Laparoscopic adrenalectomy in Cushing's syndrome and pheochromocytoma

Does size still matter? - Feasibility of posterior retroperitoneoscopic adrenalectomy for tumors >6cm

PURPOSE

Retroperitoneoscopic adrenalectomy (RPA) has proven to be safe and feasible with favorable postoperative courses. The role of RPA for tumor sizes larger than 6 cm is still controversial. The aim of the study was to evaluate the postoperative outcome for removal of larger adrenal tumors via the retroperitoneoscopic route.

METHODS

In this retrospective study, from 105 conducted RPA procedures, thirteen patients with adrenal tumor sizes larger than 6 cm received RPA in our hospital between January 2017 and December 2020. Clinicopathological factors, length of hospital stay, operative time and postoperative outcomes were included in this analysis.

RESULTS

From this patient cohort, six (46.15%) were female and seven (53.85%) were male with a mean age of 53.85 ± 7.89 years and a mean BMI of 28.64 ± 3.61 kg/m2, Cushing's syndrome being the most common diagnosis (53.85%). Mean lesion size was 73.31 ± 10.39 mm, tumor size varied from 60 mm up to 92 mm. Two patients (15.38%) required conversion to open laparotomy due to uncontrollable bleeding or an unclear view on the basis of adhesions. Postoperative complications were noted for one patient (7.69%), who suffered from a small superficial wound infection. Neither capsule ruptures nor mortality were documented. The median hospital stay was 3 days.

CONCLUSION

A re-evaluation of the arbitrarily placed cut-off should be discussed, since even with a slightly higher but nevertheless acceptable risk of conversion rate, RPA offers many advantages.

Robotic vs. Laparoscopic Adrenalectomy for Pheochromocytoma-A Systematic Review and Meta-Analysis

Background: The application of robotic adrenalectomy (RA) has been increasing. However, there is still controversy about whether RA is more feasible than laparoscopic adrenalectomy (LA) for pheochromocytoma (PHEO). Methods: We conducted a systematic review of published articles between 2013 and 2025 according to the PRISMA statement and the Cochrane Handbook for systematic reviews of interventions. The search was conducted in MEDLINE (PubMed, Scholar, and Cochrane databases). Results: Overall, seven studies including 879 patients (RA 358; LA 521) were included. RA might have larger tumor size (MD -0.66, 95% CI -1.18 to 0.13; p < 0.00001) but not for BMI patients (MD -0.24, 95% CI -1.44 to 0.96; p < 0.00001). There were no statistically significant differences in intraoperative complication, conversion to open surgery, postoperative complications, transfusion rate, and perioperative hemodynamic outcomes with the exception of a higher lowest systolic blood pressure in the LA group (MD -1.09, 95% CI -2.35 to 0.18; p < 0.00001). Moreover, estimated blood loss (MD 29.52, 95% CI 4.19 to 54.84; p < 0.00001), operative time (MD 3.85, 95% CI -16.11 to 23.80; p < 0.00001), and the length of hospital stay were in favor of RA (MD 0.42, 95% CI 0.09 to 0.74; p < 0.0001). Conclusions: Both LA and RA are safe and feasible approaches for adrenalectomy in the case of pheochromocytoma. RA seems to have better perioperative results, but further prospective randomized control studies are required to draw definitive conclusions.

Progress in treatment and follow-up of pheochromocytoma

Pheochromocytoma (PHEO) is an uncommon neuroendocrine tumor originating from the chromaffin cells of the adrenal medulla. These tumors are capable of producing and releasing substantial amounts of catecholamine (CA) hormones. Individuals with PHEO often experience transient blood pressure fluctuations, headaches, and palpitations, among other symptoms. In extreme cases, they may develop severe complications, including cardiovascular and cerebrovascular incidents, myocardial disorders, and gastrointestinal issues. At the advanced stage, PHEO can affect multiple organs, potentially leading to pheochromocytoma crisis. However, the clinical manifestations of pheochromocytoma may be diverse. Some patients have no typical triad of headache, palpitations, and sweating, and are not accompanied by obvious clinical symptoms or signs. There are only abnormalities in imaging and biochemical indicators, which will pose a challenge for early diagnosis. The primary treatment options for PHEO encompass surgical and non-surgical approaches. In contrast to many other adrenal pathologies, there is currently no consensus on the optimal surgical versus non-surgical management of PHEO. Laparoscopic surgery, as opposed to traditional open surgery, offers numerous benefits. However, whether retroperitoneal or transperitoneal laparoscopic adrenalectomy remains controversial. Da Vinci robot-assisted adrenalectomy has the advantages of highly precise operation and excellent hemostasis capabilities. The day surgery management model for adrenalectomy procedures has proven to be both safe and feasible. However, current research on its long - term effectiveness and wide - scale application still has limitations. Additionally, the application of the Senhance robot in urology, particularly in adrenalectomy, has seen relatively little investigation thus far. In terms of non-surgical treatment for pheochromocytoma, chemotherapy, radionuclide therapy, targeted therapy and immunotherapy, as well as radiofrequency ablation and microwave ablation chemotherapy have all advanced significantly. This article aims to review the latest advancements in the treatment of pheochromocytoma.

Is the Mayo adhesive probability score predictive of post-operative Clavien-Dindo complication grade in laparoscopic adrenalectomy?

INTRODUCTION

Laparoscopic adrenalectomy (LA) continues to be considered the optimum approach to the surgical treatment of small benign adrenal tumours. The present study explores the correlation between the Mayo adhesive probability (MAP) score, derived from computed tomography images and delineating such perinephric fat characteristics as thickness and adhesiveness, and post-operative complications in patients undergoing LA.

PATIENTS AND METHODS

Data of patients who underwent LA between 2013 and 2023 were subjected to a retrospective analysis, and MAP scores were calculated for all patients. Intraoperative and post-operative surgical outcomes, as well as any complications, were categorised using Modified Clavien-Dindo grading, and the relationship between their MAP scores and outcomes was analysed.

RESULTS

The mean body mass index, rate of overweight patients, Clavien-Dindo scores of II, III or IV, surgical time, hospitalisation duration, transfusion requirement and post-operative blood loss of the group of patients with MAP scores of 2-3 were significantly higher than those in the group with MAP scores in the 0-1 range (P < 0.05). Each one-point increase in MAP score led to a 2.559-times greater probability of a Clavien-Dindo Grade > I (95% confidence interval: 1.391-4.708, P < 0.05).

CONCLUSION

A high MAP score is associated with Grade II and higher Clavien-Dindo complications in LA.

Early readmission after adrenalectomy for pheochromocytoma. A retrospective study

PURPOSE

Adrenalectomy for pheochromocytoma (PHEO) presents a significant challenge due to the high incidence of early hospital readmission (ER). This study evaluated the incidence and risk factors of ER for PHEO within 30 days of adrenalectomy.

METHODS

A retrospective analysis of 346 patients > 18 years with unilateral PHEO who underwent adrenalectomy between September 2012 and September 2024. The patients were categorised into ER (n = 49) and no ER (n = 297) groups. Logistic regression analyses were performed to predict risk factors for ER.

RESULTS

The most common causes of ER were postoperative maintained hypotension (42.9%), bleeding (6.1%), ileus (24.5%), wound infection (4.1%), hyperkalemia (8.2%), pneumonia (2%), intra-abdominal abscess (2%), acute MI (4.1%), and colonic injury (6.1%). Most postoperative complications were Clavien-Dindo grade II (n = 40, 81.6%). Two perioperative deaths (4%) occurred in the ER group. Logistic regression showed that low body mass index (OR 0.849, 95% CI, 0.748-0.964; p = 0.012), tumor size < 5 cm (OR 0.096, 95% CI, 0.030-0.310; p < 0.001), and low ASA (OR 0.435, 95% CI, 0.249-0.761; p = 0.003) were associated with risk reduction for ER while malignancy (OR 5.302, 95% CI, 1.214-23.164; p = 0.027), open approach(OR 12.247, 95% CI, 5.227-28.694; p < 0.001), and intraoperative complications (OR 19.149, 95% CI, 7.091-51.710; p < 0.001) were associated with risk increase of ER.

CONCLUSION

Postoperatively maintained hypotension and ileus were the most common causes of ER. Low body mass index, tumour size < 5 cm, and low ASA were risk reductions for ER, while malignancy, open approach, and intraoperative complications were the independent risk increase factors.

Retrospective analysis of robotic versus laparoscopic surgery in the treatment of giant pheochromocytoma and paraganglioma

To compare the safety and effectiveness of robot-assisted laparoscopic surgery and traditional laparoscopic surgery in the treatment of giant pheochromocytomas and paragangliomas (PPGL). A retrospective analysis was conducted using the data of patients who underwent surgery at our institution between January 2013 and November 2023 and whose postoperative pathological examination confirmed PPGL (n = 84). Patients were divided into the robot-assisted (n = 33) and laparoscopic (n = 51) groups. Baseline data and intraoperative and postoperative recovery conditions of the two groups were compared. There was no significant difference in the baseline data between the two groups. The time to resume food intake in the robot-assisted group was shorter than that in the laparoscopic group [2 (1-2) vs. 3 (2-3) days, p < 0.001], and the incidence of postoperative morbidity was also lower (15.2% vs. 43.1%, p = 0.009); however, operating room time was longer [265 (240-370) vs. 245 (205-297.5) min, p = 0.039], and overall hospitalization costs were higher [80336.38 (72,014.3-101,555.39) vs. 60,102.13 (43,059.205-88085.35) CNY, p = 0.003]. This study results indicate that robot-assisted laparoscopic surgery has a lower postoperative complication rate and faster postoperative gastrointestinal function recovery. However, the surgery is costlier and operating room time is longer than with traditional laparoscopic surgery. Robotic surgery can be considered for giant PPGL if the patient's financial condition permits.

