Minimally invasive adrenal surgery: virtue or vice?

Minimally invasive versus open adrenalectomy for adrenocortical carcinoma: the keys surgical factors influencing the outcomes-a collective overview

PURPOSE

Adrenocortical carcinoma (A.C.C.) is a rare tumour, often discovered at an advanced stage and associated with a poor prognosis. Surgery is the treatment of choice. We aimed to review the different surgical approaches trying to compare their outcome.

METHODS

This comprehensive review has been carried out according to the PRISMA statement. The literature search was performed in PubMed, Scopus, the Cochrane Library and Google Scholar.

RESULTS

Among all studies identified, 18 were selected for the review. A total of 14,600 patients were included in the studies, of whom 4421 were treated by mini-invasive surgery (M.I.S.). Ten studies reported 531 conversions from M.I.S. to an open approach (OA) (12%). Differences were reported for operative times as well as for postoperative complications more often in favour of OA, whereas differences for hospitalization time in favour of M.I.S. Some studies showed an R0 resection rate from 77 to 89% for A.C.C. treated by OA and 67 to 85% for tumours treated by M.I.S. The overall recurrence rate ranged from 24 to 29% for A.C.C. treated by OA and from 26 to 36% for tumours treated by M.I.S.

CONCLUSIONS

OA should still be considered the standard surgical management of A.C.C. Laparoscopic adrenalectomy has shown shorter hospital stays and faster recovery compared to open surgery. However, the laparoscopic approach resulted in the worst recurrence rate, time to recurrence and cancer-specific mortality in stages I-III ACC. The robotic approach had similar complications rate and hospital stays, but there are still scarce results about oncologic follow-up.

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.

Implications of Conversion during Attempted Minimally Invasive Adrenalectomy for Adrenocortical Carcinoma

BACKGROUND

Although advocated by some, minimally invasive adrenalectomy (MIA) for adrenocortical carcinoma (ACC) is controversial. Moreover, the oncologic implications for patients requiring conversion to an open procedure during attempted MIA for ACC are not extensively reported.

PATIENTS AND METHODS

The National Cancer Database was queried for patients undergoing resection for ACC. Overall survival (OS) for patients undergoing successful MIA was compared with those requiring conversion, and additionally evaluated with a multivariable Cox regression analysis including other factors associated with OS. After propensity matching, those experiencing conversion were further compared with patients who underwent planned open resection.

RESULTS

Among 196 patients undergoing attempted MIA for ACC, 38 (19.4%) required conversion. Independent of 90-day postoperative mortality, conversion was associated with significantly reduced OS compared with successful MIA (median 27.9 months versus not reached, p = 0.002). Even for tumors confined to the adrenal, conversion was associated with worse median OS compared with successful MIA (median 34.2 months versus not reached, p = 0.003). After propensity matching for clinicopathologic covariates to establish well-balanced cohorts (N = 38 per group), patients requiring conversion during MIA had significantly worse OS than those having planned open resection (27.9 months versus 50.5 months, p = 0.020). On multivariable analysis for predictors of OS, conversion during MIA (HR 2.32, p = 0.003) was independently associated with mortality.

CONCLUSIONS

ACC is a rare tumor for which adequate oncologic resection is the only chance for cure. Given the relatively high rate of conversion and its associated inferior survival, open resection should be considered standard of care for known or suspected ACC.

Experience of an endocrine surgeon in laparoscopic transperitoneal adrenalectomy

Background

Laparoscopic adrenalectomy (LA) is currently recognized as the gold standard for the treatment of most adrenal lesions, with a high safety and feasibility profile. This study aimed to present the extensive experience of a specialized endocrine surgeon in LA in a relatively large series of patients.

Methods

A total of 116 LAs performed from June 2009 to 2018 were evaluated in terms of adrenal pathologies, perioperative management, complications, conversions, tumor size, operative time, and learning curve. The learning curve was assessed using the cumulative sum (CUSUM_OT) technique.

Results

Of 116 LAs, 107 (92.2%) were completed successfully, 77 (72%) of which were for Cushing’s syndrome (n = 43, 55.8%), pheochromocytoma (n = 26, 33.8%), and Conn’s syndrome (n = 8, 10.4%). Conversion was required in 9 cases (7.8%), the most common cause being limited space complicating dissection (n = 3). The mean operative time for successful LAs (unilateral 85, bilateral 22) was 74.7 min (range 40–210 min) and the mean hospital stay was 1.7 days (range 1–5 days). Gender, tumor size and body mass index were found to have no significant relationship with the operative time (p > 0.05). Postoperative normalization in hormone profiles was obtained in all patients but one. Aside from grade-I port-site infections in four patients (3.7%), no postoperative major complications and 30-day mortality were observed. On the CUSUM_OT graph, the learning period covered the first 34 operations.

Conclusions

Laparoscopic adrenalectomy is safe and advantageous, but requires a dedicated team involving experienced endocrine surgeons who have achieved competency after completion of the learning curve.