Randomized clinical trial of posterior retroperitoneoscopic adrenalectomy versus lateral transperitoneal laparoscopic adrenalectomy with a 5-year follow-up

A prospective case series to evaluate subcostal nerve injury with high-resolution ultrasound in posterior retroperitoneoscopic adrenalectomy

BACKGROUND

Posterior retroperitoneoscopic adrenalectomy has several advantages over transabdominal laparoscopic adrenalectomy regarding operating time, blood loss, postoperative pain, and recovery. However, postoperatively several patients report chronic pain or hypoesthesia. We hypothesized that these symptoms may be the result of damage to the subcostal nerve, because it passes the surgical area.

METHODS

A prospective single-center case series was performed in adult patients without preoperative pain or numbness of the abdominal wall who underwent unilateral posterior retroperitoneoscopic adrenalectomy. Patients received pre- and postoperative questionnaires and a high-resolution ultrasound scan of the subcostal nerve and abdominal wall muscles was performed before and directly after surgery. Clinical evaluation at 6 weeks was performed with repeat questionnaires, physical examination, and high-resolution ultrasound. Long-term recovery was evaluated with questionnaires, and photographs from the patients were examined for abdominal wall asymmetry.

RESULTS

A total of 25 patients were included in the study. There were no surgical complications. Preoperative visualization of the subcostal nerve was possible in all patients. At 6 weeks, ultrasound showed nerve damage in 15 patients, with no significant association between nerve damage and postsurgical pain. However, there was a significant association between nerve damage and hypoesthesia (p = 0.01), sensory (p < 0.001), and motor (p < 0.001) dysfunction on physical examination. After a median follow-up of 18 months, 5 patients still experienced either numbness or muscle weakness, and one patient experienced chronic postsurgical pain.

CONCLUSION

In this exporatory case series the incidence of postoperative damage to the subcostal nerve, both clinically and radiologically, was 60% after posterior retroperitoneoscopic adrenalectomy. There was no association with pain, and the spontaneous recovery rate was high.

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.

Risk factors for postoperative fever after laparoscopic adrenalectomy focusing on hormones produced: a case control study

BACKGROUND

Laparoscopic adrenalectomy is widely performed for a number of hormone-producing tumors and postoperative management depends on the hormones produced. In the present study, we conducted a retrospective analysis to clarify the risk factors for postoperative complications, particularly postoperative fever after laparoscopic adrenalectomy.

METHODS

We analyzed 406 patients who underwent laparoscopic adrenalectomy at our hospital between 2003 and 2019. Postoperative fever was defined as a fever of 38 °C or higher within 72 h after surgery. We investigated the risk factors for postoperative fever after laparoscopic adrenalectomy.

RESULTS

There were 188 males (46%) and 218 females (54%) with a median age of 52 years. Among these patients, tumor pathologies included 188 primary aldosteronism (46%), 75 Cushing syndrome (18%), and 80 pheochromocytoma (20%). Postoperative fever developed in 124 of all patients (31%), 30% of those with primary aldosteronism, 53% of those with pheochromocytoma, and 8% of those with Cushing syndrome. A multivariate logistic regression analysis identified pheochromocytoma and non-Cushing syndrome as independent predictors of postoperative fever. Postoperative fever was observed in 42 out of 80 cases of pheochromocytoma (53%), which was significantly higher than in cases of non-pheochromocytoma (82/326, 25%, p < 0.01). In contrast, postoperative fever developed in 6 out of 75 cases of Cushing syndrome (8%), which was significantly lower than in cases of non-Cushing syndrome (118/331, 35.6%, p < 0.01).

CONCLUSION

Since postoperative fever after laparoscopic adrenalectomy is markedly affected by the hormone produced by pheochromocytoma and Cushing syndrome, it is important to carefully consider the need for treatment.

Adrenal fast-track and enhanced recovery in retroperitoneoscopic surgery for primary aldosteronism improving patient outcome and efficiency

PURPOSE

No data exist on perioperative strategies for enhancing recovery after posterior retroperitoneoscopic adrenalectomy (PRA). Our objective was to determine whether a multimodality adrenal fast-track and enhanced recovery (AFTER) protocol for PRA can reduce recovery time, improve patient satisfaction and maintain safety.

METHODS

Thirty primary aldosteronism patients were included. Fifteen patients were treated with 'standard-of-care' PRA and compared with 15 in the AFTER protocol. The AFTER protocol contains: a preoperative information video, postoperative oral analgesics, early postoperative mobilisation and enteral feeding, and blood pressure monitoring at home. The primary outcome was recovery time. Secondary outcomes were length of hospital stay, postoperative pain and analgesics requirements, patient satisfaction, perioperative complications and quality of life (QoL).

RESULTS

Recovery time was much shorter in both groups than anticipated and was not significantly different (median 28 days). Postoperative length of hospital stay was significantly reduced in AFTER patients (mean 32 vs 42 h, CI 95%, p = 0.004). No significant differences were seen in pain, but less analgesics were used in the AFTER group. Satisfaction improved amongst AFTER patients for time of admission and postoperative visit to the outpatient clinic. There were no significant differences in complication rates or QoL.

CONCLUSION

Despite no difference in recovery time between the two groups, probably due to small sample size, the AFTER protocol led to shorter hospital stays and less analgesic use after surgery, whilst maintaining and even enhancing patient satisfaction for several aspects of perioperative care. Complication rates and QoL are comparable to standard-of-care.

Practical consensus for the treatment and follow-up of primary aldosteronism: a multidisciplinary consensus document

Primary aldosteronism (PA) is the most frequent cause of secondary hypertension and is associated with a higher cardiometabolic risk than essential hypertension. The aim of this consensus is to provide practical clinical recommendations for its surgical and medical treatment, pathology study and biochemical and clinical follow-up, as well as for the approach in special situations like advanced age, pregnancy and chronic kidney disease, from a multidisciplinary perspective, in a nominal group consensus approach of experts from the Spanish Society of Endocrinology and Nutrition (SEEN), Spanish Society of Cardiology (SEC), Spanish Society of Nephrology (SEN), Spanish Society of Internal Medicine (SEMI), Spanish Radiology Society (SERAM), Spanish Society of Vascular and Interventional Radiology (SERVEI), Spanish Society of Laboratory Medicine (SEQC(ML)), Spanish Society of Anatomic-Pathology and Spanish Association of Surgeons (AEC).

Modified versus three-level technique of retroperitoneal laparoscopic adrenalectomy for all patients with adrenal lesions ≤ 6cm: a retrospective, case-controlled study

Objectives

The modified three-level technique for retroperitoneal laparoscopic adrenalectomy (RLA) has proven beneficial in the treatment of adrenal lesions in patients with BMI≥25 Kg/m2. This paper aims to summarize our institution's seven-year experience using this technique for all patients with Adrenal Lesions ≤ 6cm.

Patients and methods

Between January 2016 and December 2022. The patients underwent laparoscopic adrenal surgery were categorized into Zhang's technique (ZT) (Three-level Technique) group and modified technique (MT) group. The fundamental characteristics and perioperative data were analyzed, with statistical significance set at p<0.05.

Results

In total, 731 patients were stratified into two groups: ZT (n=448) and MT (n=283). Statistically significant distinctions were not detected between the two groups regarding sex, BMI, tumor location, tumor size, tumor type, or American Society of Anesthesiologists (ASA) score (p>0.05). The MT group demonstrated superior outcomes compared to the ZT group in terms of operative time, estimated blood loss, drainage volume, diet recovery time, complication rates, and postoperative hospitalization duration (p<0.05). 17 (4.34%) in the ZT group required unplanned adrenalectomy, while there was none in MT group (P<0.05).

