Laparoscopic Adrenalectomy is Feasible for Large Adrenal Masses > 6cm

Outcomes of Minimally Invasive Adrenalectomy for Large Adrenal Masses: A Multi-Centre Experience in Saudi Arabia

Introduction Advancements in radiological imaging technology have increased the discovery of adrenal incidentalomas. Large adrenal tumors (LATs) are not common, and the likelihood of malignancy increases with tumor size. LATs were defined as tumors larger than four centimeters (cm) with various pathologic diagnoses. Traditionally, open adrenalectomy was considered the gold standard for LATs, but with recent advancements in minimally invasive surgery (MIS), optimum perioperative and long-term outcomes are achievable by the MIS approach. The findings presented in this paper show that even large adrenal masses measuring up to 21 centimeters can be safely removed using a minimally invasive approach. Methodology After Institutional Review Board (IRB) approval, we reviewed medical records of adult patients who had adrenalectomies at two Saudi Arabian centers from January 2013 to February 2023. Inclusion criteria were laparoscopic or robotic adrenalectomy and adrenal lesions ≥5cm. Pediatric patients and those with open adrenalectomies were excluded. Pre-surgery, patients had imaging studies to assess mass characteristics. Pheochromocytoma patients received a 2-week adrenergic blocker treatment. Perioperative data including demographics, comorbidities, mass characteristics, surgery details, and follow-up were analyzed using SPSS-23. Patients provided informed consent and had follow-up appointments and imaging. Results Our experience involved 35 patients, 29 of whom received laparoscopic treatment and six of whom underwent robotic surgery. Of the 35 patients, more than half were females (57.1%), with a mean age of 41.7±14.9 years, the youngest and oldest participants being 16 and 73 years of age, respectively. The mean body mass index (BMI) of the participants was in the overweight range (26±6.0 kg/m2). The most common mode of presentation was incidental (42.9%), followed by hypertension (17.1%). Most patients had right-sided adrenal gland involvement (48.6%), with only four patients showing bilateral involvement. Most of the patients were classified as American Society of Anesthesiology score (ASA) 2 (40.0%) or ASA 3 (40.0%). Most of the patients were diagnosed with myelolipoma or adenoma (22.9% each) followed by pheochromocytoma (17.1%). The average estimated blood loss (EBL) was 189.3±354.6 ml for patients who underwent laparoscopic surgery and 80.0 ±34.6 ml for patients who underwent robotic surgery. The average operative room time (ORT) was 220.1±98.7 minutes (min) for laparoscopic surgery and 188.3±10.3 min for robotic surgery. One patient had to be converted from laparoscopic to open surgery due to aortic injury. The average length of stay (LOS) was 9.5±6.7 days for laparoscopic treatment and 5.5±1.9 days for robotic surgery. The mean tumor size in the greatest dimension was 8.0±4.4 cm. Only one patient who underwent unilateral laparoscopy experienced perioperative complications and converted to open surgery; nine patients who underwent unilateral laparoscopy required blood transfusion, and none of the patients who underwent robotic surgery required transfusion. None of the 35 patients experienced a recurrence of their adrenal disease during the mean follow-up period which lasted around 58 months. Conclusion MIS in Saudi Arabia is growing and is a safe method for LATs, with satisfactory surgical results compared to the traditional open surgery approach. It offers advantages in terms of EBL, complications, and disease recurrence.

Management of Adrenal Masses

An adrenal mass can be either symptomatic or asymptomatic in the form of adrenal incidentalomas (AIs) in up to 8 % in autopsy and 4 % in imaging series. Once a diagnosis of adrenal mass is made, we need to differentiate whether it is functioning or nonfunctioning, benign, or malignant. In this article, we provide a literature review of the diagnostic workup including biochemical evaluation and imaging characteristics of the different pathologies. We also discuss the surgical strategies with laparoscopy as the mainstay with partial adrenalectomy in select cases and adrenalectomy in large masses. Follow-up protocol of AIs and adrenocortical carcinoma is also discussed.

