Laparoscopic adrenalectomy for pheochromocytoma: a literature review

[Surgical treatment of pheochromocytoma]

This review article contains a summary of modern aspects of preoperative preparation, surgical treatment, and follow-up of patients with adrenal pheochromocytomas. The main component of preoperative preparation is the use of alpha-blockers. The need to prescribe them to all patients is increasingly disputed, especially for patients without severe hypertension. An increasing number of publications demonstrate positive results of treatment without the use of alpha-blockers, advocating an individual approach and the use of the drug according to certain indications. Minimally invasive endoscopic techniques of adrenalectomy have become widespread in surgical treatment. They are represented by laparoscopic and retroperitonescopic technic, including using their single-port modifications. The earliest possible intersection of the central vein in the past was considered the most important aspect of adrenalectomy for pheochromocytoma, currently, due to the development of surgical techniques and anesthesiological manuals, this has ceased to be a mandatory rule of successful surgery. Despite the significant influence of the intersection of this vessel on intraoperative hemodynamics, surgical tactics with its later intersection have their own justifications and do not lead to a deterioration in treatment results. The standard volume of surgical intervention for pheochromocytomas is total adrenalectomy, however, in the presence of hereditary syndromes, such as multiple endocrine neoplasia type 2 syndrome, neurofibomatosis type 1, von Hippel-Lindau syndrome, it is possible to perform cortical-sparing adrenalectomy.

Adrenalectomy for Adrenal-mediated Hypertension: National Surgical Quality Improvement Program Analysis of an Institutional Experience

Adrenal-mediated hypertension (AMH) has been increasingly treated by laparoscopic adrenalectomy (LA). Metabolic derangements in patients with AMH could result in perioperative complications and mortality. Long-term operative and clinical outcomes after laparoscopic treatment of AMH have not been evaluated using large clinical databases. The institutional National Surgical Quality Improvement Program (NSQIP) data for patients undergoing adrenalectomy for AMH between 2002 and 2012 were reviewed. Patient demographics, perioperative variables, and outcomes were analyzed and compared with national NSQIP adrenalectomy data. Improvement in AMH was recorded when discontinuation or reduction of antihypertensive medication occurred or with a decrease of blood pressure on the preoperative antihypertensive regimen. Ninety-four patients underwent adrenalectomy. There were 48 patients with pheochromocytoma (PHE) and 46 patients with aldosterone-producing adenoma (APA). Eighty-five patients (90%) were taking antihypertensive medications preoperatively compared with 36 patients (38%) post-operatively ( P < 0.0001). Patients with PHE were more likely to discontinue all medications compared with the patients with APA (80 vs 20%, respectively, P < 0.0001). Patients with PHE and APA, respectively, took an average of 2.0 and 3.2 antihypertensive medications preoperatively compared with 0.3 and 1.2 postoperatively. There were no conversions to open procedures or 30-day mortality. Our results were 0 per cent for cerebral vascular accident, 0 per cent for myocardial infarction, and 0.5 per cent for transfusions compared with the national NSQIP data of 0.2, 0, and 6.7 per cent, respectively. Patients presenting with significant AMH including PHE and APA can be effectively and safely treated with LA with minimal complications and with a significant number of patients eliminating or decreasing their need for antihypertensive medications.

The utility of cortical-sparing adrenalectomy in pheochromocytomas associated with genetic syndromes

Management of pediatric patients with pheochromocytomas associated with genetic syndromes, such as Von Hippel-Lindau (VHL) disease, is complex owing to the need for continuous surveillance, high rates of recurrence, multiple operations during childhood, and the possibility of lifelong exogenous steroid replacement. We report the successful treatment of two siblings with VHL who underwent a total of six cortical-sparing procedures without requiring steroid therapy.

[A clinical study of laparoscopic adrenalectomy for pheochromocytoma--analysis of clinical parameters influencing operative time and intraoperative systolic blood pressure]

PURPOSE

We retrospectively analyzed the preoperative clinical parameters which influence operative time and intraoperative maximum systolic blood pressure in patients undergoing laparoscopic adrenalectomy for pheochromocytoma.

