年12月手术治疗的50例肾上腺巨大良性肿瘤的l陆床特点。其中LA组26例,OA组24例。比较两组年龄、肿瘤大小、手术时间、术中出血量、住院时间、切口长度;LA组嗜铬细胞瘤切除6例,OA组嗜铬细胞瘤切除7例,比较两者术中血流动力学变化。结果：术后病理为肾上腺腺瘤2例,节细胞神经瘤10例,嗜铬细胞瘤13例,髓样脂肪瘤19例,肾上腺囊肿伴出血3例,神经鞘膜瘤2例,肾上腺巨淋巴结增生（Castleman病）1例。LA组和OA组比较,平均年龄分别为（45．3±15．6）岁和（52．2±13．2）岁（P=0．069）;肿瘤直径分别为（7．75±1．26）cm和（8．38±1．96）cm（P=0．098）;平均手术时间分别为（65．2±23．4）min和（126．9±32．5）min（P〈0．01）;出血量分别为（,54．1±19．5）m1和（205．0±49．6）ml（P〈O．01）;住院时间分别为（4．8±1．6）d和（7．6±2．1）d（P〈0．01）;切口长度分别为（7．56±2．06）cm和（18．28±3．25）cm（P〈O．01）。LA组无一例发生手术相关并发症或中转开放;（）A组冈肾血管损伤行一侧肾切除1例。LA组切除嗜铬细胞瘤术中最高收缩压和心率低于OA组（P〈O．05）。术后随访3～26个月,肿瘤无复发。结论：尽管I。A需延长切口取出肿瘤,但与OA相比,切除肾上腺巨大良性肿瘤仍具有手术时间短、出血少、创伤小、恢复快等优势。     

后腹腔镜八步法行巨大肾上腺肿瘤解剖性切除术

目的:介绍采用后腹腔镜八步法行巨大(直径≥5cm)肾上腺肿瘤解剖性切除术的手术技巧及临床效果。方法:2009年1月~2013年10月期间对34例巨大肾上腺肿瘤患者采用后腹腔镜八步法行巨大肾上腺肿瘤解剖性切除术:①清除腹膜外脂肪;②打开Gerota筋膜,游离肾脏背侧间隙;③游离肾脏腹侧间隙;④打断肾脏与肿瘤之间的连接;⑤游离肾上腺肿瘤膈面;⑥游离肾上腺肿瘤腹侧;⑦处理肾上腺肿瘤上极;⑧完整切除肿瘤。结果:34例腹腔镜手术全部完成,仅1例中转开放手术。肿瘤平均直径〔7.3±2.4(5.5~14.5)〕cm,平均手术时间〔89±44(30~185)〕min,术中平均估计出血量〔172±246(10~1000)〕ml。1例术中输血800ml,1例术后输血400ml;1例术后并发急性肺水肿,保守治疗后康复;术后平均恢复饮食时间为〔1.6±0.9(1~4)〕d,术后平均住院时间为〔6.3±2.6(3~14)〕d。结论:按照八步法行后腹腔镜巨大肾上腺肿瘤解剖性切除术,具有操作空间充分、层次清楚、视野清晰、手术成功率高、创伤小、出血少及并发症少等优点。后腹腔镜八步法巨大肾上腺肿瘤解剖性切除术安全可行。     

Laparoscopic adrenalectomy for malignant tumors

Objectives:   The treatment of malignant adrenal tumors using laparoscopic surgery remains controversial. We thus compared the perioperative outcome of the laparoscopic adrenalectomy for the treatment of malignant tumors with the outcome for benign tumors. We also evaluated the oncological outcome of the laparoscopic adrenalectomy for a malignancy.
Methods:   Since 1999 a total of nine laparoscopic adrenalectomies for a malignancy have been performed in nine patients. The median adrenal tumor size was 3 cm. The laparoscopic approach was transperitoneal in all cases. Seven patients had no evidence of a systemic metastatic disease, whereas two patients with a metastatic renal cell carcinoma had systemic metastatic disease at the time of the operation.
Results:   The median operation time was 165 min and the estimated blood loss was 75 mL in the laparoscopic adrenalectomy for a malignancy. There was no significant difference between laparoscopic adrenalectomy for malignant and benign tumors. Regarding the oncological outcome, seven of the nine patients, including the two palliative cases, treated with a laparoscopic adrenalectomy for a malignancy were alive at a median follow-up of 20 months. One patient died of other causes.
Conclusions:   Our results clearly indicate that a laparoscopic adrenalectomy for the treatment of a metastatic adrenal malignancy can be performed with an acceptable outcome as a minimally invasive method in carefully selected patients.     

