Nonfunctioning Adrenal Tumors Research Articles

Follow-up of patients with adrenal incidentaloma, in accordance with the European society of endocrinology guidelines: Could we be safe?

Recently, the European Society of Endocrinology (ESE) published new guidelines on the management of adrenal incidentalomas. At the same time Lopez and coworkers published on the Annals of Internal Medicine an important study showing that even patients with non-functioning adrenal tumors have an increased risk of incident diabetes. In consideration of previous data and of the results of the study of Lopez and coworkers, some points emerge from the ESE Guidelines that deserve attention. Firstly, it must be observed that the term "autonomous cortisol secretion," introduced by the ESE Panel in the place of the commonly used "subclinical hypercortisolism," seems questionable, since the guidelines do not suggest determining the adrenocorticotroph hormone levels that could give the certain proof of a truly autonomous cortisol secretion. Secondly, the ESE Guidelines suggest against repeated hormonal workup in AI patients with a normal hormonal secretion at initial evaluation, but also in those with a "possible autonomous cortisol secretion," if in the absence of comorbidities potentially related to hypercortisolism. Thirdly, the ESE Guidelines suggest against further imaging during follow-up in patients with an adrenal mass below 4cm in size with clear benign features on imaging studies. Considering the available literature data that are briefly summarized in this comment, we believe that no sufficient evidence is available to date for giving sharp-cutting recommendations about the uselessness of a biochemical and morphological follow-up in AI patients, even in those with initially benign and not hypersecreting adrenal adenomas. However, if a recommendation has to be given on the basis of the present evidences, we should suggest to biochemically and morphologically follow-up AI patients for at least 5years.

"Nonfunctional" Adrenal Tumors and the Risk for Incident Diabetes and Cardiovascular Outcomes: A Cohort Study.

Benign adrenal tumors are commonly discovered on abdominal imaging. Most are classified as nonfunctional and are considered to pose no health risk, but some are considered functional because they secrete hormones that increase risk for metabolic and cardiovascular diseases. To evaluate the hypothesis that nonfunctional adrenal tumors (NFATs) increase risk for cardiometabolic outcomes compared with absence of adrenal tumors. Cohort study. Integrated hospital system. Participants with benign NFATs ("exposed"; n= 166) and those with no adrenal tumor ("unexposed"; n= 740), with at least 3 years of follow-up. Medical records were reviewed from the time of abdominal imaging for development of incident outcomes (hypertension, composite diabetes [prediabetes or type 2 diabetes], hyperlipidemia, cardiovascular events, and chronic kidney disease) (mean, 7.7 years). Primary analyses evaluated independent associations between exposure status and incident outcomes by using adjusted generalized linear models. Secondary analyses evaluated relationships between NFATs and cortisol physiology. Participants with NFATs had significantly higher risk for incident composite diabetes than those without adrenal tumors (30 of 110 [27.3%] vs. 72 of 615 [11.7%] participants; absolute risk, 15.6% [95% CI, 6.9% to 24.3%]; adjusted risk ratio, 1.87 [CI, 1.17 to 2.98]). No significant associations between NFATs and other outcomes were observed. Higher "normal" postdexamethasone cortisol levels (≤50 nmol/L) were associated with larger NFAT size and higher prevalence of type 2 diabetes. Potential bias in the selection of participants and ascertainment of outcomes. Participants with NFATs had a significantly higher risk for diabetes than those without adrenal tumors. These results should prompt a reassessment of whether the classification of benign adrenal tumors as "nonfunctional" adequately reflects the continuum of hormone secretion and metabolic risk they may harbor. National Institutes of Health and Doris Duke Charitable Foundation.

THERAPY OF ENDOCRINE DISEASE: Improvement of cardiovascular risk factors after adrenalectomy in patients with adrenal tumors and subclinical Cushing's syndrome: a systematic review and meta-analysis.

