Laparoscopic adrenalectomy for large adrenal masses: pushing the envelope

Comparative outcomes and prognostic indicators in adrenalectomy for adrenal metastasis

PURPOSE

The indications for adrenalectomy and feasibility of laparoscopic adrenalectomy for adrenal metastasis are controversial. This study aimed to compare the surgical outcomes between open adrenalectomy (OA) and laparoscopic adrenalectomy (LA) and to evaluate the prognostic factors for oncological outcomes of adrenal metastasis.

MATERIALS AND METHODS

We conducted a retrospective chart review of 141 consecutive patients who underwent adrenalectomy for adrenal metastasis at Seoul National University Hospital from April 2005 to February 2021. Surgical and oncological outcomes were compared between OA and LA.

RESULTS

OA was performed in 95 (67.4%) patients, and 46 (32.6%) patients underwent LA. Among the patients who underwent adrenalectomy without adjacent organ resection for adrenal tumors less than 8 cm, LA was associated with a shorter operation time (100.1 ± 48.8 vs. 158.6 ± 81.2, P = 0.001), less blood loss (94.8 ± 93.8 vs. 566.8 ± 1156.0, P = 0.034), and a shorter hospital stay (3.7 ± 1.3 vs. 6.9 ± 5.8, P = 0.003). For locoregional recurrence-free survival (LRRFS), on multivariate analysis, a positive pathological margin (hazard ratio [HR]: 5.777, P = 0.002), disease activity at the primary site (HR: 6.497, P = 0.005), other metastases (HR: 4.154, P = 0.015), and a relatively larger tumor size (HR: 1.198, P = 0.018) were significantly associated with poor LRRFS. Multivariate analysis indicated that metachronous metastasis (HR: 0.51, P = 0.032) was associated with a longer overall survival (OS), whereas a positive pathological margin (HR: 2.40, P = 0.017), metastases to other organs (HR: 2.08, P = 0.025), and a relatively larger tumor size (HR: 1.11, P = 0.046) were associated with a shorter OS.

CONCLUSIONS

LA is a feasible treatment option for adrenal metastasis in selected patients. The pathological margin, metastases to other organs, and tumor size should be considered in adrenalectomy for adrenal metastasis.

Comparison of the retroperitoneal laparoscopic adrenalectomy versus transperitoneal laparoscopic adrenalectomy for large (≥6cm) pheochromocytomas: A single-centre retrospective study

Objectives

To compare the efficacy and safety of retroperitoneal laparoscopic adrenalectomy (RLA) and transperitoneal laparoscopic adrenalectomy (TLA) in the treatment of large (≥6cm) adrenal pheochromocytomas.

Methods

We retrospectively collected the clinical data of 130 patients with large pheochromocytoma who underwent RLA or TLA in our hospital from 2012 to 2022. The perioperative parameters and follow-up outcomes of the two groups were compared, and univariate and multivariate analyses were used to evaluate the risk factors of hemodynamic instability (HI).

Results

A total of 57 patients underwent TLA and 73 underwent RLA. There was no difference in demographic characteristics such as age, sex and tumor size between the two groups. Compared with the TLA group, patients in the RLA group had shorter operation time (P<0.001) and less estimated blood loss (EBL) (P<0.001). The time to ambulation, time to oral food and time to removal of drainage of RLA group were earlier than those of TLA group. In addition, the hospital stay was shorter in the RLA group than in the TLA group. There were no differences in HI, complications, or blood pressure (BP) improvement between the two groups. The mean follow-up time was 61.4 and 65.5 months, respectively, during which no tumors recurred or metastasized. Multivariate analysis showed that elevated hormone levels and larger tumor size were independent risk factors for HI.

Conclusions

Both RLA and TLA are effective treatment methods for large pheochromocytomas, but the perioperative outcomes of RLA are better than that of TLA. Our study demonstrates the superiority of RLA for the treatment of large pheochromocytomas.

Laparoscopic adrenalectomy: comparison of outcomes between posterior retroperitoneoscopic and transperitoneal adrenalectomy with 10 years' experience

Background

Laparoscopic adrenalectomy is widely used for treating various adrenal tumors. Posterior retroperitoneoscopic adrenalectomy was introduced after transperitoneal laparoscopic adrenalectomy. The comparability and superiority of posterior retroperitoneoscopic adrenalectomy have been widely investigated. We aimed to compare the outcomes of posterior retroperitoneoscopic adrenalectomy and transperitoneal laparoscopic adrenalectomy using 10 years' data. The changes in outcomes over time were also analyzed.

Methods

This was a retrospective observational study. A total of 505 patients who underwent laparoscopic adrenalectomy between 2009 and 2018 were included. The patients were divided into two groups: transperitoneal (n=114) and retroperitoneal (n=391) groups. Patients who underwent posterior retroperitoneoscopic adrenalectomy were further classified into sub-groups (sub-group 1: 2009-2012; sub-group 2: 2013-2015; and sub-group 3: 2016-2018) based on time periods. Clinicopathological factors and postoperative outcomes were retrospectively reviewed and analyzed.