Laparoscopic radical adrenalectomy with adrenal vein tumor thrombectomy: technical considerations

PURPOSE: We describe the technique of adrenal vein tumor thrombectomy during laparoscopic radical adrenalectomy for cancer. MATERIALS AND METHODS: During laparoscopic adrenalectomy for a heterogeneous 7 cm left adrenal mass an adrenal vein thrombus was detected intraoperatively. Laparoscopic ultrasonography was used to delineate precisely the tumor thrombus and its extension into the left main renal vein. The left renal artery and vein were transiently controlled with atraumatic vascular clamps. The renal vein was incised and the intact tumor thrombus was removed en bloc with the radical adrenalectomy specimen. The renal vein was suture repaired with 4-zero prolene and the kidney was revascularized. RESULTS: Renal warm ischemia time was 21 minutes, blood loss was 300 cc and operative time was 6.2 hours. Pathological evaluation revealed a 7.5 cm 68 gm adrenal cortical cancer with tumor thrombus. Soft tissue and adrenal vein margins were negative for cancer. CONCLUSIONS: Laparoscopic radical adrenalectomy with en bloc adrenal vein tumor thrombectomy can be exclusively performed intracorporeally, while respecting oncological principles. Essential technical steps include wide margin excision of the adrenal gland, intraoperative ultrasonography, renal vascular control, en bloc tumor thrombectomy and renal venous suture repair in a bloodless field.     

Laparoscopic adrenalectomy for functioning and non-functioning adrenal tumors: Analysis of surgical aspects based on histological types

BACKGROUND: The aim of this study was to evaluate whether hormonal functions of the tumor influence the operative results of laparoscopic adrenalectomy, and to analyse the clinical outcomes in patients with various hormonally active adrenal tumors. METHODS: Clinical and pathological records of 68 patients were reviewed. The average age of patients was 40 years (range 20-75); 39 were women and 29 men. For the comparison, patients were divided into the non-functioning tumor group (n = 22) and the functioning tumor group (n = 46). RESULTS: All laparoscopic adrenalectomies were finished successfully, and no open surgery was necessary. The median operative time and blood loss in the two groups were similar; however, in subgroup analysis, operative time for pheochromocytoma was significantly longer than that for non-functioning tumor (P = 0.044). No difference was noted in intra- and postoperative data between the groups. Of the 22 patients with aldosteronoma, 18 (81.8%) became normotensive and no longer required postoperative blood pressure medications. Adrenalectomy led to an overall reduction in the median number of antihypertensive medications (P < 0.001). All patients with Cushing adenoma had resolution or improvement of the signs and symptoms during follow-up periods. There was no evidence of biochemical or clinical recurrence in any patient with pheochromocytoma. CONCLUSION: The results of this retrospective review document that laparoscopic adrenalectomy is a safe and effective treatment for functioning as well as non-functioning adrenal tumors, although endocrinologic features may play a significant role.     

经腹腔镜切除肾上腺肿瘤8例报告

目的　评价腹腔镜下肾上腺肿瘤切除的效果。　方法　经腹腔镜切除肾上腺皮质腺瘤 7例及原发性醛固酮增多症 1例 ,所有肿瘤均在右侧 ,直径均 <6cm。　结果　 8例腹腔镜手术都获得成功。平均手术时间 2 .2小时 ;术中平均出血量 70ml;术后平均禁食时间是 1.5天。　结论　经腹腔镜行肾上腺肿瘤切除具有切口小 ,创伤小 ,出血量少 ,术后恢复快的优点     

Laparoscopic simultaneous bilateral adrenalectomy for testosterone‐secreting bilateral adrenal tumors

Laparoscopic adrenalectomy is widely accepted as a safe and minimally‐invasive procedure. Although it is a standard procedure for the surgical treatment of adrenal tumors, its simultaneous use with bilateral adrenalectomy is relatively rare. A 21‐year‐old woman was referred to Hamamatsu University School of Medicine University Hospital complaining of a deepening voice, hirsutism and secondary amenorrhea. Abdominal computed tomography showed bilateral adrenal tumors, and hormonal examinations showed that the tumors secreted excessive testosterone, resulting in virilizing symptoms. Laparoscopic simultaneous bilateral adrenalectomy was carried out. Postoperatively, serum testosterone levels immediately recovered to within the normal range. Menstruation began the month after the operation, and the hirsutism gradually regressed. This is the third reported case of bilateral virilizing adrenal tumors, and the first to be successfully treated with laparoscopic simultaneous bilateral adrenalectomy.     