MATERIALS AND METHODS

Between January 1992 and September 2010, we performed 28 laparoscopic adrenalectomies for pheochromocytoma at Hamamatsu University School of Medicine. These 28 cases were characterized based on the following parameters: body mass index (BMI), tumor size, history of hypertension, preoperative blood pressure, serum concentration of catecholamine, and 24-h urinary excretion of catecholamine metabolite. We retrospectively analyzed whether or not these parameters influenced operative time or intraoperative maximum systolic blood pressure.

RESULTS

All 28 cases of laparoscopic adrenalectomy were performed safely and without intraoperative complications and needed neither blood transfusion nor conversion to laparotomy. The median operative time was 203 minutes, and intraoperative hypertension (systolic blood pressure > 200 mmHg) occurred in 46% (13/28) of cases. Median day of discharge in all patients was post-operative day 5. Significant positive correlation was shown between tumor size and operative time and between intraoperative maximum systolic blood pressure and serum concentration of catecholamine or 24-h urinary excretion of catecholamine metabolite (p < 0.05).

CONCLUSION

The lengthened operative time for large tumors and elevated intraoperative blood pressure for tumors with high preoperative catecholamine activity necessitate careful perioperative management in patients receiving laparoscopic adrenalectomy for pheochromocytoma.

Comparison of robot-assisted laparoscopic adrenalectomy with traditional laparoscopic adrenalectomy - 1 year follow-up

BACKGROUND

Laparoscopic adrenalectomy offers distinct benefits to patients and has now become the gold standard for the removal of adrenal lesions. Nonetheless, the procedure poses a challenge for surgeons in regards to the maneuverability of instruments, the two-dimensional operating field and the counterintuitive movements. This study reports our experience using the Zeus robotic surgical system in laparoscopic adrenalectomy compared with traditional laparoscopic adrenalectomy.

PATIENTS AND METHODS

From January 2003 to February 2005, a total of 12 patients were prospectively enrolled to receive robot-assisted laparoscopic adrenalectomy (RALA) or traditional laparoscopic adrenalectomy (TLA). The time necessary for robotic setup and operation was recorded, as well as complications, technical problems, postoperative hospital stay, morbidity, and mortality.

RESULTS

Five RALA procedures and seven TLA were successfully completed. There was no significant difference between the groups in terms of age, body mass index, and tumor size. Resection times were longer in the RALA group (168.0 +/- 30.7 min vs. 131.4 +/- 29.0 min, p = 0.05). There were no perioperative complications. There was neither postoperative mortality nor morbidity at the time of discharge and during one year follow-up.

CONCLUSIONS

RALA is as safe and technically feasible as TLA, It provides a real benefit for the surgeon with the three dimensional view, a comfortable sitting position, the elimination of the surgeon's tremor, and increased degrees of freedom of the operative instruments compared with TLA. However, patient outcomes and operative costs should be evaluated further.

Retroperitoneoscopic Adrenalectomy Without Previous Control of Adrenal Vein Is Feasible and Safe for Pheochromocytoma

OBJECTIVES

To evaluate the effectiveness and safety of retroperitoneal laparoscopic adrenalectomy for pheochromocytoma and report our experience in adrenalectomy without previous control of the adrenal vein.

METHODS

From January 2000 to December 2005, 56 patients underwent 58 retroperitoneal laparoscopic adrenalectomy procedures for the treatment of pheochromocytoma. Adequate preoperative antihypertensive preparation was performed. Intraoperative hemodynamic changes were documented in detail. During surgery, the adrenal vein was identified and ligated after dissection and mobilization of the adrenal gland.

RESULTS

One patient required conversion to open surgery. The mean operative time and estimated blood loss was 50.4 +/- 19.8 minutes (range 25 to 150) and 76.4 +/- 23.5 mL (range 20 to 300), respectively. A systolic blood pressure greater than 200 mm Hg or less than 80 mm Hg was observed in 6 and 3 patients, respectively. Moreover, an upward fluctuation of systolic blood pressure (20 mm Hg or greater) was recorded during laparoscopic manipulation in 21 patients (37.5%), and in 8 of them, it was 50 mm Hg or greater. The mean diameter of the excised masses was 4.6 +/- 1.7 cm (range 1.5 to 10.0). The mean hospital stay was 5.2 +/- 1.3 days (range 3 to 9). No patients had a major complication and none died. During the follow-up period of 5 months to 3 years, 36 patients recovered normal blood pressure without antihypertensive drugs. No tumor recurrences developed.

