Adrenal Vessels Research Articles

Anatomical variations of the canine adrenal vessels.

The canine adrenal glands receive blood from the celiac artery, cranial mesenteric artery, caudal phrenic artery, cranial abdominal artery, phrenicoabdominal trunk, abdominal aorta, renal artery and lumbar artery. These are classified into three types: cranial, middle and caudal adrenal branches. It is also known that the adrenal vein flows into the phrenicoabdominal vein. However, individual differences in the branching pattern of adrenal vessels have not been systematically analysed. We evaluated adrenal vessels in dogs that underwent contrast-enhanced abdominal computed tomography (CT). There were 255 arteries travelling to the adrenal glands in 47 cases, with 1-6 arteries travelling per adrenal gland. The arteries included 67 caudal phrenic arteries, 62 aortic arteries, 60 cranial abdominal arteries, 39 renal arteries, 12 phrenicoabdominal trunks, 8 cranial mesenteric arteries, 6 celiac arteries and 1 lumbar artery. Most of the branches were from the aorta and caudal phrenic artery on the left side, and the cranial abdominal and caudal phrenic artery on the right side. A total of 110 adrenal veins were identified. Inflow into the phrenicoabdominal vein and into the right and left renal veins was observed, and we identified no inflow into other veins. This study demonstrated two points: laterality and individual differences in adrenal blood vessels. When evaluating adrenal blood vessels with abdominal contrast-enhanced CT, it is recommended to take images under general anaesthesia with breath-holding and observe them using multiplanar reconstruction.

Adrenal Gland Trauma: An Observational Descriptive Analysis from a Level 1-Trauma Center.

Introduction:We aimed to describe the presentation, classification, and outcome of traumatic adrenal injury in a single Level-1 trauma center.Methods:A retrospective study was conducted to include all patients identified to have adrenal trauma from 2011 to 2014. Data were retrieved from charts and electronic medical records for all patients with adrenal trauma with a 3-year follow-up for mortality.Results:A total of 116 patients who were admitted with adrenal injury (12.9% of abdominal trauma and 20% of total solid organ injury admissions) were included in the study, 104 were males and 12 were females. In our population, 86% of adrenal injuries involved the right adrenal gland, 14% in the left, and 12% had bilateral injuries. The majority of associated injuries were rib fractures accounting for 42%, while 37% had associated lung injuries, and 35% had head injuries. As per the American Association for the Surgery of Trauma classification, 46% of adrenal traumas were grade one. Of all adrenal trauma, 25 patients were operated (21%), whereas the majority were admitted to the intensive care unit or surgical ward. Surgical interventions were indicated for associated injury to the bowel, spleen, diaphragm, mesentery, kidneys, or inferior vena cava. One patient underwent angioembolization of the adrenal vessels due to contrast leak. The mortality rate was 14.6%, and no further mortality was reported during a 3-year follow-up. On multivariable analysis, admission systolic blood pressure, Glasgow Coma Scale, and injury severity score were predictors of hospital mortality.Conclusions:Adrenal injury is not rare and often unilateral with right-sided predominance. Associated injuries influence the clinical findings, management, and outcome. Surgical interventions are rarely required except for few cases of active bleeding. Long-term outcome postadrenal injury is still not well studied.

Histological changes of the adrenal glands vessels after experimental thermal trauma and under the conditions of lyophilized xenoskin use

