Laparoscopic adrenalectomy for large adrenal masses: Is it really more complicated?

A novel method of tunneling retroperitoneoscopic adrenalectomy: a prospective study

BACKGROUND

To introduce the surgical technique and our team's extensive experience with tunnel method in laparoscopic adrenalectomy.

METHODS

From July 2019 to June 2022, we independently designed and conducted 83 cases of " Tunnel Method Laparoscopic Adrenalectomy," a prospective study. There were 45 male and 38 female patients, ages ranged from 25 to 73 years(mean: 44.6 years).The cases included 59 adrenal cortical adenomas, 9 pheochromocytomas, 6 cysts, 4 myelolipomas, 1 ganglioneuroma, and 4 cases of adrenal cortical hyperplasia. In terms of anatomical location, there were 39 cases on the left side, 42 on the right side, and 2 bilateral cases. Tumor diameters ranged from 0.6 to 5.9 cm(mean: 2.9 cm). Utilizing ultrasound monitoring, percutaneous puncture was made either directly to the target organ or its vicinity, and the puncture path was manually marked. Then, under the direct view of a single-port single-channel laparoscope, the path to the target organ in the retroperitoneum or its vicinity was further delineated and separated. This approach allowed for the insertion of the laparoscope and surgical instruments through the affected adrenal gland, thereby separating the surface of the target organ to create sufficient operational space for the adrenalectomy.

RESULTS

All 83 surgeries were successfully completed. A breakdown of the surgical approach reveals that 51 surgeries were done using one puncture hole, 25 with two puncture holes, and 7 with three puncture holes. The operation time ranged from 31 to 105 min (mean: 47 min), with a blood loss of 10 to 220mL (mean: 40 mL). Notably, there were no conversions to open surgery and no intraoperative complications. Postoperative follow-up ranged from 6 to 28 months, during which after re-examination using ultrasound, CT, and other imaging methods, there were no recurrences or other complications detected.

CONCLUSIONS

The completion of the tunnel method laparoscopic adrenalectomy represents a breakthrough, transitioning from the traditional step-by-step separation of retroperitoneal tissues to reach the target organ in conventional retroperitoneoscopic surgery. This method directly accesses the target organ, substantially reducing the damage and complications associated with tissue separation in retroperitoneoscopic surgery, As a result, it provides a new option for minimally invasive surgery of retroperitoneal organs and introduces innovative concepts to retroperitoneoscopic surgery.

Laparoscopic Adrenalectomy: Tailoring Approaches for the Optimal Resection of Adrenal Tumors

In this study, we investigated the outcomes of laparoscopic approaches for adrenal tumor resection in 67 patients from a single center with a median age of 51 (range 40-79). Predominantly comprising women, the majority of patients were overweight or obese. Adrenal tumors larger than 6 cm were mostly treated using the laparoscopic transperitoneal method (p < 0.001). Our results revealed that patients subjected to the retroperitoneal approach exhibited quicker recovery, as evidenced by faster resumption of oral intake and ambulation, along with reduced intraoperative blood loss and shorter hospitalization (p-value < 0.05). In contrast, patients subjected to the transperitoneal approach experienced minimal complications, though not statistically significant, despite the technique's intricacy and slower recovery. These findings emphasize the significance of tailoring the surgical approach to individual patient characteristics, with particular emphasis on the tumor size. The choice between the retroperitoneal and transperitoneal methods should be informed by patient-specific attributes to optimize surgical outcomes. This study underscores the need for a comprehensive evaluation of factors such as tumor characteristics and postoperative recovery when determining the most suitable laparoscopic approach for adrenal tumor resection. Ultimately, the pursuit of individualized treatment strategies will contribute to improved patient outcomes in adrenal tumor surgery.