Conclusion

MT retroperitoneal laparoscopic adrenalectomy has demonstrated its benefits in the treatment of adrenal lesions across all patients with adrenal lesions ≤ 6cm, serving as a valuable point of reference for the surgical management of adrenal diseases.

Patient summary

We have made modifications to the classic retroperitoneal laparoscopic adrenalectomy and achieved superior surgical outcomes, resulting in a procedure known as modified retroperitoneal laparoscopic adrenalectomy. This technique is suitable for both obese individuals and the general population with adrenal lesions ≤ 6cm.

Treatment of primary aldosteronism: Clinical practice guidelines of the Taiwan Society of Aldosteronism

Primary aldosteronism (PA) is the most common cause of secondary hypertension and one of the few medical diseases that can be cured by surgery. Excessive aldosterone secretion is highly associated with cardiovascular complications. Many studies have shown that patients with unilateral PA treated with surgery have better survival, cardiovascular, clinical, and biochemical outcomes than those who receive medical treatment. Consequently, laparoscopic adrenalectomy is the gold standard for treating unilateral PA. Surgical methods should be individualized according to the patient's tumor size, body shape, surgical history, wound considerations, and surgeon's experience. Surgery can be performed through a transperitoneal or retroperitoneal approach, and via a single-port or multi-port laparoscopic approach. However, total or partial adrenalectomy remains controversial in treating unilateral PA. Partial excision will not completely eradicate the disease and is prone to recurrence. Mineralocorticoid receptor antagonists should be considered for patients with bilateral PA or patients who cannot undergo surgery. There are also emerging alternative interventions, including radiofrequency ablation and transarterial adrenal ablation, for which data on long-term outcomes are currently lacking. The Task Force of Taiwan Society of Aldosteronism developed these clinical practice guidelines with the aim of providing medical professionals with more updated information on the treatment of PA and improving the quality of care.

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.

A cadaveric anatomical study of the adrenals: vascular relationship

The adrenal gland is a retroperitoneal organ with intimate relationships with neighboring organs but also with the large retroperitoneal vessels. Our aim was to study the vascular relationships of the adrenal gland with the large abdominal vessels. Our work is an anatomical dissection of 80 fresh cadaveric adrenals. The subjects didn't have a history of retroperitoneal surgery. Dissection conditions were similar to those in the living. All measurements were made in situ. On the right side, the average distance between the adrenal gland and the renal vein (DR) was 13 mm (0-20). In one case, the adrenal gland laid directly on the right renal vein (DR = 0). The average length L, over which the right adrenal gland entered behind the inferior vena cava (IVC), was 8 mm (0-12). In 4 cases, the right adrenal was lateral to the IVC and in 6 cases the length L exceeded 10 mm. On the left side, the mean distance DL, separating the adrenal gland from the left renal vein was 8 mm with extremes ranging from 0 mm to 18 mm. In eleven cases, the adrenal gland laid directly on the left renal vein. The right adrenal gland has a close relationship with the IVC and is often located behind it. This close relationship helps to explain the increased incidence of IVC lesions during surgery. The left adrenal gland has an intimate relationship with the left renal vein and often lies on top of it. This explains the risk of injury to the left renal pedicle during left adrenal surgery.

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.

Perioperative, functional, and oncologic outcomes of laparoscopic partial nephrectomy versus open partial nephrectomy for complex renal tumors: a systematic review and meta-analysis

Background

The primary aim of this present study is to undertake a comprehensive comparative analysis of the perioperative, functional, and oncologic outcomes associated with laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN) as interventions for the treatment of complex renal tumors, defined as PADUA or RENAL score ≥ 7.

Methods

We systematically carried out an extensive search across four electronic databases, namely PubMed, the Cochrane Library, Embase, and Web of Science. Our objective was to identify pertinent studies published in the English language up to December 2023, and encompassed controlled trials comparing LPN and OPN as interventions for complex renal tumors.

Results

This study encompassed a total of seven comparative trials, involving 934 patients. LPN exhibited a noteworthy reduction in the length of hospital stay (weighted mean difference [WMD] -2.06 days, 95% confidence interval [CI] -2.62, -1.50; p < 0.00001), blood loss (WMD -34.05mL, 95% CI -55.61, -12.48; p = 0.002), and overall complications (OR 0.38, 95% CI 0.19, 0.79; p = 0.009). However, noteworthy distinctions did not arise between LPN and OPN concerning parameters such as warm ischemia time, renal function, and oncological outcomes.

Conclusions

This study reveals that LPN presents several advantages over OPN. These benefits encompass a shortened hospital stay, diminished blood loss, and a reduced incidence of complications. Importantly, LPN achieves these benefits while concurrently upholding comparable renal function and oncological outcomes.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=457716, identifier CRD42023453816.

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.

[Surgical treatment of pheochromocytoma]

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

Retroperitoneoscopic adrenalectomy may be superior to laparoscopic transperitoneal adrenalectomy in terms of costs and profit: a retrospective pair-matched cohort analysis

BACKGROUND

A direct comparison of the cost-benefit analysis of retroperitoneoscopic adrenalectomy (RPA) versus the minimally invasive transperitoneal access (LTA) approach is currently lacking. We hypothesized that RPA is more cost effective than LTA; promising significant savings for the healthcare system in an era of ever more limited resources.

METHODS

We performed a monocentric retrospective observational cohort study based on data from our Endocrine Surgery Registry. Patients who were operated upon between 2019 and 2022 were included. After pair-matching, both cohorts (RPA vs. LTA) were compared for perioperative variables and treatment costs (process cost calculation), revenue and profit.

RESULTS

Two homogenous cohorts of 43 patients each (RPA vs. LTA) were identified following matching. Patient characteristics between the cohorts were comparable. In terms of both treatment-associated costs and profit, the RPA procedure was superior to LTA (costs: US$5789.99 for RPA vs. US$6617.75 for LTA, P = 0.043; profit: US$1235.59 for RPA vs. US$653.33 for LTA, P = 0.027). The duration of inpatient treatment and comorbidities significantly influenced the cost of treatment and the overall profit.

CONCLUSIONS

RPA appears not only to offer benefits over LTA in terms of perioperative morbidity and length of hospital stay, but also has a superior financial cost/benefit profile.

It is easy and effective to locate adrenal gland during retroperitoneal laparoscopic left adrenalectomy by the landmark of left PFSV

To evaluate the feasibility and clinical significance of the left perinephric fat sac vein (PFSV) as an anatomical landmark in locating left adrenal gland (LAD) during retroperitoneal laparoscopic left adrenalectomy (RLLA). In this study, a total of 36 patients who underwent RLLA were enrolled from February 2019 and March 2021. By following a vein vessel on the internal surface of perinephric fat sac (PFS), known as PFSV, LAD was searched finally along the upper edge of this vein. The demographic and clinical characteristics of these patients were acquired, including tumor features and perioperative outcomes (operating time, estimated blood loss, complications). The operations were successfully completed in all the 36 patients without conversion to open surgery. In addition, the LAD was successfully found along the upper edge of PFSV in 34 patients. For all operations, the mean operative time was 75 min (range 60-95) and the estimated blood loss was 20 ml (range 10-50). The median oral intake was 20.7 h (range 6-39). The median hospital stay was 6.3 days (range 4-9), and the median follow-up was 12.3 months (range 9-17). Moreover, no intraoperative complications were observed and no residual tumors were detected after 9 to 15 months follow-up. It may be a safe and efficient procedure to use PFSV as a landmark for searching LAD during RLLA, especially for beginners. However, more studies with larger sample size are need to be conducted to further evaluate the outcomes of this method and the significance of PFSV in searching LAD during RLLA.