Burns, as a stress factor, cause circulatory and microcirculation disorders in the organs. In the scientific literature, the issues of structural reorganization of the vascular bed of the adrenal glands in thermal trauma and under conditions of correction by lyophilized xenoskin are insufficiently covered and therefore require further study. The aim of our study was to study the microscopic changes of the vessels of the adrenal glands in the dynamics after experimental thermal trauma and under conditions of correction. The experiment was performed on adult white male rats. Grade III burn (18-20 % of the skin surface) was applied under thiopental-sodium anesthesia with copper plates heated in water to a temperature of 97-1000C, on the epilated surface of the skin of the back for 10 seconds. One day after the thermal injury, an early necrectomy was performed and the wound was covered with a substrate of lyophilized xenoskin. Animal decapitation and microscopic changes were studied at days 7, 14, and 21 of injury modeling. The manufacture of histopreparations was carried out according to conventional methods. Histological examinations after experimental thermal trauma and correction of xenoskin substrate on the 7th day showed that already in this period of the experiment there were less pronounced destructive changes in the structure of the vessels of the adrenal glands. Some blood vessels were unevenly filled and dilated. The hemocapillaries of the microcirculatory tract are blood-filled, the vessel wall is destructively altered, and perivascular edema is present. On the 14th day of the experiment, moderately blood vessels were observed. The wall of large vessels is slightly swollen, partially thickened, hemocapillaries are moderately blood-filled, with dilated lumens and continuous endothelial lining. Under the conditions of application of the substrate of lyophilized xenoskin on the 21st day of the experiment, the structural organization of the vascular bed of the adrenal glands was significantly better compared to the previous terms of the study. Most vessels had evenly dilated lumens and moderate blood supply, and wall edema was insignificant. The walls of microvessels are preserved, well structured, endotheliocytes without severe damage, without signs of infiltration and edema. Thus, the results of microscopic examination showed that early necrectomy, and subsequent closure of the wound with a substrate of lyophilized xenoskin, creates optimal conditions for regenerative processes in both burns and vascular bed of the adrenal glands. On the 7th day after the burn and under conditions of correction, the study of the vascular bed of the adrenal glands showed a moderate degree of destructive changes in the vascular bed of the adrenal glands and the initial signs of their regeneration. In the late terms (14-21 days) of the experiment the relative normalization of cellular parenchymal components of the organ was established against the background of restoration of the structural organization of the microcirculatory tract.

The use of preoperative embolization as a method of preventing intraoperative hemodynamic disorders in a patient with pheochromocytoma

A clinical case of treating a patient with large pheochromocytoma complicated by acute cerebrovascular accident is presented. Its peculiarity is the implementation of preoperative embolization of the adrenal vessels in order to prevent intraoperative bleeding and intraoperative hemodynamic instability independent risk factors for perioperative complications and mortality. Such an approach allowed us to successfully perform laparoscopic adrenalectomy with minimal blood loss in conditions of stable hemodynamics.
 The treatment of patients with pheochromocytoma was discussed, special attention was paid to the category of patients with large tumors. The technical features of adrenalectomy in this group of patients, modern ideas about the safety of laparoscopic interventions are highlighted. The topics of the effectiveness of preoperative drug prevention of blood pressure fluctuations, as well as the use of endovascular methods in the treatment of patients with catecholamine-producing tumors are discussed.

V10-01 ICG-GUIDED ROBOTIC-ASSISTED PARTIAL ADRENALECTOMY

You have accessJournal of UrologyAdrenal Surgery & Kidney Cancer II (Advanced Kidney Cancer & Vascular Reconstruction) (V10)1 Apr 2020V10-01 ICG-GUIDED ROBOTIC-ASSISTED PARTIAL ADRENALECTOMY Mariaconsiglia Ferriero*, Riccardo Mastroianni, Gabriele Tuderti, Umberto Anceschi, Alfredo Bove, Aldo Brassetti, Salvatore Guaglianone, Michele Gallucci, and Giuseppe Simone Mariaconsiglia Ferriero*Mariaconsiglia Ferriero* More articles by this author , Riccardo MastroianniRiccardo Mastroianni More articles by this author , Gabriele TudertiGabriele Tuderti More articles by this author , Umberto AnceschiUmberto Anceschi More articles by this author , Alfredo BoveAlfredo Bove More articles by this author , Aldo BrassettiAldo Brassetti More articles by this author , Salvatore GuaglianoneSalvatore Guaglianone More articles by this author , Michele GallucciMichele Gallucci More articles by this author , and Giuseppe SimoneGiuseppe Simone More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000935.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Near Infrared Fluorescence Imaging (NIFI) with Indocyanine Green (ICG) applied to robotic platforms can facilitate surgery in many urologic settings. Concerning adrenal surgery, ICG was of greater benefit in cortical lesions, as these tumors tended to be hyperfluorescent compared to surrounding retroperitoneal tissues. The video shows a case of ICG-guided robotic partial adrenalectomy (RPA). METHODS: We present a case of a 54-year old female patient with a 1 cm left adrenal aldosterone-secreting lesion. Patient was symptomatic and required hypotensive treatment. Serum aldosteron levels were increased. Patient was placed in extended flank position and side docking. A transperitoneal five-port access was performed using a 30° scope. Once the adrenal gland was identified, under NIFI, the adrenal nodule appeared hyperintense compared to the adrenal parenchyma. The lesion was progressively mobilized following the pseudocapsule plane. A blunt and sharp dissection using monopolar scissors was employed to maximize adrenal parenchyma preservation. Blood pressure was carefully monitored intraoperatively to ensure hemodynamic stability during the procedure. The dissection was carried out without any isolation of adrenal vessels, in order to avoid accident or injury to adrenal vessels. The remnant adrenal margins were approximated with a sliding-clip running suture (3/0 Monocryl). RESULTS: Operative time was 60 minutes. Blood loss was 180 ml. Post-operative course was uneventful. Blood Pressure was normalized without the need of medications. Patient was discharged on second post-operative day. Pathologic examination showed an adenoma of adrenal cortex. At three-month follow up, no antihypertensive medications were needed. Aldosteron levels returned to normal values. A Complete Clinical Success according to PASO classification was obtained. CONCLUSIONS: ICG-guided RPA is a safe and feasible procedure, providing excellent functional outcomes. The real time feed-back of ICG technology is best suited for small lesions to improve visualization of resection margins and to minimize unintended resection of healthy parenchyma. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e931-e931 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mariaconsiglia Ferriero* More articles by this author Riccardo Mastroianni More articles by this author Gabriele Tuderti More articles by this author Umberto Anceschi More articles by this author Alfredo Bove More articles by this author Aldo Brassetti More articles by this author Salvatore Guaglianone More articles by this author Michele Gallucci More articles by this author Giuseppe Simone More articles by this author Expand All Advertisement PDF downloadLoading ...