Results

The retroperitoneal group showed significantly shorter operation time, diet initiation time, and hospital stay compared to the transperitoneal group (P=0.000, 0.000 and 0.000, respectively). Analgesics were used less frequently in the retroperitoneal group than in the transperitoneal group (P=0.048). In the retroperitoneal group, the time to postoperative diet initiation shortened over time (P=0.000).

Conclusions

Posterior retroperitoneoscopic adrenalectomy is a favorable surgical method that results in patient outcomes that are comparable to those of conventional transperitoneal laparoscopic adrenalectomy, without compromising patient safety.

Outcomes of malignant pheochromocytoma based on operative approach: A National Cancer Database analysis

BACKGROUND

Malignant pheochromocytoma is often managed with adrenalectomy. Most literature focusing on postoperative outcomes are from single institutions. This study aimed to describe outcomes of adrenalectomy for malignant pheochromocytoma using a national database. We hypothesized that minimally invasive approaches might be associated with improved short-term outcomes but potentially inferior oncologic efficacy.

METHODS

Patients who underwent adrenalectomy for malignant pheochromocytoma were identified in the National Cancer Database (2010-2016). Patients were categorized as minimally invasive adrenalectomy or open adrenalectomy. Short- and long-term outcomes were compared.

RESULTS

A total of 276 patients underwent adrenalectomy for malignant pheochromocytoma: 50.7% open adrenalectomy and 49.3% minimally invasive adrenalectomy. Demographics were similar, except those who underwent open adrenalectomy had larger tumors compared to minimally invasive adrenalectomy (8.2 cm vs 4.7 cm; P < .001). Tumor size ≥6 cm was associated with a reduced likelihood of minimally invasive adrenalectomy (relative to open adrenalectomy) on multivariable regression (odds ratio = 0.23; P < .001). Open adrenalectomy was associated with longer duration of stay relative to minimally invasive adrenalectomy (6 vs 3 days; P < .001). Rates of positive margins, unplanned readmissions, or 30-/90-day mortalities were similar based on operative approach. Five-year survival rates were similar (open adrenalectomy 74.3%, minimally invasive adrenalectomy 79.1%). There was no association between overall survival and operative approach on multivariable Cox analysis when controlling for tumor size, laterality, and clinicodemographic variables.

CONCLUSION

Patients with larger malignant pheochromocytomas were more likely to undergo an open adrenalectomy. With the exception of an increased duration of stay, there was no difference in short- or long-term postoperative outcomes. These data suggest that minimally invasive adrenalectomy appears safe among tumors <6 cm.

Laparoscopic Versus Open Adrenalectomy: a Retrospective Comparative Study

BACKGROUND

Laparoscopic Adrenalectomy (LA) has rapidly become the gold standard in management of adrenal tumors as it has been found to be associated with better cosmoses, shorter hospital stay and rapid convalescence.

OBJECTIVE

The aim of this study was to compare laparoscopic and open approach to adrenal glands in terms of operative time, hospital stay, indications and blood loss at a tertiary medical center in Jordan.

METHODS

A retrospective comparative study which included all patients who underwent adrenalectomy (open or laparoscopic) from 2005 to 2015 at King Hussein Medical Center (KHMC). Patients' demographics ,outcomes and essential study variables were extracted from patients' files. Data analysis was performed using SPSS17 and Stata 10.

RESULTS

One hundred and three patients (mean age 44.9 years) were included, 90.2% of them underwent laparoscopic adrenalectomy. The size of the tumors ranged from 2 to 17 cm (mean 6.6 cm).The operative time, blood loss and hospital stay were significantly less in the laparoscopic group (P value <0.001). Patients in Open group had a significantly higher risk of incomplete excision of the tumors (P value=0.020).

CONCLUSION

Laparoscopic adrenalectomy is associated with decreased operative time, blood loss and hospital stay compared to open approach. Tumor size and its malignant potential should be no more regarded as an absolute contraindication to laparoscopic adrenal surgery.

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

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

Laparoscopic transperitoneal and retroperitoneal adrenalectomy: a 20-year, single-institution experience with an analysis of the learning curve and tumor size [lap transper and retroper adrenalectomy]

BACKGROUND

The superiority of laparoscopic transperitoneal (TP) versus retroperitoneal (RP) adrenalectomy is an ongoing debate.

METHODS

Data from 163 patients (TP: n = 135; RP: n = 28) undergoing minimally invasive adrenalectomy were analyzed. Both operative [intraoperative blood loss, previous abdominal surgery, conversion rate, operative time and tumor size] and perioperative [BMI (body mass index), ASA (American Society of Anesthesiologists) score, time of hospitalization, time of oral intake, histology and postoperative complications] parameters were compared. Both the learning curve (LC) and tumor size were analyzed.

