Laparoscopic Partial Adrenalectomy Research Articles

Can the Mayo Adhesive Probability Score Predict Perioperative Outcomes in Laparoscopic Total and Partial Adrenalectomy?

Objective: This study aimed to determine whether the Mayo adhesive probability (MAP) score could predict perioperative outcomes in transperitoneal laparoscopic total adrenalectomy (LTA) and laparoscopic partial adrenalectomy (LPA). Materials and Methods: The clinical data of 139 patients who underwent transperitoneal LTA (n = 116) or LPA (n = 23) between March 2013 and September 2022 were retrospectively analyzed. According to the images obtained from preoperative contrast-enhanced computed tomography or magnetic resonance imaging, the patients were divided into two groups: the low MAP score group (0-1 points) and the high MAP score group (2-5 points). General clinical features and perioperative outcomes were compared between the groups. Results: In patients with a high MAP score, the mean body mass index (BMI) (p: 0.005), tumor size (p: 0.005), operative time (p: 0.002), estimated blood loss (EBL) (p: 0.001), and complication rate (p: 0.013) were significantly higher compared with those with a low MAP score. The comparison of the patients between the LTA and LPA subgroups revealed that operative time and EBL were significantly higher in both subgroups among the patients with a high MAP score. Moreover, the complication rate in the LTA subgroup was significantly higher in the high MAP score group compared with the other group. The Multivariate analyses revealed that a high MAP score was a risk factor for prolonged operative time (Odds Ratio [OR]: 3.081, 95% Confidence Interval [CI]: 1.284-7.398, p: 0.012), increased EBL (OR: 2.495, 95% CI: 1.114-5.588, p: 0.026), and complications (OR: 6.085, 95% CI: 1.532-24.171, p: 0.01) Conclusions: Patients with a high MAP score had a prolonged operative time, increased EBL, and a higher complication rate compared with those with a low MAP score. In addition, we found that a high MAP score was an independent risk factor for perioperative parameters and complications in patients who underwent LTA and LPA.

Bilateral Cortical-sparing Adrenalectomy for the Treatment of Bilateral Aldosterone-producing Adenomas

Abstract Aldosterone-producing adenoma (APA) is 1 of the major subtypes of primary aldosteronism (PA). Although most APA occurs unilaterally, bilateral APAs have rarely been documented. Because of its rarity, optimal management of patients with bilateral APAs has not been established. Here, we report a case of bilateral APAs that was successfully treated with simultaneous bilateral cortical-sparing surgery. A 44-year-old Japanese woman was referred to us for the evaluation of PA. She had typical clinical characteristics of PA, including hypertension, hypokalemia, and high plasma aldosterone concentration with suppressed renin. She was diagnosed as having PA based on the results of confirmatory testing. Computed tomography revealed bilateral adrenal nodules with diameters of 17 and 10 mm on the right and left adrenal gland, respectively. Adrenal venous sampling indicated excess aldosterone production from bilateral adrenal lesions. She underwent simultaneous bilateral laparoscopic partial adrenalectomy that normalized her blood pressure and serum potassium levels. Aldosterone synthase immunohistochemistry on the resected adrenal tumor tissue confirmed the diagnosis of bilateral APAs. Long-term postsurgical follow-up data suggest cure of the disease without the need for glucocorticoid replacement therapy. Bilateral cortical-sparing adrenalectomy appears to be a viable treatment option at least for selected patients with bilateral APAs.

A case of adrenal lymphangioma successfully treated with laparoscopic partial adrenalectomy

IntroductionAdrenal lymphangioma is a rare benign tumor of lymphatic origin, usually incidentally detected from various imaging studies taken for an unrelated purpose. We present a case of a right adrenal lymphangioma treated successfully with surgical intervention.Case presentationA 36‐year‐old previously healthy woman was referred to our urology department for a right adrenal mass, discovered during a routine health checkup. The tumor had no endocrinological activity, and the patient opted for surgical resection following a concern for malignancy. A laparoscopic right partial adrenalectomy was performed, and on histological examination, the tumor was diagnosed as right adrenal lymphangioma.ConclusionAdrenal lymphangiomas lack disease specific radiological characteristics that allow for a definitive diagnosis from imaging alone. To rule out tumors of potentially malignant nature, surgical intervention should be considered.

High aldosterone levels in the renal capsular vein from the left aldosterone-producing adenoma on adrenal venous sampling.