Beneficial effects of adrenalectomy on cardiovascular risk factors in patients with subclinical Cushing's syndrome (SCS) are uncertain. We sought to conduct a systematic review and meta-analysis with the following objectives: (i) determine the effect of adrenalectomy compared with conservative management on cardiovascular risk factors in patients with SCS and (ii) compare the effect of adrenalectomy on cardiovascular risk factors in patients with SCS vs those with a nonfunctioning (NF) adrenal tumor. MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE, EMBASE and Cochrane Central Register of Controlled Trial were searched on 17 November 2015. Reviewers extracted data and assessed methodological quality in duplicate. We included 26 studies reporting on 584 patients with SCS and 457 patients with NF adrenal tumors. Studies used different definitions of SCS. Patients with SCS undergoing adrenalectomy demonstrated an overall improvement in cardiovascular risk factors (61% for hypertension, 52% for diabetes mellitus, 45% for obesity and 24% for dyslipidemia). When compared with conservative management, patients with SCS undergoing adrenalectomy experienced improvement in hypertension (RR 11, 95% CI: 4.3-27.8) and diabetes mellitus (RR 3.9, 95% CI: 1.5-9.9), but not dyslipidemia (RR 2.6, 95% CI: 0.97-7.2) or obesity (RR 3.4, 95% CI: 0.95-12). Patients with NF adrenal tumors experienced improvement in hypertension (21/54 patients); however, insufficient data exist for comparison to patients with SCS. Available low-to-moderate-quality evidence from heterogeneous studies suggests a beneficial effect of adrenalectomy on cardiovascular risk factors in patients with SCS overall and compared with conservative management.

Application of posterior approach in retroperitoneoscopic adrenalectomy in the treatment of adrenal tumors

Objective To investigate the feasibility and efficacy of posterior retroperitoneoscopic adrenalectomy (PRA). Methods From September 2013 to September 2015, the clinical data of 35 patients who underwent posterior retroperitoneoscopic adrenalectomy were reviewed. There were 14 males and 21 females, aged 15-70 years, with the average of 45.8 years. Preoperative CT scan showed 19 adrenal tumors in the left side, 16 in the right side, and one case with the left adrenal adenoma combining with right renal cyst. Tumor diameter is between 10~60mm, with the average of 31mm.Twenty-two cases were diagnosed as primary aldosteronism, 4 pheochromocytoma, and 9 non-functional adrenal tumor. The posterior retroperitoneoscopic adrenalectomy were performed in all of the cases, which are under general anesthesia with tracheal intubation and prone position with hip joints and knee joints flexion of 90. Results Thirty-five operations were successfully completed via the posterior approach demonstrating clear anatomical layers. The operation time was 38-138min(mean 70 min), the drainage tube indwelling duration was 1-5d(average 2d), and the hospital stay was 2-6d(average 4d). Total costs of hospitalization were 14 789-31 992 yuan RMB, with an average of 21 239 yuan RMB. No complications occurred during the perioperative period. The average follow-up was 11 months, and no complications such as tumor recurrence occured. Conclusions Retroperitoneoscopic adrenalectomy provided clear anatomical views. It could be a safe and effective operation for the treatment of adrenal tumors. Key words: Prone position; Adrenalgland neoplasms; Posterior approach

Teaching Laparoscopic Adrenalectomy to Surgical Residents.

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. 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. 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. 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.

Landmarks in the history of adrenal surgery.

The last 100 years have seen a revolution in the understanding of adrenal disease and its surgical treatment. The isolation of hormones, the detailed study of the adrenal medulla and cortex, as long as the enormous expansion of surgery served as catalysts to this revolution. The original surgical procedures described were modified as time went by and nowadays laparoscopic adrenalectomy serves as the first-line therapy choice for the management of most functional and non-functional adrenal tumors. With respect to the pioneers who, often at the risk of compromising their careers, surpassed significant milestones at their times, we review the historical evolution of adrenal surgery and report in a chronological fashion its major landmarks from antiquity to the current era.