Lesson learned from bariatric surgery: Preventing intra- and perioperative complications in patients with obesity undergoing laparoscopic adrenalectomy: Role of ketogenic preoperative diet: A propensity score matching analysis of a single-center experience

BACKGROUND

Laparoscopic adrenalectomy is the preferred surgical approach for adrenal resection. The simultaneous presence of obesity and subsequent liver steatosis may complicate the procedure, increasing the risk of intra- and perioperative complications. This study explores the effectiveness of a preoperative very low-calorie ketogenic diet in improving surgical outcomes in patients with obesity undergoing laparoscopic adrenalectomy.

METHODS

A retrospective analysis was conducted on 70 patients from January 2021 to July 2024 at the Bariatric and Endocrine-Metabolic Surgery Unit, University of Naples "Federico II." Among these, 54 patients with a body mass index ≥30 kg/m2 were divided into 2 groups: group A, which underwent a 4-week very low-calorie ketogenic diet, and group B, which did not receive any dietary intervention. Propensity score matching was used to balance the groups for confounding factors. Furthermore, a subanalysis between groups was performed according to right and left laparoscopic adrenalectomy.

RESULTS

Group A had a significantly reduced operative time (94.59 ± 54.11 minutes) compared with group B (129.22 ± 51.06 minutes, P = .01). Additionally, group A exhibited fewer perioperative complications (P = .01). The very low-calorie ketogenic diet was also associated with a significant reduction in body mass index from 31.74 ± 1.31 kg/m2 to 29.05 ± 0.99 kg/m2 (P = .001) before surgery.

CONCLUSIONS

Our analysis suggests preoperative very low-calorie ketogenic diet can significantly improve surgical outcomes in patients with obesity scheduled to adrenal glands surgery. The study supports the integration of dietary interventions into the preoperative management of patients with obesity undergoing laparoscopic adrenalectomy. Future research with larger sample sizes and randomized controlled trials is recommended to validate these findings and optimize preoperative care protocols.

Transperitoneal Laparoscopic Adrenalectomy in Children - Initial Experience in an Emerging Tertiary Center in Eastern India

Background

Adrenal tumors account for 0.2%-1% of all tumors in children. They can be benign or malignant, secretory or nonsecretory, and can arise either from the cortex or medulla. The common indication in children undergoing laparoscopic adrenalectomy (LA) is neuroblastic tumors (neuroblastoma, ganglioneuroma, and ganglioneuroblastoma).

Methodology

This is a retrospective observational study conducted from October 2021 to February 2024 (28 months) in the pediatric surgery unit at our institute. All children under 18 years of age referred to us for surgery of adrenal mass were included in this study. Any children with image-defined risk factors (IDRFs + ve) were excluded from the study. Children were worked up and managed according to the protocol of the Institute Pediatric Tumor Board. The laparoscopic transperitoneal approach was used for all. All adrenal lesions with IDRF +ve were excluded from the study and resected via open approaches.

Results

A total of six patients were included (three each in male and female groups). The mean age was 31 months (range 22 months-39 months). There were two cases of neuroblastoma, and one each of pheochromocytoma, adrenal adenoma, adrenocortical carcinoma, and paraganglioma. The median follow-up period was 24 months (range 7-32 months). On follow-up, there are no recurrences reported till date with zero mortality.

Conclusion

LA is a safe and feasible operation in children without any IDRF. It should be preferred in children with small lesion with good plane between the tumor and normal tissues. For larger lesion and ACC, it should be used cautiously to prevent spillage. Thought difficult, laparoscopic resection is a safe approach for these adrenal tumors.

A comparative study of retroperitoneal laparoscopic adrenalectomy via intra and extra perinephric fat approaches

OBJECTIVE

To investigate the safety and effectiveness of retroperitoneal adrenalectomy via extra and intra perinephric fat approaches to provide experience and basis for resection of adrenal tumors through the retroperitoneal cavity.

METHODS

The clinical data of 284 patients undergoing retroperitoneal adrenalectomy in our hospital from December 2017 to March 2023 were collected. The basic characteristics of the two groups of patients and the changes in perioperative indicators were retrospectively analyzed.

RESULTS

A total of 117 patients with intra perinephric fat approach (IPFA) were included,and 167 patients with extra perinephric fat approach (EPFA) were included. The estimated blood loss in the IPFA group (123.59 ± 50.76 ml) was higher than that in the EPFA group (99.10 ± 99.51 ml) (p = 0.015),and the operative time in the IPFA group(105.25 ± 42.25 min) was longer than that in the EPFA group(81.75 ± 30.45 min) (p < 0.001).The hospitalization expenses of IPFA patients (36,306.39 ± 7544.25RMB) were higher compared with patients receiving EPFA (32,122.77 ± 7284.00RMB) (p < 0.001).There were no significant differences between the two groups in terms of tumor size,blood transfusion times and postoperative hospitalization time.

CONCLUSION

Retroperitoneal laparoscopic adrenalectomy is a safe and effective procedure that can be performed via extra and intra perinephric fat approaches.IPFA is associated with higher estimated blood loss, and the operation time of EPFA is shorter than IPFA. The choice of surgical approach may depend primarily on the experience of the surgeon, the characteristics of adrenal tumor, and the nature of perirenal adipose tissue.

Impact of surgical volume on outcomes of laparoscopic adrenalectomy for benign adrenal tumors: A Japanese nationwide database analysis

OBJECTIVE

To analyze the recent status of laparoscopic adrenalectomy for benign adrenal tumors, focusing on the relationship between the number of surgeries and complication rates per facility.

METHODS

Data were obtained from the Diagnosis Procedure Combination database, covering surgeries performed between April 2012 and March 2020. The inclusion criteria were laparoscopic adrenalectomy for benign adrenal tumors. Basic characteristics and outcomes, including anesthesia time, blood transfusion, and medical costs, were analyzed. The facilities were divided into five categories in increments of five adrenalectomies per year. The relationship between the number of surgeries per facility and complication rates was analyzed using the Cochran-Armitage trend test and chi-square tests with the Holm method applied for multiple comparisons.

RESULTS

A total of 15 174 laparoscopic adrenalectomies for benign adrenal tumors were performed across 543 facilities during the 9-year study period. The number of adrenalectomies performed annually was <5, 5-9, 10-14, 15-19, ≥20 in 434 (79.9%), 58 (10.7%), 28 (5.2%), 12 (2.2%), and 11 (2.0%) facilities, respectively, showing that only 51 facilities (9.4%) conducted 10 or more surgeries per year. The overall complication rate was 9.1%. A trend was demonstrated showing that facilities with a higher number of surgeries per year had reduced complication rates. Facilities with 20 or more surgeries per year had the shortest anesthesia times and the lowest medical costs. No significant differences were found in blood transfusion rates or in-hospital mortality.

CONCLUSION

Laparoscopic adrenalectomy for benign adrenal tumors can be performed at lower complication rates in facilities with a higher number of surgeries.

Surgical and functional outcomes of bilateral synchronous adrenalectomy for functional tumors: A cohort study

Introduction

Bilateral synchronous adrenalectomy has the potential for significant surgical and functional morbidity. We reviewed our 15-year experience with bilateral synchronous adrenalectomy to assess the safety, surgical outcomes, morbidity, and impact on health-related quality of life (QoL).

Materials and Methods

In an IRB-approved study, we reviewed our database of patients who underwent bilateral synchronous adrenalectomy for functional tumors between April 2008 and August 2022. Demographic profile, metabolic and radiological parameters, operative details, and complications were recorded. Follow-up was obtained either in-person or telephonically and analyzed for resolution of symptoms, QoL using the WHO-QoL BREF questionnaire, and complications of chronic steroid intake. Data were reported descriptively and compared between laparoscopic and open approaches.

Results

During the study period, 337 adrenalectomies were performed, of which, 51 were bilateral and in 48 patients both the surgeries were performed synchronously. Thirty-three of these 48 patients had bilateral pheochromocytomas and 15 had Cushing's syndrome. Among patients with Cushing's syndrome, three had life-threatening symptoms requiring urgent bilateral surgery. Forty patients underwent transperitoneal laparoscopic surgery and 8 underwent open surgery. There were two intraoperative and 7 post-operative complications. Forty-three patients were available for follow-up. All had resolution of symptoms and body mass index (BMI) changes, and only two patients continued to receive one antihypertensive medication. Episodes of steroid deficiency occurred in 7 patients while steroid excess occurred in 3 patients. QoL was satisfactory in all the patients in all the domains.

Conclusions

Bilateral synchronous adrenalectomy is safe and feasible for functional adrenal tumors. It leads to symptom resolution with amelioration of hypertension and BMI changes with satisfactory overall QoL.

Perioperative and oncologic outcomes of robotic surgery for pediatric solid abdominal tumors: a single-center 10-year experience

Introduction

Minimally invasive surgery (MIS) has revolutionized oncological surgery with benefits such as smaller incisions and quicker recovery. However, its use in pediatric population is debated due to concerns about complete tumor resection and complications. Robotic surgery, offering enhanced visualization and precision, may address these issues. This study reviews a decade of robotic surgery for pediatric solid abdominal tumors at a single center, assessing perioperative and oncological outcomes.

Methods

This prospective, single-arm study involved patients aged over six months, treated between 2013 and 2023 for solid abdominal tumors. Exclusion criteria included weight <6 kg, distant metastasis, and tumors >6 cm in shortest diameter. All patients underwent thorough preoperative assessment, including imaging and multidisciplinary evaluation. Surgeries were performed using the da Vinci Si Surgical System and data on patient demographics, perioperative outcomes, and follow-up were systematically collected.

Results

The study cohort included 20 patients (9 boys and 11 girls) with a median age of 3.5 years. The median operative time was 114 min, with a median hospital stay of 3 days. Conversion to open surgery was necessary in 10% of cases. R0 resection was achieved in all cases, with a satisfactory lymph node sampling. Median follow-up of 5 years showed overall survival and event-free survival rates of 90%.