Feasibility and Safety of Clipless and Sutureless Laparoscopic Adrenalectomy: A 7-Year Single Center Experience.

Laparoscopic adrenalectomy (LAD) is considered the gold standard surgical method for resecting adrenal tumors. To date, only few small studies have investigated the safety of clipless laparoscopic adrenalectomy in which the adrenal vessels were controlled by the LigaSure system or bipolar coagulation. The aim of the present study was to evaluate the safety and feasibility of sutureless and clipless laparoscopic adrenalectomy operations performed in our center. All patients with functional adrenal tumors, nonfunctional adrenal tumors larger than 5 cm and secondary adrenal metastases from the kidneys, lungs or breasts who had underwent an LAD procedure between 2012 to 2019 were included in our study. In all of the cases, complete coagulation of adrenal veins was achieved through bipolar cautery and no vascular staplers, clips or other energy sources were used for controlling the adrenal vessels whatsoever. Outcomes of interest included operation time, length of hospital stay, changes of serum hemoglobin level, and occurrence of major complications. Of a total 251 patients, unilateral right and left-side adrenalectomy was performed in 168 and 67 cases, respectively, and 16 cases had underwent bilateral adrenal resection. The mean age (SD) of patients was 40.7 (13.6) years old at the time of operation and the mean size (SD) of the adrenal lesions was 5.2 (3.1) cm as measured by the greatest diameter. Histological examination showed that the most common pathology of the resected adrenal glands was pheochromocytoma (n=78). None of the laparoscopic operations required a conversion to open surgery. Also, major bleeding or other serious complications did not occur in any of the cases either intraoperatively or postoperatively. Clipless and sutureless laparoscopic adrenalectomy seems to be feasible and safe for removing adrenal tumors. Moreover, bipolar cautery is associated with an acceptable outcome for vessel closure.

Laparoscopic transperitoneal adrenalectomy: a comparative study of different techniques for vessel sealing