Laparoscopic surgery in functional and nonfunctional adrenal tumors: A single-center experience

BackgroundLaparoscopic adrenalectomy (LA) is a safe and minimally invasive operation for benign adrenal tumours. The purpose of this study was a retrospective analysis of outcomes following laparoscopic lateral transabdominal adrenalectomy performed for benign adrenal tumours responsible for various endocrinological disorders and non-functioning tumours. MethodsA total of 100 laparoscopic adrenalectomy were carried out between January 2007 and March 2013 via the lateral transabdominal approach. The analysed factors included demographic data of patients, indication for surgery, tumour size and side, intraoperative and postoperative outcome of laparoscopic lateral transabdominal adrenalectomy including duration of surgery, length of hospital stay, the complication rate, as well as the conversion rate to open adrenalectomy. ResultsThere were 34 patients with non-functioning tumours (Group 1) and 66 with functioning tumours (Group 2). The intraoperative and postoperative outcomes were not significantly different in the cases among the analysed groups of patients. The median operative time was 101 ± 4.3 (range, 30–210) minute in group 1 and 95 ± 5.9 (range, 30–190) minute in group 2, there was not statistically significant (p = 0.56). The median duration of the postoperative hospital stay in the group 1 was bigger than group 2, this did not differ significantly (p = 0.08). Peroperative complications were occured in 9 (9%) patients, observing 6 (9%) patients in Group 1 and 3 (8.8%) patients in Group 2. There was not statistically significant (p = 0.96). In the postoperative period, three patients in group I, 1 patient in group II developed complications, this difference was not statistically significant (p = 0.69). The conversion to open surgery was found in 9 (9%) patients. ConclusionThis study shows that laparoscopic lateral transabdominal adrenalectomy is a safe, effective, and technically feasible procedure in the treatment of both functioning and nonfunctioning benign tumours of the adrenal gland.

Synchronous ipsilateral renal cell carcinoma and urothelial carcinoma of kidney or ureter: Cases report and literature review

Synchronous ipsilateral renal cell carcinoma and urothelial carcinoma of kidney or ureter: Cases report and literature review

The clinical analysis of adrenal tumor combined with renal carcinoma in 42 patients

Objective To summarize the clinical characteristics of adrenal tumors combined with renal carcinoma and to extend the clinical understanding of the situation. Methods To analyze the data of 1 100 patients with adrenal tumors hospitalized in Peking University First Hospital from Jan. 1994 to Mar. 2012 retrospectively, in the series there were 42 combined with renal carcinoma. Results There were 27 males, 15 females, aged 29 to 83 years, mean 60.5 years old. In 42 renal carcinomas, there were 29(69.0%)clear cell carcinomas, 5(11.9%)cystic renal carcinomas, 2(4.8%)clear cell with granulosa cell hybrid carcinomas, 1 renal lymphoma, 1(2.4%)spindle cell tumor, 1 acidophilic cell adenoma, and 1 undifferentiated type of renal cell carcinoma and pathologically not clear in 2 cases(4.8%). Clinical manifestations were not specific. In 42 adrenal tumors, 20 situated in the left, and 17 right, and 5 were bilateral. 35 cases were considered primary adrenal tumors, in which 3 were diagnosed primary hyperaldosteronism, 32 were non-functional tumors. Other 7 were non-functional matastatic carcinomas. 25 patients underwent resection of adrenal tumors, and pathology revealed 22(88.0%)were primary, in which 12(54.6%)were cortical adenomas, 7(31.9%)hyperplasia, 1(4.5%)pheochromocytoma, 1(4.5%)ganglioneuroma, 1(4.5%)adenoma with hyperplasia; 2(8.0%)metastatic tumors, and 1(4.0%)non-Hodgkin's lymphoma. The mean diameter of primary adrenal tumors was 1.9 cm, while that of metastatic carcinoma was 3.84 cm. 25 underwent abdominal ultrasonography, 40 underwent computed tomography(CT)scan, 6 underwent magnetic resonance imaging(MRI)scan, positive rate was 72.0%, 97.5%, and 100.0% respectively. 25 patients who underwent surgery were followed up, 17 survived for 8 months-6 years, 4 died, in which 1 metastatic carcinoma died of intraoperative bleeding, 1 died of adrenal lymphoma, 2 died because of other disease, 4 were lost to follow-up. Conclusions The most common type of renal carcinoma combined with adrenal tumors was clear cell carcinoma, while majority of the adrenal tumors were primary with non-specific clinical manifestations and function. The adrenal tumors might be located in the same or the opposite side of renal carcinoma, also might be bilateral which were more common in metastatic carcinomas and always bigger than primary ones. CT/MRI scans were important in judging the nature of the tumors and pathology was the gold standard. The non-functioning primary adrenal tumors could be safely followed up, and the isolated metastatic carcinoma should be resected. Prognosis depends mainly on that of renal carcinoma. (Chin J Endocrinol Metab, 2015, 31: 342-345) Key words: Adrenal tumor; Renal carcinoma; Primary; Metastatic carcinoma