Laparoscopic adrenalectomy for large adrenal tumors

BACKGROUND AND PURPOSE: Laparoscopic adrenalectomy remains a controversial procedure for large tumors. We examined the outcome and complications of laparoscopic adrenalectomy for such lesions. PATIENTS AND METHODS: A total of 178 patients underwent laparoscopic adrenalectomy, of whom 29 patients had large (>or =5 cm) tumors. Their mean age was 47.9 years (range 21-72 years), and the mean tumor size was 6.5 cm (range 5.0-11.0 cm). They were compared with patients whose adrenal tumors were <5 cm. RESULTS: The large-tumor group had a mean operating time of 176 +/- 48 minutes (range 84-278 minutes) and a mean blood loss of 136.6 mL (range 10-800 mL) and required a mean of 1.8 days before starting oral intake. None of these values is significantly different from the results in the control group (P > 0.05). The length of recovery was significantly longer in the large-tumor group (5.4 v 4.5 days; P < 0.05), but this was not true if a patient with a 23-day postoperative stay is excluded. The overall incidence of complications was 12% in the large-tumor group, which was not significantly different from that in the control group (P > 0.05). CONCLUSIONS: The operating time, blood loss, and incidence of complications after laparoscopic adrenalectomy did not differ between the patients with large and small adrenal tumors, indicating that experienced surgeons can safely and effectively use laparoscopy for larger tumors. However, it is necessary to consider carefully whether laparoscopic surgery is indicated for tumors that show infiltration on preoperative imaging or for patients who have undergone previous upper-retroperitoneal surgery.     

Laparoscopic resection of large adrenal ganglioneuroma

We report on a 23-year-old woman with a right adrenal tumor 13 cm in diameter who was treated by laparoscopy. The patient was asymptomatic, and the tumor was incidentally diagnosed on abdominal ultrasonography. A subsequent computed tomography (CT) of the abdomen confirmed a 12 x 7 x 8-cm homogenous mass of the right adrenal. Magnetic resonance imaging (MRI) showed a solid mass measuring 13 x 7 x 7.5 cm arising from the right adrenal. Laparoscopic complete excision of the mass was accomplished through a transabdominal lateral approach. The postoperative period was uneventful, and the patient was discharged on the second postoperative day. Histology was consistent with an adrenal ganglioneuroma. Two years later, there is no evidence of recurrence on abdominal CT scan.     

Laparoscopic adrenalectomy for phaeochromocytoma: with caution

INTRODUCTION: Laparoscopic adrenalectomy is well described and many series include patients with phaeochromocytoma. Our aim was to establish whether laparoscopic adrenalectomy for phaeochromocytoma was a safe and feasible technique at our institution. METHODS: Patients requiring adrenalectomy were entered into a prospective database that included patient details, operative data, hormone excretion, tumour size, hospital stay and complications. All operations were performed under the supervision of a single surgeon. Analysis was performed for those patients with a diagnosis of phaeochromocytoma. RESULTS: Of 60 patients having laparoscopic adrenal surgery, 18 had phaeochromocytoma as the indication. Seventeen (89%) of 19 tumours in these 18 patients were successfully removed laparoscopically. Median operative time was 180 min (range 130-300 min) and this was significantly longer compared with other adrenal pathology. The median tumour size was 6 cm which was significantly larger than other adrenal tumours. Seven (38%) patients developed complications and median postoperative inpatient stay was 5 days (range 3-8 days). CONCLUSIONS: The postoperative stay was equivalent to other laparoscopic series and laparoscopic removal was successful in 89%. The laparoscopic approach to the adrenal gland in phaeochromocytoma is safe and effective treatment.     