Conclusion

Robotic surgery for pediatric abdominal tumors is safe and effective, reducing blood loss and hospital stays without compromising oncological outcomes. Proper case selection and adherence to oncological principles are essential. Further multicenter studies are needed to validate these findings and optimize the use of robotic surgery in pediatric oncology.

Laparoscopic adrenalectomy performed with the Endo GIA™ Stapler as an easy and safe approach

BACKGROUND

The purpose of this study was to determine whether the application of the Endo GIA™ Stapler (Medtronic, Dublin, Ireland) could be helpful in the dissection of adrenal tumors in complicated cases.

METHODS

We retrospectively reviewed the records of patients who underwent laparoscopic adrenalectomy between 2012 and 2022 at the College of Medicine, Yeouido St. Mary's Hospital, The Catholic University of Korea (Seoul, Republic of Korea). We adopted the Endo GIA™ Stapler (Medtronic) to seal vessels around adrenal gland and separate adrenal gland completely when it was difficult to perform meticulous dissection and isolation with laparoscopic instruments. Thirteen patients who underwent laparoscopic adrenalectomy with Endo GIA™ staplers were reviewed and compared with 45 other patients who underwent laparoscopic adrenalectomy without Endo GIA™ staplers.

RESULTS

There were no statistical differences between the two groups in demographic, tumor-related, and diagnostic variables. Surgical outcomes such as margin involvement, bleeding, operation duration, rate of conversion to open surgery, blood transfusion, complications, and recurrence were not different between the two groups.

CONCLUSIONS

In our experience, applying of the Endo GIA™ Stapler (Medtronic) in laparoscopic adrenalectomy is a feasible and acceptable approach.

Surgical outcomes from robotic-assisted adrenalectomy: a case series on experience in a large tertiary referral centre

BACKGROUND

Robotic-assisted surgery is gaining wider acceptance in most surgical specialties. However, in the United Kingdom, endocrine surgery has not fully adopted robotics. This paper aims to present the early experience and outcomes of patients who underwent robotic-assisted adrenalectomy at a tertiary referral endocrine surgery department. Outcomes were compared to national and international performance measures.

METHODS

Seventy-two elective robotic adrenalectomies were performed over a 24-month period. Data collected included patient demographics, co-morbidities, indication for surgery and tumour size. Outcomes assessed were console time, conversion rates, complications, length of stay and excision margin.

RESULTS

Seventy-two cases were included for analysis. Sixty-six percent (n = 48) of the patients were female with a median age of 60 years. Median BMI was 28. Functional tumours accounted for 76% (n = 55) of cases with the most common being phaeochromocytomas and cortisol producing adenomas. Median docking time was 5 min with a median intraoperative time on the console of 45.5 min. Tumour size ranged from 1 to 14 cm. Median length of stay postoperatively was 1 day. There was only one conversion to open procedure. Two patients reported post-op superficial surgical site infections and there were no mortalities.

CONCLUSION

This case series demonstrates robotic-assisted adrenalectomies performed in a tertiary care centre were safe and feasible in a selected cohort of patients with functional and non-functional tumours. Large randomised controlled trials with long-term follow-up are required to establish the benefits of robotic adrenal surgery over conventional laparoscopic adrenalectomy.

Impact of Obesity on Short-Term Outcomes in Patients Undergoing Retroperitoneal Laparoscopic/Retroperitoneoscopic Adrenalectomy for Benign or Malignant Adrenal Diseases: A Meta-Analysis

Background and Objectives: Retroperitoneal laparoscopic adrenalectomy (RLA) is one of two laparoscopic procedures used to treat benign and malignant adrenal diseases. Obesity in patients undergoing minimally invasive adrenal surgery is a frequently discussed topic. Our meta-analysis aimed to provide updated evidence by comparing intraoperative and perioperative outcomes on non-obese (NOb) and obese (Ob) patients who underwent RLA due to benign or malignant disease. Materials and Methods: We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed/MEDLINE, Scopus, Web of Science (Science and Social Science Citation Index), and Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL)) databases were used to identify articles of interest. The meta-analysis was performed using RevMan [Computer program] Version 5.4. Results: The four included comparative studies (809 patients: 552 NOb versus 257 Ob) covered an approximately 15-year-study period (2007-2022). All the included studies were observational in nature. By comparing the Ob and NOb groups, shorter operative time and lower overall postoperative complication rates in the NOb population were recorded through the meta-analysis. Considering the subgroup analysis (BMI ≥ 30 kg/m2), just the operative time maintained statistical significance. Conclusions: Obesity did not appear to impact RLA safety and effectiveness. Due to important biases (small overall sample size and few analyzed events), the interpretation of our results must be a careful one. Later randomized and multi-center trials may help the confirmation of our results.

Robotic Versus Laparoscopic Adrenalectomy for Adrenal Tumors: An Up-to-Date Meta-Analysis on Perioperative Outcomes

Background: Minimally invasive surgery (MIS) for adrenal glands is becoming increasingly developed worldwide and robotic surgery has advanced significantly. Although there are still concerns about the generalization of outcomes and the cost burden, the robotic platform shows several advantages in overcoming some laparoscopic shortcomings. Materials and Methods: A systematic review and meta-analysis were conducted using the PubMed, MEDLINE and Cochrane library databases of published articles comparing RA and LA up to January 2024. The evaluated endpoints were technical and post-operative outcomes. Dichotomous data were calculated using the odds ratio (OR), while continuous data were analyzed usingmean difference (MD) with a 95% confidence interval (95% CI). A random-effects model (REM) was applied. Results: By the inclusion of 28 studies, the meta-analysis revealed no statistically significant difference in the rates of intraoperative RBC transfusion, 30-day mortality, intraoperative and overall postoperative complications, re-admission, R1 resection margin and operating time in the RA group compared with the LA. However, the overall cost of hospitalization was significantly higher in the RA group than in the LA group, [MD USD 4101.32, (95% CI 3894.85, 4307.79) p < 0.00001]. With respect to the mean intraoperative blood loss, conversion to open surgery rate, time to first flatus and length of hospital stay, the RA group showed slightly statistically significant lower rates than the laparoscopic approach. Conclusions: To our knowledge, this is the largest and most recent meta-analysis that makes these comparisons. RA can be considered safe, feasible and comparable to LA in terms of the intraoperative and post-operative outcomes. In the near future, RA could represent a promising complementary approachto LA for benign and small malignant adrenal masses, particularly in high-volume referral centers specializing in robotic surgery. However, further studies are needed to confirm these findings.

Equivalent Pain and Opioid Use Between Transabdominal and Retroperitoneal Adrenalectomy

INTRODUCTION

Laparoscopic transabdominal adrenalectomy (LTA) and posterior retroperitoneoscopic adrenalectomy (PRA) are safe, effective surgical approaches. A direct comparison of postoperative pain and narcotic use is needed.

METHODS

Adults who had laparoscopic adrenalectomy at a tertiary institution from 2015 to 2021 were identified from a surgical database. Evaluated key outcomes included opioid use and patient-reported pain during the perioperative period, which were analyzed by surgical approach and compared using multivariate linear regression. Additional data on pain postdischarge, prescription refills, length of stay, and 30-d readmission were also collected.

RESULTS

Eighty-eight (69.3%) surgeries were LTA and 39 (30.7%) were PRA. The studied patient population was 58% female and had an average age of 54 (standard deviation 13). Adrenal tumors were 75% functional and 3.4 cm on average (standard deviation 2.6). Postoperative pain scores at rest (4.4 LTA versus 4.5 PRA, P = 0.87) and activity (4.7 LTA versus 5.6 PRA, P = 0.08) did not reach statistical significance. Patients undergoing LTA used a median of 110.3 morphine milligram equivalents (interquartile range 70.1-144.5) of opioids during their hospital stay compared to 91.0 (interquartile range 59.1-133.3) for PRA (P = 0.16). Linear regression demonstrated no significant difference in postoperative opioid use between approaches (-9.3 morphine milligram equivalents [95% confidence interval -40.7 to 22.1]).

CONCLUSIONS

Our analysis found no significant advantage of PRA over LTA in terms of postoperative pain or opioid use, contrary to earlier findings by Barczyński et al., who reported lower postoperative pain with PRA. Both approaches show similar clinical outcomes, and the choice between them should be based on individual patient factors rather than differences in patient-reported pain and opioid usage.

Posterior Retroperitoneal Laparoscopic Adrenalectomy: An Anatomical Essay and Surgical Update

Posterior retroperitoneal laparoscopic adrenalectomy (PRLA) has emerged as a revolutionary, minimally invasive technique for adrenal gland surgery, offering significant advantages over traditional open approaches. This narrative review aims to provide a comprehensive update on PRLA, focusing on its anatomical foundations, surgical technique, and clinical implications. We conducted an extensive review of the current literature and surgical practices to elucidate the key aspects of PRLA. The procedure leverages a unique "backdoor" approach, accessing the adrenal glands through the retroperitoneum, which necessitates a thorough understanding of the posterior abdominal wall and retroperitoneal anatomy. Proper patient selection, meticulous surgical planning, and adherence to key technical principles are paramount for successful outcomes. In this paper, the surgical technique is described step by step, emphasizing critical aspects such as patient positioning, trocar placement, and adrenal dissection. PRLA demonstrates reduced postoperative pain, shorter hospital stays, and faster recovery times compared to open surgery, while maintaining comparable oncological outcomes for appropriately selected cases. However, the technique presents unique challenges, including a confined working space and the need for surgeons to adapt to a posterior anatomical perspective. We conclude that PRLA, in the right clinical setting, offers a safe and effective alternative to traditional adrenalectomy approaches. Future research should focus on expanding indications and refining techniques to further improve patient outcomes.