Activation of classical brown adipocytes in the adult human perirenal depot is highly correlated with PRDM16-EHMT1 complex expression.

Brown fat generates heat to protect against cold and obesity. Adrenergic stimulation activates the thermogenic program of brown adipocytes. Although the bioactivity of brown adipose tissue in adult humans had been assumed to very low, several studies using positron emission tomography–computed tomography (PET–CT) have detected bioactive brown adipose tissue in adult humans under cold exposure. In this study, we collected adipose tissues obtained from the perirenal regions of adult patients with pheochromocytoma (PHEO) or non-functioning adrenal tumors (NF). We demonstrated that perirenal brown adipocytes were activated in adult patients with PHEO. These cells had the molecular characteristics of classical brown fat rather than those of beige/brite fat. Expression of brown adipose tissue markers such as uncoupling protein 1 (UCP1) and cell death-inducing DFFA-like effector A (CIDEA) was highly correlated with the amounts of PRD1-BF-1-RIZ1 homologous domain-containing protein-16 (PRDM16) – euchromatic histone-lysine N-methyltransferase 1 (EHMT1) complex, the key transcriptional switch for brown fat development. These results provide novel insights into the reconstruction of human brown adipocytes and their therapeutic application against obesity and its complications such as type 2 diabetes.

Single-port laparoscopic left adrenalectomy (SILS): 3 years' experience of a single institution.

Laparoscopic adrenalectomy by 3 or 4 trocars is a well-established procedure. This report describes the initial experience with single-incision laparoscopic surgery (SILS) using the transperitoneal approach for left adrenalectomy. Between April 2010 and January 2013, all consecutive patients with adrenal masses who agreed to undergo SILS adrenalectomy were included in a prospective study. The left 2.5 cm subcostal incision was the sole point of entry. Data of patients undergoing SILS adrenalectomy were compared with those from an uncontrolled group of patients undergoing conventional laparoscopic adrenalectomy during the same study period. There were 40 patients in each study group. SILS was successfully performed and none of the patients required conversion to an open procedure. In 1 case of SILS procedure, an additional lateral 5 mm port was needed for retraction of the kidney. The mean (SD) duration of the operation was 80 (20) minutes in the SILS group and 75 (8) minutes in the conventional laparoscopic adrenalectomy group (P=0.150). No intraoperative or postoperative complications occurred. Differences between the 2 study groups in postoperative pain, number of patients resuming oral intake within the first 24 hours, final pathologic diagnosis (Conn syndrome, Cushing adenomas, nonfunctioning adrenal tumors), and length of hospital stay were not observed. SILS left adrenalectomy is a technically feasible and safe procedure in carefully selected patients and seems to have results similar to a conventional approach in our initial comparison.