巨大肾上腺肿瘤腹腔镜手术(附光盘)

腹腔镜技术已经成为肾上腺手术的金标准,但对于一些体积巨大的肾上腺肿瘤,腹腔镜手术仍有一定难度,并发症发生率相对较高。经腹腔途径巨大肾上腺肿瘤腹腔镜手术可以减少手术并发症,降低手术难度,本文重点阐述该手术方法和技术要点。     

Laparoscopic resection of large adrenal tumors

Background The maximum size of adrenal tumors that should be removed with a laparoscopic approach is controversial. It has been suggested that laparoscopic adrenalectomy is appropriate only for adrenal tumors <6 cm in size. We report our experience with laparoscopic adrenalectomy in patients with adrenal tumors of ≥6 cm compared with patients with smaller tumors. Methods We retrospectively reviewed a consecutive series of patients who had a laparoscopic adrenalectomy. Patients were considered candidates for laparoscopic adrenalectomy if their computed tomography (CT) scan showed a well-encapsulated tumor confined to the adrenal gland. Results Sixty laparoscopic adrenalectomies were performed in 53 patients. Twelve of the adrenalectomies (20%) were for tumors that were ≥6 cm (median, 8 cm; range, 6 to 12 cm). There have been no local or regional recurrences but one patient with adrenocortical carcinoma developed pulmonary metastases. When the 12 patients with large tumors were compared with the 36 patients with tumors <6 cm, the median operative time (190 vs. 180 minutes;P=.32), operative blood loss (100 vs. 50 mL;P=.53), and postoperative hospital stay (2 vs. 2 days;P=1.0) were similar. Conclusions The size of an adrenal tumor should not be the primary factor in determining whether a laparoscopic adrenalectomy should be performed. Large adrenal tumors that are confined to the adrenal gland on CT can be removed with a laparoscopic approach.     

Laparoscopic adrenalectomy for large adrenal metastasis from contralateral renal cell carcinoma.

We present herein the case of a patient with solitary metachronous contralateral adrenal metastasis from renal cell cancer. The patient had undergone left radical nephrectomy and adrenalectomy for localized renal cancer 7 years previously. Laparoscopic transperitoneal right adrenalectomy was performed. The postoperative period was uneventful. Histology showed right adrenal metastasis from renal cancer. At 6-month follow-up, there was no evidence of recurrence.     

Simultaneous bilateral laparoscopic adrenalectomy is safe for synchronous large adrenal tumors.

Laparoscopy is now considered the gold standard for treating benign monolateral adrenal lesions. We present the case of a patient affected by Cushing's syndrome due to large bilateral adrenal adenomas (7.5 cm) who underwent simultaneous laparoscopic bilateral adrenalectomy. An anterior, lateral transperitoneal approach was used. Operative time was 200 minutes, and blood loss was 200 mL. No intraoperative complications were encountered. The postoperative course was uneventful, and the patient was discharged after 3 days. Laparoscopic bilateral adrenalectomy is a safe, effective procedure when performed by experienced hands and may be an alternative treatment for large adrenal lesions.     

后腹腔镜肾上腺肿瘤切除术22例临床分析

目的评价经腹膜后腔行腹腔镜肾上腺肿瘤切除术的临床价值。方法对本科2002年3月至2003年6月开展的22例后腹腔镜肾上腺肿瘤切除术进行分析。22例中11例为皮质醇腺瘤，10例为醛固酮腺瘤，1例嗜铬细胞瘤。结果22例手术均获成功。手术时间60～140min，平均100min；失血量30～100mL，平均55mL，术中及术后均未输血；1例术后发生后腹膜腔血肿。结论后腹腔镜肾上腺肿瘤切除术具有对组织损伤小、出血少、术后恢复快、并发症少等优点．为非嗜铬细胞瘤肾上腺良性疾病的首选方法。     

机器人辅助腹腔镜下肾上腺复杂肿瘤手术(附光盘)

目前,传统腹腔镜肾上腺切除术(laparoscopic adrenalectomy,LA)已成为治疗大部分肾上腺肿瘤的首选方法,但其在处理一些复杂性肾上腺肿瘤时仍较困难。达芬奇机器人手术系统在泌尿外科领域的广泛应用和发展是当今世界临床医学发展的里程碑。机器人辅助腹腔镜下肾上腺切除术(robot-assisted laparoscopic adrenalectomy,RALA)使得一些不适合传统腹腔镜手术的肾上腺肿瘤的微创治疗成为可能。本文就达芬奇机器人手术系统、RALA用于复杂肾上腺肿瘤治疗、RALA的手术步骤和技巧做一概述。     

Laparoscopic simultaneous bilateral adrenalectomy: assessment of feasibility and potential indications