Clinical Efficacy Analysis of Different Surgical Methods for Giant Adrenal Tumors (≥10 cm): A Single-Center Study of 44 Cases

Objective: The objective of this study was to compare the efficacy and safety of open adrenalectomy (OA) and laparoscopic adrenalectomy (LA) by summarizing the clinical features and treatment experience of giant adrenal tumors. Methods: The clinical data of 44 patients with adrenal tumors ≥10 cm admitted to the Second Hospital of Lanzhou University from January 2006 to August 2022 were retrospectively analyzed. The mean tumor diameter was 11.6 ± 1.8 cm. Regular follow-up was performed to observe the outcome of symptoms and the recurrence after operation. Results: All the 44 patients successfully completed the operation and were divided into the OA group (21 cases) and the LA group (11 cases of transabdominal laparoscopic adrenalectomy [TLA] and 12 cases of retroperitoneal laparoscopic adrenalectomy [RLA]) according to different operation methods. The analysis results showed that the proportion of estimated blood loss (EBL) >100 mL and the postoperative length of stay (PLOS) in the LA group were superior to those in the OA group, and there were no significant differences in other surgical indicators (P > .05); subgroup analysis was conducted for patients in the LA group according to different surgical pathways, and the results showed that there were no significant differences in each surgical indicator between TLA and RLA (P > .05). Among the 44 patients, 15 (34.1%) had intraoperative complications, 19 (43.2%) had postoperative complications, and 5 (21.7%) were converted from LA to OA. The median follow-up time was 68 (5-162) months. Conclusions: For adrenal tumors with diameter ≥10 cm, both LA and OA have relatively large damage to the patients, and the incidence of conversion to open surgery is also high. However, LA is superior to OA in EBL and PLOS. Given the fact that giant adrenal tumors are mainly pheochromocytoma and paraganglioma and have an increased possibility of malignancy, we suggest that the relationship between tumors and peripheral important blood vessels and organs should be carefully evaluated before operation, and the operative methods should be selected according to the experience of the surgeon.

Laparoscopic transperitoneal adrenalectomy in the large adrenal tumor from single center experience

Background

The role of laparoscopic adrenalectomy (LA) in a large adrenal tumor is controversial due to the risk of malignancy and technical difficulty. In this study, we compared the perioperative outcomes and complications of LA on large (≥ 6 cm) and (< 6 cm) adrenal tumors.

Methods

We retrospectively reviewed all clinical data of patients who underwent unilateral transperitoneal LA in our institution between April 2000 and June 2019. Patients were classified by tumor size into 2 groups. Patients in group 1 had tumor size < 6 cm (n = 408) and patient in group 2 had tumor size ≥ 6 cm (n = 48). Demographic data, perioperative outcomes, complications, and pathologic reports were compared between groups.

Results

Patients in group 2 were significant older (p = 0.04), thinner (p = 0.001) and had lower incident of hypertension (p = 0.001), with a significantly higher median operative time (75 vs 120 min), estimated blood loss (20 vs 100 ml), transfusion rate (0 vs 20.8%), conversion rate (0.25 vs 14.6%) and length of postoperative stays ( 4 vs 5.5 days) than in group 2 (all p < 0.001). Group 2 patients also had significantly higher frequency of intraoperative complication (4.7 vs 31.3%; adjust Odds Ratio [OR] = 9.67 (95% CI 4.22–22.17), p-value < 0.001) and postoperative complication (5.4 vs 31.3%; adjust OR = 5.67 (95% CI 2.48–12.97), p-value < 0.001). Only eight (1.8%) major complications occurred in this study. The most common pathology in group 2 patient was pheochromocytoma and metastasis.

Conclusions

Laparoscopic transperitoneal adrenalectomy in large adrenal tumor ≥ 6 cm is feasible but associated with significantly worse intraoperative complications, postoperative complications, and recovery. However, most of the complications were minor and could be managed conservatively. Careful patient selection with the expert surgeon in adrenal surgery is the key factor for successful laparoscopic surgery in a large adrenal tumor.

Trial registration: This study was retrospectively registered in the Thai Clinical Trials Registry on 02/03/2020. The registration number was TCTR20200312004.