Perioperative and oncologic outcomes of minimally-invasive surgery for renal cell carcinoma with venous tumor thrombus: a systematic review and meta-analysis of comparative trials

BACKGROUND

The present study aimed to conduct a pooled analysis to compare the perioperative and oncologic outcomes of minimally-invasive radical nephrectomy with tumor thrombus (MI-RNTT) with open radical nephrectomy with tumor thrombus (O-RNTT).

METHODS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Four electronic databases (PubMed, Embase, Web of Science, and the Cochrane Library database) were systematically searched to identify relevant studies published in English up to December 2022. The primary outcomes were perioperative results, complications, and oncologic outcomes. Review Manager 5.4 was used for this analysis.

RESULTS

In total, eight retrospective trials with a total of 563 patients were included. Compared to O-RNTT, MI-RNTT had shorter hospitalization time [weighted mean difference (WMD) -3.58 days, 95% CI: -4.56 to -2.59; P <0.00001), lower volumes of blood loss (WMD -663.32 ml, 95% CI: -822.22 to -504.42; P <0.00001), fewer transfusion rates (OR 0.18, 95% CI: 0.09-0.35; P <0.00001), fewer overall complications (OR 0.33, 95% CI: 0.22-0.49; P <0.00001), and fewer major complications s (OR 0.49, 95% CI: 0.24-1.00; P =0.05). However, operative time, intraoperative complications, mortality rate (intraoperative, within 30 days, and total mortality), overall survival, recurrence-free survival, and cancer-specific survival did not significantly differ between the two groups.

CONCLUSIONS

MI-RNTT possesses more benefits than O-RNTT in terms of length of hospital stay, blood loss, and complications and provides comparable mortality rates and oncologic outcomes. However, more comprehensive and rigorous research is warranted to further validate the outcomes, which should include a larger sample size and comprehensive data from high-volume medical centers.

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.

Posterior retroperitoneal versus transperitoneal laparoscopic adrenalectomy in adults: results from the EUROCRINE® surgical registry

PURPOSE

This study aims to compare posterior retroperitoneal laparoscopic adrenalectomy (PRLA) and laparoscopic transperitoneal adrenalectomy (LTA) in adults using pan-European data as conflicting results have been published regarding length of hospital stay, institutional volume, and morbidity.

METHODS

This retrospective cohort study analyzed data from the surgical registry EUROCRINE®. All patients undergoing PRLA and TLA for adrenal tumours and registered between 2015 and 2020 were included and compared for morbidity, length of hospital stay, and conversion to open surgery.

RESULTS

A total of 2660 patients from 11 different countries and 69 different hospitals were analyzed and 1696 LTA were compared to 964 PRLA. Length of hospital stay was shorter after RPLA, with less patients (N = 434, 45.5%, vs N = 1094, 65.0%, p < 0.001) staying more than 2 days. In total, 96 patients (3.6%) developed a complication Clavien-Dindo grade 2 or higher. No statistical difference was found between both study groups. After propensity score matching, length of hospital stay was shorter after PRLA (> 2 days 45.2% vs 63.0%, p < 0.001). After multivariable logistic regression, factors associated with morbidity were age (OR 1.03), male sex (OR 1.52), and conversion to open surgery (OR 5.73).

CONCLUSION

This study presents the largest retrospective observational analysis comparing LTA and PRLA. Our findings confirm the shorter length of hospital stay after PRLA. Both techniques are safe leading to comparable morbidity and conversion rates.

Comparing surgical outcomes of approaches to adrenalectomy - a systematic review and network meta-analysis of randomised clinical trials

BACKGROUND

No randomised clinical trials (RCTs) have simultaneously compared the safety of open (OA), transperitoneal laparoscopic (TLA), posterior retroperitoneal (PRA), and robotic adrenalectomy (RA) for resecting adrenal tumours.

AIM

To evaluate outcomes for OA, TLA, PRA, and RA from RCTs.

METHODS

A NMA was performed according to PRISMA-NMA guidelines. Analysis was performed using R packages and Shiny.

RESULTS

Eight RCTs with 488 patients were included (mean age: 48.9 years). Overall, 44.5% of patients underwent TLA (217/488), 37.3% underwent PRA (182/488), 16.4% underwent RA (80/488), and just 1.8% patients underwent OA (9/488). The mean tumour size was 35 mm in largest diameter with mean sizes of 44.3 mm for RA, 40.9 mm for OA, 35.5 mm for TLA, and 34.4 mm for PRA (P < 0.001). TLA had the lowest blood loss (mean: 50.6 ml), complication rates (12.4%, 14/113), and conversion to open rates (1.3%, 2/157), while PRA had the shortest intra-operative duration (mean: 94 min), length of hospital stay (mean: 3.7 days), lowest visual analogue scale pain scores post-operatively (mean: 3.7), and was most cost-effective (mean: 1728 euros per case). At NMA, there was a significant increase in blood loss for OA (mean difference (MD): 117.00 ml (95% confidence interval (CI): 1.41-230.00)) with similar blood loss observed for PRA (MD: - 10.50 (95% CI: - 83.40-65.90)) compared to TLA.

CONCLUSION

LTA and PRA are important contemporary options in achieving favourable outcomes following adrenalectomy. The next generation of RCTs may be more insightful for comparison surgical outcomes following RA, as this approach is likely to play a future role in minimally invasive adrenalectomy.

PROSPERO REGISTRATION

CRD42022301005.

Perioperative, functional, and oncologic outcomes of robot-assisted versus open partial nephrectomy for complex renal tumors (RENAL score ≥ 7): an evidence-based analysis

This study aims to assess the efficacy and safety of robot-assisted partial nephrectomy (RAPN) compared with open partial nephrectomy (OPN) in the management of complex renal tumors (defined as RENAL score ≥ 7). We conducted a comprehensive literature search in PubMed, Embase, Web of Science, and Cochrane Library to identify relevant comparative studies up to January 2023. This study was conducted with the Review Manager 5.4 software, and included RAPN and OPN-controlled trials for complex renal tumors. The prime outcomes were to assess the perioperative results, complications, renal function, and oncologic outcomes. A total of 1493 patients were included in seven studies. Compared to OPN, RAPN was associated with a significantly shorter hospital stay (weighted mean difference [WMD] - 1.53 days, 95% confidence interval [CI] - 2.44, - 0.62; p = 0.001), less blood loss (WMD - 95.88 mL, 95% CI - 144.19, - 47.56; p = 0.0001), lower transfusion rates (OR 0.33, 95% CI 0.15, 0.71; p = 0.005), fewer major complications (OR 0.63, 95% CI 0.39, 1.01; p = 0.05), and fewer overall complications (OR 0.49, 95% CI 0.36, 0.65; p < 0.00001). Nevertheless, no statistically significant differences were found between the two groups in operative time, warm ischemia time, estimated glomerular decline, intraoperative complications, positive surgical margins, local recurrence, overall survival, and recurrence-free survival. The study demonstrated that RAPN had superior perioperative parameters and fewer complications when compared to OPN for complex renal tumors. However, no significant differences were found in terms of renal function and oncologic outcomes.