A 42-year-old female patient was referred to our hospital with hypertension and hypokalemia and was diagnosed with primary aldosteronism. Dynamic contrast-enhanced computed tomography images revealed a 13-mm nodule on the lateral segment of the left adrenal gland and a fine venous connection between the nodule and the prominent renal capsular vein running nearby. The venograms in the left lateral tributary with a microcatheter confirmed alternative drainage to the left renal capsular vein during adrenal venous sampling, and the left renal capsular vein sampling was added. The patient was diagnosed with a left aldosterone-producing adenoma (APA) using the lateralization index (48.3) and a higher plasma aldosterone concentration (PAC) of the left lateral tributary (66 700 pg/mL) than other tributary samples after adrenocorticotropic hormone stimulation. Furthermore, markedly higher PAC (224 000 pg/mL) was observed in the left renal capsular vein blood than in the left adrenal central vein (45 000 pg/mL) and tributaries, confirming the diagnosis. Laparoscopic left partial adrenalectomy and following histopathological analysis revealed a CYP11B2-positive adrenocortical adenoma. Complete clinical and biochemical success for primary aldosteronism was achieved after 6 months. Direct evidence of APA blood venous drainage into the renal capsular vein has been demonstrated. Sampling from an alternative drainage pathway could be beneficial for APA diagnosis if such APA blood drainage is assumed. Aldosterone-producing adenomas may drain blood into an alternative pathway but for the adrenal vein. The presence of alternative venous drainage could be assumed by contrast-enhanced computed tomography or venogram during adrenal venous sampling. Sampling in the alternative drainage veins and demonstrating elevated aldosterone levels could help in diagnosing aldosterone-producing adenoma.

Feasibility of single-port laparoscopic partial adrenalectomy with selective adrenal venous sampling and high-resolution ultrasound for unilateral aldosterone-producing adenomas

BackgroundThe surgical and endocrinological outcomes of single-port laparoscopic partial adrenalectomy for patients with aldosterone-producing adenomas are unknown. Precise diagnosis of intra-adrenal aldosterone activity and a precise surgical procedure may improve outcomes. In this study, we aimed to determine the surgical and endocrinological outcomes of single-port laparoscopic partial adrenalectomy with preoperative segmental selective adrenal venous sampling and intraoperative high-resolution laparoscopic ultrasound in patients with unilateral aldosterone-producing adenomas. We identified 53 patients with partial adrenalectomy and 29 patients with laparoscopic total adrenalectomy. Single-port surgery was performed for 37 and 19 patients, respectively. MethodsA single-center, retrospective cohort study. All patients with unilateral aldosterone-producing adenomas diagnosed by selective adrenal venous sampling and treated surgically between January 2012 and February 2015 were included. Follow-up with biochemical and clinical assessments was set at 1 year after surgery for short-term outcomes and was performed every 3 months after surgery. ResultsWe identified 53 patients with partial adrenalectomy and 29 patients with laparoscopic total adrenalectomy. Single-port surgery was performed for 37 and 19 patients, respectively. Single-port surgery was associated with shorter operative and laparoscopic times (odds ratio, 0.14; 95% confidence interval, 0.039–0.49; P = .002 and odds ratio, 0.13; 95% confidence interval, 0.032–0.57; P = .006, respectively). All single-port and multi-port partial adrenalectomy cases showed complete short-term (median 1 year) biochemical success, and 92.9% (26 of 28 patients) who underwent single-port partial adrenalectomy and 100% (13 of 13 patients) who underwent multi-port partial adrenalectomy showed complete long-term (median 5.5 years) biochemical success. No complications were observed with single-port adrenalectomy. ConclusionSingle-port partial adrenalectomy is feasible after selective adrenal venous sampling for unilateral aldosterone-producing adenomas, with shorter operative and laparoscopic times and a high rate of complete biochemical success.

Pitfalls in the diagnosis and treatment of a hypertensive patient with unilateral primary aldosteronism and contralateral pheochromocytoma: a case report

BackgroundPrimary aldosteronism (PA) is a common cause of secondary hypertension, whereas pheochromocytoma is a rare cause of it. Thus, concomitant PA and pheochromocytoma is a very rare condition.Case presentationA 52-year-old woman was admitted to our hospital with suspected PA based on the presence of hypertension, spontaneous hypokalemia, and a high aldosterone-to-renin ratio. She had no catecholamine excess symptoms other than hypertension. Abdominal computed tomography (CT) showed a right lipid-rich adrenal mass and a left lipid-poor adrenal mass. PA was diagnosed by the captopril challenge test. The 24-h urinary fractionated metanephrines were slightly elevated. Adrenal vein sampling (AVS) confirmed that the right adrenal gland was responsible for aldosterone hypersecretion. Medical therapy with eplerenone was started because the patient refused surgery. Five years later, she requested surgery for PA. The second AVS confirmed right unilateral hyperaldosteronism, as expected. Repeated abdominal CT showed the enlargement of the left adrenal mass. The 24-h urinary fractionated metanephrines had risen to the diagnostic level. 123I- metaiodobenzylguanidine (MIBG) scintigraphy showed a marked tracer uptake in the left adrenal mass with no metastatic lesion. After preoperative management with α-blockade, laparoscopic left partial adrenalectomy was performed. Immunohistochemical examination of the tumor showed chromogranin A positivity leading to the diagnosis of left pheochromocytoma.ConclusionsWe report an extremely rare case of concomitant unilateral PA and contralateral pheochromocytoma. When diagnosing unilateral PA by AVS, especially in cases with a lipid-poor adrenal mass, clinicians should rule out the possibility of the presence of pheochromocytoma before proceeding to undergo unilateral adrenalectomy. Although there is no standard treatment for this rare condition, it is essential to select personalized treatment from the perspective of conserving the adrenal gland.