Applicability of laparoscopic approach to the resection of large adrenal tumours: a retrospective cohort study on 200 patients

BACKGROUND

Controversies exist in the best surgical approach (open vs. laparoscopy) to large adrenal tumours without peri-operative evidence of primary carcinoma, mainly due to possible capsular disruption of an unsuspected malignancy. In addition, intra-operative blood loss, conversion rate, operative time, and hospital stay may be increased with laparoscopy.

THE AIMS OF OUR STUDY WERE

(1) to compare clinical outcomes of laparoscopic adrenalectomy for large versus small adrenal tumours and (2) to identify risk factors associated with increased operative time and hospital stay in laparoscopic adrenalectomy.

METHODS

This is a multicentre retrospective cohort study in a large patient population (N = 200) who underwent laparoscopic adrenalectomy in 2004-2014 at three Italian academic hospitals. Patients were divided into two cohorts according to tumour size: "large" tumours were defined as ≥5 cm (N = 50) and "small" tumours as <5 cm (N = 150). Further analysis adopting a ≥8 cm (N = 15) cut-off size was performed.

RESULTS

The study groups were comparable in age and gender distribution as well as their tumour characteristics. The operative time (p = 0.671), conversion rate (p = 0.488), intra- (p = 0.876) and post-operative (p = 0.639) complications, and hospital stay (p = 0.229) were similar between groups. With a cut-off size ≥5 cm, the early study period (2004-2009), which included operators' learning curve, was associated with increased risk of longer operative time (HR 0.57; 95 % CI 0.40-0.82), while American Society of Anaesthesiology score ≥3 was associated with prolonged hospital stay (HR 0.67; 95 % CI 0.47-0.97). Tumour size ≥8 cm was associated with prolonged operative time (HR 0.47; 95 % CI 0.24-0.94).

CONCLUSIONS

Surgeons skilled in advanced laparoscopy and adrenal surgery can perform laparoscopic adrenalectomy safely in patients with ≥5-cm tumours with no increase in hospital stay, or conversion rate, although operative time may be increased for ≥8-cm tumours. Surgeon' experience, size ≥8 cm, and patient comorbidities have the largest impact on operative time and length of hospital stay in laparoscopic large adrenal tumour resection.

A 10-year single-center experience with surgical management of adrenal myelolipoma

OBJECTIVE

The purpose is to report our 10-year experience with surgical management of large or symptomatic adrenal myelolipoma.

PATIENTS AND METHODS

Patients receiving surgical treatment for adrenal myelolipoma between December 2001 and September 2011 in our institution were retrospectively reviewed. Patients were divided into two groups: open surgery and laparoscopic surgery. Patient demographic data, lesion size evaluated by computed tomography scan or magnetic resonance imaging, operation time, blood loss, time of returning to diets, perioperative complications, and length of hospital stay were collected and analyzed.

RESULTS

Forty patients (14 received open surgery and 26 received laparoscopic surgery) were enrolled in our study. Both procedures were successful and no patient in the retroperitoneal laparoscopic group required conversion to open surgery. The mean age of the patients was 52.7 years. The median size of the tumor was 5.0 cm. Forty-three percent of patients suffered from lumbago. There was no statistical difference in perioperative complications between the two groups (p>0.05). Retroperitoneal laparoscopic adrenalectomy patients had a shorter operation time (90.66±37.97 min vs 141.82±62.78 min, p=0.017), less blood loss (150, 100-200 mL vs 450, 300-525 mL, p=0.000), earlier time of returning to diets (2, 2-3 days vs 3, 2-4.5 days, p=0.036), and a shorter hospital stay (6, 5-7 days vs 10, 8-11.25 days, p=0.000) when compared with open surgery patients.

CONCLUSION

Both open and laparoscopic surgeries are efficient and safe treatments for large or symptomatic adrenal myelolipoma, and retroperitoneal laparoscopic surgery has the advantages of minimal invasion and rapid postoperative recovery.