CONCLUSIONS

Retroperitoneal laparoscopic adrenalectomy without previous control of the adrenal vein is effective and safe for ablation of pheochromocytoma. For experienced surgeons, the tumors larger than 6 cm in diameter can also be removed using the retroperitoneal endoscopic approach.

Transperitoneal, Transmesocolic Approach for Laparoscopic Excision of an Extra-adrenal Pheochromocytoma

Laparoscopic surgery is an established treatment modality for adrenal disease, especially pheochromocytomas. We describe the successful excision of an extra-adrenal pheochromocytoma using a novel transperitoneal, transmesocolic approach. The tumor was located inferior to the left renal hilum in the para-aortic region and was found bulging through the descending mesocolon at laparoscopy. The tumor was removed without mobilization of the descending colon.

Laparoscopic Adrenal Surgery: New Frontiers

After about 10 years of experience, laparoscopic adrenalectomy has become the gold standard for the treatment of adrenal lesions. Here, we describe the presenting features, imaging methods, and current surgical approaches to diseases of the adrenal gland. There is general agreement on the suitability of the laparoscopic approach for benign adrenal lesions, but controversy exists about using laparoscopy for suspected adrenal malignancy, metastasis, and partial adrenalectomy. This article reviews the literature on laparoscopic adrenalectomy. In particular, we focus our attention on the new surgical approaches to the gland. We evaluate the indications, operative techniques, and tools for partial adrenalectomy, and we discuss new surgical strategies such as cryosurgery and radiofrequency ablation.

Should pheochromocytoma size influence surgical approach? A comparison of 90 malignant and 60 benign pheochromocytomas

BACKGROUND

Diagnostic tests cannot reliably distinguish malignant from benign pheochromocytomas. Laparoscopic adrenalectomy for pheochromocytomas >6 cm is controversial because of a perceived increased risk of malignancy that is based on anecdotal reports and small series. The aim of this study was to determine if pheochromocytoma size should affect the choice of surgical approach.

METHODS

Malignant pheochromocytomas in the Surveillance Epidemiology and End Results (SEER) database (1988-2000) were compared to benign pheochromocytomas in our institutional database (1993-2003). The sensitivity, specificity and likelihood ratio for tumor size to predict malignancy were calculated for both groups.

RESULTS

Ninety malignant and 60 benign pheochromocytomas were compared. Overall, malignant pheochromocytomas were larger than benign pheochromocytomas (7.6 +/- 4.2 cm vs 5.3 +/- 2.3 cm). However, tumor size was not significantly different between malignant pheochromocytomas without local invasion or metastases and benign pheochromocytomas (6.1 +/- 3.1 cm vs 5.3 +/- 2.3 cm). In pheochromocytomas with local disease only, maximum likelihood ratio to predict malignancy was at a tumor size of greater than 8 cm (2.84).

CONCLUSIONS

Although risk of malignancy increases with size for all pheochromocytomas, size does not reliably predict malignancy in pheochromocytomas with local disease only. Regardless of tumor size, laparoscopic adrenalectomy for pheochromocytoma should be converted to open adrenalectomy for difficult dissection, invasion, adhesions, or surgeon inexperience.

Laparoscopic adrenalectomy for malignancy

Laparoscopic adrenalectomy for primary malignancies and tumors metastatic to the adrenal is controversial. Most studies demonstrate that results of laparoscopic adrenalectomy for malignant lesions are similar to those of open adrenalectomy, without its morbidity. The results of laparoscopic adrenalectomy for tumor metastases suggest that it may benefit patients who have a metachronous metastasis from any of a variety of primary tumors. Selective laparoscopic adrenalectomy for potentially malignant tumors requires seeking signs of local invasion, lymphadenopathy, or distant metastasis; there are no other reliable preoperative criteria of malignancy. Diagnostic laparoscopy may be useful, and in some cases, may establish a diagnosis. Laparoscopic adrenalectomy should be cautiously performed, with the goals of achieving complete tumor resection without disruption of the adrenal capsule.