Laparoscopic adrenalectomy is the standard surgical approach to adrenal lesions. Adrenal vessel sealing is the critical surgical phase of laparoscopic adrenalectomy. This study aimed at comparing perioperative outcomes of laparoscopic transperitoneal adrenalectomy by means of radiofrequency energy-based device (LARFD) to those performed with traditional clipping device (LACD), while focusing on the different adrenal vessel control techniques. Patients who underwent adrenalectomy for adrenal disease between January 1994 and April 2019 at the Surgical Clinic, Polytechnic University of Marche were included in the study. Overall, 414 patients met inclusion criteria for study eligibility: 211 and 203 patients underwent LARFD and LACD, respectively. Multiple models of quantile regression, logistic regression and Poisson finite mixture regression were used to assess the relationship between operative time, conversion to open procedure, length of stay (LoS), surgical procedure and patient characteristics, respectively. LARFD reduced operative time of about 12min compared to LACD. Additional operative time-related factors were surgery side, surgery approach, conversion to open procedure and trocar number. The probability of conversion to open procedure decreased by about 76% for each added trocar, whereas it increased by about 49% for each added centimeter of adrenal lesion and by about 25% for each added year of surgery. Two patient clusters were identified based on the LoS: long-stay and short-stay. In the long-stay cluster, LoS decreased of about 30% in LARFD group and it was significantly associated with conversion to open procedure and postoperative complications, whereas in short-stay cluster only postoperative complications had a significant effect on LoS. Laparoscopic transperitoneal adrenalectomy performed by means of radiofrequency energy-based device for the sealing of adrenal vessels is an effective procedure reducing operative time with potentially improved postoperative outcomes.

Prevention of hemodynamic instability during laparoscopic adrenalectomy in patients after x-ray endovascular electrocoagulation occlusion of the adrenal vessels

Prevention of hemodynamic instability during laparoscopic adrenalectomy in patients after x-ray endovascular electrocoagulation occlusion of the adrenal vessels

Left-Sided Donor Nephrectomy Predisposes Living Kidney Donors to Latent Adrenal Insufficiency with Symptoms of Fatigue and Inferior Quality of Life

Background The rising prevalence of end-stage renal disease and the chronic organ shortage subsequently calls more people upon to consider living kidney donation. The benefits for living donor recipients and the relative low risk of physical complications for donors have been well documented. The risks of impaired quality of life and particularly symptoms of chronic fatigue, however, remain less well understood and dampen the enthusiasm of living kidney donor outcomes. Material and Methods We hypothesized that left-sided donor nephrectomy predisposes donors to symptoms of chronic fatigue due to impairment of blood supply of the left adrenal gland. We retrospectively analyzed 356 living kidney donors undergoing nephrectomy from 1998 to 2013, and aimed to address the impact of donation on physical health and quality of life using the standardized short form-8 questionnaire (SF-8). In addition, we prospectively followed 27 living kidney donors 2014/2015 for symptoms of chronic fatigue. Morning cortisol and ACTH levels were performed at baseline, in the first week, and +6 months post donation. Data were compared between right- and left-sided donation. Results The response rate amounted to 90.2%. Using a standardized quality of life score, left-sided donors showed a significant worse quality of life compared to right-sided donors (p=0.037). Left-sided donors were more likely to develop symptoms of chronic fatigue and less likely to develop hypertension post donation (p<0.05). Donors with symptoms of fatigue were more likely to be younger and have physically and mentally demanding jobs (p<0.05).Among our prospectively followed donors we identified 4/11 left-sided donors with self-reported fatigue symptoms compared with 1/16 right-sided donors. No differences were observed for morning cortisol and ACTH levels between right-sided and left sided donors at baseline (p>0.05). However, right-sided donors were more likely to show stable morning cortisol levels from pre to +6 months post donation, while left-sided donors showed a decline of morning cortisol levels (p<0.05). While 5/16 right-sided donors developed hypertension in the first-year post donation, no left-sided donor developed hypertension (p=0.059). Conclusion Our results strongly indicate that the side of donor nephrectomy has major impact on physical and mental quality of life in long-term follow-up. Here, impaired function of the left adrenal gland due to transection of adrenal vessels may result in latent adrenal insufficiency with symptoms of chronic fatigue and less hypertension. The impact of side-selection on long-term outcomes of living donors may greatly influence donor education and the surgical approach to donor nephrectomy.

LAPAROSCOPIC TECHNIQUE VERSUS OPEN TECHNIQUE IN SWINES ADRENALECTOMY

Among the main benefits of laparoscopic adrenalectomy (LA) compared to open adrenalectomy (OA) the rapid recovery of patients with decreased length of stay in hospital can be highlighted. The objective of this study was to compare the open adrenalectomy with laparoscopic adrenalectomy in swine. Thirty-two swine were operated. The animals had been divided into four groups (n = 8), one group was submitted to OA and the other to LA, together with its respective control group. Parameters were evaluated regarding operative time, body temperature, hematocrit, postoperative and intraoperative complications and time to deambulation. There was no meaningful difference between operative and deambulation times, even though the latter having been higher in the group submitted to OA. The most frequent intercurrences were in bowel, damage to adrenal vessels and renal hematoma. There were no significant blood losses, and observed hypothermia did not have any clinical impact. Laparoscopy in swine experimental adrenalectomy is a reliable technique that can serve as a reference for the surgical treatment of patients with adrenal diseases with surgical indications in other animal species.

