Unilateral adrenalectomy in primary bilateral macronodular hyperplasia

Abstract

The aim of this review is to analyze the benefits and potential drawbacks of unilateral adrenalectomy (UA) for the treatment of patients with primary bilateral macronodular adrenal hyperplasia (PBMAH) and hypercortisolism with either overt or subclinical Cushing's syndrome (CS). UA has progressively emerged as an interesting treatment for PBMAH as it offers a high rate of remission of CS, even in patients with free urinary cortisol well above 2 times the upper limit of normal. UA carries a risk for secondary adrenal insufficiency, which cannot be properly identified by the cosyntropin test but is both limited and transient. This makes it an attractive alternative to bilateral adrenalectomy (BA), which condemns the patient to total and definitive primary adrenal insufficiency and a risk for adrenal crisis. Recently, however, the issue has been raised of a potential risk of mortality in UA patients, linked to persistent dysregulated secretion of cortisol or recurrence. Further studies are necessary to better compare the long-term risks of dysregulated secretion of cortisol with UA vs adrenal insufficiency in BA. Up to now, the clinician has to remember that UA can be transformed in BA, whereas the opposite is impossible