Advances in Endocrine Surgery

Recent changes in the landscape of endocrine surgery include a shift from total thyroidectomy for almost all patients with papillary thyroid cancer to the incorporation of thyroid lobectomy for well-selected patients with low-risk disease; minimally invasive parathyroidectomy with, and potentially without, intraoperative parathyroid hormone monitoring for patients with well-localized primary hyperparathyroidism; improvement in the management of parathyroid cancer with the incorporation of immune checkpoint blockade and/or targeted therapies; and the incorporation of minimally invasive techniques in the management of patients with benign tumors and selected secondary malignancies of the adrenal gland.

Minimally invasive techniques in benign and malignant adrenal tumors

Minimally invasive adrenalectomy has become the main treatment modality for most adrenal lesions. Both laparoscopic transabdominal and retroperitoneoscopic approaches are safe and feasible options, each with respective advantages, including better surgical outcomes, fewer complications, and faster recovery over open adrenalectomy. While open surgery remains a valid modality in treatment of adrenocortical cancer in the presence of some findings such as invasion, robotic platforms, and minimally invasive surgery have gained popularity as technology continues to evolve. Organ preservation during adrenalectomy is feasible in some conditions to prevent adrenal insufficiency. Ablative technologies are increasingly utilized in benign and malignant tumors, including the adrenal gland, with various outcomes. A multidisciplinary team, an experienced surgeon, and a high-volume center are recommended for any surgical approaches and management of adrenal lesions. This review article evaluated recent findings and current evidence on minimally invasive adrenalectomy.

[Minimally invasive techniques in adrenal gland surgery]

Today, adrenalectomy can be performed by a variety of laparoscopic and retroperitoneoscopic approaches. Of particular importance are the lateral transperitoneal and the posterior retroperitoneoscopic access routes. Comparative studies of transperitoneal and retroperitoneal procedures still demonstrate heterogeneous results. Nevertheless, retroperitoneal access techniques seem to enable less postoperative pain and a faster recovery. Robotic procedures are gaining in popularity but the final importance cannot yet be determined. All minimally invasive techniques are considered to be so safe and reliable that open approaches are only justified in exceptional cases.

Predicting surgical outcome in posterior retroperitoneoscopic adrenalectomy with the aid of a preoperative nomogram

BACKGROUND

Posterior retroperitoneoscopic adrenalectomy (PRA) has several advantages over transperitoneal laparoscopic adrenalectomy (TLA) regarding operative time, blood loss, postoperative pain, and recovery. However, it can be a technically challenging procedure. To improve patient selection for PRA, we developed a preoperative nomogram to predict operative time.

METHODS

All consecutive patients with tumors of ≤ 7 cm and a body mass index (BMI) of < 35 kg/m2 undergoing unilateral PRA between February 2011 and March 2020 were included in the study. The primary outcome was operative time as surrogate endpoint for surgical complexity. Using ten patient variables, an optimal prediction model was created, with a best subsets regression analysis to find the best one-variable up to the best seven-variable model.

RESULTS

In total 215 patients were included, with a mean age of 52 years and mean tumor size of 2.4 cm. After best subsets regression analysis, a four-variable nomogram was selected and calibrated. This model included sex, pheochromocytoma, BMI, and perinephric fat, which were all individually significant predictors. This model showed an ideal balance between predictive power and applicability, with an R2 of 38.6.

CONCLUSIONS

A four-variable nomogram was developed to predict operative time in PRA, which can aid the surgeon to preoperatively identify suitable patients for PRA. If the nomogram predicts longer operative time and therefore a more complex operation, TLA should be considered as an alternative approach since it provides a larger working space. Also, the nomogram can be used for training purposes to select patients with favorable characteristics when learning this surgical approach.

A cadaveric anatomical study: anatomy and anatomical variations of left adrenal vein

PURPOSE

Control of adrenal vein is the key of adrenal surgery. Its anatomy can present variations. Our aim was to study the anatomy of the main left adrenal vein (LAV) and its anatomical variations.

METHODS

Our work is based on dissection of 40 cadavers. We studied the number of LAV and the drainage of the main adrenal vein as well as its level of termination. We measured its length, its width and the distance between its termination level and the termination level of the gonadal vein (GV).

RESULTS

The average length of the LAV was 21 mm its mean width was 5 mm. It ended in 100% of cases at the upper edge of the left renal vein after an anastomosis with the lower phrenic vein in 36 cases (90%) and without anastomosis with the lower phrenic vein in four cases (10%). The left adrenal vein ended at the upper edge of the left renal vein either at the same level as the termination of the left GV in 14 cases (35%) or within the termination of the left GV in 26 cases (65%) by an average of 8 mm. The LAV was unique central vein in 22 cases (55%) and in 12 cases (30%), a major central adrenal vein with several small veins was found.

CONCLUSIONS

The LAV is usually unique but there are variations in number. There are also variations in the level of its termination in the left renal vein as well as its anastomosis. During surgery, in case of difficulty, the left GV and the adrenal-diaphragmatic venous trunk could be used as benchmarks.

Hypotension in Posterior Retroperitoneoscopic Versus Transperitoneal Laparoscopic Adrenalectomy

INTRODUCTION

Despite preoperative optimization, hemodynamic instability can be a major challenge during adrenalectomy. Even brief episodes of intraoperative hypotension can be associated with ischemia-reperfusion injury. This study aimed to compare intraoperative hemodynamic parameters between posterior retroperitoneoscopic adrenalectomy (PRA) and transperitoneal laparoscopic adrenalectomy (TPA).

METHODS

This is a retrospective study of patients undergoing PRA and TPA without conversion or concomitant intraabdominal pathology from 2008 to 2019. The primary outcome was intraoperative hypotension defined by mean arterial pressure <60 mm Hg or the need for ≥1 intravenous vasopressors at least 30 min after anesthetic induction.

RESULTS

Overall, 108 patients met the inclusion criteria; 33 (30.6%) had pheochromocytoma, 26 (24.1%) had aldosterone excess, 8 (7.4%) had corticosteroid excess, and 41 (38.0%) had nonfunctioning adrenal tumors. Of these, 68 (63.0%) underwent PRA and 40 (37.0%) underwent TPA. Age, sex, body mass index, preinduction blood pressure, number of preoperative antihypertensives, and histopathological diagnosis were similar in the two groups. Tumor size was greater in the TPA group. The presence of pheochromocytoma was an independent risk factor for hypotension. Multivariate analysis revealed that PRA was associated with a higher risk of experiencing a mean arterial pressure <60 mm Hg (odds ratio 4.44, 95% confidence interval 1.27-15.54, P = 0.02) and the need for ≥1 intravenous vasopressors (odds ratio 9.97, 95% confidence interval 3.34-29.78, P < 0.001) compared with TPA.

CONCLUSIONS

Although PRA offers several advantages over TPA, it carries a greater risk of intraoperative hypotension. A prospective trial is required to validate these findings. Nevertheless, institution of risk reduction strategies is encouraged to be considered for individuals undergoing PRA.

Minimally invasive adrenalectomy: a comprehensive systematic review and network meta-analysis of phase II/III randomized clinical controlled trials

PURPOSE

The best approach for minimally invasive adrenalectomy is still under debate.

METHODS

A systematic search of randomized clinical trials was carried out. A frequentist random-effects network meta-analysis was made reporting the surface under the cumulative ranking (SUCRA). The primary endpoint regarded both in-hospital mortality and morbidity. The secondary endpoints were operative time (OP), blood loss (BL), length of stay (LOS), conversion, incisional hernia, and disease recurrence rate.