OUR EXPERIENCE IN LAPAROSCOPIC ADRENALECTOMY

BACKGROUND: Laparoscopic adrenalectomy (LA) has become the procedure of choice to treat functioning and non-functioning adrenal tumours. With improving experience, large adrenal tumours (> 5 cm) are being successfully tackled by laparoscopy. MATERIALS AND METHODS: Thirty-eight laparoscopic adrenalectomies was performed for adrenal lesions during the period 2006 to 2012 were reviewed. RESULTS: A total of 35laparoscopic adrenalectomies were done in 32 patients. The mean tumour size was 5.03 cm (2-11 cm). The lesions were localised on the right side in 17 patients and on the left side in 15 patients, with bilateral tumours in 3 patients. Functioning tumours were present in 32 of the 46 patients. The average blood loss was 112 ml (20–400 ml) with the mean operating time being 144 min (45 to 270 min). Three patients underwent conversion to open procedure. Three of the 32 patients (9.52%) on final histology had malignant tumours. CONCLUSION: LA is safe and feasible for large adrenal lesions. Mere size should not be considered as a contraindication to laparoscopic approach in large adrenal masses. Graded approach, good preoperative assessment, team work and adherence to anatomical and surgical principles are the key to success.

Extrapancreatic solid pseudopapillary neoplasm: Report of a case of primary retroperitoneal origin and review of the literature

Solid pseudopapillary tumors (SPTs) occurring as primary tumors outside the pancreas are exceedingly rare. The present study reports such a case occurring as a non-functional adrenal tumor in a 22-year-old female. The tumor was completely removed from the retroperitoneum by laparoscopic surgery. A well-defined, encapsulated tumor measuring 6×6×5 cm was histologically characterized by a combination of the solid and pseudopapillary growth patterns of tumor cells with eosinophilic cytoplasm. Ectopic pancreatic tissue was also found histologically within the resected tumor. On immunostaining, the tumor was positive for progesterone receptor, CD56, cytokeratin and CD10. The morphological and immunohistochemical features were compatible with those of SPT. To the best of our knowledge, this is the first case report of extrapancreatic SPT with evidence of a pre-existing ectopic pancreas in the retroperitoneum. A review of the published English literature uncovered 12 cases of extrapancreatic SPTs, and revealed that extrapancreatic SPTs are likely to have a favorable clinical course and a clinical profile similar to their pancreatic counterparts.

Initial experience of a series of robotic-assisted laparoscopic adrenalectomy

ObjectivesWe present our initial experience using robotic-assisted laparoscopic adrenalectomy in the surgical treatment of adrenal masses. Material and methodsA total of 18 patients (11 women and 7 men) diagnosed of a functioning or non-functioning adrenal tumor mass were operated on in our facilities between October 2009 and October 2011. Surgical variables, intra-hospital recovery time, pathological findings and peri- and post-operatory findings were evaluated. ResultsMean age of the population intervened was 51.2 years (range 18–81), average ASA score 2.11 (range 1–4) and BMI 27.0 (range 18.8–36.1). Of the 18 patients, 11 were operated on the left side and 7 on the right. Mean surgery time was 150 (range 84–329) min and intra-operatory bleeding 121 (range 10–1500) ml, with a mean loss of hemoglobin and hematocrits of 2.11g/dl and 6.33%, respectively. Two patients were converted to conventional surgery. The factors influencing surgical conversion were: normal size (>10cm), tumor weight (>100g), active pheochromocytoma and left localization of the tumor. Seven functioning cortical adenomas, 6 metastatic adrenal tumors, 3 pheochromocytoma and 2 incidental tumors were excised. Mean tumor size was 5.39 (range 3–15) cm. Median hospital stay was 6 days (range 4–14). Five patients had peri-operatory complication. Of these, only one (5%) had major complications (Clavien III). Mean follow-up was 6 months (range 2–24). ConclusionsRobotic technology for laparoscopic adrenalectomies is a valid option for adrenal tumor treatment. In our experience with a relatively short learning curve, it makes it possible to reduce hospital treatment times and the intra- and post-operatory complications, without affecting the oncological and post-operatory functional results.