PS-R03-7: PARTIAL ADRENALECTOMY IN A PATIENT WITH ACTH-INDEPENDENT MACRONODULAR ADRENAL HYPERPLASIA: A CASE REPORT

Background: The standard treatment for ACTH-independent macronodular adrenal hyperplasia (AIMAH) with overt Cushing's syndrome is bilateral adrenalectomy. Here we show a case of AIMAH who underwent total adrenalectomy on one side and partial adrenalectomy on the other, resulting in the successful debulking of cortisol-secreting adrenal masses and improvement of Cushing's syndrome, yet not necessitating postoperative steroid replacement. Case presentation: A 74-year-old female patient with hypertension, type 2 diabetes and dyslipidemia developed edema of the legs. She visited her primary physician and was found to have lumbar vertebral compression fractures. The blood test and 24-hr urine collection revealed the plasma cortisol levels of 26.1 μg per dL, adrenocorticotropic hormone of 1.1 pg per mL, and urine free cortisol of 340 μg per day. Computed tomographic scan and adrenal scintigraphy confirmed bilateral adrenal nodules with notable tracer uptake. Diagnosis of AIMAH with Cushing's syndrome was made. Laparoscopic partial adrenalectomy, i.e., total removal of the left adrenal gland and partial removal of the right counterpart, was conducted aiming to avert from steroid replacement therapy. After the surgery, blood pressure and glycemic control were markedly improved and maintained for 4 years whilst adrenocortical functions were preserved. Conclusion: Partial adrenalectomy could be an effective therapy in selected cases of AIMAH.

PS-R03-2: UNILATERAL PRIMARY ALDOSTERONISM AND CONTRALATERAL GROWING ADRENAL MASS: GROWING CONCERN FOR PHEOCHROMOCYTOMA

Concomitant unilateral primary aldosteronism (PA) and pheochromocytoma is extremely rare. A 52-year-old previously healthy woman with no family history of endocrine disease was admitted to our hospital with suspected PA based on high blood pressure, spontaneous hypokalemia, and a high aldosterone-to-renin ratio. She had no catecholamine excess symptoms other than hypertension. Abdominal computed tomography (CT) showed a right lipid-rich adrenal mass and a left lipid-poor adrenal mass. PA was diagnosed by the captopril challenge test. The 24-h urinary fractionated metanephrines were slightly elevated. Adrenal vein sampling (AVS) confirmed that the right adrenal gland was responsible for aldosterone hypersecretion. Medical therapy with eplerenone was started because the patient refused surgery. Five years later, she requested surgery for PA. The second AVS confirmed right unilateral hyperaldosteronism, as expected. Repeat abdominal CT showed the enlargement of the left adrenal mass. The 24-h urinary fractionated metanephrines had risen to the diagnostic level. 123I-MIBG scintigraphy showed a marked accumulation in the left adrenal tumor with no metastatic lesion. After preoperative management of alpha-blockade, laparoscopic left partial adrenalectomy was performed. Immunohistochemical examination of the tumor showed chromogranin A positivity leading to the diagnosis of left pheochromocytoma. One year after surgery, blood pressure and serum K levels remain well controlled. No surgical treatment for the right adrenal mass has been performed, and PHEO has not recurred. This case highlights the potential pitfalls in the treatment and diagnosis of unilateral primary aldosteronism with contralateral pheochromocytoma. In cases of unilateral PA with contralateral lipid-poor adrenal mass, clinicians should rule out if the contralateral adrenal mass is pheochromocytoma to proceed to undergo unilateral adrenalectomy for the treatment of PA.

Retroperitoneal laparoscopic partial adrenalectomy (RLPA) for 20-40mm nonfunctional adrenal tumors in the day surgery mode.