Objective: To report a single‐center experience with laparoscopic simultaneous bilateral adrenalectomy (LSBA) and to evaluate its safety, surgical outcomes, and potential indications of the procedure. Methods: A total of 21 patients underwent LSBA between 2000 and 2010 at our institution. Four patients had bilateral Cushing's syndrome (CS), two had bilateral pheochromocytoma, and one had a bilateral metastatic tumor. Eleven patients had unilateral or bilateral aldosterone‐producing adenoma (APA), associated with CS or subclinical CS. Three patients had unilateral APA with contralateral non‐functioning adenoma. Partial adrenalectomy was performed first by using with four ports. After the excision of one gland, the contralateral gland was removed after repositioning of the patient. Results: LSBA was completed in all 21 patients without major complications. Mean operative time was 329.7 min and the estimated blood loss was 94.1 mL. Mean tumor size was 21.8 mm. Of the 16 patients receiving an adrenal‐sparing procedure, nine of 11 discontinued glucocorticoid replacement after 2 years. The remaining five patients receiving bilateral total adrenalectomy required 0.5–0.75 mg of dexamethasone permanently. No open conversions, no deaths or no adrenal insufficiencies were encountered. Conclusions: LSBA represents a safe and viable treatment option for selected patients with bilateral adrenal disease.     

Laparoscopic adrenal surgery in children

PURPOSE: The laparoscopic approach to the adrenal gland was first reported in 1992. Since then, more than 400 studies have been published, comprising hundreds of adults. There are few reports of laparoscopic adrenalectomy in the pediatric population. We reviewed our experience with laparoscopic adrenal surgery in children. MATERIALS AND METHODS: Laparoscopic adrenalectomy was performed in 8 girls and 5 boys 15 years or younger (mean age 6.3) between December 1994 and August 2001. The clinical diagnosis before surgery was virilizing tumor in 5 cases, nonfunctioning solid adrenal tumor in 3, Cushing's syndrome in 2, pheochromocytoma in 2 and Cushing's pituitary disease in 1. Unilateral adrenal lesions were 15 to 80 mm. at the longest axis (mean 41.4) on computerized tomography. RESULTS: Two of the 13 procedures (15.4%) were converted to open surgery. No deaths occurred. No patients presented with postoperative complications. Average operative time in unilateral nonconverted procedures was 107 minutes (range 25 to 195). Blood transfusion was required in 1 case (7.7%). Average hospital stay was 5.5 days (range 1 to 17). Average postoperative followup was 16 months (range 1 to 60). The final clinicopathological diagnosis was virilization in 4 cases, Cushing's syndrome in 2, pheochromocytoma in 2, neuroblastoma in 2, Cushing's pituitary disease in 1, teratoma in 1 and primary carcinoma in 1. CONCLUSIONS: Laparoscopic adrenalectomy is feasible and shows positive results in select pediatric patients.     

Laparoscopic radical adrenalectomy for malignancy in 31 patients

PURPOSE: Laparoscopic adrenalectomy for malignancy is controversial. We analyzed our experience with laparoscopic radical adrenalectomy for cancer with an emphasis on predictors of surgical outcome and oncological followup data. MATERIALS AND METHODS: Since July 1997, 31 patients have undergone a total of 33 laparoscopic adrenalectomies for malignancy. Mean adrenal tumor size was 5 cm (range 1.8 to 9). The laparoscopic approach was transperitoneal in 17 cases, retroperitoneal in 15 and transthoracic in 1. Data were obtained from patient charts, radiographic reports and direct telephone calls to patient families. RESULTS: Associated organ resection (radical nephrectomy) was performed in 3 patients. One case was electively converted to open surgery. There was no operative mortality. The pathological diagnoses were metastatic cancer in 26 cases and primary adrenal malignancy in 7. Current median followup, available on 30 patients, was 26 months (range 1 to 69). Overall 15 patients (48%) died and 16 (52%) were alive, of whom 13 (42%) showed no evidence of disease. Cancer specific survival at a median followup of 42 months was 53% and 5-year actuarial survival was 40%. Local recurrence was noted in 7 patients (23%). There were no port site metastases. Survival was similar in patients with tumors less than 5 cm vs 5 cm or greater. Survival was not associated with patient age, tumor size, operative time or surgical approach. Survival was compromised in patients with local recurrence (p = 0.016). CONCLUSIONS: Laparoscopic radical adrenalectomy can be performed with acceptable outcomes in the carefully selected patient with a small, organ confined, solitary adrenal metastasis or primary adrenal carcinoma. To our knowledge the largest series in the literature to date is presented.