Removal Of Adrenal Gland Research Articles

Glucocorticoids impair T lymphopoiesis after myocardial infarction.

The thymus, where T lymphocytes develop and mature, is sensitive to insults such as tissue ischemia or injury. The insults can cause thymic atrophy and compromise T-cell development, potentially impairing adaptive immunity. The objective of this study was to investigate whether myocardial infarction (MI) induces thymic injury to impair T lymphopoiesis and to uncover the underlying mechanisms. When compared with sham controls, MI mice at day 7 post-MI exhibited smaller thymus, lower cellularity, as well as less thymocytes at different developmental stages, indicative of T-lymphopoiesis impairment following MI. Accordingly, the spleen of MI mice has less T cells and recent thymic emigrants (RTEs), implying that the thymus of MI mice releases fewer mature thymocytes than sham controls. Interestingly, the secretory function of splenic T cells was not affected by MI. Further experiments showed that the reduction of thymocytes in MI mice was due to increased thymocyte apoptosis. Removal of adrenal glands by adrenalectomy (ADX) prevented MI-induced thymic injury and dysfunction, whereas corticosterone supplementation in ADX + MI mice reinduced thymic injury and dysfunction, indicating that glucocorticoids mediate thymic damage triggered by MI. Eosinophils play essential roles in thymic regeneration postirradiation, and eosinophil-deficient mice exhibit impaired thymic recovery after sublethal irradiation. Interestingly, the thymus was fully regenerated in both wild-type and eosinophil-deficient mice at day 14 post-MI, suggesting that eosinophils are not critical for thymus regeneration post-MI. In conclusion, our study demonstrates that MI-induced glucocorticoids trigger thymocyte apoptosis and impair T lymphopoiesis, resulting in less mature thymocyte release to the spleen.NEW & NOTEWORTHY The thymus is essential for maintaining whole body T-cell output. Thymic injury can adversely affect T lymphopoiesis and T-cell immune response. This study demonstrates that MI induces thymocyte apoptosis and compromises T lymphopoiesis, resulting in fewer releases of mature thymocytes to the spleen. This process is mediated by glucocorticoids secreted by adrenal glands. Therefore, targeting glucocorticoids represents a novel approach to attenuate post-MI thymic injury.

The effects of adrenal gland hormones depletion on thermal pain in animal model

The studies have shown that adrenal hormones may exert modulatory effects on pain perception in animals. To investigate the analgesic effects of adrenal gland hormones in response to thermal nociceptive stimulation in rats, the present study evaluated the effects of adrenalectomy on the thermal pain threshold. The rats were divided into control and adrenalectomized female and male groups. Adrenalectomy was achieved using a dorsal midline incision at the level of the first through third lumbar vertebrae and removal of adrenal gland. The tail immersion assay was used for evaluating the analgesic potential of adernalectomy. To measure thermal pain threshold, the end of the tail was placed in a 50°C water bath and the pain threshold was measured as the time required to elicit a flick of the tail. Thermal pain threshold was measured 10 and 30 days after adrenalectomy and compared between adrenalectomized and control intact rats. Thermal pain threshold did not significantly change in male and female rats 10 and 30 days after adrenalectomy compared to control group. These data indicate that depletion of adrenal hormones 10 or 30 days after adrenalectomy does not significantly modulate the pain-induced behavioral responses related to thermal nociception.

Анестезіологічний менеджмент феохромоцитом в умовах спеціалізованого ендокринологічного центру

