Cystic lesions of the adrenal gland

Cystic lesions of the adrenal glands are relatively uncommon and most of them are clinically silent. Though rarely associated with malignant changes, they may carry clinically detrimental consequences if misdiagnosed. Cystic adrenal lesions exhibit a broad histomorphological spectrum, ranging from pseudocysts, endothelial cysts, epithelial cysts and parasitic cysts. Here we present the case of a young woman with left-sided abdominal pain and contrast-enhanced CT showing a 10.4×7.7×7.8 cm fluid-filled left suprarenal lesion. The patient underwent exploratory laparotomy with cyst excision, and the histopathological examination of the specimen revealed a pseudocyst of the left adrenal gland. Despite being rare, usually benign and asymptomatic, the diagnosis and management of these cystic lesions of the adrenal glands are often unclear. Any functional lesion, potentially malignant lesion or lesion more than 5 cm deserves surgical management, whereas others can be managed conservatively.

A RARE CASE OF RAPIDLY ENLARGING MYELOLIPOMA IN SICKLE CELL DISEASE

Objective

Adrenal myelolipoma (AM) is a benign tumor composed of mature fat cells and hemopoietic elements. Most AMs are incidental findings on imaging and clinically asymptomatic. The purpose of this case report is to describe a rare case of AM and explore its clinical manifestations, imaging features, and treatment.

Methods

In this study, we report a case of a rapidly growing right AM in a patient with uncontrolled hemoglobin sickle cell disease. A 38-year-old male presented to our institution's endocrine surgery clinic for evaluation of an enlarging right adrenal mass. This mass was incidentally found during an abdominal ultrasound performed for transaminitis and thrombocytopenia. Patient was asymptomatic without any abdominal discomfort, back pain, nausea, or vomiting.

Results

Patient was lost to follow up until 2018. Follow-up computed tomography scan in 2018 showed the right adrenal mass measuring 12.3 cm in greatest dimension with significant macroscopic fat. Given the imaging features, AM was the presumed diagnosis. However, with a medical history of uncontrolled sickle cell disease, extra-medullary hematopoiesis and rapidly growing liposarcoma could not be ruled out. Surgical excision was performed due to size and significant tumor growth. Diagnosis was confirmed with histopathology and revealed myelolipoma.

Conclusion

Image characteristics can be helpful in diagnosis of AM; however, the appearance of this lesion on computed tomography can be similar to other adrenal gland pathologies such as liposarcoma and mass-forming extramedullary hematopoiesis. Percutaneous needle biopsy may be indicated if the diagnosis remains unclear.

Adrenal extramedullary hematopoiesis associated with beta-thalassemia trait in an adult woman: a case report and review of literature

INTRODUCTION

Adrenal myelolipoma with extramedullary hematopoiesis (EMH) is a rare condition.

CASE PRESENTATION

We report a case of 48-year-old woman suffering from recurrent right hypochondrial pain for two years. Laboratory work-up revealed chronic microcytic iron deficiency anemia with beta thalassemia trait, right adrenal myelolipoma with histopathological evidence of hematopoietic cells (EMH). The patient underwent open resection of the adrenal gland and the post-operative course was uneventful.

CONCLUSIONS

EMH could be presented with several clinical hematological disorders. Surgical management becomes inevitable in certain adrenal EMH cases especially in the presence of a large adrenal mass.

Teaching Laparoscopic Adrenalectomy to Surgical Residents

INTRODUCTION

Laparoscopic adrenalectomy is the surgical treatment for various adrenal diseases. The procedure is a common surgical practice for urologists and general surgeons and requires fundamental laparoscopic skills, nowadays common in the surgical education of residents in these practices. The aim of this study is to assess whether laparoscopic adrenalectomy differs in outcome between certified and trained surgeons and surgical residents and whether the learning curve changes the endpoint of the surgery.

MATERIALS AND METHODS

A cohort retrospective study, including all adult patients who underwent laparoscopic adrenalectomy between June 2008 and June 2014, was conducted. Patients' demographic, clinical, and surgical data were recorded and analyzed.