Giant cavernous hemangioma of the adrenal gland

INTRODUCTIONCavernous hemangioma of the adrenal gland is a rare non-functioning benign neoplasm. PRESENTATION OF CASEA 62-year-old woman with chronic obstructive pulmonary disease was diagnosed as having an incidental non-functioning adrenal tumor. Because of the impossibility of ruling out the presence of malignancy, conventional surgical resection was carried out. The histopathology revealed a 12.5cm×11.5cm×8cm adrenal mass with large and lacunae vascular spaces lined with mature endothelial cells. These findings were compatible with cavernous hemangioma. DISCUSSIONThe majority of patients in the literature underwent surgical resection due to the impossibility of excluding malignancy, because of related symptoms in patients with large masses, or because of the risk of spontaneous tumoral rupture. CONCLUSIONThese tumors are quite infrequent. Due to the low frequency and the lack of specific symptoms, most adrenal hemangiomas are diagnosed postoperatively.

Giant suprarenal tumor

Adrenal tumors evoke considerable interest and represent various diagnostic challenges. Adrenal tumors can be stratified into adrenal medullary and adrenocortical tumors. Approximately 60% of adrenocortical tumors are hormonally active and show specific signs and symptoms. Patients with a nonfunctioning adrenal tumor usually present with abdominal discomfort due to the mass effect of the tumor. An imaging feature that differentiates benign from malignant adrenal neoplasms is the tumor size. Thus, for the differential diagnosis of adrenal lesions, measurement of the Hounsfield units on an unenhanced computed tomographic scan is of great value when differentiating malignant from benign lesions. Herein, we describe a young female patient who presented with a huge left suprarenal tumor. She underwent complete resection of the adrenal tumor. The final pathological diagnosis was an adrenocortical carcinoma. There has been no evidence of recurrence for the last 4 years.

Experiencia inicial con una serie de adrenalectomía laparoscópica asistida por robot

ObjectivesWe present our initial experience using robotic-assisted laparoscopic adrenalectomy in the surgical treatment of adrenal masses. Material and methodsA total of 18 patients (11 women and 7 men) diagnosed of a functioning or non-functioning adrenal tumor mass were operated on in our facilities between October 2009 and October 2011. Surgical variables, intra-hospital recovery time, pathological findings and peri- and post-operatory findings were evaluated. ResultsMean age of the population intervened was 51.2 years (range 18-81), average ASA score 2.11 (range 1-4) and BMI 27.0 (range 18.8-36.1). Of the 18 patients, 11 were operated on the left side and 7 on the right. Mean surgery time was 150 (range 84-329) min and intra-operatory bleeding 121 (range 10-1500) ml, with a mean loss of hemoglobin and hematocrits of 2.11g/dl and 6.33%, respectively. Two patients were converted to conventional surgery. The factors influencing surgical conversion were: normal size (>10cm), tumor weight (>100g.), active pheochromocytoma and left localization of the tumor. Seven functioning cortical adenomas, 6 metastatic adrenal tumors, 3 pheochromocytoma and 2 incidental tumors were excised. Mean tumor size was 5.39 (range 3-15) cm. Median hospital stay was 6 days (range 4-14). Five patients had peri-operatory complication. Of these, only one (5%) had major complications (Clavien III). Mean follow-up was 6 months (range 2-24). ConclusionsRobotic technology for laparoscopic adrenalectomies is a valid option for adrenal tumor treatment. In our experience with a relatively short learning curve, it makes it possible to reduce hospital treatment times and the intra- and post-operatory complications, without affecting the oncological and post-operatory functional results.