Мета роботи: упровадження сучасного анестезіологічного менеджменту пацієнтів із фео­хромоцитомою в умовах спеціалізованого ендокринологічного центру із застосуванням алгоритму етапного періопераційного гемодинамічного контролю.Матеріали й методи. Проведена імплементація анестезіологічного менеджменту в 33 жінок із фео­хромоцитомою надниркових залоз при її хірургічному видаленні шляхом відеоасистованої лапароскопічної адреналектомії. Усім пацієнткам застосовувався алгоритм етапного періопераційного гемодинамічного менедженту (ЕПОГМ): передопераційна таблетована гіпотензивна терапія до надходження в стаціонар, передопераційна інфузійна керована гіпотензивна терапія урапідилом та корекція гіповолемії збалансованими кристалоїдними розчинами та 10% розчином гідроксіетилкрохмалю (ГЕК) (200/0,5) на другому етапі, інтраопераційна інфузійна керована гіпотензивна терапія урапідилом на третьому етапі під контролем інвазивного та неінвазівного моніторингу гемодинаміки і профілактика надниркової недостатності та корекція гіповолемії на четвертому етапі.Результати та обговорення. У всіх хворих був відмічений вірогідно (p < 0,001) підвищений рівень метанефринів добової сечі до 1831,6 ± 337,9 мкг/24 год (контроль 169,3 ± 12,7 мкг/24 год). Згідно з розробленим алгоритмом ЕПОГМ на першому етапі застосовували доксазозин 10,0 ± 1,0 мг або урапідил 144,0 ± 11,2 мг у 2 прийоми. На другому етапі виконували гемодилюцію 10% розчином ГЕК (200/0,5) та інфузійну керовану гіпотензивну терапію урапідилом із середньою швидкістю 9,7 ± 1,9 мг/год. На третьому етапі інтраопераційно швидкість інфузії урапідилу становила 1,25 ± 0,08 мг/хв (додатково при хірургічному видаленні надниркової залози з феохромоцитомою болюсно вводився урапідил 25–50 мг в/в при виявленні навіть мінімального підвищення артеріального тиску). На четвертому етапі здійснювалась профілактика надниркової недостатності та гіповолемії.Висновки. Упровадження анестезіологічного менеджменту пацієнтів із феохромоцитомами в спеціалізованому ендокринологічному центрі забезпечило високу ефективність та безпеку при лапароскопічних адреналектоміях під час загальної анестезії та відсутність випадків із летальним кинцем. ЕПОГМ при підготовці до операції та під час хірургічного втручання є ефективним, легко керованим та безпечним методом стабілізації показників гемодинаміки у пацієнтів із феохромоцитомами під час адреналектомії.

Anesthetic Management for Patients With Pheochromocytoma : Series of Three Cases

1.1. Background. This study describes a case series that addresses the complex anesthetic management of adrenalectomy for patients with pheochromocytoma. It is a rare tumor, originating in the chromaffin cells of the adrenal medulla and a catecholamine-secreting agent, whose most common triad of symptoms is headache, sweating and tachycardia. 1.2. Cases: The first case corresponds to a 47-year-old woman with a history of three acute myocardial infarctions with a lesion located unilaterally in the left adrenal gland. After adrenal removal and due to persistence of hypertension, it was necessary to perform a left nephrectomy. The second case describes the conduction of a multimodal and opioid-free anesthesia of a 26-year-old female patient with dilated cardiomyopathy who underwent video laparoscopic right adrenalectomy The first report involves the case of a 14-year-old male patient with von Hippel-Lindau Syndrome, who underwent bilateral open adrenalectomy. All three cases were successfully preoperatively prepared and operated on and were discharged home between the 5th and 6th day compensated and without physiological changes. No genetic study of the three patients was performed. Continuous epidural anesthesia was performed in two patients, without hypotension and need for vasopressor. 1.3. Conclusion: In this pathology, it is essential to emphasize the extreme importance of the multidisciplinary approaches carried out in the three cases. We can affirm affirm that the favorable outcomes were only possible thanks to a great joint effort and judicious for monitoring the Endocrinology and Pediatrics services and for the coordinated relationship between the anesthetic and surgical teams, which were essential for obtaining hospital discharge in the first six days after surgery

Glucocorticoids reset circadian clock in choroid plexus via period genes.

