Laparoscopic adrenalectomy for primary and secondary malignant adrenal tumors

Open versus minimally invasive surgery for suspected adrenocortical carcinoma

Adrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis. Although laparoscopy has been widely adopted for management of benign adrenal tumors, minimally invasive surgery for ACC remains controversial. Retrospective analyses, frequently with fewer than one hundred participants, comprise the majority of the literature. High-quality data regarding the optimal surgical approach for ACC are lacking due to the rarity of the disease and the fact that determination of tumor type (e.g., adenoma or carcinoma) is determined after adrenalectomy, since adrenal tumors are generally not biopsied. While the benefits of minimally invasive surgery including lower intra-operative blood loss and decreased hospital length-of-stay have been consistently demonstrated, clinical equipoise for long-term survival and recurrence outcomes between open and minimally invasive adrenalectomy (MIA) remains. This review examines retrospective studies that directly compare patients with ACC who underwent either open or laparoscopic adrenalectomy, and considers these findings in the context of current guideline recommendations for surgical management of ACC.

Multidisciplinary collaborative approach for management of adrenal tumors: Outcomes of minimally invasive adrenalectomy at a single center

INTRODUCTION

Laparoscopy is currently the gold standard for the management of adrenal tumors as it is associated with less morbidity. Owing to technological advances, even large adrenal tumors are currently amenable to laparoscopic removal. In this work, we describe our multidisciplinary collaborative approach for management of adrenal tumors at a single center.

MATERIAL AND METHODS

Between January 2017 and January 2020, 18 patients with adrenal lesions were operated at our center. Five of these patients had incidentalomas. All patients were evaluated in coordination with endocrinologists and anesthetists. All patients underwent transperitoneal laparoscopic adrenalectomy. The surgical complications were classified as per Clavein-Dindo system. All patients with pheochromocytoma and Cushing syndrome were followed up by the endocrinologist for further evaluation and titration of glucocorticoids and antihypertensive medication.

RESULTS

Two out of the 18 patients had American Society of Anesthesiologists (ASA) physical status III. Out of the 18 patients, only one required conversion to open surgery. Five patients developed intraoperative hypertensive crisis while three patients developed hypotensive crisis. All patients were ambulated on the first postoperative day and were discharged on the third post operative day. None of the patients developed any major (Clavein-Dindo III-V) intra operative or post operative complications.

CONCLUSION

Laparoscopic adrenalectomy is the procedure of choice for adrenal tumors. A multi-disciplinary approach involving the endocrinologist, anesthesiologist, and laparoscopic surgeon can help achieve favorable outcomes.

Laparoscopic resection of primary adrenal ganglioneuroma: A case report and review of the literature

Adrenal ganglioneuroma (AGN) is an extremely rare, benign tumor that originates from the neural crest tissue of the sympathetic nervous system. The majority of cases are detected incidentally, since the disease often lacks clear clinical manifestations or is asymptomatic. In addition, AGN is often misdiagnosed as being an adrenal adenoma or adrenal pheochromocytoma. The present study describes a 58-year-old female who visited the outpatient clinic of the Affiliated Hospital of Guangdong Medical College (Zhanjiang, Guangdong, China) with symptoms of face and lower extremity dropsy. Color Doppler ultrasonography revealed a solid tumor in the right kidney, and abdominal computed tomography identified an irregular, solid tumor measuring ~6×4.5×7 cm³ and arising from the right adrenal gland, with a clear boundary. Magnetic resonance imaging was not performed. An initial diagnosis of adrenal adenoma was established. The patient was treated by laparoscopy in order to remove the tumor. However, following surgery, a pathological examination suggested that the tumor was a GN originating from the adrenal medulla. The formation of a correct diagnosis can be extremely challenging, as AGNs do not exhibit any specific clinical manifestations. Therefore, detection often depends entirely upon imaging studies, and the final diagnosis can be only by confirmed following a histopathological evaluation.

Robotic assisted laparoscopic adrenalectomy: Initial experience from a tertiary care centre in India

INTRODUCTION

Laparoscopic adrenalectomy (LA) is now considered the standard for treatment of surgically correctable adrenal disorders. Robotic adrenalectomy has been performed worldwide and has established itself as safe, feasible and effective approach. We hereby present the first study in robotic transperitoneal LA from Indian subcontinent.