RESULTS

We found significant differences in the mean operative time (p = 0.019) and rate of previous abdominal surgery (p = 0.038) in favor of TP. Significantly larger tumors were removed with TP (p = 0.018). Conversion rates showed no significant difference (p = 0.257). Also, no significant differences were noted for time of hospitalization, intraoperative blood loss and postoperative complications. In terms of the LC, we saw significant differences in previous abdominal surgery (p = 0.015), conversion rate (p = 0.011) and operative time (p = 0.023) in favor of TP. Large (LT) and extra-large tumors (ELT) were involved in 47 lesions (LT: 40 vs. ELT: 7), with a mean tumor size of 71.85 and 141.57 mm, respectively. Mean intraoperative blood loss was 64.47 ml vs. 71.85 ml, time of hospitalization was 5.10 vs. 4.57 days and mean operative time was 76.52 vs. 79.28 min for LT and ELT, respectively.

CONCLUSION

A shorter operative time and lower conversion rate in favor of TP were noted during the learning curve. TP proved to be more effective in the removal of large-, extra-large and malignant lesions. The RP approach was feasible for smaller, benign lesions, with a more prolonged learning curve.

Volume-outcome correlation in adrenal surgery-an ESES consensus statement

BACKGROUND

Published data in the last decade showed that a majority of adrenal operations are done by surgeons performing only one such case per year and based on the distribution of personal workloads 'high-volume' surgeons are defined as those doing 4 or more cases/year.

PURPOSE

This paper summarises literature data identified by a working group established by the European Society of Endocrine Surgeons (ESES). The findings were discussed during ESES-2019 conference and members agreed on a consensus statement.

RESULTS

The annual of adrenal operations performed yearly in individual countries was reported to be 800/year in UK and over 1600/year in France. The learning curve of an individual surgeon undertaking laparoscopic, retroperitoneoscopic or robotic adrenalectomy is estimated to be 20-40 cases. Preoperative morbidity and length of stay are more favourable in high-volume centres.

CONCLUSION

The main recommendations are that adrenal surgery should continue only in centres performing at least 6 cases per year, surgery for adrenocortical cancer should be restricted to centres performing at least 12 adrenal operations per year, and an integrated multidisciplinary team should be established in all such centres. Clinical information regarding adrenalectomies should be recorded prospectively and contribution to the established EUROCRINE and ENSAT databases is strongly encouraged. Surgeons wishing to develop expertise in this field should seek mentorship and further training from established adrenal surgeons.

Transperitoneal versus retroperitoneal laparoscopic adrenalectomy for large pheochromocytoma: Comparative outcomes

OBJECTIVES

To evaluate operative and oncological outcomes of laparoscopic adrenalectomy through a transperitoneal approach and retroperitoneal approach for large (>5 cm in diameter) pheochromocytomas.

METHODS

We retrospectively compared the results of a transperitoneal approach with those of a retroperitoneal approach in 22 patients (mean age 57.5 years, range 38-76 years) with unilateral large pheochromocytomas (12 right, 10 left). The mean body mass index, operation time, pneumoperitoneum time, estimated blood loss, fluctuation in blood pressure and complication rate were compared between the two approaches.

RESULTS

The mean tumor diameter (range) was 7.0 cm (range 5.2-15.5 cm), and no significant differences were observed between the transperitoneal approach and retroperitoneal approach in any baseline clinical parameter. For right-sided procedures, significant differences were found for operation time (113 vs 85 min), pneumoperitoneum time (93 vs 64 min) and estimated blood loss (96 vs 23 mL; P < 0.05, transperitoneal approach and retroperitoneal approach, respectively). No open conversion or recurrence was reported, but one right transperitoneal approach case required blood transfusion. No difference in these parameters was noted on the left side.

CONCLUSIONS

For right side procedures, the retroperitoneal approach is feasible, safer and faster than the transperitoneal approach for large pheochromocytomas. Early transection of the feeding artery is beneficial for managing the tumor and reducing the risk of bleeding.

Surgical management of large adrenal tumors: impact of different laparoscopic approaches and resection methods on perioperative and long-term outcomes

Background

The indication of retroperitoneal laparoscopic adrenalectomy (RLA) was extended with the retroperitoneal approach and has been wildly accepted and technologically matured. However, the management of large adrenal tumors via this approach still remains controversial. The aim of this study was to perform a comprehensive analysis on the minimally invasive surgical management of larger adrenal tumors.

Methods

A total of 78 patients with large adrenal tumors (> 5 cm) and 97 patients with smaller adrenal tumors (< 5 cm) were enrolled in this study. The patient characteristics were preferentially analyzed. The intra-operative and postoperative indicators were compared between those who underwent RLA and those who underwent transperitoneal laparoscopic adrenalectomy (TLA); the intra-operative and postoperative indicators were also compared between the large tumor group and smaller tumor group of those who underwent RLA. Furthermore, the analyses of partial RLA were focused on the perioperative indicators and follow-up results.