The epithelial cells of choroid plexus (CP) in brain ventricles produce cerebrospinal fluid and act as the blood-cerebrospinal fluid barrier. In this study, we confirmed that CP in the 4th ventricle is composed of cellular oscillators that all harbor glucocorticoid receptors and are mutually synchronized to produce a robust clock gene expression rhythm detectable at the tissue level in vivo and in vitro. Animals lacking glucocorticoids (GCs) due to surgical removal of adrenal glands had Per1, Per2, Nr1d1 and Bmal1 clock gene rhythmicity in their CP significantly dampened, whereas subjecting them to daily bouts of synthetic GC analog, dexamethasone (DEX), reinforced those rhythms. We verified these in vivo effects using an in vitro model of organotypic CP explants; depending on the time of its application, DEX significantly increased the amplitude and efficiently reset the phase of the CP clock. The results are the first description of a PRC for a non-neuronal clock in the brain, demonstrating that CP clock shares some properties with the non-neuronal clocks elsewhere in the body. Finally, we found that DEX exhibited multiple synergic effects on the CP clock, including acute activation of Per1 expression and change of PER2 protein turnover rate. The DEX-induced shifts of the CP clock were partially mediated via PKA-ERK1/2 pathway. The results provide the first evidence that the GC rhythm strengthens and entrains the clock in the CP helping thus fine-tune the brain environment according to time of day.

PD49-08 HYPERTENSION AND CARDIOVASCULAR MORBIDITY FOLLOWING RADICAL NEPHRECTOMY ARE ONLY SUSTAINED BY RENAL PARENCHYMA LOSS AND CARDIOVASCULAR MORBIDITY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy V (PD49)1 Apr 2020PD49-08 HYPERTENSION AND CARDIOVASCULAR MORBIDITY FOLLOWING RADICAL NEPHRECTOMY ARE ONLY SUSTAINED BY RENAL PARENCHYMA LOSS AND CARDIOVASCULAR MORBIDITY Alessandro Nini*, Chiara Re, Fabio Muttin, Alberto Martini, Giuseppe Rosiello, Villa Luca, Francesco Trevisani, Daniela Canibus, Francesco Montorsi, Andrea Salonia, Alberto Briganti, Roberto Bertini, Alessandro Larcher, and Umberto Capitanio Alessandro Nini*Alessandro Nini* More articles by this author , Chiara ReChiara Re More articles by this author , Fabio MuttinFabio Muttin More articles by this author , Alberto MartiniAlberto Martini More articles by this author , Giuseppe RosielloGiuseppe Rosiello More articles by this author , Villa LucaVilla Luca More articles by this author , Francesco TrevisaniFrancesco Trevisani More articles by this author , Daniela CanibusDaniela Canibus More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , Andrea SaloniaAndrea Salonia More articles by this author , Alberto BrigantiAlberto Briganti More articles by this author , Roberto BertiniRoberto Bertini More articles by this author , Alessandro LarcherAlessandro Larcher More articles by this author , and Umberto CapitanioUmberto Capitanio More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000943.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In patients with no history of preoperative hypertension or major cardiovascular event, the onset of hypertension after radical nephrectomy (RN) is an early event, due probably to the acute loss of renal parenchyma and cardiovascular modifications. The aim of the present study was to test if the removal of adrenal gland during RN, together with acute loss of renal parenchyma, is associated with higher risk of hypertension or major cardiovascular events. METHODS: Within a single institution database, we identified 1,783 patients treated with RN for renal tumour from a prospectively collected database of 3,645 patients between 1990 and 2019. Exclusion criteria were represented by single kidney, metachronous and synchronous kidney tumours. Descriptive statistics were used to report patients´ characteristics. Frequencies and proportions were used for categorical variables. Means, medians, and interquartile ranges (IQR) were used for continuously coded variables. Cox-regression models were used to predict hypertension or major cardiovascular events at follow-up. RESULTS: Median age resulted 62 years (Interquartile range 53-71 years). Overall, 62% underwent RN with adrenalectomy. Preoperative, 44% (199) of patients presented with hypertension, 11% (139) with diabetes, 8% (139) with acute myocardial infarction, 1.9% (33) with heart failure and 3.5% (60) with nephropathy. At discharge, the serum creatinine was over the cut-off in 41% of female patients (1.1 mg/dl) and 77% of male patients (1.2 mg/dl). At a median follow-up of 3 years, 7% (125/1783) of patients had hypertension or major cardiovascular events, one-fourth (31/125) before discharge. At Cox-regression models, predictors of hypertension or major cardiovascular events at follow-up, were age (HR 1.01, CI95% 1.02-1.06, p-value <0.001), nephropathy (HR 2.8, CI95% 1.4-5.6, p-value=0.003) and acute myocardial infarction (HR 1.9, CI95% 1.1-3.2, p=0.01). The removal of adrenal gland was not associated with an increased risk of hypertension or major cardiovascular events at follow-up (p>0.05). CONCLUSIONS: In patients undergoing RN, the risk of hypertension or major cardiovascular events is predicted by presence of nephropathy, heart failure or history of myocardial infarction, but not by the removal of adrenal gland at surgery. The first observation underlines the role of renal parenchyma loss and cardiovascular abnormalities in exposing patients to higher risk of hypertension or major cardiovascular events. The latter may be explained by compensation mechanism of the contralateral adrenal gland. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1003-e1004 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alessandro Nini* More articles by this author Chiara Re More articles by this author Fabio Muttin More articles by this author Alberto Martini More articles by this author Giuseppe Rosiello More articles by this author Villa Luca More articles by this author Francesco Trevisani More articles by this author Daniela Canibus More articles by this author Francesco Montorsi More articles by this author Andrea Salonia More articles by this author Alberto Briganti More articles by this author Roberto Bertini More articles by this author Alessandro Larcher More articles by this author Umberto Capitanio More articles by this author Expand All Advertisement PDF downloadLoading ...