Application of data mining for predicting hemodynamics instability during pheochromocytoma surgery

Background

Surgical resection of pheochromocytoma may lead to high risk factors for intraoperative hemodynamic instability (IHD), which can be life-threatening. This study aimed to investigate the risk factors that could predict IHD during pheochromocytoma surgery by data mining.

Method

Relief-F was used to select the most important features. The accuracies of seven data mining models (CART, C4.5, C5.0, and C5.0 boosted), random forest algorithm, Naive Bayes and logistic regression were compared, the cross-validation, hold-out, and bootstrap methods were used in the validation phase. The accuracy of these models was calculated independently by dividing the training and the test sets. Receiver-Operating Characteristic curves were used to obtain the area under curve (AUC).

Result

Random forest had the highest AUC and accuracy values of 0.8636 and 0.8509, respectively. Then, we improved the random forest algorithm according to the classification of imbalanced data. Improved random forest model had the highest specificity and precision among all algorithms, including relatively higher sensitivity (recall) and the highest f1-score integrating recall and precision. The important attributes were body mass index, mean age, 24 h urine vanillylmandelic acid/upper normal limit value, tumor size and enhanced computed tomography difference.

Conclusions

The improved random forest algorithm may be useful in predicting IHD risk factors in pheochromocytoma surgery. Data mining technologies are being increasingly applied in clinical and medical decision-making, and provide continually expanding support for the diagnosis, treatment, and prevention of various diseases.

Large Adrenal Lesion Series in a Tertiary Care Center in Northern India: Diagnostic and Operative Challenges

Large adrenal tumors pose varied challenges to surgeons in terms of diagnosis, planning surgical approach, and also intra-operative difficulties in resection. The aim of this study is to discuss challenges in the management of large and difficult adrenal lesions. A retrospective analysis was done on data of all patients with large adrenal lesions/paragangliomas managed from 1 June 2016 to 30 August 2018. Forty-eight patients with adrenal lesions underwent treatment in 2 years duration. Pain in the abdomen was the most common presentation. Mean age was 34.4 years (range 2-60), female to male (23:25) and right to left side to bilateral tumor 30:16:2. Thirty-one (64.6%) patients had large adrenal masses (size > 6 cm). Surgical approaches included open transperitoneal adrenalectomy (n = 20) and laparoscopic transperitoneal (n = 9 and 2 others had conversion to open procedure). Challenges faced are described in the table below: [Table: see text] There were no major peri-operative morbidities, but two patients died in perioperative period. Large adrenal tumors pose a challenge in surgical planning, approach, and resection and need careful planning and multidisciplinary team approach to have the best outcomes.

Nomogram for predicting severe morbidity after pheochromocytoma surgery

PURPOSE

Although resection is the primary treatment strategy for pheochromocytoma, surgery is associated with a high risk of morbidity. At present, there is no nomogram for prediction of severe morbidity after pheochromocytoma surgery, thus the aim of the present study was to develop and validate a nomogram for prediction of severe morbidity after pheochromocytoma surgery.

METHODS

The development cohort consisted of 262 patients who underwent unilateral laparoscopic or open pheochromocytoma surgery at our center between 1 January 2007 and 31 December 2016. The patients' clinicopathological characters were recorded. The least absolute shrinkage and selection operator (LASSO) binary logistic regression model was used for data dimension reduction and feature selection, then multivariable logistic regression analysis was used to develop the predictive model. An independent validation cohort consisted of 128 consecutive patients from 1 January 2017 and 31 December 2018. The performance of the predictive model was assessed in regards to discrimination, calibration, and clinical usefulness.

RESULTS

Predictors of this model included sex, BMI, coronary heart disease, arrhythmia, tumor size, intraoperative hemodynamic instability, and surgical duration. For the validation cohort, the model showed good discrimination with an AUROC of 0.818 (95% CI, 0.745, 0.891) and good calibration (Unreliability test, P = 0.440). Decision curve analysis demonstrated that the model was also clinically useful.