Value of the CT "capsular sign" as a potential indicator of acute adrenal ischemia.

Acute adrenal ischemia represents a rare cause of adrenal insufficiency which should be promptly diagnosed in order to preserve adrenal vitality and function. Our study aims to retrospectively evaluate the diagnostic accuracy of the CT capsular sign as an indicator of adrenal ischemia and its association with vascular involvement. Between January 2013 and January 2014, 69 consecutive patients (47 men, 22 women; mean age 46; range 22-67) with suspected adrenal insufficiency based on clinical and biochemical data underwent 320-row CT examination in our Emergency Department. Written informed consent was obtained for the CT examinations, and the institutional review board approval was obtained for our retrospective study. CT multi-planar images were retrospectively and independently analyzed by two radiologists searching for the patency of adrenal vessels, enlarged adrenals, the presence of the "capsular sign" represented by a peripheral subtle hyperdense line around a hypodense enlarged adrenal, and the presence of any periadrenal inflammatory changes. All CT findings were then compared with the surgical findings (n = 5), follow-up examinations (n = 20), or autopsy (n = 4). Sensitivity, specificity, diagnostic accuracy (DA), positive predictive value (PPV), and negative predictive value (NPV) were calculated for the "capsular sign" and were further evaluated by ROC analysis. Acute adrenal ischemia occurred in 29/69 patients (42%), unilateral in 20, and bilateral in 9. Forty of sixty-nine patients (58%) had no evidence of adrenal disease on CT. Thrombosis of the main adrenal vein was found in 20/29 (69%) and non-venous ischemia in 9/29 (31%). The capsular sign was found in 24/29 patients (83%). Sensitivity, specificity, DA, PPV, and NPV values of 83, 100, 93, 100, and 89%, respectively, were obtained. The capsular sign represents a CT indicator of acute adrenal ischemia, with a specificity of 100% and leading to a prompt diagnosis in the early phase of the disease.

TÉCNICA LAPAROSCÓPICA VERSUS TÉCNICA ABERTA PARA ADRENALECTOMIA EM SUÍNOS

Among the main benefits of laparoscopic adrenalectomy (LA) compared to open adrenalectomy (OA) the rapid recovery of patients with decreased length of stay in hospital can be highlighted. The objective of this study was to compare the open adrenalectomy with laparoscopic adrenalectomy in swine. Thirty-two swine were operated. The animals had been divided into four groups (n = 8), one group was submitted to OA and the other to LA, together with its respective control group. Parameters were evaluated regarding operative time, body temperature, hematocrit, postoperative and intraoperative complications and time to deambulation. There was no meaningful difference between operative and deambulation times, even though the latter having been higher in the group submitted to OA. The most frequent intercurrences were in bowel, damage to adrenal vessels and renal hematoma. There were no significant blood losses, and observed hypothermia did not have any clinical impact. Laparoscopy in swine experimental adrenalectomy is a reliable technique that can serve as a reference for the surgical treatment of patients with adrenal diseases with surgical indications in other animal species. Keywords : adrenal glands; animal models; blood supply; laparoscopy.

Retrograde Renal Ablation via the Renal Vein as a New Treatment Option for Renovascular Hypertension

Renovascular hypertension is a hormonal response to decreased renal blood supply. Treatments include medication, balloon angioplasty, arterial embolization, and nephrectomy. We attempted a new method, retrograde renal ablation via the renal vein. Our institutional review board approved this procedure. A 51-year-old man had uncontrolled hypertension for 3 years despite taking four antihypertensive drugs (calcium antagonist, angiotensin II receptor blocker, β-blocker, and α-blocker). The high serum renin level (4 20 ng/mL/h) and dynamic computed tomography (CT) findings (left renal arterial occlusion, renal atrophy, and parenchymal enhancement delay) suggested renovascular hypertension. Arterial embolization was attempted twice to eliminate the left renal function. Tortuous collateral arteries including lumbar and adrenal vessels supplied the kidney, so absolute ethanol and gelatin sponge embolization of these

A review of the anatomy and clinical significance of adrenal veins.