Infradian Rhythms of Resistance to a Dissociative Anesthetic in Wistar Male Rats under Normal Conditions and After Surgical Removal of the Adrenal Glands and Testes.

Daily dynamics of changes in the latency of a response to dissociative anesthetic tiletamine (time from injection to ataxia) was studied in mature Wistar rats. Both intramuscular and intravenous administration of the anesthetic was associated with 4-day oscillations of the latent period synchronous with the dynamics of changes in the concentration of glucocorticoid hormones. The period and phases of the infradian rhythm of resistance to the anesthetic remained unchanged after removal of both adrenal glands and testes and administration of corticosterone synthesis blocker trilostane diminishing the 4-day cycle of changes in corticosterone level. Therefore, hormones of the adrenal glands and testes do not play the key role in the mechanisms of formation of the 4-day infradian rhythm.

Acute intermittent hypoxia in rats activates muscle proteolytic pathways through a gluccorticoid-dependent mechanism.

Although it is well known that chronic hypoxia induces muscle wasting, the effects of intermittent hypoxia on skeletal muscle protein metabolism remain unclear. We hypothesized that acute intermittent hypoxia (AIH), a challenge that activates the hypothalamic-pituitary-adrenal axis, would alter muscle protein homeostasis through a glucocorticoid-dependent mechanism. Three-week-old rats were submitted to adrenalectomy (ADX) and exposed to 8 h of AIH (6% O2 for 40 s at 9-min intervals). Animals were euthanized, and the soleus and extensor digitorum longus (EDL) muscles were harvested and incubated in vitro for measurements of protein turnover. AIH increased plasma levels of corticosterone and induced insulin resistance as estimated by the insulin tolerance test and lower rates of muscle glucose oxidation and the HOMA index. In both soleus and EDL muscles, rates of overall proteolysis increased after AIH. This rise was accompanied by an increased proteolytic activities of the ubiquitin(Ub)-proteasome system (UPS) and lysosomal and Ca2+-dependent pathways. Furthermore, AIH increased Ub-protein conjugates and gene expression of atrogin-1 and MuRF-1, two key Ub-protein ligases involved in muscle atrophy. In parallel, AIH increased the mRNA expression of the autophagy-related genes LC3b and GABARAPl1. In vitro rates of protein synthesis in skeletal muscles did not differ between AIH and control rats. ADX completely blocked the insulin resistance in hypoxic rats and the AIH-induced activation of proteolytic pathways and atrogene expression in both soleus and EDL muscles. These results demonstrate that AIH induces insulin resistance in association with activation of the UPS, the autophagic-lysosomal process, and Ca2+-dependent proteolysis through a glucocorticoid-dependent mechanism.NEW & NOTEWORTHY Since hypoxia is a condition in which the body is deprived of adequate oxygen supply and muscle wasting is induced, the present work provides evidence linking hypoxia to proteolysis through a glucocorticoid-dependent mechanism. We show that the activation of proteolytic pathways, atrophy-related genes, and insulin resistance in rats exposed to acute intermittent hypoxia was abolished by surgical removal of adrenal gland. This finding will be helpful for understanding of the muscle wasting in hypoxemic conditions.