[Robotic adrenalectomy-current evidence]

Laparoscopic adrenalectomy is worldwide currently considered the gold standard technique for patients suffering from benign lesions. There has been an increasing number of robotic-assisted adrenalectomies in the last decade due to the systematic further development of minimally invasive surgery resulting in the implementation of robot-assisted surgery. Interestingly, the available studies show some perioperative advantages for robotic surgery but overall the current evidence is weak and there are economic aspects that are not negligible. Therefore, further high-quality studies about robotic-assisted adrenalectomy are mandatory to strengthen the current evidence.

Hyper-realistic rendering-assisted laparoscopic adrenalectomy for giant adrenal tumors: a pilot study

PURPOSE

This study aimed to explore the application value of hyperrealistic rendering (HRR) in laparoscopic giant adrenal tumor resection.

METHODS

We retrospectively analyzed 25 patients with giant adrenal tumors from January 2021 to January 2024, with a median age of 56 (40.5, 58.5) years and a tumor median diameter of 7.20 (6.80, 8.50) cm. All patients underwent preoperative medical HRR based on enhanced computed tomography, followed by laparoscopic adrenal tumor resection.

RESULTS

HRR was used to initially determine the nature of the tumor and develop a detailed surgical plan, which was completed in 25 patients preoperatively. All 24 cases of tumors were located in the adrenal gland, 1 case was located in the retroperitoneum, and 13 and 12 cases were on the left and right side, respectively. Preoperative HRR 3D imaging was consistent with the intraoperative situation, and 25 cases had successful surgeries. The median operation time was 165 (120.0, 250.0) min, and median bleeding and blood transfusion volume were 200 (150.0, 450.0) and 200.0 (150.0, 450.0) mL, respectively. There were no collateral injuries to important organs and major vessels and no cases of conversion to open surgery.

CONCLUSION

For large retroperitoneal adrenal tumors, HRR for three-dimensional (3D) reconstruction imaging enables the operator to fully understand the relationship between the tumor and surrounding organs and blood vessels preoperatively, which can reduce intraoperative bleeding and collateral injuries, improve the success rate of laparoscopic resection, and safety of the operation.

The effect of obesity on the outcomes of laparoscopic adrenal surgery in patients with Cushing syndrome

Purpose

The aim of this study is to investigate the effect of obesity on the results of laparoscopic adrenal surgery in patients with Cushing syndrome.

Methods

This retrospective study was performed in Department of General Surgery at Erciyes University School of Medicine between January 2010 and January 2023. Our analysis included Cushing syndrome patients who underwent unilateral laparoscopic adrenalectomy (LA) with the transabdominal lateral approach. All patients were evaluated in terms of age, sex, tumor diameter, body mass index (BMI), American Society of Anesthesiologists physical status classification, morbidities, surgery history, tumor side, operative time, conversion to open surgery, complications, and length of hospital stay.

Results

A total of 90 patients (75 females and 15 males) underwent a transperitoneal LA. Patients were divided into 2 groups according to their BMI: obese group (≥30 kg/m2; n = 53, 58.8%) and nonobese group (<30 kg/m2; n = 37, 41.2%). All patients were classified into 3 subgroups: obese patient group, BMI ≥30-39 kg/m2 (n = 23); morbidly obese patient group, BMI ≥40 kg/m2 (n = 14); and nonobese patient group, BMI <30 kg/m2 (n = 53). There was no significant difference in intraoperative complications, conversion to open surgery, operative time, or length of hospital stay between the groups. Only conversion to open surgery was a risk factor for postoperative complications in univariate and multivariate analyses (odds ratio, 15.4; 95% confidence interval, 1.277-185.599; P = 0.031).

Conclusion

Our results showed that LA is safe and effective in patients with Cushing syndrome with morbid obesity, allowing acceptable morbidity and length of hospital stay.

Side-specific factors for intraoperative hemodynamic instability in laparoscopic adrenalectomy for pheochromocytoma: a comparative study

BACKGROUND

Adrenalectomy for pheochromocytoma (PHEO) is challenging because of the high risk of intraoperative hemodynamic instability (HDI). This study aimed to compare the incidence and risk factors of intraoperative HDI between laparoscopic left adrenalectomy (LLA) and laparoscopic right adrenalectomy (LRA).

METHODS

We retrospectively analyzed two hundred and seventy-one patients aged > 18 years with unilateral benign PHEO of any size who underwent transperitoneal laparoscopic adrenalectomy at our hospitals between September 2016 and September 2023. Patients were divided into LRA (N = 122) and LLA (N = 149) groups. Univariate and multivariate logistic regression analyses were used to predict intraoperative HDI. In multivariate analysis for the prediction of HDI, right-sided PHEO, PHEO size, preoperative comorbidities, and preoperative systolic blood pressure were included.

RESULTS

Intraoperative HDI was significantly higher in the LRA group than in the LLA (27% vs. 9.4%, p < 0.001). In the multivariate regression analysis, right-sided tumours showed a higher risk of intraoperative HDI (odds ratio [OR] 5.625, 95% confidence interval [CI], 1.147-27.577, p = 0.033). The tumor size (OR 11.019, 95% CI 3.996-30.38, p < 0.001), presence of preoperative comorbidities [diabetes mellitus, hypertension, and coronary heart disease] (OR 7.918, 95% CI 1.323-47.412, p = 0.023), and preoperative systolic blood pressure (OR 1.265, 95% CI 1.07-1.495, p = 0.006) were associated with a higher risk of HDI in both LRA and LLA, with no superiority of one side over the other.

CONCLUSION

LRA was associated with a significantly higher intraoperative HDI than LLA. Right-sided PHEO was a risk factor for intraoperative HDI.

The effect of mass functionality on laparoscopic adrenalectomy outcomes

PURPOSE

This study aimed to determine the effect of adrenal mass functionality and different hormone subtypes synthesized by the adrenal masses on laparoscopic adrenalectomy (LA) outcomes.

MATERIALS AND METHODS

The study included 298 patients, 154 of whom were diagnosed with nonfunctional masses. In the functional group, 33, 62, and 59 patients had Conn syndrome, Cushing's syndrome, and pheochromocytoma, respectively. The variables were analyzed between the functional and nonfunctional groups and then compared among functional masses through subgroup analysis.

RESULTS

The incidence of diabetes mellitus, hypertension, and obesity, blood loss, and length of hospital stay (LOH) were significantly higher in the functional group than in the nonfunctional group. In the subgroup analysis, patients with pheochromocytoma had significantly lower body mass index but significantly higher mass size, blood loss, and LOH than the other two groups. A positive correlation was found between mass size and blood loss in patients with pheochromocytoma (p ≤ 0.001, r = 0.761). However, no significant difference in complications was found among the groups.

CONCLUSIONS

In this study, patients with functional adrenal masses had higher comorbidity rates and American Society of Anesthesiologists scores. Moreover, blood loss and LOH were longer on patients with functional adrenal masses who underwent LA. Mass size, blood loss, and LOH in patients with pheochromocytoma were significantly longer than those in patients with other functional adrenal masses. Thus, mass functionality did not increase the complications.

Safety and surgical outcomes of robotic adrenalectomy from a 15-year experience at a single institution

Robotic adrenalectomy (RA) has gained significant popularity in the management of adrenal gland diseases. We report our experience at a single tertiary institution and evaluate the safety and surgical outcomes of RA. The data of 122 consecutive patients who underwent RA from October 2009 to December 2022 at Korea University Anam Hospital (Seoul, Korea) were reviewed. There were no perioperative complications. Clinicopathological features and surgical outcomes were retrospectively analyzed through complete chart reviews. Noteworthy findings include the influence of sex, tumor size, and body mass index on operation time, with the female and small tumor groups exhibiting shorter operation times (P = 0.018 and P = 0.009, respectively). Pheochromocytoma was identified as a significant independent risk factor for a longer operation time in the multivariate analysis [odds ratio (OR), 3.709; 95% confidence interval (CI), 1.127-12.205; P = 0.031]. A temporal analysis revealed a decreasing trend in mean operation times across consecutive groups, reflecting a learning curve associated with RA adoption. RA is a safe and effective operative technique alternative to laparoscopic adrenalectomy that has favorable surgical outcomes and enhances the convenience of the operation.

Surgical Technique and Perioperative Outcomes Following Single-Port Robotic Adrenalectomy: A Single Institutional Experience

Objective: To describe a single institution's experience with single-port robotic adrenalectomy (SP-RA) and report perioperative outcomes. Materials and Methods: This is a retrospective, single-center study of adult patients who underwent SP-RA between January 2019 and April 2022 by a single surgeon using an IRB-approved institutional database. Patient demographics, perioperative data, surgical pathology, and postoperative outcomes were assessed. Results: Nineteen patients were identified who underwent SP-RA by a single surgeon over the period reviewed. One patient underwent bilateral SP-RA for bilateral adrenal masses, totaling 20 SP-RA procedures performed. Mean operative time was 80.7 ± 22.9 minutes and mean length of stay was 33.1 ± 27.9 hours. Two minor complications (Clavien-Dindo Collapse

Key Words

• adrenal
• minimally invasive surgery
• robotics
• single-port

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MESH Headings

• Adult
• Humans
• Adrenalectomy/methods
• Robotic Surgical Procedures/methods
• Retrospective Studies
• Robotics
• Adrenal Gland Diseases
• Laparoscopy/methods

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Grants Collapse

Affiliation(s)

Benjamin Rudnick Hackensack University Medical Center, Hackensack, New Jersey, USA
Mubashir Shabil Billah Hackensack University Medical Center, Hackensack, New Jersey, USA
Jennifer Nguyen Hackensack University Medical Center, Hackensack, New Jersey, USA
Fahad Sheckley Hackensack University Medical Center, Hackensack, New Jersey, USA
Mutahar Ahmed Hackensack University Medical Center, Hackensack, New Jersey, USA

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Collaborators Collapse

Time to Flip the Approach: Retroperitoneoscopic Adrenalectomy

INTRODUCTION

Retroperitoneoscopic adrenalectomy (RPA) has gained increasing popularity with its excellent perioperative outcomes and direct surgical access compared to other adrenalectomy approaches. We review perioperative outcomes of RPA by a specialized endocrine surgeon before and after expert intensive trainings (EITs), and to that of other laparoscopic adrenalectomy approaches at our center over a 9-year period, aiming to ascertain if RPA is worth the steep learning curve.