CONCLUSIONS

A nomogram was developed to facilitate the individualized prediction of severe morbidity after pheochromocytoma surgery and may help to improve the perioperative strategy and treatment outcome.

Minimally invasive adrenalectomy results in equivalent perioperative outcomes versus open adrenalectomy for adrenal mass larger than 6 cm: A retrospective propensity score-matched study

INTRODUCTION

The indication for choosing the minimally invasive approach for large adrenal mass remains controversial. This study is to assess perioperative outcomes after minimally invasive adrenalectomy (MIA) versus open adrenalectomy (OA) for adrenal mass ≥ 6 cm.

MATERIALS AND METHODS

A cohort of 173 patients underwent adrenalectomy for adrenal mass ≥ 6 cm in our urology center between May 2005 and April 2018 was included. MIA was performed in 96 patients, whereas 77 patients underwent OA. We performed a retrospective propensity score-matched study to compare MIA versus OA.

RESULTS

After propensity score-matched, 58 matched pairs of patients identified from each group. There were no significant differences between the groups in postoperative morbidity (p = 0.146), operative time (p = 0.163), intraoperative hypertension (p = 0.248) and drainage time (p = 0.188). Estimated blood loss, the rate of blood transfusions postoperative hospital stay was less in MIA group (p < 0.0001; p = 0.007; p < 0.0001). Total expense was significantly more in the MIA group [49379.28 (38496.69, 68008.69) CNY vs 39951.48 (30666.33, 50292.03) CNY, p = 0.001].

CONCLUSIONS

MIA results in equivalent perioperative outcomes compared with OA and is an effective and safe surgical method for patients with an adrenal mass more than 6 cm in diameter.

Development and validation of a clinical model to predict intraoperative hemodynamic instability in patients with pheochromocytomas surgery

Although currently the primary strategy for the treatment of pheochromocytomas is surgery, it is associated with a high risk of intraoperative hemodynamic instability (IHD), even with adequate preoperative medical preparation, which may result in life-threatening situations. The aim of this study was to develop and validate a nomogram for preoperative prediction of IHD related to pheochromocytoma surgery. The development cohort consisted of 283 patients with pheochromocytoma who underwent unilateral laparoscopic or open adrenaletomy at our center between January 1, 2007 and December 31, 2016. The clinicopathological characteristics of each patient were recorded. The least absolute shrinkage and selection operator binary logistic regression model was used for data dimension reduction and feature selection, while multivariable logistic regression analysis was used to develop the prediction model. An independent cohort consisting of 119 consecutive patients from January 1, 2017 to December 31, 2018 was used for validation. The performance of the prediction model was assessed in regards to discrimination, calibration, and clinical usefulness. The predictors of this model included body mass index, coronary heart disease, tumor size, and preoperative use of crystal/colloid fluid. For the validation cohort, the model showed good discrimination with an area under the receiver operating characteristic of 0.767 (95% CI, 0.667-0.857) and good calibration (unreliability test, p = 0.852; Hosmer-Lemeshow test, p = 0.9309). Decision curve analysis demonstrated that the model was clinically useful. This nomogram to facilitate preoperative individualized prediction of IHD in patients with pheochromocytoma may help to improve the perioperative strategy and treatment outcome.

Development and validation of a predictive model for predicting cardiovascular morbidity in patients after pheochromocytoma surgery

OBJECTIVE

Although surgical resection is the primary treatment method for pheochromocytoma, it carries a high risk of morbidity, especially cardiovascular-related morbidity. There are no models for predicting cardiovascular morbidity after pheochromocytoma surgery. Thus, we developed and validated a model for the preoperative prediction of cardiovascular morbidity after pheochromocytoma surgery.