The adrenal veins may present with a multitude of anatomical variants, which surgeons must be aware of when performing adrenalectomies. The adrenal veins originate during the formation of the prerenal inferior vena cava (IVC) and are remnants of the caudal portion of the subcardinal veins, cranial to the subcardinal sinus in the embryo. The many communications between the posterior cardinal, supracardinal, and subcardinal veins of the primordial venous system provide an explanation for the variable anatomy. Most commonly, one central vein drains each adrenal gland. The long left adrenal vein joins the inferior phrenic vein and drains into the left renal vein, while the short right adrenal vein drains immediately into the IVC. Multiple variations exist bilaterally and may pose the risk of surgical complications. Due to the potential for collaterals and accessory adrenal vessels, great caution must be taken during an adrenalectomy. Adrenal venous sampling, the gold standard in diagnosing primary hyperaldosteronism, also requires the clinician to have a thorough knowledge of the adrenal vein anatomy to avoid iatrogenic injury. The adrenal vein acts as an important conduit in portosystemic shunts, thus the nature of the anatomy and hypercoagulable states pose the risk of thrombosis.

Laparoscopic Left Adrenalectomy for a Left Corticosteroid-Producing Adrenal Tumor

Cushing Syndrome (CS) is a chronic condition due to sustained exposure to glucocorticoid excess. Most frequent clinical manifestations are obesity, “moon face”, muscle weakness, osteoporosis, menstrual irregularities, high blood pressure, diabetes. Sometimes the signs and symptoms are overt (subclinical Cushing Syndrome). The most frequent tests used are 24 hours urinary free cortisol, dexamethasone suppression tests, plasma ACTH levels as well as CT/ MRI to localize the adrenal tumor. The surgical treatment is adrenalectomy. This video present a left laparoscopic adrenalectomy for a CS secondary to a left adrenal adenoma. The patient is placed in a right lateral position. Operative steps are: mobilization of the left colon, mobilization of the spleen and tail of the pancreas by dividing the splenoparietal ligament, division of the splenorenal ligament, identification of the adrenal vessels, dissection of the adrenal gland (starting medial, continuing posterior and ending lateral on the surface of the kidney) and extraction of the specimen in an endobag. Postoperative follow-up was uneventful. CONCLUSION: In our opinion laparoscopic adrenalectomy is the gold standard procedure for adrenal CS.

V765 LAPAROSCOPIC ADRENALECTOMY FOR PHEOCHROMOCYTOMA ASSOCIATED WITH HORSESHOE KIDNEY

You have accessJournal of UrologyOncology (TCC & Adrenal) & Teaching Techniques1 Apr 2010V765 LAPAROSCOPIC ADRENALECTOMY FOR PHEOCHROMOCYTOMA ASSOCIATED WITH HORSESHOE KIDNEY Thomas Christiano, Nitin Patel, Jennifer Yates, Jayant Uberoi, and Ravi Munver Thomas ChristianoThomas Christiano More articles by this author , Nitin PatelNitin Patel More articles by this author , Jennifer YatesJennifer Yates More articles by this author , Jayant UberoiJayant Uberoi More articles by this author , and Ravi MunverRavi Munver More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1359AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Adrenal pheochromocytoma is associated with various genetic syndromes including multiple endocrine neoplasia and neurofibromatosis type 1 (NF-1). Patients with NF-1 are more likely to have renal anomalies including a horseshoe kidney. Laparoscopic adrenalectomy is the standard technique for the surgical removal of benign adrenal masses, including pheochromocytoma. This video illustrates the excision of a right adrenal pheochromocytoma in a patient with neurofibromatosis and a horseshoe kidney. METHODS A 62 year old female with NF-1 was referred for a diagnosis of a right adrenal mass. Radiographic characteristics and endocrinologic evaluation revealed the mass to be consistent with a pheochromocytoma in the setting of a horseshoe kidney. The patient elected surgical management via a laparoscopic approach. Appropriate preoperative medical management was instituted. RESULTS A transperitoneal approach was employed with the use of 4 trocars, including three 5 mm trocars and one 12 mm trocar. The procedure began with extensive mobilization of the liver. An upper pole renal artery and vein were noted to be in close proximity to the inferior border of the adrenal gland as they coursed to the kidney from a cephalad direction. Meticulous dissection resulted in identification of the inferior vena cava and a large hepatic vein. Further dissection revealed an anomalous main adrenal vein that drained into the hepatic vein. The adrenal vein was dissected, ligated with clips, and transected with a bipolar vessel-sealing device. The upper, lateral, and inferior attachments of the adrenal gland were dissected from surrounding structures and the adrenal gland was placed into a laparoscopic bag and extracted. The operative time was 104 minutes and blood loss was 5 milliliters. The patient was discharged home on the first postoperative day without complication. Final pathology revealed a 3.5 cm pheochromocytoma. CONCLUSIONS Laparoscopic adrenalectomy in the setting of a horseshoe kidney may be complicated by anomalous anatomy. In particular, anomalies or multiplicity of the adrenal vessels or renal hilar vessels must be suspected. Cautious dissection and recognition of potential abnormalities can result in successful minimally-invasive removal of the adrenal gland in patients with horseshoe kidneys. Hackensack, NJ© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e299 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Thomas Christiano More articles by this author Nitin Patel More articles by this author Jennifer Yates More articles by this author Jayant Uberoi More articles by this author Ravi Munver More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Immunohistochemical demonstration of Angiopoietin-2 in lymphatic vascular development