MATERIAL AND METHODS

One hundred twenty one adrenalectomies were performed between January 2014 to June 2022. Patient demographic, tumor characteristics, and perioperative outcomes were retrospectively reviewed. The primary endpoints included procedure duration, complications, and length of stay. Part I of the study examined the effect of EITs on RPA's learning curve, and part II compared these outcomes with that of the alternative approach, transabdominal lateral adrenalectomy (TLA).

RESULTS

Both procedure duration and days in hospital markedly decreased after the two EITs for RPA. RPA resulted in a shorter procedure duration and hospital stay compared to TLA, and had lesser and milder intraoperative and postoperative complications compared to TLA.

CONCLUSIONS

RPA results in safe and excellent outcomes, and offers additional benefit of direct surgical access, feasibility in patients with previous abdominal surgery, high body mass index, and multiple comorbidities. The steep learning curve can be overcome and shortened by EITs, motivating centers with specialized endocrine surgery to integrate RPA training into its curriculum, given its foreseeable rewarding outcomes.

Comparison of clinical efficacy and safety between robotic-assisted and laparoscopic adrenalectomy for pheochromocytoma: a systematic review and meta-analysis

To compare the clinical efficacy and safety of robot-assisted adrenalectomy (RA) and laparoscopic adrenalectomy (LA) for pheochromocytoma (PHEO). We conducted a comprehensive search of PubMed, the Cochrane Library, and Embase databases for studies comparing RA and LA treatment for PHEO, covering the period from database inception to January 1, 2024. Two researchers will independently screen literature and extract data, followed by meta-analysis using Review Manager 5.3 software. Six studies with 658 patients were included in the analysis. There were no significant differences in operation time [MD = -8.03, 95% CI (-25.68,9.62), P > 0.05], transfusion rate [OR = 1.10, 95% CI (0.55, 2.19) , P > 0.05], conversion rate [OR = 0.31, 95% CI (0.08, 1.12), P > 0.05], complication rate [OR = 0.93, 95% CI (0.52, 1.70), P > 0.05], Intraoperative max SBP [MD = -4.08, 95% CI (-10.13,1.97), P > 0.05], Intraoperative min SBP [MD = -2.71, 95% CI (-9.60,4.18), P > 0.05] among patients undergoing RA and LA. However, compared with patients who underwent LA, patients who underwent RA had less estimated blood loss [MD = -37.72, 95% CI (-64.11,-11.33), P < 0.05], a shorter length of hospital stay [MD = -0.43, 95% CI (-0.65,-0.21) P < 0.05]. RA has higher advantages in some aspects compared to LA. RA is a feasible, safe, and comparable treatment option for PHEO.

Comparison of perioperative outcomes between robot-assisted adrenalectomy and laparoscopic adrenalectomy: a propensity score matching analysis

This study aimed to evaluate and compare the perioperative outcomes of robot-assisted adrenalectomy (RAA) and laparoscopic adrenalectomy (LA) using propensity score matching. This retrospective study included 395 patients who underwent minimally invasive adrenalectomy: 354 who underwent LA and 41 who underwent RAA between February 2015 and March 2023. To mitigate potential confounding factors, 2:1 propensity score matching was conducted based on age, sex, body mass index, American Society of Anesthesiologists score, tumor laterality, and tumor size. Perioperative outcomes and complications were compared between the two groups, and prognostic factors for complications were analyzed. Propensity score matching analysis identified 123 patients, with 82 and 41 in the LA and RAA groups, respectively. Operative time (81.4 ± 26.6 min vs. 83.5 ± 25.9 min, P = 0.675), estimated blood loss (77.7 ± 68.3 mL vs. 83.2 ± 73.9 mL, P = 0.683), and post-operative stay (3.8 ± 1.0 days vs. 4.0 ± 0.9 days, P = 0.211) showed no significant differences between two groups. Intraoperative complications occurred in 8 patients (9.8%) in the LA group, while no patients (0%) experienced intraoperative complications in the RAA group (P = 0.051). In both groups, post-operative complications occurred in 2.4% (P = 1). The only factor contributing to complications after adrenalectomy was tumor size (OR 1.026, 95% CI 1.001-1.051, P = 0.042). RAA exhibited comparable perioperative outcomes and presented an improved intraoperative complication rate compared with LA. Tumor size was the only factor that contributed to complications after adrenalectomy.

Transabdominal and retroperitoneal adrenalectomy: comparative study

BACKGROUND

Laparoscopic adrenalectomy is recognized as the "gold standard" approach for benign adrenal tumors. The majority of surgeons opt for laparoscopic transabdominal adrenalectomies (LTA), while retroperitoneoscopic adrenalectomies (RPA) in the prone position have certain advantages for patients. The aim of this study was to compare the effectiveness and safety of the transabdominal and retroperitoneoscopic laparoscopic adrenalectomies.

MATERIALS AND METHODS

Between 2000 and 2021, our clinic performed 472 laparoscopic adrenalectomies. The age ranged from 19 to 79 years, with a mean age of 50.5 ± 10.2 years. The patient pool consisted of 315 women and 157 men. Tumor sizes ranged from 1 to 10 cm.

RESULTS

In a study of 316 patients undergoing LTA versus 156 with RPA, the TLA averaged 82.5 min (70-98), while the RPA took 56.4 min (46-62) (P < 0.001). Intraoperative blood loss was 110 cc for the LTA group and 80 cc for the RPA group (P < 0.05) Conversion rates stood at 2.5% for transabdominal and 4.5% for retroperitoneoscopic procedures (P = 0.254). At 24 h post-operation, pain scores were 3.6 and 1.6, respectively (P < 0.001). Time to resume solid oral intake was 15.2 h for TLA and 8 h for RPA, with hospital stays at 4.5 days and 3 days respectively (P < 0.001). Short-term complications occurred in 8.9% of transabdominal and 12.2% of retroperitoneoscopic patients (P = 0.257).

CONCLUSIONS

For small tumors, RPA offers advantages over the transabdominal method in surgery time, blood loss, post-op pain, and recovery. These benefits are enhanced for patients with prior abdominal surgeries. However, large tumors present challenges in the retroperitoneal approach due to limited space and anatomical orientation. If complications emerge, surgeons can seamlessly switch to the LTA.

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.

Can the Mayo Adhesive Probability Score Predict Perioperative Outcomes in Laparoscopic Total and Partial Adrenalectomy?

Objective: This study aimed to determine whether the Mayo adhesive probability (MAP) score could predict perioperative outcomes in transperitoneal laparoscopic total adrenalectomy (LTA) and laparoscopic partial adrenalectomy (LPA). Materials and Methods: The clinical data of 139 patients who underwent transperitoneal LTA (n = 116) or LPA (n = 23) between March 2013 and September 2022 were retrospectively analyzed. According to the images obtained from preoperative contrast-enhanced computed tomography or magnetic resonance imaging, the patients were divided into two groups: the low MAP score group (0-1 points) and the high MAP score group (2-5 points). General clinical features and perioperative outcomes were compared between the groups. Results: In patients with a high MAP score, the mean body mass index (BMI) (p: 0.005), tumor size (p: 0.005), operative time (p: 0.002), estimated blood loss (EBL) (p: 0.001), and complication rate (p: 0.013) were significantly higher compared with those with a low MAP score. The comparison of the patients between the LTA and LPA subgroups revealed that operative time and EBL were significantly higher in both subgroups among the patients with a high MAP score. Moreover, the complication rate in the LTA subgroup was significantly higher in the high MAP score group compared with the other group. The Multivariate analyses revealed that a high MAP score was a risk factor for prolonged operative time (Odds Ratio [OR]: 3.081, 95% Confidence Interval [CI]: 1.284-7.398, p: 0.012), increased EBL (OR: 2.495, 95% CI: 1.114-5.588, p: 0.026), and complications (OR: 6.085, 95% CI: 1.532-24.171, p: 0.01) Conclusions: Patients with a high MAP score had a prolonged operative time, increased EBL, and a higher complication rate compared with those with a low MAP score. In addition, we found that a high MAP score was an independent risk factor for perioperative parameters and complications in patients who underwent LTA and LPA.

A 1:1 matched comparison of posterior retroperitoneal and lateral transabdominal adrenalectomy using a robotic platform

BACKGROUND

Posterior retroperitoneal adrenalectomy is considered less invasive compared with lateral transperitoneal counterpart. There is controversy in the literature about how the two approaches compare regarding perioperative outcomes. Moreover, no studies have compared both approaches while incorporating the use of a robotic platform. The aim of this study was to compare the outcomes of robotic posterior retroperitoneal adrenalectomy and lateral transperitoneal adrenalectomy using a 1:1 matched propensity analysis.

METHODS

Patients who underwent robotic posterior retroperitoneal adrenalectomy were matched 1:1 to patients who underwent robotic lateral transperitoneal adrenalectomy between 2008 and 2022 at a single center. Matching factors included diagnosis, tumor size, Gerota's fascia-to-skin distance, and perinephric fat thickness. Perioperative outcomes were compared between groups using the χ2 analysis and Wilcoxon Rank Sum test.

RESULTS

A total of 511 robotic adrenalectomies were performed during the study period, of which 77 patients in each group were matched. There was no difference between posterior retroperitoneal adrenalectomy and lateral transperitoneal adrenalectomy groups, respectively, in terms of operative time (134 vs 128 min, P = .64), conversion to open (0% vs 0%, P = .99), pain level on a postoperative day 1 (visual analog scale 5 vs 6, P = .14), morphine milligram equivalents used (18 vs 20 morphine milligram equivalents /day, P = .72), length of stay (1 vs 1 day, P = .48), and 90-day complications (2.6% vs 3.9%, P = .65). Estimated blood loss for posterior retroperitoneal adrenalectomy was statistically lower (5 vs 10 mL, P = .001) but not considered to be clinically significant.