DESIGN

The development cohort consisted of 262 patients who underwent unilateral laparoscopic or open pheochromocytoma surgery at our centre between 1 January 2007 and 31 December 2016. Patient's clinicopathologic data were recorded. The LASSO regression was used for data dimension reduction and feature selection; then, multivariable logistic regression analysis was used to develop the prediction model. An independent cohort consisting of 112 consecutive patients from 1 January 2017 and 31 December 2018 was used for validation. The performance of this prediction model was assessed with respect to discrimination, calibration and clinical usefulness.

RESULTS

The predictors in this prediction model included body mass index, history of coronary heart disease, tumour size, intraoperative hemodynamic instability and use of crystal/colloid fluids preoperatively. In the validation cohort, the model showed good discrimination with an AUROC of 0.869 (95% CI, 0.797, 0.940) and good calibration (unreliability test, P = .852). Decision curve analysis demonstrated that the model was also clinically useful.

CONCLUSION

This study presented a good nomogram that could facilitate the preoperative individualized prediction of cardiovascular morbidity after pheochromocytoma surgery, which may help improve perioperative strategy and good treatment outcomes.

Risk factors for postoperative cardiovascular morbidity after pheochromocytoma surgery: a large single center retrospective analysis

Surgical resection is the primary treatment strategy for pheochromocytoma; however, it carries a high risk of morbidity and mortality, especially with respect to cardiovascular complications, which is the most common kinds of morbidity. The risk factors for morbidity remain unclear and require further exploration, moreover no studies focus on risk factors for cardiovascular morbidity. Herein we identified the risk factors for cardiovascular morbidity after pheochromocytoma surgery in Chinese patients. We retrospectively reviewed 262 patients who underwent unilateral surgical resection of pheochromocytoma at our center between 1 January 2007 and 31 December 2016. Patient demographics and extensive perioperative data were recorded and evaluated. Adjusted odds ratios and 95% confidence intervals were determined by multivariate logistic regression. Cut-off values and the area under the curve for continuous risk factors were calculated based on receiver operating characteristic curve analysis. A p-value <0.05 was considered statistically significant. Of the 262 patients, 63 (24.0%) had cardiovascular morbidity. The independent risk factors for cardiovascular morbidity were low body mass index, large radiographic tumor size, coronary heart disease, no preoperative crystal/colloid administration, and intraoperative hemodynamic instability; the corresponding odds ratio were 0.762 (p < 0.001), 1.208 (p = 0.010), 2.378 (p = 0.012), 2.720 (p = 0.011), and 4.764 (p = 0.001), respectively. The optimal cut-off values for body mass index and radiographic tumor size were 24.59 kg/m² and 6.05 cm. We found that cardiovascular morbidity is common in patients after pheochromocytoma surgery. We identified five independent risk factors for cardiovascular morbidity. Identification of these risk factors may help to improve treatment strategies.

Retroperitoneal laparoscopic adrenalectomy with transient renal artery occlusion for large adrenal tumors (≥8 cm)

OBJECTIVES

To analyze our experience in retroperitoneal laparoscopic adrenalectomy (RLA) with transient renal artery occlusion for large adrenal tumors (≥8 cm) and to explore the safety and feasibility of this surgical procedure.

METHODS

A retrospective cohort study was conducted with a surgical data review of 18 patients with large adrenal tumors who underwent RLA with transient renal artery occlusion in our hospital.

RESULTS

Eighteen patients were treated by RLA with transient occlusion of the renal artery, and none were converted to open adrenalectomy. The renal artery occlusion time, operative time, estimated blood loss, perirenal drainage time, postoperative hospital stay, and postoperative drainage were 7.6 ± 1.0 min, 176.3 ± 49.7 min, 247.2 ± 274.1 mL, 4.1 ± 1.02 days, 6.3 ± 1.4 days, and 73.6 ± 47.9 mL, respectively. No severe complications occurred, with the exception of hemodynamic instability in one patient with a pheochromocytoma and one transfusion during the operation. Only one case of adrenal crisis occurred postoperatively. Pathological examination revealed 9 cases of pheochromocytoma, 6 cases of adrenal myelolipoma, 1 case of adrenal ganglioneuroma, 1 case of hygromata, and 1 case of adrenal teratoma. No recurrence or evidence of metastasis was observed during the 7-to-30-month follow-up period.