To investigate the outcome and safety of retroperitoneal laparoscopic partial adrenalectomy in the treatment of nonfunctional unilateral adrenal tumors in the day surgery mode. Nineteen patients bearing nonfunctional unilateral 20-40mm adrenal tumors were prospectively enrolled and underwent retroperitoneal laparoscopic partial adrenalectomy in the day surgery unit of our hospital between June 2021 and March 2022. All patients were diagnosed with non-functional adrenal tumors as outpatients before being admitted to the day surgery unit with their consent. Patient demographics and perioperative data were prospectively documented. The patients were followed up by telephone on day 1, 3 and 7 after discharge and followed up for 6 months. The patient's age was 50.5 ± 11.9 yr (range from 19.0 - 69.0). Seven patients were female. Twelve patients underwent surgery on the left side. The maximal diameter of tumor was 28.3 ± 5.7mm (20.0 - 40.0mm). Operation time was 72.1 ± 14.9min (58.0 - 120.0min). Mean blood loss was 64.7 ± 50.4ml (30.0 - 200.0ml). The gastrointestinal function recovery time was 9.7 ± 2.6h (6.0 - 16.0h). Retroperitoneal drainage was removed 24.8 ± 13.3h (range 18.0 - 72.0) after surgery. Four patients were transferred to the general ward for postoperative management, while others were discharged within 24 hours after surgery. Length of hospital stay was 48.8 ± 13.1h (38.0 - 85.0h). Hospitalization expense was 24168.4 ± 2910.3 RMB¥ (20844.3 - 34369.8 RMB¥). Postoperative pathology revealed 17 cortical adenoma, 1 pheochromocytoma and 1 lymphatic duct tumor. Retroperitoneal laparoscopic partial adrenalectomy for nonfunctional unilateral adrenal tumors in the day surgery mode is safe when strict selection criteria and perioperative management protocol are followed, which has the potential to shorten length of hospital stay and reduce lower hospitalization costs.

ODP052 Recurrent Pheochromocytoma Concerning For Surgical Seeding From Prior Partial Adrenalectomy

Abstract Introduction Surgery for a sporadic pheochromocytoma does not always lead to long-term cure, even in patients with a benign tumor, with an estimated recurrence rate of 3% (1). We present a patient with a history of pheochromocytoma s/p partial adrenalectomy 10 years prior found to have recurrence not within the adrenal parenchyma, but in the prior resection bed and diaphragm, concerning for seeding of the surgical bed from prior surgery. Clinical Case A 56-year-old man with a history of pheochromocytoma s/p a laparoscopic left partial adrenalectomy 10 years prior, with no detected rupture of the capsule at time of surgery, presented with symptoms of palpitations and anxiety. The patient had previously tested negative for SDHB, SDHD, MEN2, and VHL. Repeat labs were concerning for recurrence: 24-hour urine normetanephrines 1192 μ g (156-729 μ g) and metanephrines 204 μ g (58-276 μ g), plasma normetanephrine 479.4 pg/mL (0. 0-136.8 pg/mL), metanephrines 38.2 pg/mL (0. 0-88. 0 pg/mL), and chromogranin A 129. 0 ng/mL (0. 0-101.8 ng/mL). MRI with contrast showed a mildly enhancing mass in the left adrenalectomy postsurgical bed with no changes noted in the liver, and an I-123 MIBG scan showed focal uptake in the left adrenal gland corresponding to the mass seen on MRI as well as heterogeneous uptake in the left hepatic lobe. A DOTATE PET scan done prior was negative. The patient underwent laparoscopic left adrenalectomy; the left adrenal gland was dissected and the patient was found to have multiple satellite lesions along the left diaphragm which were excised. On pathology, immunostains were positive for chromogranin and synaptophysin. Multiple nodules of pheochromocytoma/paraganglioma were seen involving the soft tissue of the diaphragm (<0.1-0.6 cm) and the periadrenal soft tissue and prior resection bed (<0.1-2.5 cm), with no tumor seen within the residual adrenal parenchyma. The tumor extended to the cauterized tissue edges and no lymphovascular invasion was seen. No necrosis, no increased mitotic activity, no atypical mitotic figures were noted, and Ki-67 proliferation index was <1%. Testing done six weeks postoperatively showed plasma normetanephrine 49.9 pg/mL, metanephrine <10 pg/mL, and chromogranin A 87.9 ng/mL. Repeat genetic testing was negative for SDHB, SDHD, VHL, and MEN2. One year postoperatively, the patient's blood pressures are well-controlled on a small dose of doxazosin, kept on as a prophylactic measure. Conclusion This case demonstrates a rare presentation of recurrent pheochromocytoma found in the diaphragm, periadrenal tissue, and surgical bed from a prior partial adrenalectomy, concerning for recurrence in setting of surgical seeding from prior surgery. This case highlights the importance of perhaps considering a total adrenalectomy rather than partial when possible. Reference: (1) Holscher I, et al. Recurrence Rate of Sporadic Pheochromocytomas After Curative Adrenalectomy: A Systematic Review and Meta-analysis. J Clin Endocrinol Metab. 2021 Jan 23;106(2): 588-597. Presentation: No date and time listed