RESULTS

Fifty-three patients were included in the database (21 men, 32 women) with a mean age of 54 years (range 17-77). The cause for surgery was most commonly a benign adrenal tumor (27 patients, 50.9%) followed by large nonfunctioning adrenal tumors (16 patients, 30.1%), and adrenal cancer (8 patients, 15%). Eighteen patients (33.9%) were operated by residents (4-6 years into the residency) and 35 patients by a certified senior surgeon (66.1%). Left-sided adrenalectomy was preferred to right-sided adrenalectomy for resident tutoring (P = .03). Overall, intraoperative complications were seen in 6 patients (11.3%) and postoperative complications were seen in 9 patients (16.9%). There were no differences in operation time (P = .36), intraoperative complications (P = .76), postoperative complications (P = .96), and length of stay (P = .34) between the patients operated by senior residents and certified surgeons.

CONCLUSION

Laparoscopic adrenalectomy is a complex surgical procedure that should be a part of the surgical training of surgery residents, as it is safe in guided hands.

Laparoscopic adrenalectomy for the management of benign and malignant adrenal tumors

Laparoscopic adrenalectomy has become the preferred approach for removal of the adrenal gland. Many published studies support the use of laparoscopic adrenalectomy, with comparisons to open adrenalectomy suggesting many advantages to laparoscopy, including less postoperative pain, shorter hospital stay and earlier return to work. Adrenalectomy is usually required for the removal of adrenal tumors causing excess hormone production or because a malignant adrenal tumor cannot be excluded. Current controversies include the appropriateness of laparoscopic adrenalectomy for large or malignant tumors, the role of partial adrenalectomy and the management of some conditions with uncertain natural history (such as subclinical hypercortisolism). With the increased use of sensitive cross-sectional imaging, the detection of clinically inapparent adrenal masses is likely to continue to increase. Due to the fact that malignancy cannot be excluded with certainty in some patients with cortical adenomas, it is expected that the rate of laparoscopic adrenalectomy will continue to increase.

Myelolipomas and other fatty tumours of the adrenals

Background

Lipomatous tumours of the adrenals are almost always benign. The importance of recognising their characteristic radiological features, leading to their correct treatment, is fundamental, as there has been an increase in the identification of these lesions. Our goal was to review all lipomatous tumours of the adrenal glands, particularly myelolipomas, their imaging methods and surgical management, updated in 2011.

Methods

This was a retrospective review of articles published in the USA and Europe, from 1979 to date. The sites from which information was retrieved covered PubMed, Medscape, Clinical Imaging, Histopathology, Urologia Internationalis, Archives of Surgery, JACS, the American Urological Association, BMJ, Medline, and Springer Link. We report areas of controversies in addition to well established guidelines.

Results

We reviewed 45 articles, that confirmed, with a high level of evidence-based medicine, that the diagnosis of a lipomatous adrenal tumour is made by various imaging procedures, particularly computed tomography (CT). We emphasise the importance to their management of the initial size of the adrenal mass, its increase in size over time, in addition to the presence of symptoms.

Conclusion

Lipomatous tumours of the adrenals are most frequently benign. The diagnosis is usually made by various techniques, in particular CT. The fundamental characteristics indicating the necessity of surgical intervention are the symptoms presented, volume of the tumoral mass (>5 cm), and the increase in size of the tumour as shown in two consecutive imaging studies.

Minimally Invasive Adrenalectomy: A Multicenter Comparison of Transperitoneal and Retroperitoneal Approaches