Single‐Incision Transperitoneal Laparoscopic Left Adrenalectomy

Laparoscopic adrenalectomy via three or four trocars is a well-established procedure. This report describes the initial experience with single-incision laparoscopic surgery (SILS) using the transperitoneal approach for left adrenalectomy. Between April 2010 and August 2011, all consecutive patients with adrenal masses, including Conn's syndrome, Cushing's adenoma, and nonfunctional adrenal tumors, who agreed to undergo SILS adrenalectomy were included in a prospective study. The left 2.5-cm subcostal incision was the sole point of entry. Data of patients who underwent SILS adrenalectomy were compared with those from an uncontrolled group of patients who underwent conventional laparoscopic adrenalectomy during the same study period. There were 20 patients in each study group (20 men, 20 women; mean age [SD]=50 [6.5] years). SILS was successfully performed and none of the patients required conversion to an open procedure. In one case of SILS procedure, an additional lateral 5-mm port was needed for retraction of the kidney. The mean (SD) duration of the operation was 95 (20) min in the SILS group and 80 (8)min in the conventional laparoscopic adrenalectomy group (p=0.052). There were no intraoperative or postoperative complications. There were no differences between the two study groups with respect to postoperative pain, number of patients who resumed oral intake within the first 24h, final pathologic diagnosis, and length of hospital stay. SILS left adrenalectomy is a technically feasible and safe procedure in carefully selected patients. The definitive clinical, aesthetic and functional advantages of this technique require further analysis.

Laparoscopic adrenalectomy for large tumours: Single team experience

BACKGROUND:Laparoscopic adrenalectomy (LA) has become the procedure of choice to treat benign functioning and non-functioning adrenal tumours. With improving experience, large adrenal tumours (> 5 cm) are being successfully tackled by laparoscopy. This study aims to present our single unit experience of LA performed for large adrenal masses.MATERIALS AND METHODS:Forty-six laparoscopic adrenalectomies performed for large adrenal lesions more than 5 cm during the period 2001 to 2010 were reviewed.RESULTS:A total of 46 adrenalectomies were done in 42 patients. The mean tumour size was 7.03 cm (5-15 cm). Fourteen patients had tumour size more than 8 cm. The lesions were localised on the right side in 17 patients and on the left side in 21 patients with bilateral tumours in 4 patients. Functioning tumours were present in 32 of the 46 patients. The average blood loss was 112 ml (range 20–400 ml) with the mean operating time being 144 min (range 45 to 270 min). Five patients required conversion to open procedure. Three of the 46 patients (6.52%) on final histology had malignant tumours.CONCLUSION:LA is safe and feasible for large adrenal lesions. Mere size should not be considered as a contraindication to laparoscopic approach in large adrenal masses. Graded approach, good preoperative assessment, team work and adherence to anatomical and surgical principles are the key to success.

Surgical management of adrenal tumors

Laparoscopic adrenalectomy has become the preferred method for removal of almost all adrenal tumors. An important component in selecting patients for this operation is a thorough understanding of the clinical presentation (mainly hypertension) and diagnostic workup for the full variety of functioning and nonfunctioning adrenal tumors including genetic evaluation when necessary (MEN2, VonHippel-Landau [VHL], type 1 neurofibromatosis [NF1], succinate dehydrogenase mutations [SDH], and MEN1). The indications and contraindications for a laparoscopic approach are discussed with regard to each tumor type. Relevant literature about partial and bilateral adrenalectomy is also summarized. Main areas of controversy are discussed including the size threshold to avoid risk of adrenal capsular effraction and the appropriateness of laparoscopic resection for suspected and known malignancy. This article presents recent data to help the surgeon make well-informed decisions and to optimize the operative approach for a wide variety of adrenal pathologies (secreting vs. non-secreting, benign vs. malignant tumors).