V13-10 LINEAR STAPLING DEVICE IN LAPAROSCOPIC PARTIAL ADRENALECTOMY FOR PHEOCHROMOCYTOMA IN MULTIPLE ENDOCRINE NEOPLASIA TYPE 2B

You have accessJournal of UrologyCME1 May 2022V13-10 LINEAR STAPLING DEVICE IN LAPAROSCOPIC PARTIAL ADRENALECTOMY FOR PHEOCHROMOCYTOMA IN MULTIPLE ENDOCRINE NEOPLASIA TYPE 2B Patricio Garcia Marchiñena, Andrés Germán Alfieri, Facundo Barbagallo, Ricardo Hosman Basto, and Alberto Jurado Patricio Garcia MarchiñenaPatricio Garcia Marchiñena More articles by this author , Andrés Germán AlfieriAndrés Germán Alfieri More articles by this author , Facundo BarbagalloFacundo Barbagallo More articles by this author , Ricardo Hosman BastoRicardo Hosman Basto More articles by this author , and Alberto JuradoAlberto Jurado More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002646.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Solitary adrenal glands, bilateral adrenal tumors or hereditary syndromes are indications of partial adrenalectomy to avoid the need for lifelong corticosteroid replacement. Laparoscopic partial adrenalectomy (LPA) is a safe and effective method in order to provide complete removal of small adrenal lesions, as well as preservation of normal glandular parenchyma. Our objective is to describe a LPA using a linear stapling device in a hereditary pheochromocytoma. METHODS: We present the case of a 29-year-old male with hypertension, anxiety and heart palpitations due to pheochromocytoma caused by multiple endocrine neoplasia type 2B. Urinary catecholamine levels were four times higher than normal. CT scan revealed a 33 mm hypermetabolic right adrenal mass. Transperitoneal LPA was performed with the patient in left lateral decubitus. Four trocars were placed as the described technique parallel to the costal line. Right adrenal tumor was resected using a vascular linear stapling device. To preserve the blood supply of the remnant adrenal gland, it was not extensively dissected and the main adrenal vein was totally preserved. RESULTS: The patient had uneventful postoperative recovery. Surgical time was 90 minutes. Patient was discharged on the 2nd day. Pathology confirmed a 3.5 cm benign composite pheochromocytoma-ganglioneuroma with negative surgical margins. After surgery the patient achieved a complete clinical and biochemical response. During a follow-up of 6 months, no biochemical or radiological recurrence was observed. CONCLUSIONS: LPA using a linear stapling device is a valid alternative to total adrenalectomy when normal adrenal tissue has to be preserved. Source of Funding: No source of fundings © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e1034 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Patricio Garcia Marchiñena More articles by this author Andrés Germán Alfieri More articles by this author Facundo Barbagallo More articles by this author Ricardo Hosman Basto More articles by this author Alberto Jurado More articles by this author Expand All Advertisement PDF DownloadLoading ...

V05 - Laparoscopic partial adrenalectomy using near-infrared imaging in a patient with Cushing’s syndrome: A case presentation

V05 - Laparoscopic partial adrenalectomy using near-infrared imaging in a patient with Cushing’s syndrome: A case presentation

Our experience of laparoscopic partial adrenalectomy in surrenal adenomas

Aim: For adrenal lesions which are functional and bigger than four centimeters, the optional therapy is surgery. Laparoscopy for the surgery of adrenal masses is increasingly used today. In the past, total adrenalectomy was performed for any adrenal lesions without any exception; however, bilateral involvement of tumors like pheochromocytoma causes trouble and forced surgeons to try partial adrenalectomy. Recently, partial adrenalectomy is a routine surgical procedure for bilateral lesions and also becoming common for unilateral lesions. We aimed to present short-term results for patients who undergo laparoscopic total or partial adrenalectomy.
 Material and Method: We collect data retrospectively for 33 patients who were operated on in our clinic for adrenal mass between January 2010 and December 2014. 3 patients were excluded from the study. All data were gained from personal patient medical records. Follow-up records were noted with one-by-one interviews by questioning steroid usage and symptoms of adrenal insufficiency.
 Results: Patients were divided into two groups as total adrenalectomy group with 19 patients and partial adrenalectomy group with 11 patients. All patients who underwent total adrenalectomy have unilateral lesions, while 4 for 11 partial adrenalectomy patients have bilateral adrenal masses. Adrenal insufficiency developed in 3 patients for total adrenalectomy, 1 patient for unilateral partial adrenalectomy, and 1 patient for bilateral partial adrenalectomy.
 Conclusion: Partial adrenalectomy appears to be protective for adrenal insufficiency for bilateral cases with a ratio of 75%. there was no significant difference between the total or partial unilateral adrenalectomy group, considering postoperative complications, recurrence rates, and insufficiency. As a result, laparoscopic partial adrenalectomy has similar results with less morbidity for unilateral lesions and an alternative method with less adrenal insufficiency for bilateral lesions. Laparoscopic partial adrenalectomy could be performed safely after the learning period was completed and should be considered for adrenal surgeries.