Results

RLA was superior to TLA in terms of operation time (98.71 ± 32.30 min vs. 124.36 ± 34.62 min, respectively, P = 0.001), hospitalization duration (7.43 ± 2.82 days vs. 8.91 ± 3.40 days, respectively, P = 0.04), duration of drain (4.83 ± 0.37 days vs. 3.94 ± 2.21 days, respectively, P = 0.02), first oral intake (2.82 ± 0.71 days vs. 1.90 ± 0.83 days, respectively, P < 0.001) and time to ambulation (3.89 ± 1.64 days vs. 2.61 ± 1.42 days, respectively, P < 0.001). Further analyses of the RLA patients demonstrated that the larger tumor (> 5 cm) group showed superior results for the intraoperative indicators than the smaller tumor (< 5 cm) group (P < 0.05), while the results for the postoperative indicators between the two tumor size groups were similar (P > 0.05). Data confirmed that the partial resection method was superior to the total resection method from the perspective of the hormone supplement (0% vs. 48.15%, P = 0.002). The 2-year recurrence-free rates were 92.60 and 92.86% for the total and partial RLA resection methods, respectively (P = 0.97). The partial RLA resection method had a similar complete remission rate as the total RLA resection method (96.30% vs. 100%, respectively, P = 0.47).

Conclusion

Both RLA and TLA seem to provide similar effects for the surgical management of large adrenal tumors. However, partial RLA resection should be considered for the management of benign tumors to reduce the hormone supplement.

Electronic supplementary material

The online version of this article (10.1186/s12894-018-0349-0) contains supplementary material, which is available to authorized users.

Lateral retroperitoneoscopic adrenalectomy for complicated adrenal tumor larger than 5 centimeters

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Feasibility and safety of laparoscopic adrenalectomy for large tumours

Objective

To verify the feasibility and safety of laparoscopic adrenalectomy for large tumours, as since it was described, the laparoscopic approach for adrenalectomy has become the ‘gold standard’ for small tumours and for large and non-malignant adrenal tumours many studies have reported acceptable results.

Patients and methods

This is a retrospective study from a general surgery department from January 2006 to December 2013 including 45 patients (56 laparoscopic adrenalectomies). We divided patients into two groups according to tumour size: <5 or ⩾5 cm, we compared demographic data and peri- and postoperative outcomes.

Results

There was no statistical difference between the two groups for conversion rate (3.7% vs 11.7% P = 0.32), postoperative complications (14% vs 12%, P = 0.4), postoperative length of hospital stay (5 vs 6 days P = 0.43) or mortality (3.5% vs 0% P = 0.99). The only statistical difference was the operating time, at a mean (SD) 155 (60) vs 247 (71) min (P < 0.001).

Conclusion

Laparoscopic adrenalectomy for large tumours needs more time but appears to be safe and feasible when performed by experienced surgeons.

Laparoscopic Transperitoneal Lateral Adrenalectomy for Large Adrenal Tumors

BACKGROUND

Laparoscopic adrenalectomy is the gold standard for treatment of benign adrenal lesions. Tumor size is a factor that might influence decision-making concerning the use of laparoscopic approach. The aim of this study was to analyze the results of adrenalectomy for tumors ≥6 cm in diameter.

METHODS

Two groups of patients were analyzed: first group comprised 441 patients with tumors <6 cm in diameter and second group consisted of 89 patients with tumors ≥6 cm. Both groups were compared with regard to the duration of surgery, intraoperative blood loss, conversion and complications rate.

RESULTS

Median duration of surgery in groups 1 and 2 amounted to 86.6 and 111.9 min (p < 0.0001), respectively. Median intraoperative blood loss in groups 1 and 2 was 56.5 and 172.8 ml (p < 0.0001), respectively. There was a linear relationship between tumor size and the duration of surgery, and between tumor size and intraoperative blood loss (p < 0.0001). There were 2 (0.5%) and 6 (6.7%) conversions in groups 1 and 2, respectively. There were 41 (9.3%) and 14 (15.7%) complications in groups 1 and 2 (p = 0.0692), respectively.

CONCLUSIONS

Laparoscopic adrenalectomy of tumors ≥6 cm is more difficult, but it can be regarded safe and beneficial for patients.