CONCLUSION

Perioperative outcomes of lateral transperitoneal adrenalectomy, including those related to recovery, were similar to those of posterior retroperitoneal adrenalectomy when matched for tumor and patient anthropometric parameters.

Laparoscopic Transperitoneal Adrenalectomy for Adrenal Tumors in Children: Technical Considerations and Surgical Experience

Aims: This study aimed to review our surgical experience of laparoscopic adrenalectomy (LA) for adrenal masses in the pediatric age group. Materials and Methods: The electronic medical records of all patients younger than 18 years of age who underwent LA between 2016 and 2023 were retrospectively reviewed. Children with adrenal tumors localized to the site of origin without evidence of encasement of major vasculature or involvement of adjacent organs were considered for LA. Patients with diagnosis of malignant adrenal tumor on preoperative work-up underwent open adrenalectomy. Data were collected regarding demography, clinical presentation, hormonal workup, imaging, duration of surgery, transfusion requirement, conversion rate, postoperative recovery, duration of intravenous (i.v.) analgesia and hospital stay, pathology, complications, and status at follow-up. Results: Between 2016 and 2023, LA adrenalectomy was performed in 11 patients (6 boys and 5 girls) with a mean age of 46.3 (8-120) months. A functional tumor was detected in 6 (54.5%) children, manifesting clinically with Cushing's syndrome (3), virilization (1), feminization (1), or Conn's syndrome (1). Seven (63.6%) tumors originated from the right adrenal, and 4 (36.4%) from the left adrenal gland. The mean tumor weight and size was 49.1 (10-80) g and 5.6 (3-8) cm, respectively. Histopathology included adrenal adenoma (5), ganglioneuroma (3), ganglioneuroblastoma (1), myelolipoma (1), and intermediate adrenocortical tumor (1). The mean surgery duration was 186.6 (120-265) minutes. Intraoperative blood transfusion was required in 2 (18.2%) patients and none required conversion. Full feeds were resumed at 42.7 (24-60) hours, i.v. analgesia requirement was for 54.5 (36-72) hours and mean hospital stay was 5.1 (3-8) days. All patients were symptom-free with no recurrence at mean follow-up period of 50.6 (3-83) months. Conclusions: In children with well-circumscribed, localized, and noninvasive adrenal tumors, LA is feasible, effective, and safe with all advantages of minimally invasive surgery.

Exploring the Benefits of a Reduced-Port Approach in Robotic Posterior Retroperitoneoscopic Adrenalectomy: A Comparative Study of the Two-Port and Three-Port Techniques

Background: Robotic adrenalectomy has become a surgical treatment option for benign and selected malignant adrenal diseases. We aimed to evaluate the eligibility of two-port robotic posterior retroperitoneoscopic adrenalectomy (PRA) as an alternative to the conventional three-port technique by comparing their surgical outcomes. Materials and Methods: This retrospective cohort study compared the clinicopathological factors and surgical outcomes among 197 patients who underwent two-port or three-port robotic adrenalectomy between 2016 and 2020 in a single tertiary center. For further evaluation, propensity score matching was performed to reduce the selection bias in population characteristics. Results: Patients were categorized by the number of ports (two-port group, 87; and three-port group, 110). The two-port group compared with the three-port group was significantly older (P = .006) and had a smaller mean tumor size (P = .003) and shorter mean operation time (P = .001). Upon comparing clinicopathologic characteristics according to adrenal disorders, for pheochromocytoma, the three-port group had a larger tumor size and a longer operation time. For Cushing's syndrome, the operation time was short and numeric rating scale pain score was significantly low in the two-port group. After propensity score matching, the two-port group had a short operation time and a significantly low postoperative pain score (P < .05). Predictive factors associated with prolonged operation time included male gender, an increased number of ports, and large tumor size. Conclusions: The two-port technique resulted in a shorter operation time and lower pain score compared with the three-port technique. The two-port technique may be a safe alternative to the conventional three-port technique for robotic PRA.

Evaluation of predictive factors for i-CLARAS (intraoperative complications in laparoscopic renal and adrenal surgery): a multicentre international retrospective cohort study

The laparoscopic approach represents the standard of treatment for renal and adrenal diseases, and its use is increasing even outside referral centres. Although most procedures are routinely performed, intraoperative complications do not occur, and the rate and predictive factors of these complications have not been established. The aim of this study was to evaluate the incidence and type of intraoperative complications and to identify predictive factors in patients undergoing laparoscopic renal and adrenal surgery. This was a cohort, multicentre, international retrospective study. Patients who underwent laparoscopic renal and adrenal surgeries between April 2017 and March 2022 were included in the study. Bivariate analysis was performed using contingency tables and the χ2 test for independent samples to compare qualitative variables and the T test and Mood test for continuous variables. Multivariate analysis was performed using a logistic regression model to obtain adjusted odds ratios. A total of 2374 patients were included in the study. Intraoperative complications were reported for 8.09% of patients who underwent renal surgery, with the most common complications reported being hollow viscus and vascular complications, and for 6.75% of patients who underwent adrenal surgery, with the most common complication reported being parenchymatous viscous complications. Multivariate analysis revealed that both adrenal and renal surgery radiological preoperative factors, such as invasive features during adrenalectomy and the RENAL score during nephrectomy, are predictive factors of intraoperative complications. In contrast to existing data, surgeon experience was not associated with a reduction in the incidence of perioperative complications.

Perirenal fat thickness is a powerful predictor for surgical outcomes of transperitoneal laparoscopic adrenalectomy

OBJECTIVES

Laparoscopic adrenalectomy has been the gold standard surgical procedure. However, the adaptation criteria for malignant tumors and predictors of perioperative outcomes are not well defined. Therefore, this study tried to identify valid predictors for perioperative outcomes of laparoscopic adrenalectomy and consider the adaptation criteria.

METHODS

We retrospectively reviewed the preoperative and perioperative data of 216 patients who underwent transperitoneal laparoscopic adrenalectomy in our hospital. Preoperative factors associated with perioperative outcomes were analyzed using multiple regression analysis.

RESULTS

Among 216 patients, 165 (76.4%), 26 (12.0%), and 25 (11.6%) were suspected of having benign tumors, pheochromocytoma, and malignant tumors, respectively. Median tumor size was 25.0 mm (interquartile range 18.0-35.0); median perirenal fat thickness was 9.2 mm (interquartile range 4.9-15.6) on preoperative computed tomography scans. The median operative time was 145.5 min (interquartile range 117.5-184.0) and the median estimated blood loss was 0.0 mL (interquartile range 0.0-27.3). Perirenal fat thickness (p < 0.001), tumor size (p < 0.001), and malignant tumors (p = 0.020) were associated with operative time, and perirenal fat thickness (p = 0.038) and malignant tumors (p = 0.002) were associated with estimated blood loss.

CONCLUSIONS

Perirenal fat thickness, tumor size, and malignant tumors are valid predictors of the surgical outcomes of transperitoneal laparoscopic adrenalectomy. As only perirenal fat thickness is associated with both surgical outcomes except for malignant tumors, it is a powerful predictor. Transperitoneal laparoscopic adrenalectomy for large malignant adrenal tumors with thick perirenal fat should be performed with caution.

Laparoscopic transperitoneal adrenalectomy for adrenal tumours of 6 cm or greater: A single-centre experience

BACKGROUND

The present study aimed to evaluate the safety and efficacy of transperitoneal laparoscopic adrenalectomy (LA) for large adrenal tumours by comparing the outcomes of tumours larger than 6 cm with those smaller than 6 cm and also to identify the risk factors associated with prolonged operative time in transperitoneal LA.

PATIENTS AND METHODS

One hundred and sixty-three patients underwent LA at our clinic from January 2014 to December 2020. Bilateral LA was performed in 20 of these 163 patients. A total of 143 patients were included in this study. Data were analysed retrospectively from the patients' medical records collected.

RESULTS

Large tumour (LT) group consists of 33 patients and the small tumour (ST) group consists of 110 patients. There was no statistically significant difference between the groups regarding conversion to open surgery and complications. A multiple regression analysis was conducted to identify the independent predictors of prolonged operation time. The tumour size ≥8 cm (odds ratio [OR], 19.132; 95% confidence interval [CI], 3.881-94.303; P < 0.001) and diagnosis of pheochromocytoma (OR, 2.762; 95% CI, (1.123-6.789, P = 0.026) were the significant predictors of prolonged operation time.

CONCLUSION

Our study shows that LA can be considered the treatment of choice for small and large adrenal tumours. The tumour size ≥8 cm and diagnosis of pheochromocytoma are the independent risk factors for the prolonged operative time in transperitoneal LA.

Long-term outcome of retroperitoneoscopic partial versus total adrenalectomy in patients with Cushing's syndrome

BACKGROUND

We analyze the long-term outcome of surgery for Cushing's syndrome (CS) and the influence of the extent of surgical resection on the duration of postoperative cortisone substitution.

METHODS

One-hundred forty-one patients (129 female, 12 males; mean age: 45.7 ± 12.8 years) operated between January 2000 to June 2020 were included in the analysis. Patients suffered from manifest (124) or subclinical (17) CS due to benign unilateral adrenal neoplasia. All tumors were removed by the posterior retroperitoneoscopic approach. 105 patients had total (TA) and 36 partial (PA) adrenalectomies. All patients were discharged with ongoing corticosteroid supplementation therapy.