V04-02 ROBOT ASSISTED RIGHT PARTIAL ADRENALECTOMY

You have accessJournal of UrologyAdrenal & Renal Oncology I (Nephron Sparing Surgery) (V04)1 Sep 2021V04-02 ROBOT ASSISTED RIGHT PARTIAL ADRENALECTOMY Joshua Cabral, Bryan Cortez, Onaje Artist, Anish Jain, and Adam Metwalli Joshua CabralJoshua Cabral More articles by this author , Bryan CortezBryan Cortez More articles by this author , Onaje ArtistOnaje Artist More articles by this author , Anish JainAnish Jain More articles by this author , and Adam MetwalliAdam Metwalli More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002000.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pheochromocytomas are rare, functional catecholamine producing neuroendocrine tumors that can be adrenal or extra adrenal in origin. Their estimated incidence is 0.1% in the general population. Adrenalectomy is the gold standard treatment of pheochromocytoma, and since the 1990’s, laparoscopic and robotic techniques have emerged and replaced open approaches for managing small, benign masses. Currently, laparoscopic adrenalectomy remains controversial for large (size greater than 8-10 cm) tumors with more evidence needed to assess for viability and safety. Our study demonstrates the successful removal of a 14.6x15.7x10.6 cm using a robot assisted laparoscopic technique. METHODS: Our patient was a 57-year-old Hispanic male who presented with headaches, dizziness, and 30lb weight loss in the setting of a large right upper quadrant mass on abdominal ultrasound. Abdominal CT showed a 14.6x15.7x10.6 cm heterogenous mass within the right upper quadrant, with cystic and solid components, causing displacement of adjacent structures. Hormonal workup showed markedly elevated catecholamines consistent with a pheochromocytoma. The patient was consented for and underwent a Robotic Assisted Laparoscopic Right Partial Adrenalectomy. He underwent alpha blockade and catecholamine synthesis inhibition for the two weeks prior to surgery. RESULTS: After the mass was removed the inferior vena cava resumed its orthotopic position intraoperatively, was no longer effaced, and appeared relatively full and normal in caliber. Post-operatively the patient was admitted to the SICU, and required 48 hours of pressor support with pharmacological agents, crystalloid and colloid. His postoperative course was otherwise unremarkable, and he was discharged on postoperative day (POD) 5. He was seen in the clinic on POD 27 with no complaints and with resolution of his symptoms and normalization of his catecholamines. CONCLUSIONS: Robot Assisted Partial Adrenalectomy can successfully be performed for large (>10 cm) pheochromocytomas. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e291-e291 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joshua Cabral More articles by this author Bryan Cortez More articles by this author Onaje Artist More articles by this author Anish Jain More articles by this author Adam Metwalli More articles by this author Expand All Advertisement Loading ...

Laparoscopic adrenal-sparing approach for children with bilateral pheochromocytoma in Von Hippel-Lindau disease

IntroductionVon Hippel-Lindau disease (VHL) is a rare cause of hereditary bilateral Pheochromocytomas (PHEO). Traditionally, treatment has been total adrenalectomy due to a lifetime risk of developing new tumors. Limited data exists on the surgical management of bilateral PHEO in children with VHL. We reviewed our experience with laparoscopic partial adrenalectomy for bilateral PHEO. MethodsA retrospective review was performed of patients undergoing adrenalectomy for PHEO in children with VHL from 2004 to 2019. ResultsEight children with VHL diagnosed with bilateral PHEO underwent 16 adrenalectomies (10 synchronous, 5 metachronous, 1 for recurrence). Median age at diagnosis was 13 [range 8–17] years with a median tumor size of 2.3 [range 0.5–7.7] cm. Of 16 adrenalectomies, all were performed laparoscopically, 14 were partial adrenalectomies; 2 patients required a contralateral total adrenalectomy due to size and diffuse multinodularity. There were no postoperative complications. No patients required corticosteroid replacement at the end of the study period. Two patients had new ipsilateral tumors identified after a median follow up of 5 [range 4–6] years with one undergoing repeat partial adrenalectomy. There were no mortalities in the study period. ConclusionPartial adrenalectomy for bilateral PHEO in patients with VHL is safe and does not compromise outcomes. When technically feasible, laparoscopic partial adrenalectomy should be considered as a primary surgical approach for children with VHL. Level of EvidenceLevel IV - Case series with no comparison group

Adrenal-sparing surgery for a hormonally active tumour - a single-centre experience.