Minimally invasive approach for adrenal lesions: Systematic review of laparoscopic versus retroperitoneoscopic adrenalectomy and assessment of risk factors for complications

In the last decades, minimally invasive transperitoneal laparoscopic adrenalectomy has become the standard of care for surgical resection of the adrenal gland tumors. Recently, however, adrenalectomy by a mininvasive retroperitoneal approach has reached increasingly popularity as alternative technique. Short hospitalization, lower postoperative pain and decrease of complications and a better cosmetic resolution are the main advantages of these innovative techniques. In order to determine the better surgical management of adrenal neoplasms, the Authors analyzed and compared the feasibility and the postoperative complications of minimally invasive adrenalectomy approaches. A systematic research of the English literature, including major meta-analysis articles, clinical randomized trials, retrospective studies and systematic reviews was performed, comparing laparoscopic transperitoneal adrenalectomy versus retroperitoneoscopic adrenalectomy. Many studies support that posterior retroperitoneal adrenalectomy is superior or at least comparable to laparoscopic transperitoneal adrenalectomy in operation time, pain score, blood loss, hospitalization, complications rates and return to normal activity. However, laparoscopic transperitoneal adrenalectomy is up to now a safe and standardized procedure with a shorter learning curve and a similar low morbidity rate, even for tumors larger than 6 cm. Nevertheless, further studies are needed to objectively evaluate these techniques, excluding selection bias and bias related to differences in surgeons' experiences with this approaches.

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

BACKGROUND

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

THE AIMS OF OUR STUDY WERE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Laparoscopic and robotic adrenal surgery: transperitoneal approach

Recent advances in technology and the need to decrease surgical morbidity have led a rapid progress in laparoscopic adrenalectomy (LA) over the past decade. Robotics is attractive to the surgeon owing to the 3-dimensional image quality, articulating instruments, and stable surgical platform. The safety and efficacy of robotic adrenalectomy (RA) have been demonstrated by several reports. In addition, RA has been shown to provide similar outcomes compared to LA. Development of adrenal surgery has involved the description of several surgical approaches including the anterior transperitoneal, lateral transperitoneal (LT) and posterior retroperitoneal (PR). Among these, the most frequently preferred technique is LT adrenalectomy, primarily due to the surgeon's familiarity of the operative field, wider working space and visibility. The LT technique is suitable for the resection of larger, unilateral tumors and in scenarios where conversion to an open transperitoneal approach is warranted, it offers a lesser burden. Also, the larger view of the entire abdominal cavity and excellent exposure of both adrenal glands and surrounding structures provided by the LT technique render it safe and feasible in pediatric and pregnant individuals.

Risk of adrenocortical carcinoma in adrenal tumours greater than 8 cm

BACKGROUND

Adrenocortical cancer (ACC) is a rare malignancy. In the absence of metastatic disease, the suspicion of ACC is based on size and radiological appearance. The aim of this study was to analyse the long-term outcome of patients with large adrenal cortical tumours (>8 cm).

METHODS

A prospective database recorded clinical, biochemical, operative and histological data on patients operated for cortical adrenal tumours between January 2000 and February 2013. Out of 130 patients operated for cortical adrenal tumours, analysis was restricted to 37 cortical tumours >8 cm.

RESULTS

There were 31 (84 %) ACCs and 6 (16 %) benign adenomas (p < 0.01). The most common presentation was that of an abdominal mass [17 (55 %) vs. 3 (50 %), ACC vs. benign, respectively]. There was no difference in size between stage II and stage III-IV tumours; however, there was a trend for tumours to be heavier in advanced stages (920 ± 756 vs. 1,435 ± 1,022 g, p = 0.08, stage II vs. stage III-IV, respectively). No mortality was observed in patients with benign tumours during a median follow-up of 70 months (range 36-99 months). Mortality in the ACC group occurred in 17/31 (55 %) patients. Mitotane was administered in 12 (71 %) patients with stage III-IV ACCs with a 5-year survival rate 25 % compared to 20 % in patients who did not receive Mitotane. In stage II ACC, eight (57 %) patients received Mitotane with a 50 % mortality at 5 years.

CONCLUSIONS

The high incidence of ACC in cortical tumours >8 cm underlines the need for adequate surgical resection via open surgery aiming to avoid local recurrence. Beyond surgery, the impact of other therapies is not fully characterised and the efficacy of adjuvant Mitotane treatment is yet to be proven.

Complications associated with laparoscopic adrenalectomy: Description and standardized assessment

OBJECTIVE

Laparoscopic adrenalectomy (LA) is the procedure of choice for surgical management of the adrenal masses. Our objective is to show a standardized assessment of perioperative complications in one LA series.

MATERIAL AND METHODS

322 LA were performed consecutively between June of 1993 and September of 2012 in patients diagnosed with suprarenal tumour. In order to evaluate perioperative complications, data were collected prospectively and analysed retrospectively. Intraoperative complications were defined using Satava classification and Clavien-Dindo classification of postoperative complications.

RESULTS

Twenty five LA showed perioperative complications (7.3%); 11 (3.2%) were intraoperative complications, most of them vascular diaphragmatic lesions (Satava Grade 2); and 14 (4.1%) were postoperative complications. Six patients showed complications requiring surgery (Clavien IIIa/IIIb) and/or support in Intensive Care Unit (Clavien IV). Conversion to open surgery was necessary in one case (.3%). Despite all appropriate preoperative endocrine measures were taken, an uncontrolled hypertensive crisis and cardio-respiratory arrest recovered were developed during surgery in one patient carrier of pheochromocytoma who died from massive cerebral infarction at 5 days (Clavien V).