RESULTS

Eight studies were included, involving 359 patients clustered as follows: 175 (48.7%) in the TPLA arm; 55 (15.3%) in the RPLA arm; 10 (2.8%) in the Ro-TPLA arm; 25 (7%) in the TPAA arm; 20 (5.6%) in the SILS-LA arm; and 74 (20.6%) in the RPA arm. The RPLA had the highest probability of being the safest approach (SUCRA 69.6%), followed by RPA (SUCRA 63.0%). TPAA, Ro-TPLA, SILS-LA, and TPLA have similar probability of being safe (SUCRA values 45.2%, 43.4%, 43.0%, and 38.5%, respectively). Analysis of the secondary endpoints confirmed the superiority of RPA regarding OP, BL, LOS, and incisional hernia rate.

CONCLUSIONS

The best choice for patients with adrenal masses candidate for minimally invasive surgery seems to be RPA. An alternative could be RPLA. The remaining approaches could have some specific advantages but do not represent the first minimally invasive choice.

Robotic Adrenalectomy Using the da Vinci SP Robotic System: Technical Feasibility Comparison with Single-Port Access Using the da Vinci Multi-arm Robotic System

BACKGROUND

Laparoscopic adrenalectomy is the gold standard for adrenal tumor; however, robotic adrenal surgery has gained interest recently. For minimally invasive surgeries, we first reported on robotic adrenalectomy using a single-port access performed using the da Vinci multi-arm robotic system (RA-SA) in 2011. Since its introduction in 2018, we first performed robotic adrenalectomy using the da Vinci SP robotic system in 2020.

OBJECTIVE

We aimed to introduce the novel single-port robotic system (RA-SP) for adrenalectomy and evaluate its technical feasibility by comparing it with the surgical outcomes of patients who underwent robotic adrenalectomy using the RA-SA.

METHODS

Eight patients who underwent robotic adrenalectomy using the RA-SP from February 2020 to June 2021 were compared with 11 patients who underwent RA-SA from 2011 to 2015 by a single surgeon.

RESULTS

The two groups were similar in age, sex, body mass index, type of operation, and final pathologic diagnosis. Despite no significant differences, RA-SP resulted in moderately less mean operation time, estimated blood loss, and length of hospitalization.

CONCLUSIONS

The Da Vinci SP robotic system is a novel, safe, and feasible technique to improve the convenience of operation and cosmetic effect for adrenalectomy.

Risk factors for haemodynamic instability and its prolongation during laparoscopic adrenalectomy for pheochromocytoma

OBJECTIVE

Pheochromocytoma is a rare neuroendocrine tumour that secretes catecholamines and originates in the adrenal gland. Although surgical resection is the only curative therapy for pheochromocytoma, it is associated with a risk of haemodynamic instability (HDI), such as extremely high blood pressure and/or post tumour removal hypotension and shock. We investigated the risk factors for HDI during pheochromocytoma surgery.

DESIGN AND PATIENTS

Eighty-two patients who underwent laparoscopic adrenalectomy for pheochromocytoma between July 2002 and February 2020 were examined. We excluded 3 patients with bilateral disease and 11 without detailed 24 h urinary data. We defined HDI as systolic blood pressure ≥ 200 or <80 mmHg. We investigated the risk factors for HDI during laparoscopic adrenalectomy for pheochromocytoma.

RESULTS

There were 29 males and 39 females with a median age of 50.5 years. Tumours were localised on the right adrenal gland in 28 patients and on the left in 40. The median tumour diameter was 37.5 mm and the median pneumoperitoneum time was 93.5 min. Twenty-five out of sixty-eight patients (37%) developed HDI. A multivariate analysis identified diabetes mellitus (DM; odds ratio: 3.834; 95% confidence interval: 1.062-13.83; p = .04) as an independent predictor of HDI. In terms of hormonal data, median 24 h urinary epinephrine levels (p = .04) and metanephrine levels (p = .01) were significantly higher in the HDI group. DM was also considered as a risk factor for prolonged HDI (p = .02).

CONCLUSION

Surgeons and anaesthesiologists need to be aware of the risk of HDI and its prolongation during laparoscopic adrenalectomy for pheochromocytoma for DM patients.

New predictive factors for prolonged operation time of laparoscopic posterior retroperitoneal adrenalectomy; retrospective cohort study

BACKGROUND

Laparoscopic adrenalectomy is a standard surgical procedure for benign adrenal diseases. Laparoscopic posterior retroperitoneal adrenalectomy (LPRA) has many benefits. However, it is associated with factors such as prolong operation time. The aim of the study was to determine the predictive factors associated with prolonged operation time in LPRA.

MATERIALS AND METHODS

This study retrospectively analyzed data from 284 patients who underwent LPRA between 2014 and 2019 at Asan Medical Center. Then, we analyzed the predictive factors prolonging operation time using multivariate logistic regression analysis and classified the differences according to the learning curve using cumulative sum analysis.

RESULTS

In multivariate logistic regression analysis, the following were determined as factors associated with prolonged operation time: male sex (OR, 2.540; 95% CI, 1.225-5.266), pheochromocytoma (OR, 3.669; 95% CI, 1.548-8.694), right site (OR, 2.499; 95% CI, 1.086-5.748), surgeon A (OR, 3.293; 95% CI, 1.522-7.122), depth of descended adrenal tumor location to kidney (OR, 3.793; 95% CI, 1.660-8.667), large periadrenal fat volume (OR, 2.366; 95% CI, 1.120-4.996), and posterior adiposity index (PAI) (OR, 2.171; 95% CI, 1.090-4.324) (all p < 0.05). However, in the period after the learning curve, periadrenal fat volume was not a significant predictor of surgery time prolongation.

CONCLUSION

This study demonstrates that depth of descended adrenal tumor location to kidney is a new and important independent predictive factor for prolonged operation time in LPRA. In addition, periadrenal fat volume is a predictor of surgery time prolongation for beginner surgeons before the learning curve.

Robotic Posterior Retroperitoneal Adrenalectomy: Patient Selection and Long-Term Outcomes

BACKGROUND

Recently, efficacy of laparoscopic posterior retroperitoneal adrenalectomy (PRA) for pheochromocytoma and malignancy has been questioned. Although robotic technique using wristed instruments may improve limitations of laparoscopic PRA, the worldwide experience with robotic PRA is limited. This study aimed to describe patient characteristics, surgical technique, and long-term outcomes of robotic PRA from a 12-year single-center experience.

METHODS

This analysis was an institutional review board-approved retrospective study. In this study, PRA was performed robotically, with intraoperative ultrasound and indocyanine green imaging guidance. Long-term outcomes and predictors of operative time (OT) were assessed using descriptive and regression analyses. Using OT as a surrogate for difficulty of procedure, receiver operating characteristic curve analysis was performed to quantify anthropometric thresholds that would predict a more challenging procedure.

RESULTS

Altogether, 112 robotic PRA procedures were performed. Three cases (3%) were converted to a lateral approach, and one case (1%) was converted to open surgery. The morbidity rate was 2%. Microscopic capsular disruption occurred for one patient. No patient experienced persistent disease or local recurrence from pheochromocytoma or malignant adrenal tumors during the follow-up period (median, 48 months). Operating time was independently predicted by perirenal fat thickness, with 18.5 mm as the critical threshold.

CONCLUSION

In this study, favorable PRA outcomes were achieved with careful patient selection and meticulous surgical technique that used robotic articulation guided by intraoperative imaging.

Comparison of Posterior Retroperitoneoscopic Adrenalectomy Versus Lateral Transperitoneal Laparoscopic Adrenalectomy for Adrenal Tumors: A Systematic Review and Meta-Analysis

Objective

To discuss the differences in the effectiveness and security for adrenal tumors by posterior retroperitoneoscopic adrenalectomy (PRA) and lateral transperitoneal laparoscopic adrenalectomy (LTA).