Minimally invasive adrenalectomy (MIA) is both feasible and safe with either transperitoneal or retroperitoneal entry. However, only a few studies have rigorously compared these two techniques. The aim of the current study is to compare transperitoneal and retroperitoneal adrenalectomy to detect significant differences in patient selection and perioperative outcomes. Between 1995 and 2009, 171 patients underwent MIA through transperitoneal (n = 127) or retroperitoneal access (n = 44). The respective cohorts were then examined retrospectively through matched and unmatched comparisons. Multivariate analyses of intraoperative blood loss, postoperative morbidity, and length of hospital stay were performed. Surgical indications were benign lesions (70.2%), malignant tumors (11.1%), and pheochromocytomas (18.7%). The postoperative morbidity rate was 15.8 per cent, but mortality was null. The rate of conversion to open surgery was 5.3 per cent. Blood loss and operative time were significantly lower with the transperitoneal approach, whereas time to oral intake was shorter for the retroperitoneal group. Tumor size less than 4.5 cm was associated with less blood loss, shorter hospital stay, and lower postoperative morbidity. Laparoscopic and retroperitoneal routes are both effective and safe for excising adrenal lesions. In the present study, however, laparoscopic adrenalectomy demonstrated shorter operative times with less blood loss. Regardless of this, we remain cautious in recommending one procedure preferentially. Other important measures of clinical outcome such as required pain control, ease of patient recovery, and cost considerations were not included in this analysis. Further randomized trials, with large patient numbers, are therefore desirable for defining an optimal surgical method.

Predictive factors for malignant pheochromocytoma: analysis of 136 patients

PURPOSE

We evaluated the clinical characteristic, tumor feature and immunohistochemistry factors predicting malignant pheochromocytoma.

MATERIALS AND METHODS

Between January 1999 and December 2008 we retrospectively reviewed the records of 136 patients with pheochromocytoma at Ruijin Hospital. We compared clinical characteristics (age, gender, symptoms and biochemical analysis), tumor features (site, weight and diameter) and the expression of 3 angiogenesis/metastasis related genes (VEGF, Cox-2 and MVD) by immunohistochemical analysis of benign vs malignant pheochromocytomas.

RESULTS

Of the 136 patients 105 (77%) had benign and 31 (23%) had malignant pheochromocytoma. Malignant tumors were larger and heavier than benign tumors, and accompanied by higher plasma metanephrine secretion (each p <0.001). Mean tumor catecholamine and preoperative 24-hour urinary metanephrine or normetanephrine were obviously higher in malignant than in benign tumors (p <0.001). Also, 25 malignant tumors (81%) were immunopositive for VEGF while only 24 benign tumors (23%) showed this characteristic (p <0.001). Microvessel density and the rate of positive staining for Cox-2 protein in malignant samples were higher than in benign samples (p <0.001).

CONCLUSIONS

Several promising predictive parameters are currently available to distinguish benign from malignant pheochromocytoma. Large (5 cm or greater) or heavy (250 gm or greater) tumors, multifocal and extra-adrenal tumors, early onset postoperative hypertension and higher plasma or urine metadrenaline are high risk factors predictive of malignant pheochromocytoma. Also, expression of the 3 angiogenesis or metastasis related genes VEGF, Cox-2 and MVD helps determine the diagnosis of malignancy and suggests strict followup.

[Development and evolution of laparoscopic adrenalectomy in an specialized team: from the beginning to the outpatient setting]

BACKGROUND

After the first reports in 1992, laparoscopic adrenalectomy (LA) has evolved technically until becoming the standard approach for the treatment of most of the adrenal gland diseases.

MATERIAL AND METHODS

Retrospective and descriptive study of 67 patients who underwent 68 LA between January-1998 and December-2008 in the Laparoscopic Surgery Unit of the General and Digestive Surgery Service in a third level hospital (only one case of bilateral LA). The group was divided in 2 periods, P-1 (1998-2003, 22 cases) and P-2 (2004-2008, 45 cases), which have been compared to evaluate the evolution of the LA technique.

RESULTS

Indications for LA were: 19 incidentalomas, 19 primary hyperaldosteronism, 18 pheocromocitoms, 5 cases of symptomatic and non-functioning adrenal masses, 4 Cushing adenomas and 2 metastases. There was no mortality, only 4 patients had minor complications (6%) and conversion rate was only 3% (2 cases). Mean size of adrenal glands resected was 3.83 cm and the mean operative time was 86 minutes. Mean postoperative hospital stay was 3 days and in P-2 seventeen patients were discharged on an outpatient basis (hospital stay less than 23 hours).