CONCLUSIONS

Standardized criteria of surgical complications are necessary. Standardization is possible by combined application of two tools. We believe that this evaluation concept of the surgery morbidity must be used systematically in order to achieve a new standard refined, concise and comparative for reports of adverse perioperative events.

Laparoendoscopic single site, laparoscopic or open surgery for adrenal tumors: Selecting the optimal approach

Numerous surgical modalities are available to treat adrenal lesions. Minimally-invasive approaches for adrenalectomy are indicated in most circumstances, and new evidence continues to be accumulated. In this context, current indications for open surgical adrenalectomy (OS-A), minimally-invasive adrenalectomy (MI-A), and laparoendoscopic single-site adrenalectomy (LESS-A) remain unclear. A comprehensive English-language literature review was performed using MEDLINE/PubMED to identify articles and guidelines pertinent to the surgical management of adrenal tumors. A comprehensive chart review was performed for three illustrative cases. Clinical recommendations were generated based on relevant literature and the expertise of the investigator group. MI-A offers advantages over OS-A in properly selected patients, who experience fewer complications, lower blood loss, and shorter hospital stays. Robot-assisted laparoscopic and retroperitoneoscopic adrenalectomy may offer advantages over transperitoneal surgery, and LESS-A may be an even less-invasive option that will require further evaluation. MI-A remains the surgical treatment of choice for most adrenal lesions. Tumor size and stage are the primary indications for selecting alternative treatment modalities. OS-A remains the gold standard for large tumors (> 10 cm) and suspected or known advanced stage malignancy. LESS-A appears to be an appropriate initial approach for small tumors (< 4-5 cm), including pheochromocytoma and isolated adrenal metastases.

Surgical management of adrenocortical tumours

The surgical treatment of adrenal tumours has evolved over the past century, as has our understanding of which hormones are secreted by the adrenal glands and what these hormones do. This article reviews the preoperative evaluation of patients with adrenal tumours that could be benign or malignant, including metastases. The biochemical evaluation of excess levels of hormones is discussed, as are imaging characteristics that differentiate benign tumours from malignant tumours. The options for surgical management are outlined, including the advantages and disadvantages of various open and laparoscopic approaches. The surgical management of adrenocortical carcinoma is specifically reviewed, including controversies in operative approaches as well as surgical management of invasive or recurrent disease.

Laparoscopic trans- and retroperitoneal adrenal surgery for large tumors

BACKGROUND

Laparoscopic adrenalectomy for tumors larger than 6 cm is currently a matter of controversial discussion because of difficult mobilization from surrounding organs and a possible risk of capsule rupture.

MATERIALS AND METHODS

Data of consecutive patients undergoing laparoscopic adrenalectomy between 1/1994 and 7/2012 were collected and analysed retrospectively. Intra- and postoperative morbidity in patients with tumors ≤6 cm (group 1, n = 227) were compared to patients with tumors >6 cm, (group 2, n = 52).

RESULTS

Incidence of adrenocortical carcinoma was significantly higher in group 2 patients (6.3% vs. 0.4%, P = 0.039) whereas the incidence of aldosterone-producing adenoma was lower (2% vs. 25%, P = 0.001). Mean duration of surgery was longer (105 min vs. 88 min, P = 0.03) and the estimated blood loss was higher (470 mL vs. 150 mL) in group 2 patients. Intraoperative bleeding rate (5.7% vs. 0.8%, P = 0.041), and the conversion rate were significantly higher (5.7% vs. 1.3%, P = 0.011) in group 2. Also, postoperative complication rate was significantly higher in group 2 (11.5% vs. 3.0%, P = 0.022). However, only two major complications occurred, one in each group.

CONCLUSION

Minimally invasive adrenal surgery can be performed by an experienced surgeon even in patients with large tumors (>6 cm) with an increased but still acceptable intra- and postoperative morbidity.

Risk factors affecting operative approach, conversion, and morbidity for adrenalectomy: a single-institution series of 402 patients

BACKGROUND

Risk factors for selecting patients for open adrenalectomy (OA) and for conversion are limited in most series. This study aimed to investigate variables that are important in selecting patients for OA, predict risk of conversion from laparoscopic adrenalectomy (LA), and impact 30-day outcomes of OA and LA.

METHODS

A retrospective cohort study of prospectively collected data was conducted. Patients (≥ 16 years old) who underwent adrenalectomy in the Division of General Surgery at Barnes-Jewish Hospital (1993-2010) were grouped by operative approach (LA vs. OA) and compared using nonparametric tests and regression analyses (α < 0.05).