RESULTS

Follow-up data could be obtained for 83 patients. Twenty-four (1 male, 23 females; mean age 42.3 years) underwent PA and 59 TA (6 males, 53 females; mean age 44.6 years). Mean follow-up time was 107 ± 68 months (range: 6-243 months). The median duration of postoperative corticosteroid therapy was 9.5 months after PA and 11 months after TA (p = 0.1). Significantly, more patients after total adrenalectomy required corticosteroid therapy for more than 24 months (25% vs. 4%; p = 0.03). Recurrent ipsilateral disease occurred in one case after partial adrenalectomy and was treated by completion adrenalectomy. A case of contralateral recurrence associated with subclinical Cushing's syndrome was observed after total adrenalectomy.

CONCLUSIONS

The risk of local recurrence after partial adrenalectomy in CS is low. Cortical-sparing surgery may shorten corticosteroid supplementation therapy after surgery.

Enhanced U-Net with GridMask (EUGNet): A Novel Approach for Robotic Surgical Tool Segmentation

This study proposed enhanced U-Net with GridMask (EUGNet) image augmentation techniques focused on pixel manipulation, emphasizing GridMask augmentation. This study introduces EUGNet, which incorporates GridMask augmentation to address U-Net's limitations. EUGNet features a deep contextual encoder, residual connections, class-balancing loss, adaptive feature fusion, GridMask augmentation module, efficient implementation, and multi-modal fusion. These innovations enhance segmentation accuracy and robustness, making it well-suited for medical image analysis. The GridMask algorithm is detailed, demonstrating its distinct approach to pixel elimination, enhancing model adaptability to occlusions and local features. A comprehensive dataset of robotic surgical scenarios and instruments is used for evaluation, showcasing the framework's robustness. Specifically, there are improvements of 1.6 percentage points in balanced accuracy for the foreground, 1.7 points in intersection over union (IoU), and 1.7 points in mean Dice similarity coefficient (DSC). These improvements are highly significant and have a substantial impact on inference speed. The inference speed, which is a critical factor in real-time applications, has seen a noteworthy reduction. It decreased from 0.163 milliseconds for the U-Net without GridMask to 0.097 milliseconds for the U-Net with GridMask.

Robotic posterior retroperitoneal adrenalectomy versus laparoscopic posterior retroperitoneal adrenalectomy: outcomes from a pooled analysis

Background

The comparative advantages of robotic posterior retroperitoneal adrenalectomy (RPRA) over laparoscopic posterior retroperitoneal adrenalectomy (LPRA) remain a topic of ongoing debate within the medical community. This systematic literature review and meta-analysis aim to assess the safety and efficacy of RPRA compared to LPRA, with the ultimate goal of determining which procedure yields superior clinical outcomes.

Methods

A systematic search was conducted on databases including PubMed, Embase, Web of Science, and the Cochrane Library database to identify relevant studies, encompassing both randomized controlled trials (RCTs) and non-RCTs, that compare the outcomes of RPRA and LPRA. The primary focus of this study was to evaluate perioperative surgical outcomes and complications. Review Manager 5.4 was used for this analysis. The study was registered with PROSPERO (ID: CRD42023453816).

Results

A total of seven non-RCTs were identified and included in this study, encompassing a cohort of 675 patients. The findings indicate that RPRA exhibited superior performance compared to LPRA in terms of hospital stay (weighted mean difference [WMD] -0.78 days, 95% confidence interval [CI] -1.46 to -0.10; p = 0.02). However, there were no statistically significant differences observed between the two techniques in terms of operative time, blood loss, transfusion rates, conversion rates, major complications, and overall complications.

Conclusion

RPRA is associated with a significantly shorter hospital stay compared to LPRA, while demonstrating comparable operative time, blood loss, conversion rate, and complication rate. However, it is important to note that further research of a more comprehensive and rigorous nature is necessary to validate these findings.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=453816, identifier CRD42023453816.

Development and validation of machine-learning models for the difficulty of retroperitoneal laparoscopic adrenalectomy based on radiomics

Objective

The aim is to construct machine learning (ML) prediction models for the difficulty of retroperitoneal laparoscopic adrenalectomy (RPLA) based on clinical and radiomic characteristics and to validate the models.

Methods

Patients who had undergone RPLA at Shanxi Bethune Hospital between August 2014 and December 2020 were retrospectively gathered. They were then randomly split into a training set and a validation set, maintaining a ratio of 7:3. The model was constructed using the training set and validated using the validation set. Furthermore, a total of 117 patients were gathered between January and December 2021 to form a prospective set for validation. Radiomic features were extracted by drawing the region of interest using the 3D slicer image computing platform and Python. Key features were selected through LASSO, and the radiomics score (Rad-score) was calculated. Various ML models were constructed by combining Rad-score with clinical characteristics. The optimal models were selected based on precision, recall, the area under the curve, F1 score, calibration curve, receiver operating characteristic curve, and decision curve analysis in the training, validation, and prospective sets. Shapley Additive exPlanations (SHAP) was used to demonstrate the impact of each variable in the respective models.

Results

After comparing the performance of 7 ML models in the training, validation, and prospective sets, it was found that the RF model had a more stable predictive performance, while xGBoost can significantly benefit patients. According to SHAP, the variable importance of the two models is similar, and both can reflect that the Rad-score has the most significant impact. At the same time, clinical characteristics such as hemoglobin, age, body mass index, gender, and diabetes mellitus also influenced the difficulty.

Conclusion

This study constructed ML models for predicting the difficulty of RPLA by combining clinical and radiomic characteristics. The models can help surgeons evaluate surgical difficulty, reduce risks, and improve patient benefits.

Same day discharge after minimally invasive adrenalectomy: a national study

BACKGROUND

Same day discharge (SDD) may be considered in some patients undergoing minimally invasive adrenalectomy (MIA). Recent studies have demonstrated similar outcomes between SDD and admitted patients; however, most excluded pheochromocytoma and adrenal metastases. This study evaluates 30-day complications and hospital readmission in a large cohort of patients undergoing MIA.

METHODS

Adult patients undergoing MIA (2010-2020) for benign adrenal disorders, pheochromocytoma, and adrenal metastases were identified within the ACS-NSQIP database. Comparisons between patients having SDD versus admission were performed. Factors associated with 30-day complications and unplanned readmission were evaluated by multivariable regression modeling.

RESULTS

Of 7316 patients who underwent MIA, 254 had SDD. Baseline characteristics were similar between groups, although SDD patients had lower ASA class (p < 0.001) and were more likely to undergo MIA for nonfunctioning adenoma or primary aldosteronism (p = 0.001). After adjusting for covariates, higher ASA class and presence of medical comorbidities were associated with increased complications (p < 0.001; p < 0.05) and unplanned readmission (p < 0.001; p < 0.05). Additionally, prolonged operative time was associated with 30-day complications (p < 0.001). Notably, SDD was not associated with increased complications (OR 0.78, 95% CI 0.38-1.61, p = 0.502) or unplanned readmission (OR 0.76, 95% CI 0.35-1.64, p = 0.490). The rate of SDD for MIA increased from 1.48% in 2017 to 10.81% in 2020.

CONCLUSIONS

Not all patients undergoing MIA should have SDD; however, the current analysis demonstrates a trend toward SDD and supports its safety in select patients with adrenal metastases and benign adrenal disorders including pheochromocytoma.

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.

Comparison of Perioperative Outcomes Between Laparoscopic and Robot-Assisted Adrenalectomy for Large Pheochromocytoma (≥ 5cm): A Retrospective Study

Purpose

The objective of this study was to compare perioperative outcomes in patients with large (≥5cm) pheochromocytomas who underwent adrenalectomy.

Patients and Methods

We retrospectively reviewed patients who underwent laparoscopic adrenalectomy (LA) and robot-assisted adrenalectomy (RA) for large pheochromocytoma (≥ 5cm) at our center between January 2015 to February 2023. We compared the perioperative outcomes between the two groups and investigated impact of high Nor-Metanephrine (NMN) levels on perioperative outcomes by analyzing this subgroup.

Results

A total of 115 patients were included in the study, with 48 patients in the robotic group and 67 patients in the laparoscopic group. The following significant difference were identified in favor of RA: shorter operative (excluding docking time) time (190.0 vs 220.0 min, p=0.002), lower estimated blood loss (50.0 vs 120.0 mL, p=0.013), however, RA group has higher surgical expenses (37933.0 vs 7936.0 CNY, p< 0.001). This finding remained consistent when analyzing patients with high NMN levels.

Conclusion

Patients with large pheochromocytoma may experience reduced blood loss and shorter operative time when undergoing robot-assisted adrenalectomy. However, it is important to note that the RA approach is associated with significantly higher costs.

Robot-assisted adrenalectomy: Step-by-step technique and surgical outcomes at a high-volume robotic center

Objective

In the last years, robotic surgery was introduced in several different settings with good perioperative results. However, its role in the management of adrenal masses is still debated. In order to provide a contribution to this field, we described our step-by-step technique for robotic adrenalectomy (RA) and related modifications according to the type of adrenal mass treated.

Methods

We retrospectively analyzed 27 consecutive patients who underwent RA at Onze-Lieve-Vrouw hospital (Aalst, Belgium) between January 2009 and October 2022. Demographic, intra- and post-operative, and pathological data were retrieved from our prospectively maintained institutional database. Continuous variables are summarized as median and interquartile range (IQR). Categorical variables are reported as frequencies (percentages).

Results

Twenty-seven patients underwent RA were included in the study. Median age, body mass index, and Charlson's comorbidity index were 61 (IQR: 49-71) years, 26 (IQR: 24-29) kg/m2, and 2 (IQR: 0-3), respectively, and 16 (59.3%) patients were male. Median tumor size at computed tomography scan was 6.0 (IQR: 3.5-8.0) cm. Median operative time and blood loss were 105 (IQR: 82-120) min and 175 (IQR: 94-250) mL, respectively. No intraoperative complications were recorded. Overall postoperative complications rate was 11.1%, with a postoperative transfusion rate of 3.7%. A total of 10 (37.0%) patients harbored malignant adrenal masses. Among them, 3 (11.1%) had adrenocortical carcinoma, 6 (22.2%) secondary metastasis, and 1 (3.7%) malignant pheochromocytoma on final pathological exam. Only 1 (10.0%) patient had positive surgical margins.