CONCLUSION

RLA with transient renal artery occlusion is a feasible, effective, and safe treatment for large adrenal tumors (≥8 cm).

Preoperative risk factors for massive blood loss in adrenalectomy for pheochromocytoma

Background

This retrospective analysis of patients who underwent adrenalectomy for pheochromocytoma aimed to determine preoperative risk factors for intraoperative massive blood loss. Preoperative identification of patients at high-risk of massive blood loss may be helpful in anesthesia management and preoperative preparation.

Materials and Methods

The study involved data of 268 patients who had undergone pheochromocytoma surgery at the Peking Union Medical College Hospital between January 1, 2013 and October 31, 2016. For analysis, the patients were grouped according to intraoperative blood loss: ≥ 20% of estimated blood volume (group A, n = 38) and < 20% of estimated blood volume (group B, n = 230). Perioperative characteristics were compared between the two groups. Significant variables were selected for a forward stepwise binary logistic regression analysis to determine the independent risk factors for massive blood loss.

Results

The two groups showed significant differences in tumor location, tumor size, operative approach, preoperative 24-hour urine level of total noradrenaline, preoperative hemoglobin concentration, phenoxybenzamine maximum daily dose, preoperative preparation time, intraoperative urine volume, crystalloid and colloidal fluid volumes, allogeneic red blood cell transfusion, plasma and autologous blood transfusion volumes, incidence of prolonged hypotension, postoperative drainage volume, lowest and discharge hemoglobin concentrations, length of stay in intensive care unit and length of postoperative hospitalization. Binary logistic regression analysis indicated increased risk of intraoperative massive blood loss in subjects with tumors proximal to vessels or other organs (odds ratio (OR): 4.227), with tumors ≥ 5 cm (OR: 7.321), or with preoperative preparation time of ≤ 14 days (OR: 17.747).

Conclusions

Tumors proximal to vessels and other organs or with maximum diameter of ≥ 5 cm (as shown by preoperative radiographic evidence), and preoperative preparation time of ≤ 14 days were independent risk factors of intraoperative massive blood loss in patients treated with adrenalectomy for pheochromocytoma.

Patients criteria determining difficulty of the laparoscopic lateral transperitoneal adrenalectomy. A retrospective cohort study

BACKGROUND

Identification of patients in whom adrenalectomy may be more difficult, can help in decision making in borderline and doubtful cases. The aim of the study was to determine patients criteria influencing difficulty of laparoscopic lateral transperitoneal adrenalectomy (LTA).

MATERIAL AND METHODS

The study enrolled 275 patients who underwent LTA. We analyzed the impact of gender, age, history of previous abdominal surgery, body mass index, risk of anesthesia measured as ASA scale, size, localization (left/right), and histological type of the tumor on parameters reflecting the level of difficulty of the procedure: operative time, intraoperative blood loss, conversion rate and intraoperative complications rate.

RESULTS

Multivariate logistic regression showed that following factors were associated with longer operative time: gender, tumor size and malignant lesions. In another model it was shown that age, size of the tumor and malignancy were associated with more excessive blood loss. Moreover, it was shown, that tumor size predictive factor for conversion. Univariate analysis showed a relation with malignancy, but multivariate analysis revealed no significance.

CONCLUSIONS

Patient age, gender, size and histological type of the tumor are criteria influencing parameters reflecting the level of difficulty. This criteria could be considered as predictors of the difficulty of LTA. Surgery in case of patients with combination of this risk factors should be handled by surgeon with sufficient experience to minimalize the risk of adverse events.

Lateral retroperitoneoscopic adrenalectomy for complicated adrenal tumor larger than 5 centimeters

BACKGROUND

The role of lateral retroperitoneoscopic adrenalectomy (LRA) for complicated tumor with large diameter remains controversial, this study aimed to evaluate the effectiveness of this procedure on the management of tumor larger than 5cm in diameter.