Surgeries that spare the adrenal cortex during adrenalectomy have profound justification. Indications for this type of surgery are fairly strict, and more than 30 years of observations continuously verify the results of the procedure. Of a total of 650 adrenalectomies, 22 (3.4%) were adrenal cortex-sparing surgeries. There were 16 women and six men in this group. In 10 cases, surgery was performed for pheochromocytoma, eight cases involved Conn's syndrome, and in four cases - paragangliomas located in the para-adrenal region. Secretory activity was identified in all cases. Laparoscopic partial adrenalectomy was performed in 20 patients. Conversion to open laparotomy was necessary in two cases. In patients after bilateral resection of pheochromocytoma surgery, glucocorticoids were supplemented for six weeks. No significant surgical complications were observed in this group. Partial adrenalectomy for minor lesions should be a much more commonly utilised treatment method (of choice). Where bilateral adrenalectomy is necessary, a sparing procedure on one side protects patients from the need for hormonal substitution. The remaining part of the adrenal gland undertakes satisfactory secretory function after six weeks at the latest.

Laparoscopic right partial adrenalectomy (with video)

Laparoscopic right partial adrenalectomy (with video)

Adrenal-sparing surgery: current concepts on a theme from the past.

Adrenal insufficiency represents a debilitating condition which mandates lifelong steroid replacement and which is associated with significant long-term morbidity, due to either inadequate or excessive replacement. The concept of preserving healthy cortical tissue by means of partial adrenalectomy has evolved as a means of avoiding the detrimental consequences of adrenal insufficiency. The advent of advanced technology in adrenal surgery has greatly facilitated the performance of partial adrenalectomy, enabling utilization of this method in an increasing number of endocrine diseases. Hereditary pheochromocytoma, Conn's syndrome, Cushing's syndrome, and non-functional adrenal masses represent the current indications for partial adrenalectomy, although the specific circumstances under which adrenal-sparing surgery should be proposed are still debatable. Partial adrenalectomy can be achieved by all types of minimally invasive surgery. In the absence of randomized, prospective, controlled studies designed to compare laparoscopic, retroperitoneoscopic, and robot-assisted partial adrenalectomy, none of these techniques has as yet been proven to be the gold standard for adrenal-sparing surgery. Apart from indications for surgery, results of surgery, and different types of partial adrenalectomy, controversial topics addressed in this review article include technical aspects such as the volume of residual adrenal tissue needed, ligation of adrenal vein, and means of tumor identification. Discussion of these controversial topics represents an attempt to define the role of partial adrenalectomy in modern adrenal surgery.

SAT-222 Aggressive Phenotype Pheochromocytoma Associated with NF-1 and BRCA Mutation