CONCLUSIONS

In our experience, LA for the treatment of adrenal diseases has shown to be safe, effective and reproducible with low complications and excellent tolerance by patients. When the learning curve is overcome, hospital stay and operative time clearly decrease. As a consequence, LA can be planned in selected cases as outpatient surgery with good results.

Diagnosis and surgical management for primary hyperaldosteronism

The evaluation of primary hyperaldosteronism presents a challenge to endocrinologists, radiologists, and urologic surgeons. A multidisciplinary approach with biochemical screening and radiologic evaluation is essential in order to assess the nature and function of hypersecreting adrenal glands. Furthermore, it is of great importance to identify individuals that are morbidly affected by aldosterone hypersecretion. Traditionally, open adrenalectomy was the preferred option for these patients. More recently, laparoscopic adrenalectomy has offered a minimally invasive approach, with its resultant advantages of improved perioperative parameters. Herein we describe the evaluation and surgical management for patients with a suspected diagnosis of primary hyperaldosteronism.

Laparoscopic adrenalectomy for beginners without open counterpart experience: initial results under staged training

OBJECTIVES

To develop a staged laparoscopic training program for beginners to perform laparoscopic adrenalectomy (LA) and to determine its safety and feasibility.

METHODS

From January 2002 to October 2007, 5 beginners (postgraduate years 1-5) without previous experience in open adrenalectomy were selected randomly to receive the staged laparoscopic training, including box-trainer, animal model, and mentor-initiated clinical training. During the clinical training, the trainees acted as the camera holder first, and then selectively performed simple operations, such as laparoscopic renal cyst unroofing. Finally, they performed 30 LAs independently under the mentor's supervision using the technique of anatomic retroperitoneoscopic adrenalectomy. The clinical data of the 30 LAs performed by each the trainees (150 LAs total) were collected and compared with the data from the initial 30 LAs of the mentor.

RESULTS

All LAs were completed successfully. No procedure required conversion to open surgery. The median operative time of the trainees was 82.3 minutes (range 59-133), which was obviously shorten than the mentor's (median operative time 131.5 minutes, range 73-230, P < .001). The learning curve among the trainees was shorter compared with that of the mentor. No major complications were observed. The minor intraoperative and postoperative complication rate for the trainees was 0.67% and 6.7%, respectively, not significantly different from those of the mentor (0% and 3.3%, respectively; both P > .05). All complications developing in patients treated by the trainees required only conservative therapy.

CONCLUSIONS

It was safe and feasible for beginners without previous open counterpart experience to perform LA using staged training.

Laparoscopic adrenalectomy after prior abdominal surgery

BACKGROUND

Compared with the open procedure, laparoscopic adrenalectomy (LA) is associated with decreased operative time, perioperative complications, and hospital stay. Some regard prior abdominal surgery as a contraindication to LA or suggest a retroperitoneoscopic approach. We studied the effect of prior abdominal surgery on the feasibility and safety of transabdominal LA.

METHODS

We retrospectively analyzed 246 consecutive LAs performed at four academic centers from 2002 to 2006. Cases were grouped according to prior abdominal surgery (PAS) (n=92, 37%) or no prior surgery (NPS) (n=154, 63%). Statistical power was greater than 0.90 to detect the following differences in endpoints: conversion 2%, operating time 22%, and complications 2%.

RESULTS

Mean tumor size was 3.3 cm, 8.1% of tumors were larger than 7 cm, and 20% were pheochromocytomas. Prior operations were upper abdominal (37%), lower abdominal (48%), or laparoscopic (15%). There were nine conversions (3.7%), one in the PAS group and eight in the NPS group (p=0.14), with conversions related to large tumor size and pheochromocytoma (both p<0.01). Operating time was 158+/-59 min across groups. The subgroup with prior upper abdominal surgery had nonsignificantly longer operating times compared with the NPS group (183 vs. 165 min, p=0.16). Operative blood loss was 67+/-84 ml and the perioperative complication rate was 12.2%, with no differences between groups.

CONCLUSION

Prior abdominal surgery does not impede transabdominal LA. More than one-third of patients requiring adrenalectomy will have had prior abdominal surgery, and these patients should not be denied the benefits of a laparoscopic procedure.