METHODS

A retrospective comparison was conducted of 67 patients with large complicated adrenal tumor (>5cm). 41 patients received LRA, and 26 received open adrenalectomy (OA) in our hospital between January 2011 and June 2015. Basic characteristics regarding mean age, gender, body mass index (BMI), tumor size, tumor side, previous abdominal surgery, resection method, pathology were preferentially analyzed. Operative indicators regarding operation time, estimated blood loss (EBL), conversion to ICU, complications, post-operative hospitalization, duration of drain, time to first oral intake and ambulation were compared between groups.

RESULTS

There were no significant differences between the two groups in the basic characteristics. The mean operation time for LRA was shorter than OA (98.7±32.3 min vs 152.7±72.3 min, P = 0.001). EBL was 31.9±20.0 ml for LRA and 590.0±1181.1 ml for OA (P = 0.03). There was no complication in LRA group and one patient in OA group had complications, but this difference was not significant (P = NS). The post-operative hospitalization in LRA was 7.4±2.8 days, and shorter than 9.8±2.7 days in OA group (P = 0.00). The time to first oral intake and ambulation for LRA was shorter than OA (first oral intake, 1.9±0.8 days vs 3.1±1.3 days, P = 0.00; time to ambulation, 2.6±1.4 days vs 4.2±1.6 days, P = 0.00). While the difference between groups were not significant in terms of ICU conversion (3/41 vs 4/26, P = NS) and duration of drain (3.9±2.2 days vs 4.7±1.9 days, P = NS).

CONCLUSION

Our study shows that LRA can be performed safely and effectively for complicated adrenal tumors larger than 5 cm in diameter, but it remains technically demanding.

Adrenalectomy for Cushing's syndrome: do's and don'ts

Aim. To present specific aspects of adrenalectomy for Cushing’s syndrome (CS) by introducing well established aspects (“do’s”) and less known aspects (“don’ts”).

Material and Method. This is a narrative review.

Results. The “do’s” for laparoscopic adrenalectomy (LA) are the following: it represents the “gold standard” for secretor and non-secretor adrenal tumors and the first line therapy for CS with an improvement of cardio-metabolic co-morbidities; the success rate depending on the adequate patients’ selection and the surgeon’s skills. The “don’ts” are large (>6-8 centimeters), locally invasive, malignant tumors requiring open adrenalectomy (OA). Robotic adrenalectomy is a new alternative for LA, with similar safety and conversion rate and lower pain drugs use. The “don’ts” are the following: lack of randomized controlled studies including oncologic outcome, different availability at surgical centers. Related to the sub-types of CS, the “do’s” are the following: adrenal adenomas which are cured by LA, while adrenocortical carcinoma (ACC) requires adrenalectomy as first line therapy and adjuvant mitotane therapy; synchronous bilateral adrenalectomy (SBA) is useful for Cushing’s disease (only cases refractory to pituitary targeted therapy), for ectopic Cushing’s syndrome (cases with unknown or inoperable primary site), and for bilateral cortisol producing adenomas. The less established aspects are the following: criteria of skilled surgeon to approach ACC; the timing of surgery in subclinical CS; the need for adrenal vein catheterization (which is not available in many centers) to avoid unnecessary SBA.

Conclusion. Adrenalectomy for CS is a dynamic domain; LA overstepped the former OA area. The future will improve the knowledge related to RA while the cutting edge is represented by a specific frame of intervention in SCS, children and pregnant women.

Abbreviations: ACC = adrenocortical carcinoma, ACTH = Adrenocorticotropic Hormone, CD = Cushing’s disease, CS = Cushing’s syndrome, ECS = Ectopic Cushing’s syndrome, LA = laparoscopic adrenalectomy, OA = open adrenalectomy, PA = partial adrenalectomy, RA = robotic adrenalectomy, SCS = subclinical Cushing’ syndrome