The cellular expression of Angiopoietin-2 (Ang2) was studied during lymphatic development in mouse by immunohistochemistry and compared to that of lymphatic endothelial markers. At the earliest stage of lymphvasculogenesis, Prox1-identified lymphatic precursor cells of the cardinal vein displayed an intense immunoreaction for Ang2 in their cytoplasm, implying that Ang2 may adjust lymphatic specification and sprouting from the veins under the control of Prox1. Thereafter, Ang2 was constantly expressed in Prox1 and/or LYVE-1-immunopositive endothelial cells of lymphatic sacs and vessels, ranging from lymphatic capillaries to collectors, throughout embryonic and neonatal development, and the lymphatic endothelial cells simultaneously exhibited immunoreactivity to Tie2, a primary receptor for angiopoietins. These results suggest that lymphatic endothelial cells may regulate lymphatic development via their own Ang2-Tie2 signaling. Ang2 is further immunolocalized in the developing blood vessels including hepatic sinusoids, adrenal medullary vasculature and postnatal pulmonary vessels, thereby indicating that the blood vessels, which undergo vascular remodeling and sudden alteration of blood flow during the development, are also likely to express Ang2. The present study is first to demonstrate Ang2 expression in the lymphatic endothelial cells during development, and consequently Ang2 is regarded as a molecular profile of the developing lymphatic endothelial cells required for lymphatic vascular organization.

7B.2 Antiphospholipid syndrome: clinical manifestations and treatment

Clinical manifestations Antiphospholipid syndrome has a heterogeneous clinical presentation and, consequently, may be encountered by clinicians in a range of specialties. Thrombosis of the deep limb veins, sometimes with pulmonary embolism, is a common first manifestation. However any region of the venous system can be involved including superficial, mesenteric, portal, intracranial and retinal veins. The characteristic serological feature of the syndrome is the presence of antiphospholipid antibody, typically lupus inhibitor and/or anticardiolipin/anti-b2-glycoprotein I antibody. Depending on the composition of the population examined around 3% of patients with a first DVT are positive for lupus inhibitor. Arterial thrombosis occurs also. Ischaemic stroke is the commonest manifestation, but myocardial infarction, peripheral gangrene and thrombotic occlusion of any part of the arterial tree, including mesenteric, adrenal and renal vessels, can occur. Occasionally, clinical manifestations can be ascribed to involvement of the microvasculature, for example renal impairment and seizures. “Catastrophic antiphospholipid syndrome” is an acute, dramatic and life-threatening form of thrombotic microangiopathy affecting multiple organs. Kidneys, lungs, skin and central nervous system are frequently involved. Fortunately this presentation is encountered exceedingly uncommonly. Other reported manifestations of antiphospholipid syndrome include skin lesions (typically livedo reticularis but also ulceration), cardiac valve lesions (ranging from valve thickening to sterile endocarditis with vegetations), non-stroke neurological manifestations (such as sensori/neural deafness, chorea, cognitive impairment and multifocal ischaemia mimicking demyelinating disease) and consumptive haematological cytopenias (autoimmune haemolytic anaemia and thrombocytopenia). Pregnancy failure and maternal morbidity are well recognized manifestations of antiphospholipid syndrome. Recurrent miscarriage, fetal growth retardation, fetal death and severe (often early) pre/eclampsia may occur. In many women these are the only manifestations, health remaining good when non-pregnant. Placental thrombosis may explain some of these events but alternative mechanisms probably account for very early pregnancy failure. In some cases antiphospholipid syndrome complicates established connective tissue disease, classically systemic lupus erythematosus, but in many others thrombosis or pregnancy failure is the only feature. The diagnosis of antiphospholipid syndrome may be problematic because of the high background prevalence of arterial and venous thrombosis in adults, as well as the common phenomenon of transient antiphospholipid antibodies which are often associated with self-limiting infections and are not usually associated with thrombotic events. Furthermore antiphospholipid antibodies occur in some chronic infections (classically syphilis but also chronic viral infections including hepatitis C and HIV) and iatrogenically, for example due to phenothiazine treatment. Again, thrombosis is not usually a feature in these circumstances. Diagnostic uncertainty is exacerbated by the poor performance and unreliability of the laboratory tests for antiphospholipid antibodies. Furthermore, low titre anticardiolipin antibodies are a frequent finding in the general population and are of uncertain significance.