Primary adrenal hypercortisolism: minimally invasive surgical treatment or medical therapy? A retrospective study with long-term follow-up evaluation

BACKGROUND

Because the most suitable management of subclinical Cushing syndrome (SCS, which involves hypersecretion of cortisol without clinically evident disease) still is undefined, the current study aimed to compare retrospectively the outcome for a cohort of patients treated by medical therapy or laparoscopic adrenalectomy (LA).

METHODS

Over a 12-year period, 47 patients with SCS have been treated by means of LA (19 patients, group A) or medical therapy (28 patients, group B). Group A consisted of 15 women and 4 men with a mean age of 54.8 years. Eight patients had a left adrenal mass, whereas nine had a right adrenal mass, and one patient had bilateral lesion. Group B was composed of 18 women and 10 men with a mean age of 57.8 years. Of these patients, 14 had a left adrenal lesion, 12 had a right adrenal lesion, and 1 had bilateral lesion. The patients were followed up for a mean 4 years (range, 1-11 years) by both an endocrinologist and a surgeon.

RESULTS

In group A, hypertension improved for 66.3% of the patients; body mass index (BMI) decreased for 47.4%; and hyperlipidemia based on high-density lypoproteins (HDL) cholesterol, total cholesterol ratio, and triglyceridemic concentration improved for 63.2% of the patients. No changes in bone parameters were seen after surgery in SCS patients with osteoporosis. Some patients in group B, during their long-term medical therapy, experienced worsening hypertension (14.2%), hyperlipidemia (17.8%), and diabetes mellitus (8%).

CONCLUSIONS

This retrospective study focused on a cohort of patients with SCS. Their medium long-term follow-up evaluation showed that LA is better than medical therapy for treating this condition, especially by reducing the cardiovascular risk (hypertension-hyperlipidemia).

Laparoscopic adrenalectomy for large adrenal masses: pushing the envelope

PURPOSE

To determine the role of laparoscopy for large adrenal tumors in terms of outcomes, pathology, operative time, and morbidity.

PATIENTS AND METHODS

A retrospective review of 24 patients who underwent laparoscopic adrenalectomy was performed to record the size of the lesions, surgical techniques used, operative times, estimated blood loss, duration of hospital stay, need for blood transfusion, conversion to open surgery, and complications. The laparoscopic adrenalectomy patients were divided into two groups based on tumor size: <8 cm (n = 16, group 1) and >or=8 cm (n = 8, group 2).

RESULTS

Mean tumor size was 5.6 cm for group 1 and 12.1 cm for group 2. Mean operative times were 143.12 and 188.75 minutes for groups 1 and 2, respectively. Mean estimated blood loss was 89.69 mL for group 1 and 334.38 mL for group 2. Operative time and blood loss were significantly higher in group 2. Pathologic examination revealed eight adrenal cortical adenomas, five myolipomas, four pheochromocytomas, four cysts/pseudocysts, and three adrenocortical hyperplasias. No significant difference was found between groups concerning transfusion rates, duration of hospital stay, and conversion to open surgery.

CONCLUSION

Laparoscopic adrenalectomy is a feasible procedure for large masses but results in longer operative times and higher total blood loss when compared with results for masses smaller than 8 cm. Our findings suggest, however, that laparoscopic adrenalectomy for masses larger than 8 cm can produce comparable results concerning hospital stay, conversion to open surgery rate, and pathologic outcome in comparison with results for adrenal masses smaller than 8 cm.

Laparoscopic adrenalectomy for large adrenal masses

Open adrenalectomy has been the gold-standard therapy for adrenal neoplasms. Minimally invasive treatments, however, have assumed a more central role in the management of these lesions. The traditional benefits of laparoscopy, including reduced blood loss, shorter hospital duration, and improved convalescence, extend to adrenal disease without compromising the oncologic efficacy of the surgery. Contemporary series suggest that minimally invasive surgery is also a reasonable therapeutic modality for larger adrenal masses. Laparoscopic adrenalectomy for these large masses is a technically demanding procedure that should be undertaken by experienced laparoscopic surgeons familiar with retroperitoneal anatomy and adept with vascular techniques in the event of an open conversion. Oncologic outcomes collectively suggest that in the setting of adequate surgical resection, recurrence patterns relate more to disease-process biology than surgical approach. Neither size criteria, suspicion of malignancy, nor locally invasive disease should be considered an absolute contraindication to laparoscopic adrenalectomy.