MATERIALS AND METHODS

We conducted a retrospective evaluation of 25 patients who had undergone robotic assisted LA at a tertiary health centre by a single surgeon. Demographic, clinical, histopathological and perioperative outcome data were collected and analysed.

RESULTS

Mean age of the patients was 45 years (range: 27-65 years). Eleven male and 14 female patients were operated. Mean operative time was 139 min ± 30 min (range: 110-232 min) and mean blood loss was 85 ml ± 12 ml (range: 34-313 ml). Mean hospital stay was 2.5 ± 1.05 days (range: 2-6 days). Mean visual analogue scale score was 3.2 (range: 1-6) mean analgesic requirement was 50 mg diclofenac daily (range: 0-150 mg). Histopathological evaluation revealed 11 adenomas, eight phaeochromocytomas, two adrenocortical carcinomas, and four myelolipomas. According to Clavien-Dindo classification, three patients developed Grade I post-operative complications namely hypotension and pleural effusion.

CONCLUSION

Robotic adrenalectomy is safe, technically feasible and comfortable to the surgeon. It is easier to perform with a short learning curve.

[Initial experience of a series of robotic-assisted laparoscopic adrenalectomy]

OBJECTIVES

We present our initial experience using robotic-assisted laparoscopic adrenalectomy in the surgical treatment of adrenal masses.

MATERIAL AND METHODS

A total of 18 patients (11 women and 7 men) diagnosed of a functioning or non-functioning adrenal tumor mass were operated on in our facilities between October 2009 and October 2011. Surgical variables, intra-hospital recovery time, pathological findings and peri- and post-operatory findings were evaluated.

RESULTS

Mean age of the population intervened was 51.2 years (range 18-81), average ASA score 2.11 (range 1-4) and BMI 27.0 (range 18.8-36.1). Of the 18 patients, 11 were operated on the left side and 7 on the right. Mean surgery time was 150 (range 84-329) min and intra-operatory bleeding 121 (range 10-1500) ml, with a mean loss of hemoglobin and hematocrits of 2.11g/dl and 6.33%, respectively. Two patients were converted to conventional surgery. The factors influencing surgical conversion were: normal size (>10cm), tumor weight (>100g.), active pheochromocytoma and left localization of the tumor. Seven functioning cortical adenomas, 6 metastatic adrenal tumors, 3 pheochromocytoma and 2 incidental tumors were excised. Mean tumor size was 5.39 (range 3-15) cm. Median hospital stay was 6 days (range 4-14). Five patients had peri-operatory complication. Of these, only one (5%) had major complications (Clavien III). Mean follow-up was 6 months (range 2-24).

CONCLUSIONS

Robotic technology for laparoscopic adrenalectomies is a valid option for adrenal tumor treatment. In our experience with a relatively short learning curve, it makes it possible to reduce hospital treatment times and the intra- and post-operatory complications, without affecting the oncological and post-operatory functional results.

Adrenocortical carcinoma: which surgical approach?

INTRODUCTION

There are no randomised studies comparing open and laparoscopic approaches foradrenalectomy in patients with adrenal cortical carcinoma.

METHODS

There is evidence of postoperative benefit for the patients undergoing laparoscopic adrenalectomy compared to open adrenalectomy (level B).

RESULTS

Results from comparison of oncological outcomes in ACC between open and laparoscopic approaches are equivocal: increasedrisk of local recurrence and peritoneal carcinomatosis by the laparoscopic route (level D), and identical results between the two approaches in terms of survival, recurrence and peritoneal carcinomatosis (level C).

CONCLUSION

An open approach is recommended in case of local invasion, with a view to achieving an R0 resection (level D). Laparoscopic resection of ACC/potentially malignant tumours, which includes removal of surrounding periadrenal fat and results in an R0 resection without tumour capsule rupture, may be performed for preoperative and intraoperative stage 1-2 ACC and tumours with a diameter < 10 cm (level C).

Laparoscopic adrenalectomy: where do we stand now?