IntroductionPheochromocytomas are catecholamine-secreting tumors of the adrenal medulla that occur sporadically or with familial association. Familial predilection occurs in those with multiple endocrine neoplasia type 2, von Hippel-Lindau disease, and neurofibromatosis Type 1 (NF-1). To date, more than 21 gene mutations have been identified that are involved in the development of pheochromocytomas. However, co-existence of two different mutations such as NF-1 and BRCA gene mutations with pheochromocytoma has not been well described.Clinical CaseA 40 year-old woman with NF-1 and recently diagnosed left breast invasive ductal carcinoma, estrogen positive, progesterone positive, HER-2 negative BRCA2 positive breast cancer and right breast lobular carcinoma in situ underwent staging CT scan. A 2.7 cm left adrenal incidentaloma with heterogeneous texture and 69–100 HU was discovered. Symptom review revealed chronic headaches and increasing frequency of anxiousness and irritability. She had no personal or family history of hypertension. Laboratory analysis showed elevated catecholamine levels included plasma normetanephrine of 2.8 nmol/L (normal <0.9), metanephrine of 0.9 nmol/L (normal <0.5), 24 hour urine metanephrine 498 mcg/24 hr (normal <180) and 24 hour urine normetanephrine of 1,152 mcg/24 hr (normal <451). Findings were consistent with adrenal pheochromocytoma.She was immediately started on phenoxybenzamine and encouraged to increase fluid intake to expand intravascular volume before surgery. She underwent laparoscopic left partial adrenalectomy fourteen days later. Surgical pathology revealed a 3.0 cm pheochromocytoma in a background of nodular hyperplasia of the medulla, described as an aggressive tumor phenotype based on morphological features.ConclusionsIt has been estimated that 1.5–14% of adrenal incidentalomas are pheochromocytomas. While only 3% of NF-1 patients have pheochromocytomas, 20–50% of NF-1 patients with concurrent hypertension have underlying chromaffin tumors. This association is significant when compared to the pheochromocytoma incidence of 0.1% in all hypertensive individuals. Interestingly, germline mutations of BRCA-1 associated protein-1 gene have been reported in patients with paragangliomas, therefore it may be plausible to consider interactions between NF-1 and breast cancer BRCA-2 gene mutations, resulting in an unusual and more aggressive pheochromocytoma phenotype, even when detected at an early stage, as in this case. It is also important to recognize and adequately treat pheochromocytoma prior to having surgery to avoid possible intraoperative hypertensive crisis, a concept that was underscored in this particular case when the patient was relatively asymptomatic and entirely normotensive preoperatively.

V10-02 ROBOTIC BILATERAL PARTIAL ADRENALECTOMY FOR PHEOCHROMOCYTOMA

You have accessJournal of UrologyAdrenal Surgery & Kidney Cancer II (Advanced Kidney Cancer & Vascular Reconstruction) (V10)1 Apr 2020V10-02 ROBOTIC BILATERAL PARTIAL ADRENALECTOMY FOR PHEOCHROMOCYTOMA Jeremy Archer*, Jonathan Pavlinec, Shavano Stedman, Tejal Patel, Sara Falzarano, and Li-Ming Su Jeremy Archer*Jeremy Archer* More articles by this author , Jonathan PavlinecJonathan Pavlinec More articles by this author , Shavano StedmanShavano Stedman More articles by this author , Tejal PatelTejal Patel More articles by this author , Sara FalzaranoSara Falzarano More articles by this author , and Li-Ming SuLi-Ming Su More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000935.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with multiple endocrine neoplasia type 2 (MEN2) and von Hippel-Lindau disease (VHL) are risk of bilateral adrenal pheochromocytomas. Total adrenalectomy was historically the standard of care for patients with hereditary syndromes, but this leads to lifelong steroid supplementation. Adrenal-sparing surgery has been described in the treatment of adrenal incidentaloma, aldosteronoma, isolated metastasis, and the hereditary pheochromocytomas of MEN2 and VHL. Synchronous bilateral laparoscopic partial adrenalectomy with intraoperative ultrasonography has been described for pheochromocytomas as safe and technically feasible, but the majority of bilateral lesions have been treated by staged operations. We report our experience of synchronous bilateral robotic partial adrenalectomy for multifocal bilateral adrenal pheochromocytomas. METHODS: A 36-year-old female with marfanoid habitus and biopsy-proven medullary thyroid cancer was found to have bilateral adrenal masses on staging workup. Laboratory results showed elevated serum metanephrines, and she was started on alpha blockade with phenoxybenzamine. Imaging revealed a 3 cm right adrenal mass with a separate area of 1 cm irregularity and a 2 cm left adrenal lesion. Bilateral robotic partial adrenalectomies were successfully performed using a 4-arm technique with the daVinci Xi robotic platform (Intuitive, Sunnyvale CA) and a 12mm assistant trocar at the umbilicus. The patient was positioned in full-flank positioning for each side with docking from the same side of the room. The midline subxiphoid robotic 8mm and the 12mm assistant trocars were used for both portions of the operation. RESULTS: Enucleation of the tumors was performed with a total operative time of 330 minutes and estimated blood loss of 50mL. Pathology revealed three pheochromocytomas, and the patient was started post-operatively on a steroid taper. She was referred for genetic counseling given suspicion for MEN2B syndrome. CONCLUSIONS: Bilateral adrenal-sparing surgery for pheochromocytoma is safe and feasible and may be achieved using a robotic 4-arm technique with linear trocar configuration with repositioning. This approach in patients with genetic predisposition to synchronous adrenal lesions may preclude or delay the need for lifelong steroid supplementation. Source of Funding: N/A © 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 Jeremy Archer* More articles by this author Jonathan Pavlinec More articles by this author Shavano Stedman More articles by this author Tejal Patel More articles by this author Sara Falzarano More articles by this author Li-Ming Su More articles by this author Expand All Advertisement PDF downloadLoading ...