Evaluating the learning curve for retroperitoneoscopic adrenalectomy in a high-volume center for laparoscopic adrenal surgery

BackgroundLaparoscopic adrenalectomy is an effective method for benign adrenal tumor removal. In the literature, both lateral transperitoneal (TLA) and posterior retroperitoneoscopic (RPA) approaches are described. Since 2007, the number of patients increased significantly in our center. Therefore, RPA was introduced in 2011 because of its potential advantages in operating and recovery times. The learning curve of RPA is now evaluated.MethodsAll data of patients undergoing laparoscopic adrenalectomy from 2007 until 2014 were prospectively collected. Patients were eligible for RPA with a tumor <7 cm, with BMI < 35 kg/m2, and with low suspicion of malignancy. The learning curve of RPA was measured by operating time. Furthermore, blood loss, preoperative complications and hospital stay were analyzed. Descriptive statistics were performed using SPSS 20.0.ResultsIn the study period, 290 patients underwent surgery, of whom 113 underwent RPA. After starting with RPA, operating times decreased significantly (median 100 min in the first 20 patients to 60 min after 40 patients, p < 0.05). There was a significant difference in operating times (median 108 vs. 62 min, p < 0.05) and hospital stay (median 4 vs. 3 days, p < 0.05) in unilateral surgery in favor of RPA, compared to TLA. Also in bilateral surgery, operating times were significantly shorter (median 236 vs. 117 min, p < 0.05). In both groups, few major complications occurred.ConclusionAfter the introduction of RPA, a short learning curve was seen for a single surgeon with extensive experience in laparoscopic adrenal surgery. Compared to TLA, RPA has significant advantages in operating times and hospital stay. Therefore, RPA may be the preferred approach for patients with BMI < 35 kg/m2 and small benign adrenal tumors (<7 cm).

Endogenous glucocorticoids exacerbate cholestasis-associated liver injury and hypercholesterolemia in mice

Cholestatic liver disease is characterized by a disruption of bile flow, bile acid toxicity, liver injury, and hypercholesterolemia. Relatively high secretion of glucocorticoids by the adrenals has been observed under cholestatic conditions. Here we investigated a contribution of the rise in endogenous glucocorticoids to initial stage cholestasis pathology. Adrenalectomized or sham-operated control C57BL/6 mice were given an oral dose of alpha-naphthylisothiocyanate to induce cholestasis. Adrenalectomy effectively lowered plasma corticosterone levels (18±5ng/ml vs 472±58ng/ml; P<0.001) and disrupted the metabolic and anti-inflammatory glucocorticoid function. Adrenal removal did not exacerbate the cholestasis extent. In contrast, the cholestasis-associated liver injury was markedly lower in adrenalectomized mice as compared to controls as evidenced by a 84%–93% decrease in liver necrosis and plasma alanine aminotransferase and bile acid levels (P<0.001 for all). Gene expression analysis on livers from adrenalectomized mice suggested the absence of bile acid toxicity-associated farnesoid X receptor signaling in the context of a 44% (P<0.01) and 82% (P<0.001) reduction in sodium/bile acid cotransporter member 1 transcript level as compared to respectively control and non-diseased mice. Adrenalectomy reduced the expression of the cholesterol synthesis gene HMG-CoA reductase by 70% (P<0.05), which translated into a 73% lower plasma total cholesterol level (P<0.05). Treatment of C57BL/6 mice with the glucocorticoid receptor antagonist RU-486 recapitulated the protective effect of adrenalectomy on indices of liver injury and hypercholesterolemia.In conclusion, we have shown that endogenous glucocorticoids exacerbate the liver injury and hypercholesterolemia associated with acute cholestasis in mice.