Retrospective comparison of retroperitoneoscopic versus open adrenalectomy for pheochromocytoma

PURPOSE

We compared the clinical outcomes of retroperitoneoscopic and open adrenalectomy for pheochromocytoma.

MATERIALS AND METHODS

Clinical data on 56 patients who underwent retroperitoneoscopic lateral adrenalectomy were retrospectively compared with those on 50 who underwent open adrenalectomy for pheochromocytoma, including patient demographic data, perioperative indexes and clinical outcomes.

RESULTS

Demographic data on patients were similar in the 2 groups. In the retroperitoneoscopic group such perioperative indexes were significantly different from those of the open group (each p <0.05), including operative time (mean +/- SD 52 +/- 22 vs 120 +/- 42 minutes), estimated blood loss (74 +/- 34 vs 187 +/- 64 ml), resumption of oral intake (1 vs 2 days), postoperative hospital stay (5.2 +/- 1.7 vs 8.3 +/- 1.8 days), incidence of intraoperative hypertension (17.0% or 9 of 53 patients vs 36.0% or 18 of 50) and number of patients requiring blood transfusion(1.8% or 1 of 53 vs 16.0% or 8 of 50). The incidence of systemic inflammatory response syndrome was much less in the retroperitoneoscopic group (20.8% or 11 of 53 patients vs 42.0% or 21 of 50, p <0.05). However, the duration of systemic inflammatory response syndrome and postoperative complications were similar in the 2 groups (p >0.05). Blood pressure returned to normal 3 months after the operation in 81% of the patients in the retroperitoneoscopic group and in 84% in the open group. During the followup of 5 to 36 months no tumor recurrence and/or metastasis developed.

CONCLUSIONS

Compared with open surgery retroperitoneoscopic lateral adrenalectomy for pheochromocytoma is a safe, minimally invasive and effective procedure.

Outcomes of laparoscopic adrenalectomy. Clinical experience with 68 patients

The aim of this study was to analyze feasibility and outcomes of laparoscopic adrenalectomy (LA). Pathology, size and bilateral site of lesions were considered. Between December 1998 and May 2007 in our institution a total of 68 patients of mean age of 53 years underwent unilateral (n=57) or bilateral (n=11) LA. Adrenal masses averaged 5.4cm in size (range 1.2-13cm) and 56.7g in weight (range 10-265) including 71 benign and 8 malignant lesions. A total of 79 adrenal glands were resected, 44 right sided and 35 left sided. Removal was complete in 77 cases and partial (sparing adrenalectomy) in 1 patient affected by bilateral pheochomocytoma. Three left adrenalectomies for pheochromocytoma were robot-assisted. The transperitoneal lateral approach was preferred and the posterior retroperitoneal approach was adopted in 5 patients. The mean duration of surgery for each LA was 138+/-90min and 3.8 trocar were used on average (range 3-6). Conversion was needed in 3 cases owing to difficult dissection of large masses. Estimated mean blood loss for each LA was 95+/-30ml and it was greater for bilateral LA. Mortality was nil and morbidity was 5.8%. The average length of hospital stay (LOS) in surgical unit was 4+/-2.4 days (range 2-8). Patients affected by hormone secreting or bilateral lesions, by unilateral or bilateral pheochromocytoma and by bilateral Cushing's disease were transferred to the endocrinological ward so that their overall hospital stay was prolonged to 9+/-2.8 days on average (range 7-17). Mean duration of follow-up of patients was 38 months (range 2-100) and demonstrated acceptable endocrine results. Three primary cortical carcinomas were discovered as chance findings on histologic examination. While long-term results after LA for cortical carcinomas were poor and LA is not recommended in such cases, long-term results after LA for adrenal metastases were encouraging.