Experience of retroperitoneoscopic adrenalectomy in 195 patients with primary aldosteronism

OBJECTIVES

Laparoscopic adrenalectomy has become an effective option for aldosteronoma. We evaluated the retroperitoneal approach with regard to safety, efficacy, invasiveness and cost-benefit ratio in patients with primary aldosteronism.

METHODS

Between July 1999 and June 2005, we carried out a total of 195 retroperitoneoscopic adrenalectomies (RA) in one hospital, including 108 on the left and 87 on the right, in 78 men and 113 women aged 20-78 years (mean age 48.2 years) with aldosteronoma. Average adrenal tumor size was 16 mm (range 10-32 mm). The 195 operations were divided into 10 groups of 20 operations each, and the mean duration and estimated blood loss for each group were compared.

RESULTS

The mean operating time and intraoperative blood loss in RA were 93.2 +/- 37.4 (45-210) min and 68.5 +/- 53.2 (5-210) mL, respectively. Compared to group 1 (cases 1-20), a statistically significant decrease in operative time and estimated blood loss were seen in and after group 4 (>or= case 61, 94.5 +/- 30.3 vs 139.2 +/- 44.7 min, P < 0.01), and in and after group 5 (>or= case 81, 67.5 +/- 50.5 vs 120.5 +/- 60.9 mL, P < 0.01), respectively. No differences were found in duration of surgery and estimated blood loss between left and right sided tumors (P > 0.05). The mean postoperative hospital stay was 4.5 +/- 1.2 days. Postoperative complications, including hematoma and wound infection, occurred in 4.1% of patients.

CONCLUSIONS

Retroperitoneoscopic adrenalectomy for aldosteronoma is a safe, effective, and minimally invasive approach with an advantageous cost-benefit ratio. With accumulated experience, it can expedite the learning curve for RA.

Lipomatous tumors of the adrenals--a report on 18 cases and review of the literature

The lipomatous tumors of the adrenals are hormonally inactive lesions, often of a benign nature, such as myelolipomas, lipomas, angiomyolipomas, or mature teratomas, and are rarely malignant, such as liposarcomas. The importance of recognizing their characteristic radiological images, which would lead to their correct treatment, is fundamental since there has been an increase in the demonstration of this lesion, often detected incidentally. The various imaging procedures, although not allowing to formulate a histological diagnosis, nonetheless permit to determine the volume of the tumoral mass and their evolution. These two factors are of significant importance in the planning of the correct surgical procedure, while a third important factor is the proper evaluation of the symptoms presented by the patient. Regarding the treatment, on the basis of our own experience, which agrees with that of other authors, the surgical removal of any lesion greater than 5 cm is mandatory.

Adrenalectomía laparoscópica. Consideraciones a propósito de 24 procedimientos

INTRODUCTION AND OBJECTIVES

Laparoscopic adrenalectomy has gained rapid recognition since publication of the first case in 1992. Currently it is the technique of choice for the surgical treatment of the adrenal gland. Our objective in this paper is to share our experience with this technique and offer some practical advice on how to approach it.

MATERIALS AND METHODS

Between May 1998 and August 2006 we did a total of 24 laparoscopic adrenalectomies in 22 patients (15 men, 7 women). The right gland was removed in 13 cases and the left in 11. Surgery was bilateral in two cases (one was MEN II, the other bilateral cortical hyperplasia). Average age was 49.5 +/- 14.3 years (range 24 to 78). Clinical diagnosis was: Pheochromocytoma (n = 10), Cushing (n = 6), Conn (n = 4), metastases from lung carcinoma (n = 2) and non-functioning tumor (n = 2). For surgery, all patients were in total lateral decubitus with a pillow to increase the costal-iliac space. We used four trocars on the right side and three on the left. Abdominal access was by Hasson trocar after minilaparotomy. We kept pneumoperitoneal pressure below 12 mmHg; a Veress needle was not used for this procedure.