Hippocampal Neuroinflammation, Neurodegeneration, Gliosis in Wistar rats Following Adrenal Gland Removal.

Hippocampal Neuroinflammation, Neurodegeneration, Gliosis in Wistar rats Following Adrenal Gland Removal.

The adrenal medulla, not CB1 receptors, mediates the inhibitory effect of acute transverse aortic constriction on the neurogenic vasopressor response.

Abstract Aims This study was performed to examine whether acute pressure overload induced by transverse aortic constriction (TAC) inhibits the neurogenic vasopressor response and, if so, to check the role of cannabinoid CB 1 receptors and/or other mechanisms. Main methods TAC or a sham operation was performed in pithed and vagotomised rats; sham-operated rats were infused with vasopressin to ensure a basal systolic blood pressure (SBP) comparable to that of TAC animals. SBP was increased by 40 mm Hg by electrical stimulation of the preganglionic sympathetic nerve fibres or phenylephrine injection. At the end of the experiments, the atria and aorta were isolated. Key findings TAC reduced the electrically (but not the chemically) induced pressor response by 80%; sham operation plus vasopressin had no effect. While the cannabinoid receptor agonist CP55940 and antagonists of CB 1 receptors (AM251), α 2 -adrenoceptors (rauwolscine) and K ATP channels (glibenclamide) did not modify the inhibitory effect of TAC, adrenal medulla removal did prevent this effect. The contractile effects of noradrenaline and isoprenaline were reduced (isolated left atria), whereas their chronotropic effects (right atria) were not affected by TAC, which also spared the vasoconstrictor responses to phenylephrine (isolated aorta). Significance Acute pressure overload induced by TAC reduces the neurogenic vasopressor response via an unknown presynaptic mechanism, an increase in heart rate induced by catecholamines released from the adrenal medulla and a decrease in the catecholamine-induced heart contractility. A better understanding of the negative consequences induced by the acute pressure overload may help in the design of future heart failure therapies.

Indications for adrenalectomy during radical nephrectomy for renal cancer

ObjectivesTo determine if the selection criteria for ipsilateral adrenalectomy during laparoscopic radical nephrectomy (RN) can be further restricted, with the goal of sparing more patients unnecessary adrenalectomy while preserving the removal of adrenal glands containing malignancy, as recent evidence suggests that adrenalectomy in association with RN for renal cancer can be limited to patients with abnormalities on adrenal imaging or large upper-pole renal tumours. Patients and methodsThe cohort consisted of two data sets, each from one institution, i.e., a training set and a validation set. All patients underwent RN for radiographically localised disease. Removal of the adrenal gland was based on the surgeon’s preference, related to the presence of a suspect adrenal lesion on preoperative imaging, suspicion for involvement of the adrenal gland intraoperatively, location of the tumour, size of the tumour and local tumour stage. ResultsOf 159 patients in the training cohort, three (2%) had metastatic renal cancer in the ipsilateral adrenal gland. All three patients had tumours of >7cm and either an abnormal radiographic appearance of the adrenal gland or suspect intraoperative findings. In the validation cohort of 74 patients, seven (10%) had adrenal metastasis, of which one had a tumour of <7cm and the indication for adrenalectomy was the high intraoperative suspicion. ConclusionWe recommend performing ipsilateral adrenalectomy in association with RN for renal cancer when there is either abnormal radiographic appearance of the adrenal gland or suspect intraoperative findings, with no regard for primary tumour size.

The adrenal psoas sign: surgical outcomes following a simple technique to maximize removal of extracortical adrenal tissue during bilateral laparoscopic adrenalectomy.