Methods

We systematically searched PubMed, Embase, Scopus database and Cochrane Library, and the date was from above database establishment to November 2020. Stata 16 was used for calculation and statistical analyses.

Results

Nine studies involving eight hundred patients were included. The following differences were observed in favor of PRA vs LTA: less operative time (MD: -22.5; 95% CI -32.57 to -12.45; P=0.000), Fewer estimated blood loss (MD: -15.17; 95% CI -26.63 to -3.72; P=0.009), lower intensity of postoperative pain (MD: -0.56; 95% CI, -1.05 to -0.07; P=0.026), shorter length of hospital stay (MD: -1.15; 95% CI -1.94 to -0.36; P=0.04). No differences were shown in conversion rate (OR 2.07; 95%CI 0.71 to 6.03; P=0.181) and complications (OR 0.85;95% CI 0.46 to 1.56; P=0.597).

Conclusions

Posterior retroperitoneoscopic adrenalectomy was clinically superior to lateral transperitoneal laparoscopic adrenalectomy for adrenal tumors in operative time, estimated blood loss, length of hospital stay, and postoperative pain. Only in term of conversion rate and complications, both were similar.

Contemporary Experience of Posterior Retroperitoneoscopic Adrenalectomy in the US

BACKGROUND

As the incidence of adrenalectomy increases steadily, so does the use of minimally invasive approaches like posterior retroperitoneoscopic adrenalectomy (PRA). To date, the largest studies of PRA have been from abroad, and we sought to provide a contemporary US update on the outcomes after PRA.

METHODS

A retrospective chart review was conducted on all PRAs performed at a single tertiary care institution between 2013 and 2020. Patient demographic characteristics, indication for operation, operative details, and postoperative course were abstracted. Outcomes of interest included 30-day mortality, conversion to open or transabdominal approach, postoperative complication, and 30-day readmission.

RESULTS

A total of 249 PRAs were performed between 2013 and 2020. The population was 54.2% women and mean (SD) age was 54.1 (14.1) years. Most lesions (60.6%) were left-sided, and the most common diagnosis was nonfunctioning adenoma (39.4%), followed by pheochromocytoma (21.3%) and aldosteronoma (16.6%). Mean (SD) tumor size was 3.2 cm (range 0.5 to 9.4 cm). Median operative length was 110 minutes (range 30 to 319 minutes). Overall, the complication rate was 6.4%. Nine patients (3.6%) had a minor postoperative complication (Clavien-Dindo I to III) and 5 patients (2.0%) had a major postoperative complication (Clavien-Dindo IV to V), including 1 mortality (0.4%). There were 2 conversions of approach (0.8%). The majority of patients (58.2%) were discharged on postoperative day 1, and 92.0% were discharged by postoperative day 3. The 30-day readmission rate was 1.6%.

CONCLUSIONS

Current practice demonstrates that PRA is an extremely safe approach, with a complication rate < 7% and mortality rate < 1%. In addition, the vast majority of patients are able to return home in an expedient manner.

Insufflation pressure above 25 mm Hg confers no additional benefit over lower pressure insufflation during posterior retroperitoneoscopic adrenalectomy: a retrospective multi-centre propensity score-matched analysis

BACKGROUND

Insufflation pressures of or in excess of 25 mm Hg CO2 are routinely used during posterior retroperitoneoscopic adrenalectomy (PRA) in most centres. A critical analysis of the surgical literature provides limited evidence to support this strategy.

OBJECTIVE

To determine whether high pressure (≥ 25 mm Hg) compared with lower pressure (< 25 mm Hg) retroperitoneoscopy reduces operating time and complications.

METHODS

A multi-centre retrospective cohort study was performed using data collected over a period of almost one decade (1st November 2008 until 1st February 2018) from surgical centres in Germany. A total of 1032 patients with benign adrenal tumours were identified. We compared patients undergoing PRA with insufflation pressures of < 25 mm Hg (G20 group) versus ≥ 25 mm Hg (G25 group). A propensity score matching analysis was performed using BMI, tumour size and surgeon's experience as independent variables. The main outcomes were (1) the incidence of perioperative complications and (2) the length of operating time.

RESULTS

The baseline patient characteristics were similar in both groups, with the exception of tumour size, BMI and surgeon's experience in PRA. After propensity score matching, perioperative outcomes, especially perioperative complications (3.7% vs. 5.5% in G20 and G25, respectively; p = 0.335) and operation duration (47 min vs. 45 min in G20 and G25, respectively; p = 0.673), did not significantly differ between the groups.

CONCLUSION

Neither patient safety nor operative success was compromised when PRA was performed with insufflation pressures below 25 mm Hg. Prospective studies are required to determine whether an optimal insufflation pressure exists that maximizes patient safety and minimizes the risks of post-surgical complications. Nevertheless, our results call for a careful re-evaluation of the routine use of high insufflation pressures during PRA. In the absence of prospective data, commencing PRA with lower insufflation pressures, with the option of increasing insufflation pressures to counter intraoperative bleeding or exposition difficulties, may represent a reasonable strategy.

Laparoscopic resection of a large nonadrenal ganglioneuroma adhered to the aorta and inferior mesenteric artery: A case report and literature review

•

Ganglioneuromas are well-differentiated benign tumors that arise from sympathetic ganglion cells.

•

Ganglioneuromas is difficult to diagnose preoperatively, so surgical complete resection combined with diagnostic treatment is recommended.

•

Previously many nonadrenal ganglioneuromas are resected by laparotomy due to the proximity to major vessels and gastrointestinal tract.

•

Laparoscopic resection of nonadrenal ganglioneuromas is feasible even when a tumor adheres to major blood vessels.

•

It is difficult to diagnose preoperatively, so surgical complete resection combined with diagnostic treatment is recommended.

Introduction

Ganglioneuromas are well-differentiated benign tumors that arise from sympathetic ganglion cells. In ganglioneuromas of the retroperitoneum, nonadrenal cases are resected by laparotomy due to the proximity to major vessels. There have been few reports of laparoscopic resection for retroperitoneal paraaortic ganglioneuromas. We experienced a case in which laparoscopic resection was required for a 90-mm ganglioneuroma adhered to the aorta and inferior mesenteric artery.

Presentation of case

A 49-year-old female patient presented with epigastric pain. Computed tomography showed a 90 mm retroperitoneal tumor, partially located between the aorta and inferior mesenteric artery. A definitive diagnosis was not obtained, and laparoscopic excision of the retroperitoneal tumor was performed transabdominally. The patient recovered without postoperative complications and left the hospital on postoperative day 8. Postoperative pathological findings revealed a ganglioneuroma from the abdominal periaortic plexus.

Discussion

We searched the literature for nonadrenal ganglioneuromas resected laparoscopically using a transabdominal approach and summarized the tumor locations. The median age was 33 years, and the median tumor size was 50 mm. Regarding the surgical results, the median operative time was 170.5 min, median blood loss was 21.5 mL, and median postoperative stay was 7 days.

Conclusion

Laparoscopic resection of nonadrenal ganglioneuromas is feasible even when a tumor adheres to major blood vessels.