Laparoscopic adrenalectomy (LA) has become the procedure of choice for the surgical removal of the vast majority of small sized adrenal tumors (<or= 6 cm), because of its significant and multiple advantages: reduced hospital stay and wound morbidity, decreased transfusion requirements, postoperative pain and complications. The role of LA in patients with large adrenal lesions or potential malignancy remains controversial. The aim of this article is to review the current and up-to-date surgical approaches for LA, which include: 1) transabdominal anterior or flank approach and 2) retroperitoneal technique with the patient in either lateral or prone position. Specific advantages and disadvantages are referred to for each of them. The choice of each of these techniques is determined particularly by the preference and the experience of the surgeon, but other objective criteria must be taken into consideration, such as the size of the adrenal and history of previous abdominal surgeries.

What affects the results of a laparoscopic adrenalectomy for pheochromocytoma? Evaluation with respect to intraoperative blood pressure and state of tumor

PURPOSE

To investigate the factors that affect the operative data and to evaluate the validity of a laparoscopic adrenalectomy (LA) for pheochromocytoma.

PATIENTS AND METHODS

Between July 1993 and January 2008, 172 LAs were performed in this department, and 34 of them were for pheochromocytoma. The characteristics and operative data of LAs for pheochromocytoma were examined with respect to the intraoperative systolic blood pressure (SBP) and the side of tumor.

RESULTS

The intraoperative SBP rose to 180 mm Hg or more in 17 (50%) cases of LAs for pheochromocytomas. The analysis of SBP (<180 versus >180 mm Hg), however, showed that there were no differences in the operative data between the two groups. The tumor size was significantly associated with operative time (P < 0.05) or the blood loss (P < 0.05) in an LA for pheochromocytoma. The blood loss in LAs for right adrenal tumors was greater (150 versus 79 mL) than for left tumors (P < 0.01). In particular, some procedures for right large tumors had considerable blood loss and long procedural time. In a comparison of the operative data between pheochromocytoma and other adrenal tumors, the tumor was larger (4.3 versus 2.5 cm) and the blood loss was greater (100 versus 30 mL) than for other adrenal tumors.

CONCLUSIONS

The operative data showed no correlation with the intraoperative high SBP, but they were associated with the tumor state. Although the procedure seems to be influenced by the size and state of tumor, LA is not contraindicated for pheochromocytoma, and it can therefore be performed safely.

Pheochromocytoma: diagnostic and therapeutic update

Pheochromocytomas are catecholamine-secreting tumors that arise from chromaffin cells of the sympathetic nervous system. In 80-85% of cases, these tumors are located in the adrenal medulla while the remainder is located in extra-adrenal chromaffin tissues (paragangliomas). Pheochromocytomas account for 6.5% of incidentally discovered adrenal tumors. These tumors may be sporadic or the result of several genetic diseases: multiple endocrine neoplasia type 2, von Hippel-Lindau syndrome, neurofibromatosis type 1, and familial paraganglioma associated with mutations in succinate dehydrogenase subunits. Diagnosis of pheochromocytoma should first be established biochemically by measuring plasma free metanephrines and urinary fractionated metanephrines. The radiological imaging tests of choice are computed tomography (CT) or magnetic resonance imaging (MRI). The first-line specific functional imaging test is scintigraphy with (123)I-metaiodobenzylguanidine (MIBG); if this test is unavailable, scintigraphy with (131)I-MIBG is the second choice. Positron emission tomography (PET) with (18)F-F-fluorodopamine (F-DA) is useful in metastatic disease. The treatment of choice is laparoscopic surgery after adequate alpha adrenergic blockade. Approximately 10% of tumors are malignant. Chemotherapy is used for inoperable disease. Prognosis is good except in malignant disease, in which 5-year survival is less than 50%. The identification of the genes causing hereditary pheochromocytoma has led to changes in the recommendation for genetic testing.