USE OF THE LIGASURE VESSEL SEALING SYSTEM IN LAPAROSCOPIC ADRENALECTOMY

Laparoscopic adrenalectomy is the operation of choice for benign adrenal lesions. During laparoscopic surgery, vessels are usually ligated with diathermy, ligaclips, staplers or ultrasonic coagulators. Use of the electrothermal bipolar vessel sealer (LigaSure; Valleylab, Boulder, CO, USA) has recently been described in a variety of procedures, not including adrenalectomy. This article is a retrospective study of 28 patients undergoing laparoscopic adrenalectomy within the University of Sydney Endocrine Surgical Unit at the Royal North Shore Hospital using the LigaSure vessel sealing system. Between July 2004 and August 2005, 28 consecutive patients underwent laparoscopic adrenalectomy using the LigaSure vessel sealing system to divide feeding adrenal vessels as well as the adrenal vein. There were no bleeding complications. The LigaSure vessel sealing system can be safely used to secure haemostasis, including division of the adrenal vein, in laparoscopic adrenalectomy.

Retroperitoneoscopic adrenalectomy: An early institutional experience

Objective To review our initial experience with the retroperitoneoscopic approach, which is rapidly becoming the procedure of choice for paediatric adrenalectomy. Swift access to the vascular pedicle makes this approach ideal for adrenal surgery where haemodynamic instability is a common feature. Method Patients were placed in a fully prone position and the locations of the 12th rib, iliac crest and paravertebral muscles were marked. A 10-mm incision was made lateral to the para-vertebral muscle, halfway between the iliac crest and costal margin. A retroperitoneal working space was created around the kidney using a homemade balloon. A 10-mm Hasson port was then inserted. A 5-mm working port was placed lateral to the tip of the 12th rib and, if necessary, a second was inserted medial to the camera port. Dissection was performed with diathermy and/or Harmonic Scalpel™ and the adrenal vessels were divided between clips. The specimen was retrieved in an endopouch through the 10-mm port. Results Over 16 months, six adrenalectomies were performed in five patients (three boys and two girls); two right, two left and one bilateral. Median age at surgery was 8 years. Presentation was with hypertension ( n = 2), Cushing's syndrome ( n = 2) and abdominal pain ( n = 1). Median operative time was 154 min. A single-instrument port adrenalectomy was performed in three patients. Histopathological diagnosis included adrenal cyst ( n = 1), cystic phaeochromocytoma ( n = 1), adrenal cortical tumour ( n = 2) and central Cushing's disease ( n = 1). All were completely resected. All patients remain symptom free with a median follow up of 17 months. Conclusion These cases represent our initial institutional experience with retroperitoneoscopic adrenalectomy. The senior reporting surgeons have already surmounted the general learning curve for laparoscopy, and this experience has proved vital to expand our repertoire with encouraging early results. This is our technique of choice as it provides a superior view of the adrenal gland and vessels, with good intraoperative haemodynamic stability.