Laparoscopic Adrenalectomy for Pheochromocytoma: Comparison with Conventional Open Adrenalectomy

PURPOSE

To compare the effectiveness and efficacy of laparoscopic transperitoneal adrenalectomy (LTA) with those of open adrenalectomy (OA) in patients with pheochromocytoma.

PATIENTS AND METHODS

Among 24 patients (13 male, 11 female) who underwent surgical removal of pheochromocytoma, LTA and OA were performed in 15 and 9, respectively. The mean age was 45.2 years in the LTA group and 43.3 years in the OA group, and the mean tumor size was 5.2 +/- 2.0 (SE) cm and 6.4 +/- 2.6 cm, respectively. Retrospective analysis of their clinical outcomes was performed. The mean follow-up for OA and LTA groups was 36 months and 22 months, respectively.

RESULTS

The mean operative time was 171 +/- 66.7 minutes in the LTA group and 200 +/- 73.3 minutes in the OA group. The mean blood loss was 189.5 +/- 50.4 mL and 397.1 +/- 144.7 mL, respectively (P = 0.0341). The mean number of intraoperative hypertensive crises was 0.6 +/- 0.5 during LTA and 1.67 +/- 1.1 during OA (P = 0.0146). In the LTA group, there were no conversions to open surgery and no intraoperative complications, and the blood pressure was well managed intraoperatively without medication. The mean time to oral intake was 1.1 +/- 0.3 days after LTA and 2.6 +/- 1.3 days after OA (P = 0.0037). The mean postoperative hospital stay was 5.6 +/- 2.0 days in the LTA group and 12.4 +/- 3.5 days in the OA group (P = 0.0001). Patient-controlled analgesia was needed by 2 patients (13.3%) in the LTA group and 6 (66.7%) in the OA group (P = 0.0413). In the OA group, three pneumothoraces and one case of sepsis occurred. After a mean follow-up of 36 months, two patients in the OA group redeveloped hypertension. With a mean follow-up of 22 months, none of the 15 LTA patients redeveloped hypertension.

CONCLUSIONS

Laparoscopic adrenalectomy for pheochromocytoma is a safe and effective prodcedure providing the benefits of a minimally invasive approach.

The Impact of Minimally Invasive Surgical Techniques

The use of minimally invasive techniques (MIT) in patient care is well documented in ancient history; however, it was not until the 1990s that advancements in technology enabled surgeons to realize the true potential of this approach. The minimally invasive approach has revolutionized surgical care, significantly reducing postoperative pain, recovery time, and hospital stays with marked improvements in cosmetic outcome and overall cost-effectiveness. It is now used around the world and in all major fields of surgery, compelling changes in training programs in order to assure quality control and patient safety. The bond between surgeons practicing minimally invasive surgery (MIS) and the high-tech industry is of utmost importance to future developments. Surgical robotic systems represent the most technologically advanced product of this collaboration, and their potential application in MIS shows much promise. As technology advances, additional developments in MIT are likely.

Pheochromocytoma and functional paraganglioma

PURPOSE

Pheochromocytomas and paragangliomas are rare tumors of chromaffin cell origin. Their identification is likely increasing owing to the increased use of radiographic images detecting incidental adrenal masses.

RECENT FINDINGS

The pathophysiology of hypertension induced by the release of catecholamines and newly discovered peptides has been shown to be more complex than the concept of episodic catecholamine release.

SUMMARY

This review looks at the most recent advances in the physiology and molecular basis of these tumors.

Laparoscopic adrenalectomy--indications and technique

Laparoscopic adrenalectomy has become the procedure of choice for the surgical management of most adrenal tumors, including functional and non-functional lesions. The role of laparoscopic adrenalectomy in the management of malignant adrenal tumors is controversial and most adrenocortical cancers are generally treated by open adrenalectomy. Laparoscopic adrenalectomy can be performed by both the anterior or lateral trans-abdominal approach and by the lateral or posterior retro-peritoneal approach, with each method being suitable for specific indications. Although there are no randomized trials comparing laparoscopic with open adrenalectomy, the laparoscopic approach is associated with shorter hospital stay, reduced pain and improved cosmesis. This review discusses the indications and contraindications, technique and outcomes for laparoscopic adrenalectomy.