Bilateral primary adrenal non-Hodgkin's lymphoma and primary adrenocortical carcinoma--review of the literature preoperative differentiation of adrenal tumors

Most of the adrenal tumors that are incidentally detected are benign adenomas. The incidence of malignant adrenal tumors including adrenocortical carcinoma (ACC) and primary adrenal lymphoma (PAL) is rather low. As many patients with ACC and PAL are diagnosed at an advanced stage of disease, the overall survival time of both entities remains poor. The therapeutic strategies for both entities differ. Thus an early differentiation between ACC and PAL is necessary. Unfortunately hitherto preoperative diagnosis of potentially malignant adrenal masses is still a main problem in the treatment of adrenal tumors. We present the case of a 57-year-old male patient with ACC and the case of an 87-year-old male patient with PAL and provide a systematic comparison of the clinical and pathological features of both entities. In both cases clinical and radiological features resulted in an initially false diagnosis. Primary surgical therapy was performed in both patients. The patient with PAL died five months after initial surgery. The patient with ACC showed tumor progression with local and systemic recurrence despite adjuvant therapy with mitotane and additional surgical therapy. Prognosis of patients with ACC and PAL seems to be dependant on the ability to start accurate treatment without any time delay. We propose some guidelines for diagnosis and surgical management of adrenal tumors.

Laparoscopic adrenalectomy for adrenal malignancy: a preliminary report comparing the short-term outcomes with open adrenalectomy

BACKGROUND

The laparoscopic approach to adrenal malignancy remains a topic of debate.

METHODS

A retrospective analysis of patients who had an open or laparoscopic adrenalectomy for malignancy at a tertiary care center from 1995 to 2005 were included in this study.

RESULTS

Twenty-six cases were identified: 19 women and 7 men with a median age of 48 years (range, 20-81) underwent 12 open (8 adrenocortical carcinoma [ACC] and 4 metastases) and 14 laparoscopic adrenalectomies (5 ACC, 8 metastases, and 1 lymphoma). Conversion to open surgery was required in 1 laparoscopic case (7%). Cases with obvious invasion to adjacent organs were not approached laparoscopically. There was no difference in age, sex, American Society of Anesthesiologists status or diagnosis between the two groups, but patients in the laparoscopic group had a higher body mass index. Two patients required splenectomies for splenic tears in the open group. There was no difference in operative time between the two groups, but estimated blood loss (200 vs. 550 mL; P = 0.01) and hospital stay (2 vs. 7 days; P = 0.005) were less in the laparoscopic group. The size of tumors removed by open surgery was larger than by laparoscopy (8 vs. 4 cm; P = 0.003). No locoregional recurrences are reported so far in the laparoscopic group.

CONCLUSIONS

Laparoscopic adrenalectomy is both feasible and safe for some malignant tumors of the adrenal gland in experienced hands. However, it cannot be applied to all cases. Careful selection, preoperative staging, and respect for oncologic principles are important considerations in choosing laparoscopic surgery for primary and secondary adrenal malignancy. Short-term outcomes are better when the laparoscopic approach is possible. Confirmation and long-term results with further studies are required.

Retroperitoneoscopic adrenalectomy: an early institutional experience

OBJECTIVE

To review our initial experience with the retroperitoneoscopic approach, which is rapidly becoming the procedure of choice for paediatric adrenalectomy. Swift access to the vascular pedicle makes this approach ideal for adrenal surgery where haemodynamic instability is a common feature.

METHOD

Patients were placed in a fully prone position and the locations of the 12th rib, iliac crest and paravertebral muscles were marked. A 10-mm incision was made lateral to the para-vertebral muscle, halfway between the iliac crest and costal margin. A retroperitoneal working space was created around the kidney using a homemade balloon. A 10-mm Hasson port was then inserted. A 5-mm working port was placed lateral to the tip of the 12th rib and, if necessary, a second was inserted medial to the camera port. Dissection was performed with diathermy and/or Harmonic Scalpeltrade mark and the adrenal vessels were divided between clips. The specimen was retrieved in an endopouch through the 10-mm port.

RESULTS

Over 16 months, six adrenalectomies were performed in five patients (three boys and two girls); two right, two left and one bilateral. Median age at surgery was 8 years. Presentation was with hypertension (n=2), Cushing's syndrome (n=2) and abdominal pain (n=1). Median operative time was 154 min. A single-instrument port adrenalectomy was performed in three patients. Histopathological diagnosis included adrenal cyst (n=1), cystic phaeochromocytoma (n=1), adrenal cortical tumour (n=2) and central Cushing's disease (n=1). All were completely resected. All patients remain symptom free with a median follow up of 17 months.