RESULTS

Open surgery was required in one case. Time operation was between 59 and 400 minutes (mean 182 +/- 98 min.). In the first 12 cases average time was 261 +/- 77 minutes and in the final 12 cases was 103 +/- 21 minutes (p < 0.001). Tumour diameter was between 1.3 and 6 cm (mean 3.08 +/- 1.25 cm) and tumour weight was between 8 and 92g (mean 30.13 +/- 21 g). Except in one case with 600 ml blood loss, bleeding was less than 100 ml (n = 23, range: 10-100, mean 43.26 +/- 25ml). We only had intraoperative complications in two cases: perforation of the liver by the laparoscope retractor (at the beginning of the series) and injury to the spleen capsule. Both complications were resolved laparoscopically. Cases by histologic type were: nine cortical adenomas, nine pheochromocytomas, three nodular hyperplasias, two metastases from lung carcinoma, and one adrenal pseudocyst. Discharge from hospital was between three and five days (mean 3.62 +/- 0.82) with a statistical difference (p < 0.001) between twelve first cases and the last ones.

CONCLUSIONS

The adrenal laparoscopic approach is currently the technique of choice for removing adrenal tumours although with malign tumours or over 7 cm in diameter there are some contraindications and disadvantages relative to open surgery. There is inevitably a learning curve but satisfactory results are quickly attainable.

Laparoscopic adrenalectomy

Laparoscopic adrenalectomy (LA) was first described in the literature in 1992, and has become the preferred method for the removal of benign functioning and non-functioning tumors of the adrenal gland <12 cm. The objectives of the present study are to review the experience of LA gained since it was first done in 1992 and to critically evaluate its effectiveness for the surgical management of endocrine hypertension; specifically pheochromocytoma, aldosteronoma and Cushing's syndrome and disease, as opposed to open adrenalectomy. The benefits of minimally invasive techniques for the removal of the adrenal gland include decreased requirements for analgesics, improved patient satisfaction, shorter hospital stay and recovery time when compared to open surgery. LA can be performed safely for bilateral disease and may become the standard of care for malignant tumors. Current limitations are operator-dependent and not a factor of limitations of minimally invasive techniques. A thorough pre-operative work-up is key for differentiating the various cases of hypertension and adequate pre-operative treatment is paramount when indicated.

Prospective comparison of early and late experience with laparoscopic adrenalectomy

BACKGROUND

Laparoscopic adrenalectomy has gained acceptance in the treatment of adrenal tumors. We examine our initial 73 patients and highlight the change in patient selection and outcome that experience brings.

METHODS

A prospective study from 2000 to 2005 enrolled 73 consecutive laparoscopic adrenalectomy patients at the University of British Columbia and Vancouver General Hospitals.

RESULTS

Forty patients in an initial cohort and 33 in the follow-up group underwent adrenalectomy. The follow-up group had a greater proportion of pheochromocytomas (33.3% versus 7.5%), larger tumors (4.25 versus 1.97 cm), and higher American Society of Anesthesiologist (ASA) scores (2.82 versus 2.38) and lengths of stay (2.35 versus 1.55 days). Minor complication rates (12% versus 5%) were also higher. Operative times and blood loss were similar. Pheochromocytoma was associated with higher ASA scores and longer lengths of stay. Operative times and blood loss were not affected by diagnosis.

CONCLUSIONS

Increasing experience in laparoscopic adrenalectomy allows broadening of indications to include a sicker patient population.

Transfer of skills from the experimental model to the patients

Laparoscopy is a major part of urologists' daily practice. It is becoming more and more popular and interest in it is increasing, as is the number of urologists attracted by it. Patients also frequently demand a treatment through a laparoscopic approach. Nevertheless, laparoscopy is a physically and technically demanding surgery. It has been proven that it has a long learning curve with a high complication rate at the beginning. Thus, there is need for a training program that can effectively reduce its time of apprenticeship. The learning path is a multistep process that involves several phases. The pelvic trainer is the first step of this path that is made with increasing difficulty. Gradually and gently the trainee faces up to different levels under the guidance of a mentor. At the end of training, trainees should be able to perform every procedure, both easy and difficult ones, by themselves.