RESULTS

In total, 402 patients underwent 422 adrenalectomies. Compared to LA patients, those in the OA group were older (p = 0.02), had higher ASA scores (p = 0.04), larger tumor size (p < 0.01), and fewer functioning lesions (p < 0.01). OA patients more often required concurrent procedures (p < 0.01), had a longer operative time (p = 0.04), more intraoperative complications (p = 0.02), higher estimated blood loss (EBL), and larger transfusion requirement. Preoperative factors that predicted selection for OA were higher patient age (p = 0.01), higher ASA score (p = 0.03), larger tumor size (p < 0.01), nonfunctioning lesion (p < 0.01), diagnosis of adrenocortical carcinoma (p < 0.01), and the need for concomitant procedures (p < 0.01). Conversion to open or hand-assisted approach occurred in 6.2 % of LA patients. Preoperative risks for conversion included large tumor size (>8 cm) and need for concomitant procedures (p < 0.01). Multivariate analysis revealed that large indeterminate adrenal mass, adrenocortical carcinoma, tumor size (>6 cm), an open operation, conversion, concomitant procedures, operative time >180 min, and EBL >200 mL were predictors of 30-day morbidity.

CONCLUSIONS

Adrenal tumor size and need for concurrent procedures significantly impact the selection of patients for OA, the likelihood of conversion, and perioperative morbidity. These metrics should be considered when assessing operative approach and risks for adrenalectomy.

Is previous same quadrant surgery a contraindication to laparoscopic adrenalectomy?

BACKGROUND

Previous abdominal surgery may present a challenge to safely completing laparoscopic adrenalectomy. We evaluated the impact of previous ipsilateral upper abdominal surgery on laparoscopic adrenalectomy outcomes.

METHODS

A retrospective analysis of prospective databases was performed for patients that underwent laparoscopic transabdominal adrenalectomy at 2 tertiary centers between 2001 and 2011. Patients with previous ipsilateral upper abdominal surgery, contralateral upper abdominal surgery, or no relevant surgery were compared.

RESULTS

Of the 217 patients, 38 (17%) had previous ipsilateral upper abdominal surgeries, 17 (8%) had contralateral upper abdominal surgeries, and 162 (75%) had no relevant surgery. Adhesions were more common in the ipsilateral upper abdominal surgery group (63% vs 24% vs 17%; P < .001). Mean operative times (173 ± 100 vs 130 ± 76 vs 149 ± 77 minutes; P = .16) and intraoperative complication rates (3% vs 0% vs 3%; P = .55) were not different. The rate of conversion to open surgery was similar for the 3 groups (11% vs 6% vs 3%; P = .08); all 4 conversions in the ipsilateral upper abdominal surgery group followed previous open procedures. Mean duration of stay and postoperative complication rates were also comparable between the 3 groups.

CONCLUSION

Laparoscopic adrenalectomy in patients with previous ipsilateral upper abdominal surgery is feasible and safe, with comparable outcomes to those without previous relevant surgery, including contralateral upper abdominal surgery.

Laparoscopic adrenalectomy: lessons learned from 306 cases

INTRODUCTION

Laparoscopic adrenalectomy has become the standard of care for the surgical treatment of benign adrenal pathology. We present the following case series documenting our experience in refinement of this approach.

PAIENTS AND METHODS

Analysis of patient records identified those in whom laparoscopic adrenalectomy was performed from January 1997 through February 2010. Study variables included indications, operative time, blood loss, length of hospital stay, histopathological evaluation, and complications.

RESULTS

Laparoscopic adrenalectomy was performed in 306 patients using the transperitoneal lateral approach. No major operative complications were noted, and postoperative complications included a pulmonary embolism and 2 cases of pneumonia. Conversion to the open approach was necessitated in two cases. The median operative time was 95±29 minutes (range, 45-145 minutes). Estimated blood loss was 60 mL (range, 30-150 mL). The mean size of the removed gland was 5.9±1.6 cm (range, 3-13 cm). The mean size of the tumor was 5±2 cm (range, 0.5-12 cm). The median hospitalization was 4±3.7 days (range, 2-22 days). Adrenal pathology included adenoma (n=164), pheochromocytoma (n=79), hyperplasia (n=35), metastatic carcinoma (n=22), cyst (n=9), myelolipoma (n=9), hemangioma (n=3), ganglioneuroma (n=3), and melanoma (n=2).

CONCLUSION

Laparoscopic adrenalectomy is a safe and feasible approach to adrenal pathology, providing the patients with all the benefits of minimally invasive surgery.

Anatomic retroperitoneoscopic adrenalectomy for selected adrenal tumors >5 cm: our technique and experience

OBJECTIVES

To introduce our experience in using anatomic retroperitoneoscopic adrenalectomy (ARA) for adrenal tumors >5 cm and evaluate this procedure's safety and efficiency.

METHODS

Of the 1400 ARAs performed in the past 8 years, 110 were performed on patients who had adrenal tumors with a diameter >5 cm. The perioperative indexes of these patients were retrospectively collected and analyzed.