Minimally Invasive Adrenal Surgery

Since the introduction of minimally invasive surgery, laparoscopic adrenalectomy has become the main treatment option for adrenal masses. Various studies have reported that laparoscopic adrenalectomy showed fewer postoperative complications and faster recovery than conventional open adrenalectomy. Laparoscopic adrenalectomy can be performed through either the transperitoneal approach or the retroperitoneoscopic approach, which are widely used in most adrenal surgical procedures. Furthermore, with the development of minimally invasive surgery, organ-sparing adrenalectomy has recently emerged as a way to conserve functional adrenal gland tissue. According to recent data, organ-sparing adrenalectomy shows promising surgical, functional, and oncological outcomes including less intraoperative blood loss, maintenance of adrenal function, and low recurrence. Partial adrenalectomy was initially proposed for bilateral adrenal tumors in patients with hereditary disease to avoid chronic adrenal insufficiency. However, it has also gained popularity for the treatment of unilateral adrenal disease involving a small adrenal tumor because even patients with a unilateral adrenal gland may develop adrenal insufficiency in stressful situations. Therefore, partial adrenalectomy has become increasingly common to avoid lifelong steroid replacement and recurrence in most cases, especially in bilateral adrenal disease. This review article evaluates the current evidence on minimally invasive adrenalectomy and organ-preserving partial adrenalectomy.

A cadaveric anatomical study of the adrenals: Relationship with the posterior abdominal wall muscles revisited

AIM OF THE STUDY

The main difficulties during retroperitoneal laparoscopic adrenalectomies are due to its location. Our objective was to define the relationship of the adrenals with the diaphragm and the psoas muscle.

METHODS

Our work is an anatomical dissection of 80 fresh cadavers' adrenals. To study the right adrenal, we performed a right nephrectomy and adrenal remained attached to the Inferior vena cava by its main vein. On the left, the edges of the adrenal have been identified by needles and the adrenal was reclined to study its projection on the posterior muscular wall.

RESULTS

The right adrenal is located higher, 13mm [4-20mm] above the medial arcuate ligament (MAL) in 16 cases (40%). Its lower border was at the same level as the MAL in 18 cases (45%) and 11mm [10-17mm] below the MAL in 6 cases (15%). The posterior support of the right adrenal was the right crus of the diaphragm (Right-CD) in 34 cases (85%) and straddling the Right-CD and the psoas in 6 cases (15%). The study of the relationships of the left adrenal with the MAL showed that the lower edge of the gland was at its same level in 16 cases (40%) and below in 24 cases (60%) by 14mm [8-24mm]. The posterior support of the left adrenal was the left crus of the diaphragm (Left-CD) in 16 cases (40%) and straddling the Left-CD and the psoas in 24 cases (60%).

CONCLUSIONS

Our results showed that the right adrenal is higher. The MAL is an important posterior element to the adrenal gland that could serve as an anatomical landmark to identify the adrenal during laparoscopic adrenalectomy.

Approach to the Patient: Perioperative Management of the Patient with Pheochromocytoma or Sympathetic Paraganglioma

Pheochromocytomas and sympathetic paraganglioma (PPGL) are rare chromaffin cell tumors originating in the adrenal medulla and sympathetic paraganglia, respectively, which share the capacity to synthesize and release catecholamines. The incidence of PPGL has increased in recent years. Surgical resection is the only curative treatment for PPGL. Management of patients with PPGL is complex and should be done by a specialized multidisciplinary team in centers with broad expertise. Surgical resection of a PPGL is a high-risk procedure for which optimal pretreatment with antihypertensive drugs is required in combination with state-of-the-art surgical procedures and anesthesiological techniques. In this article we discuss the underlying evidence and the pros and cons of presurgical medical preparation. Finally, the areas of uncertainty and controversies in this field are addressed.

Posterior Retroperitoneoscopic Versus Laparoscopic Transperitoneal Adrenalectomy: A Systematic Review by an Updated Meta-Analysis

BACKGROUND

Two main minimal access adrenalectomy techniques are available: laparoscopic transperitoneal (LTA) and posterior retroperitoneoscopic adrenalectomy (PRA). This study aims to compare these approaches in an updated meta-analysis of randomised controlled (RCT) and non-randomised comparative (NRT) trials.

METHODS

A systematic search of comparative LTA and PRA studies was performed. Standard demographic and surgical data were recorded. Outcome measures compared included: operative time, estimated blood loss (EBL), conversion to open, post-operative pain, time to oral intake and ambulation, early morbidity, hospital length of stay (HLOS) and mortality. Quality of RCTs and NRTs was assessed using Cochrane and ROBINS-I, respectively, and heterogeneity using the I² test. Dichotomous and continuous variables were compared using odds ratios and mean/standard difference. Studies were then combined using the Mantel-Haenszel method. Meta-analysis was performed by fixed- and random-effect models.

RESULTS

Following exclusions, 12 studies were included in the analysis: 3 RCTs and 9 NRTs. These reported a total of 775 patients: 341 (44%) PRA and 434 (56%) LTA. Demographics were similar except for tumour size which was smaller (by 0.78 cm) in PRA (p = 0.003). Significant differences in outcome were seen in EBL (18 mls less in PRA, p = 0.006), time to oral intake (3.4 h sooner in PRA p = 0.009) and HLOS (shorter in PRA by 0.84 day, p = 0.001).

CONCLUSIONS

This analysis demonstrates that while PRA tends to be performed for smaller tumours it allows for less EBL, earlier post-operative oral intake and shorter hospital stays. In appropriately selected patients, it represents an invaluable tool in the endocrine surgeon's armamentarium.

Surgical outcomes of a randomized controlled trial compared robotic versus laparoscopic adrenalectomy for pheochromocytoma

BACKGROUND

Robotic adrenalectomy for pheochromocytoma is increasingly popular because of the advantage that have been proved by some researchers recently. However, prospective randomized clinical trials comparing robotic assisted laparoscopic adrenalectomy (RA) with traditional laparoscopic adrenalectomy (LA) for pheochromocytoma are rare. The aim of this study is to compare perioperative outcomes of RA versus LA for pheochromocytoma prospectively.

METHODS

From March 2016 to April 2019, all patients with pheochromocytoma suitable for laparoscopic adrenalectomy were assigned randomly to RA or LA. The primary endpoint was the operative (exclude docking time) time. Secondary endpoints were estimated blood loss and postoperative recovery. Demographics and perioperative data were prospectively collected.

RESULTS

A total of 140 (RA 70, LA 70) patients were enrolled in this prospective research. The following significant differences were identified in favor of RA: shorter median operative (exclude docking time) time (92.5 vs 122.5 min, P = 0.007), however, RA group has higher total hospitalization cost (8869.9 vs 4721.8 $, P < 0.001). Demographics and other perioperative outcomes were similar in both groups. The RA group showed a significant lower blood loss and operative (exclude docking time) time compared with LA group (P < 0.05) for patients with high Nor-Metanephrine (NMN).

CONCLUSIONS

Both RA and LA for pheochromocytoma are safe and effective. Patients with high NMN can benefit from less blood loss and operative time when a robotic surgery system was used, but RA has a significant higher cost.

[Surgery of adrenal diseases]

Incidentally discovered adrenal alterations should be separated into those without any clinical importance and adrenal diseases that have to be surgically or conservatively treated. Before operative treatment, in addition to the possible different functional activity of tumors, a differentiation must be made between sporadically arising singular or multiple adrenal tumors or nodular adrenal hyperplasia, adrenal tumors as part of a familial syndrome and metastases of other primary malignant tumors into the adrenal glands. Benign hormonally active adrenal tumors as well as questionable malignant tumors of the adrenal cortex are resected by minimally invasive techniques. For large malignant tumors infiltrating into surrounding tissues and tumors with proven lymph node metastases, the primarily open approach is indicated. Patients with adrenal diseases should always undergo an interdisciplinary assessment and in cases with clear indications for surgery, sometimes transferred to a center with experience in surgery and postoperative management of these patients.