CONCLUSION

These cases represent our initial institutional experience with retroperitoneoscopic adrenalectomy. The senior reporting surgeons have already surmounted the general learning curve for laparoscopy, and this experience has proved vital to expand our repertoire with encouraging early results. This is our technique of choice as it provides a superior view of the adrenal gland and vessels, with good intraoperative haemodynamic stability.

Equal oncologic results for laparoscopic and open resection of adrenal metastases

BACKGROUND

While open adrenalectomy is often performed for malignant adrenal tumors, increasing numbers of surgeons have adopted the laparoscopic approach. The postoperative benefits of laparoscopic adrenalectomy are well established, but questions persist about long-term oncologic outcomes when used for malignant lesions. The current study was undertaken to compare laparoscopic with open adrenalectomy for isolated adrenal metastases.

METHODS

From March 1993 to April 2006, 20 adults underwent adrenalectomy for isolated metastases to the adrenal gland. Three patients were excluded because of a concomitant nephrectomy (2) and an unresectable tumor (1). Patient demographics, tumor characteristics, and oncologic outcomes of the remaining patients were reviewed and analyzed.

RESULTS

Of the 17 patients who received adrenalectomy for an isolated metastasis, there were 11 men and 6 women with a mean age of 58 +/- 3 y. Nine patients underwent laparoscopic adrenalectomy, and 8 patients had open adrenalectomy. Laparoscopic adrenalectomy was associated with less blood loss (63 +/- 8 mL versus 2207 +/- 1067 mL, P=0.05), a lower complication rate (0% versus 63%, P=0.009), and a shorter length of stay (2.4 +/- 0.6 d versus 5.4 +/- 0.7 d, P=0.02). With a follow-up of up to 97 mo, there were no port site metastases, no tumor recurrences, and no difference in survival between laparoscopic and open adrenalectomy (median 19 months versus 17 months, 5-year survival 34% versus 54%, P=0.96).

CONCLUSIONS

When not limited by tumor size or invasion of surrounding tissue, laparoscopic adrenalectomy is a safe alternative to open adrenalectomy with equivalent oncologic outcomes and clear postoperative benefit for patients with isolated metastases to the adrenal gland.

Laparoscopic adrenalectomy for adrenal carcinoma and metastases

PURPOSE OF REVIEW

This review article discusses topics concerned with laparoscopic adrenalectomy for adrenal pathologies.

RECENT FINDINGS

Over the past decade, laparoscopic adrenalectomy has become the operation of choice for the resection of adrenal tumors, and provides dramatically reduced morbidity associated with the operation. Although current laparoscopic adrenalectomy for metastatic or primary adrenal malignancy is a feasible procedure, great care is required. Laparoscopic adrenalectomy for these adrenal pathologies should be converted to open adrenalectomy or hand-assisted laparoscopic adrenalectomy for difficult dissection, invasion, adhesions or surgeon inexperience. In general, laparoscopic adrenalectomy can be performed with acceptable outcomes in carefully selected patients with small, organ-confined, solitary adrenal metastasis or primary adrenal carcinoma.

SUMMARY

As surgical technique and complete resection are crucial to the success of the procedure, appropriate and careful judgment on the part of the surgeon is the most important factor in the care of a patient with such adrenal malignancies.

Transperitoneal laparoscopic adrenalectomy: outline of the preoperative management, surgical approach, and outcome

The laparoscopic approach to the adrenal gland has evolved to be the gold standard for most cases of adrenal conditions requiring surgical treatment. There is general consent about the safety, efficacy, and reproducibility of laparoscopic adrenal surgery. Compared to the open surgery, significant advantages with regard to shorter hospitalization time, decreased postoperative morbidity, improved cosmetics, and quicker convalescence are evident. The anatomic location of the adrenal gland led to the development of various approaches, including lateral transperitoneal, anterior transperitoneal, lateral retroperitoneal, posterior retroperitoneal, and even transthoracic approaches. The lateral transperitoneal approach is the technique most frequently used for laparoscopic adrenalectomy. A large operative field provides good orientation and visualization of familiar landmarks known from open surgery. In particular in the early learning curve this represents an advantage of the transperitoneal laparoscopic approach. This article describes in detail the indications, contraindications, preoperative evaluation, surgical technique, management of intraoperative complications, and outcome after lateral transperitoneal adrenalectomy.