RESULTS

The mean tumor size on postoperative pathologic examination was 7.2 ± 2.1 cm (range 5-14). Only 1 patient with right-sided adrenal pheochromocytoma (7.8 cm diameter) required conversion to open surgery owing to the tumor's severe adhesions to the liver and inferior vena cava. The mean operative time and evaluated blood loss was 70.8 ± 18.6 minutes and 81.3 ± 46.1 mL, respectively. The average postoperative interval to oral intake and drainage withdrawal was 2.1 and 2.2 days, respectively. No patient died during the operation. Major intraoperative complication (ie, injury to the vena cava) occurred in 1 patient, necessitating open surgery. Minor complications during the perioperative period occurred in 10 patients (9.1%).

CONCLUSIONS

When performed by experienced surgeons, ARA is a safe and feasible procedure for large adrenal masses with a diameter >7 cm; however, this procedure results in a longer operation time and greater blood loss compared with ARA performed on smaller masses. Open surgery is indicated when the tumor adheres to, or has infiltrated, the surrounding tissues.

Laparoscopic resection of large adrenal tumors

Results of this study suggest that laparoscopic adrenalectomy should be the treatment of choice for benign adrenal tumors. However, experience in advanced laparoscopic and open abdominal surgery is necessary in the management of large adrenal tumors.

Background:

Laparoscopic adrenalectomy has rapidly replaced open adrenalectomy as the procedure of choice for benign adrenal tumors. It still remains to be clarified whether the laparoscopic resection of large (≥8cm) or potentially malignant tumors is appropriate or not due to technical difficulties and concern about local recurrence. The aim of this study was to evaluate the short- and long-term outcome of 174 consecutive laparoscopic and open adrenalectomies performed in our surgical unit.

Methods:

Our data come from a retrospective analysis of 174 consecutive adrenalectomies performed on 166 patients from May 1997 to December 2008. Fifteen patients with tumors ≥8cm underwent laparoscopic adrenalectomy. Sixty-five patients were men and 101 were women, aged 16 years to 80 years. Nine patients underwent either synchronous or metachronous bilateral adrenalectomy. Tumor size ranged from 3.2cm to 27cm. The largest laparoscopically excised tumors were a ganglioneuroma with a mean diameter of 13cm and a myelolipoma of 14cm.

Results:

In 135 patients, a laparoscopic procedure was completed successfully, whereas in 14 patients the laparoscopic procedure was converted to open. Seventeen patients were treated with an open approach from the start. There were no conversions in the group of patients with tumors >8cm. Operative time for laparoscopic adrenalectomies ranged from 65 minutes to 240 minutes. In the large adrenal tumor group, operative time for laparoscopic resection ranged from 150 minutes to 240 minutes. The postoperative hospital stay for laparoscopic adrenalectomy ranged from 1 day to 2 days (mean, 1.5) and from 5 days to 20 days for patients undergoing the open or converted procedure. The mean postoperative stay was 2 days for the group with large tumors resected by laparoscopy.

Conclusion:

Laparoscopic resection of large (≥8cm) adrenal tumors is feasible and safe. Short- and long-term results did not differ in the 2 groups.

Laparoscopic adrenalectomy in urological centres - the experience of the German Laparoscopic Working Group

OBJECTIVE

To evaluate the safety and feasibility of laparoscopic adrenalectomy (LA) performed in several German centres with different laparoscopic experience, as LA has become the gold-standard approach for benign surgical adrenal disorders; however, for solitary metastasis or primary adrenal cancer its precise role is uncertain.

PATIENTS AND METHODS

The data of 363 patients who underwent a LA were prospectively collected in 23 centres. All centres were stratified into three groups according to their experience: group A (<10 LAs/year), group B (10-20 LAs/year) and group C (>20 LAs/year). In all, 15 centres used a transperitoneal approach, four a retroperitoneal approach and four both approaches. Demographic data, perioperative and postoperative variables, including operating time, surgical approach, tumour size, estimated blood loss, complications, hospital stay and histological tumour staging, were collected and analysed.

RESULTS

The transperitoneal approach was used in 281 cases (77.4%) and the retroperitoneal approach was used in 82 patients (22.6%). In all, 263 of 363 lesions (72.5%) were benign and 100 (27.5%) were malignant. The mean (sd) operating time was 127.22 (55.56) min and 130.16 (49.88) min after transperitoneal and retroperitoneal LA, respectively. The mean complication rates for transperitoneal and retroperitoneal LA were 5% and 10.9%, respectively.

CONCLUSION

LAs performed by urologists experienced in laparoscopy is safe for the removal of benign and malignant adrenal masses. LA for malignant adrenal tumours should be performed only in high-volume centres by a surgeon performing at least >10 LAs/year.

Robotic adrenalectomy

The use of robotics in surgery is an emerging field. Robot-assisted laparoscopic adrenalectomy has been performed in small numbers worldwide. Advantages of robotic assistance over conventional laparoscopy are not acknowledged. Improvement in robotic technology, including addition of tactile feedback, miniaturization of end-effectors, reduced cost, and advances in remote surgery telecommunication technology are awaited.