Posterior retroperitoneoscopic adrenalectomy: recommendations to implement this approach

INTRODUCTION

The posterior retroperitoneoscopic approach (PRA) is seldom used in our country to perform adrenalectomies, although it offers possible advantages over laparoscopic anterior or lateral access, according to some authors. The aim of this study was to identify those features that determine the most suitable cases to start the implementation of this technique.

METHODS

A prospective observational study was performed with a 50 patients cohort. All the cases were operated using the PRA. Sex, age, body mass index (BMI), operative time, left or right side, size and anatomopathological characteristics of the lesion, conversion rates, complications and hospital stay were analyzed.

RESULTS

25 (50%) women and 25 (50%) men underwent surgery, with a median operative time of 80 minutes (45-180). A significantly shorter operative time (p = 0.002) was observed in women and in adenomas (p = 0.002). However, no correlation was observed between surgical time and BMI, lesion side or lesion size. There were no conversions. The complication rate was 14%, and most of the complications were grade i in Clavien Dindo's Scale. Median hospital stay was two days.

CONCLUSIONS

Retroperitoneoscopic adrenalectomy by posterior approach is a safe and reproducible procedure, with very good outcomes. The most suitable cases to implement this technique would be female patients with adrenal adenomas.

Propensity Score Matched Analysis Comparing Robotic-Assisted with Laparoscopic Posterior Retroperitoneal Adrenalectomy

Objectives: To compare the perioperative outcomes between robotic posterior retroperitoneal adrenalectomy (RPRA) with laparoscopic posterior retroperitoneal adrenalectomy (LPRA) for adrenal tumors and to identify which group of patients may benefit from RPRA.Methods: A total of 401 patients who fulfilled the inclusion criteria were collected and analyzed; among them, 86 and 315 patients underwent RPRA and LPRA, respectively. To adjust for potential baseline confounders, propensity score matching (PSM) was conducted at a 1:1 ratio. Patient demographics and perioperative outcomes were compared between the two groups.Results: After matching, no differences were found between the two groups in patient demographics or tumor characteristics. The median length of postoperative stay (3 vs. 4 days, p = 0.001) was significantly shorter in the RPRA group, but this group also showed a higher median total hospitalization cost (8121.89 vs. 4107.92 $, p < 0.001). There was no difference in the median operative duration (100 vs. 110 min, p = 0.554), median estimated blood loss (50 vs. 50 ml, p = 0.730), transfusion rate (p = 0.497) or incidence of postoperative complications (p = 0.428).Conclusions: According to our research, RPRA leads to a shorter postoperative hospitalization stay but a higher total hospitalization cost than LPRA after propensity score matching.

Hernia after retroperitoneoscopic adrenalectomy, case report

We report the first case of a previously undocumented complication after posterior retroperitoneal adrenalectomy (PRA). Extensive diagnostic procedures for persisting abdominal pain led to diagnosis of an incisional hernia (IH) approximately 2.5 years after surgery for a pheochromocytoma of the right adrenal gland. Thus, IHs need to be recognized as a potential complication after PRA, particularly if the symptoms are non-specific. The differential diagnosis of an IH after PRA includes a type of spontaneous lumbar hernia due to a pre-existing weakness of the abdominal wall however the treatment for both type of hernias is similar by mesh repair. A possible risk factor for IH after PRA might be obesity, due to different factors including difficulties in closing the fascia in depth under subcutaneous tissue.

Evaluation and management of adrenal neoplasms: endocrinologist and endocrine surgeon perspectives

The evaluation and management of adrenal disease is a complex endeavor that relies on an expert knowledge of human physiology and anatomy. Careful and proper patient assessment mandates a balanced approach which marries the disciplines of endocrinology, surgery, and radiology. Any of these three specialties may be on the front line in performing the initial workup when an adrenal neoplasm is discovered. With an ever-increasing volume of cross-sectional imaging, be it CT, MRI, or PET, large numbers of adrenal incidentalomas are being discovered. A close collaboration amongst specialties should strive to streamline the initial evaluation and minimize unnecessary testing and treatment.

Comparison of surgical outcomes between lateral and posterior approaches for retroperitoneal laparoscopic adrenalectomy: A single surgeon's experience

Purpose

To compare surgical outcomes between the lateral and the posterior approach for retroperitoneal laparoscopic adrenalectomy (RLA).

Materials and Methods

We retrospectively reviewed the records of 130 patients who underwent RLA for adrenal tumors by a single surgeon between January 2015 and December 2018. Patient characteristics and perioperative outcomes were analyzed and compared between two surgical groups: lateral approach (n=56) and posterior approach (n=74).

Results

There were no significant differences in perioperative outcomes between the two groups except for operative time (lateral approach, 105.4±41.21 minutes vs. posterior approach, 71.5±31.51 minutes; p=0.001). In the lateral approach group, two patients (3.6%) underwent open conversion, but there were no major complications in either group (Clavien-Dindo classification ≥3). Male sex was associated with an operative time of ≥90 minutes in the univariate analysis (p=0.019), but this effect did not remain significant in the multivariate analysis. In the multivariate analysis, large tumor size (>5 cm; p=0.020) and preoperative diagnosis of malignancy (p=0.043) were significantly associated with an operative time of ≥90 minutes.

Conclusions

Both the lateral and posterior approaches for RLA were performed safely with similar operative outcomes and are therefore comparable options for the treatment of adrenal tumors. In addition, large tumor size and preoperative diagnosis of malignancy are associated with longer operative times.

Evolution of adrenal surgery in a tertiary referral centre

BACKGROUND

Laparoscopic transperitoneal and retroperitoneoscopic adrenalectomy have largely replaced open adrenal surgery, particularly in benign disease. Laparoscopic surgery results in less post-operative pain, fewer surgical site complications and reduced length of hospital stay. The aim of this retrospective study was to analyse the characteristics of patients and evolution of surgical technique in adrenal surgery at Cork University Hospital over a 12-year period.

METHODS

All cases of adrenalectomy between January 1st, 2007 and December 31st, 2018 were retrospectively reviewed. Patient demographics, diagnosis, surgical approach, length of hospital stay, histology and complications were evaluated. Comparisons were made between open, laparoscopic transperitoneal and retroperitoneoscopic adrenalectomy cases.

RESULTS

There were 57 adrenalectomies performed on 55 patients over the 12-year period. Twenty-six patients (46%) were male, and the mean age was 49 years (range 14-84 years). Twenty-two (39%) right-sided adrenalectomies were performed, 33 (57%) left sided and 2 (4%) patients underwent bilateral surgery. Seventeen adrenalectomies were performed using an open transperitoneal approach, 30 via a laparoscopic transperitoneal approach and 10 using the retroperitoneoscopic technique. Adenoma and pheochromocytoma were the most common indications for surgery (42% and 40%, respectively). Seven percent were performed for malignancy and 5% for other benign indications. The complication rate for open adrenalectomy was 18% versus 10% in laparoscopic transperitoneal adrenalectomy and 0% for retroperitoneoscopic adrenalectomy. Two patients (7%) undergoing laparoscopic transperitoneal surgery required conversion to an open procedure. There were no 30-day mortalities and no disease recurrence within the study time frame. The mean length of hospital stay was 7.6 days in the open group, 5.8 days for the laparoscopic transperitoneal group and 3 days for the retroperitoneoscopic group (p = 0.03).

CONCLUSIONS

Adrenalectomy is a safe procedure and in our setting was primarily performed for pheochromocytoma and non-functioning adenomas. Minimally invasive adrenalectomy has become the standard of care internationally and is associated with fewer complications, shorter hospital stay and a low conversion rate.