Conclusion

We described our step-by-step technique for RA, which can be safely performed even in case of high challenging settings as malignant tumors, pheochromocytoma, and large masses. The standardization of perioperative protocol should be encouraged to maximize the outcomes of this complex surgical procedure.

Risk factors for intraoperative complications, postoperative complications, and prolonged length of stay after laparoscopic adrenalectomy by transperitoneal lateral approach: a retrospective cohort study of 547 procedures

BACKGROUND

Laparoscopic adrenalectomy (LA) is the gold standard for the resection of most adrenal lesions. A precise delineation of factors influencing its outcomes is lacking. The aim of this study was to assess factors associated with intraoperative complications, postoperative complications, and prolonged length of stay (LOS) after LA.

METHODS

Patients who underwent LA from 1999 to 2021 in a single-academic-institution were included. Patient and disease-specific data, intraoperative complications, postoperative complications according to Dindo-Clavien (DC) scale, and LOS were recorded. Predictive factors of complications and prolonged LOS were determined by logistic regression.

RESULTS

We identified 530 patients who underwent 547 LA. Intraoperative complications occurred in 33 patients (6.0%). Postoperative complications ≥  DC grade 2 occurred in 73 patients (13.35%); severe postoperative complications ≥ DC grade 3 in 14 patients (2.56%). Postoperative complications were positively associated with age ≥ 72 (OR 1.14 [95% CI 1.02-1.29]), intraoperative complications (OR 1.36 [95% CI 1.14-1.63]), and negatively associated with non functional adenomas (OR 0.88 [95% CI 0.7-0.99]), and right adrenalectomy (OR 0.91 [95% CI 0.86-0.97]). Severe postoperative complications were positively associated with chronic obstructive pulmonary disease (COPD, OR 1.08 [95% CI 1.00-1.17]), and negatively associated with right adrenalectomy (OR 0.97 [95% CI 0.92-0.99]). Prolonged LOS was associated with age ≥ 72 (OR 1.21 [95% CI 1.05-1.41]), and COPD (OR 1.20 [95% CI 1.01-1.44]).

CONCLUSIONS

LA remains safe when performed by surgeons with expertise. Right adrenalectomy resulted in less postoperative overall and severe complications. The risk-benefit equation should be carefully assessed before left LA in older patients with COPD.

Defining the feasibility of same day adrenalectomy - A prospective matched cohort study

Background

Despite technical advances, day surgery still accounts for <1 % of adrenal procedures. We investigated feasibility and safety of same day adrenalectomy (SDA).

Methods

Between We recruited 30 patients with primary hyperaldosteronism (PHA) or Cushing's syndrome (CS) into a prospective matched, single centre cohort study to evaluate the impact of exposure to a same day discharge pathway (SDA cohort; n = 10) or inpatient adrenalectomy (PIPA cohort; n = 20). We compared results to a matched cohort (n = 40) from our prospective in-patient adrenalectomy registry (RIPA cohort).

Results

Mean age was 51.3 ± 8.5 years, with 43 % female, 3.3 % ASA I and 96.7 % ASA II. Lesion size was 17 ± 9 mm (range 5-40 mm). 80 % of patients presented with PHA. The predefined primary endpoint (discharge on same calendar day without major complications, emergency presentation or readmission) was achieved in 100 % of SDA, but none of the in-patients (χ² = 57; p < 0.0001). The secondary endpoint (discharge within 23 h of surgery without major complications, emergency presentation or readmission) was achieved in 100 % of SDA, 90 % of PIPA (n.s.), 33 % of RIPA (33 %; χ2 = 14.6 p < 0.001), and 51.5 % of IPA patients (χ2 = 8.5 p < 0.01). Combining SDA and PIPA cohorts, 93.3 % of treatment episodes met widely used (WHO, United States) definitions of day surgery as completion of the hospital care episode within 23 h. Patients admitted for SDA were highly satisfied (100 %).

Conclusion

Same day discharge after adrenalectomy is feasible, safe, and well-perceived in appropriately selected patients with PHA and Cushing's syndrome.

The Impact of Obesity on Mortality and Complications in Posterior Retroperitoneoscopic Adrenalectomy

Background Obesity is a global epidemic. It influences surgical technique, ergonomics, safety, and outcomes. However, there is a paucity of evidence of obesity-related impact in posterior retroperitoneoscopic adrenalectomy (PRA). This study compared perioperative outcomes of obese and non-obese participants undergoing PRA. Methodology  This is a multi-center retrospective cohort study of elective PRA from March 2014 to December 2022. Patient demographics, surgical techniques, clinicopathological parameters, and outcomes, including overall complication rate, were analyzed using SPSS version 27 (IBM Corp., Armonk, NY, USA). Results Seventy-five patients underwent a PRA, of which 97.3% were completed retroperitoneoscopically. The overall complication rate was (9.3%), and on subgroup analysis, the obese cohort had a lower percentage complication profile at 6.5%. Male participants comprised 52%, with a median age of 55 (IQR=19). The median BMI was 29.0 (IQR=8), of which 41% were obese, and 40% were overweight. Univariate analysis showed that being obese was not significantly associated with a higher complication rate (p=0.471). In addition, there was no significant increase in conversion (p=0.508), bleeding/transfusion (p=0.508), surgical site infection (SSI; p=1.000), incisional hernia (p=1.000), ICU or high dependency unit admission (p=0.292) and any-cause mortality (p=1.000). No sentinel deaths directly related to PRA were recorded. Procedure duration was longer in obese (117 mins) vs. non-obese participants (88.9 mins, p=0.022). However, there was no significant difference in the length-of-hospital stay (p=0.592). The cohort conversion rate was (2.7%), and tumor size was associated with a higher conversion rate (35.4 vs. 62.5mm, p=0.040). Conclusion Posterior retroperitoneoscopic adrenalectomy can be a safe procedure in obese populations, and obesity does not increase perioperative morbidity or mortality.

Impact of Current Technology in Laparoscopic Adrenalectomy: 20 Years of Experience in the Treatment of 254 Consecutive Clinical Cases

BACKGROUND

Laparoscopic adrenalectomy (LA), which avoids large abdomen incisions, is considered the gold standard technique for the treatment of benign small- and medium-size adrenal masses (<6 cm) and weighing < 100 g. A trascurable mortality and morbidity rate, short hospitalization and patient rapid recovery are the main advantages compared to traditional surgery. During the past decade, a new surgical technology has been developed that expedites a "clipless" adrenalectomy. Here, the authors analyze a clinical series of 254 consecutive patients who were affected by adrenal gland neoplasms and underwent LA by the transabdominal lateral approach over the two last decades. A literature review is also presented.

METHODS

Preoperative, intraoperative and postoperative data from 254 patients who underwent LA between January 2003 and December 2022 were retrospectively collected and reviewed. Diagnosis was obtained on the basis of clinical examination, laboratory values and imaging techniques. Doxazosin was preoperatively administered in the case of pheochromocytoma (PCC) while spironolactone and potassium were employed to treat Conn's disease. The same surgeon (CG) performed all the LA and utilized the same laparoscopic transabdominal lateral approach. Different dissection tools-ultrasonic, bipolar or mixed scissors-and hemostatic agents were used during this period. The following results were obtained: 254 patients were included in the study; functioning tumors were diagnosed in 155 patients, 52 patients were affected by PCCs, 55 by Conn's disease, 48 by Cushing's disease. Surgery mean operative time was 137.33 min (range 100-180 min) during the learning curve adrenalectomies and 98.5 min (range 70-180) in subsequent procedures. Mean blood loss was respectively 160.2 mL (range 60-280) and 96.98 mL (range 50-280) in the first 30 procedures and the subsequent ones. Only three conversions (1.18%) to open surgery occurred. No mortality or postoperative major complications were observed, while minor complications occurred in 19 patients (3.54%). In 153 out of 155 functioning neoplasms, LA was effective in the normalization of the endocrine profile. According to our experience, a learning curve consisting of 30 cases was identified. In fact, a lower operative time and a lower complication rate was reported following 30 LA.

CONCLUSIONS

LA is a safe procedure, even for masses larger than 6 cm and PCCs. Undoubtedly, the development of surgical technology has made it possible reducing operative times, performing a "clipless" adrenalectomy and extending the indications in the treatment of more complex patients. A multidisciplinary team, in referral high-volume centers, is recommended in the management of adrenal pathology. A 30-procedure learning curve is necessary to improve surgical outcomes.

Surgical approaches to the adrenal gland

PURPOSE OF REVIEW

Review the literature on the surgical management of adrenal diseases, highlighting the various surgical approaches and their respective pros and cons.

RECENT FINDINGS

Minimally invasive adrenalectomy is commonly used for small and benign adrenal tumors, whereas open adrenalectomy is preferred for larger tumors and primary adrenal malignancy. Although minimally invasive adrenalectomy results in shorter recovery and fewer complications compared with open, the latter offers better oncologic outcomes in the setting of primary adrenal malignancy. Adrenalectomy is performed transabdominally or retroperitoneoscopically, both yielding equivalent results and recovery. Traditional laparoscopic or robotic equipment can be utilized for either minimally invasive approach. Subtotal adrenalectomy may be appropriate for patients with genetically associated pheochromocytoma to preserve cortical function and reduce the risk of adrenal insufficiency. However, the potential benefits of sparing adrenal function must be weighed against the risk of recurrence.

SUMMARY

Adrenalectomy is becoming increasingly common worldwide. For benign and small adrenal tumors, minimally invasive adrenalectomy is generally considered the standard approach, while open adrenalectomy is preferred for primary adrenal malignancy and larger tumors. Subtotal adrenalectomy may be appropriate for patients with bilateral adrenal pheochromocytoma, as it can reduce the need for lifelong glucocorticoid dependency.