Bilateral laparoscopic adrenalectomy (BLA) is an effective therapy for the management of persistent hypercortisolism in patients after failed transphenoidal pituitary tumor resection for Cushing's disease. Extracortical adrenal tissue has been identified as a source of persistent hypercortisolism and, if not resected along with both adrenal glands, may lead to treatment failure. We report a reliable and reproducible technique called the "psoas sign" for BLA in patients with Cushing's disease which reduces the likelihood of retained extra-adrenal cortical rests and may reduce intraoperative complications. A 16-year retrospective review of all consecutive patients who underwent transabdominal BLA at a single tertiary care center was performed. All patients underwent BLA utilizing the psoas sign technique and all procedures were performed replicating these predetermined surgical steps: (1) Identification of the inferior pole of the gland. (2) Identification of the inferior aspect of the adreno-caval groove on the right or the adrenal vein/renal vein confluence on the left. (3) Division of the adrenal vein. (4) Dissection and removal of the adrenal gland with clearance of all retroperitoneal fat overlying the psoas muscle. Between October 1996 and December 2012, 92 patients underwent BLA for refractory Cushing's disease. Patients were predominantly female (90%) with a median age of 40years (17-71). There were 3 intraoperative complications (3.2%), 2 conversions (2.2%), and 1 death (1.09%). Four patients were identified as having extracortical rests of adrenal tissue within the retroperitoneal fat (4.3%). Mean operative time was 272min (±79.25, n=68) and median estimated blood loss was 50mL (10-800mL). The psoas sign technique provides a clear view of the adrenal fossa and facilitates careful dissection of the anatomic planes around the adrenal gland. This technique is feasible, reproducible and in our experience allows for safe removal of both adrenal glands and all surrounding extracortical adrenal tissue.

Leksell Gamma Knife : An Effective Non Invasive Treatment for Rare Case of Nelson’s Syndrome

Nelson’s syndrome nowadays a rare entity results from an adrenocorticotropin (ACTH)–secreting pituitary adenoma in patients with refractory Cushing's disease after a therapeutic bilateral adrenal gland removal. We report a case of 25 year old female with cushing’s disease who was initially managed with medical treatment, but in view of severe persistent hyper cortisol state was subjected to bilateral adrenalectomy following which she developed Nelson’s syndrome after a gap of six years, which was difficult to diagnose because of limited investigations available. Patient was managed with stereotactic radiosurgery (gamma knife surgery).

Ipsilateral adrenalectomy at the time of radical nephrectomy impacts overall survival

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Adrenal-sparing approaches should be utilized when performing radical nephrectomy unless there are specific concerns for adrenal involvement. Although current literature demonstrates 10-year cancer control equivalence with adrenal-sparing approaches, such approaches remain under-used. Furthermore, we have yet to clearly define the long-term consequences of an iatrogenic solitary adrenal gland on overall patient health. In our study, we demonstrate worse overall survival in patients undergoing ipsilateral adrenalectomy with radical nephrectomy for renal cell carcinoma. We provide some of the only data demonstrating an association between adrenalectomy and long-term survival, and further emphasize the importance of adrenal-sparing approaches when performing radical nephrectomy. To assess the impact of ipsilateral adrenalectomy on overall survival, we performed a population-level analysis. Ipsilateral adrenal-gland-sparing approaches during radical nephrectomy (RN) remain under-utilized and the long-term consequences of an iatrogenic solitary adrenal gland are poorly understood. Using the Ontario Cancer Registry we identified 1651 patients in the province of Ontario, Canada, with pT1a renal cell carcinoma who underwent RN between 1995 and 2004. We linked individual patient information with pathological data from abstracted pathology reports and determined whether the ipsilateral adrenal gland was removed at the time of RN. We utilized univariable and multivariable (adjusting for age, gender, tumour size and tumour grade) Cox proportional hazard models and Kaplan-Meier curves to assess predictors of overall and cancer-specific survival. The overall rate of ipsilateral adrenalectomy at the time of RN was 30%. Median follow-up for the cohort was 109 months. Adrenal removal was associated with worse overall survival: 10-year mortality 26% compared with 20% for those in whom the adrenal gland was left in situ. Factors predictive of worse overall survival on multivariable analysis were increasing age (hazard ratio [HR] 1.07 per year, CI 1.06-1.08), high grade tumours (HR 1.38, 1.00-1.90) and having undergone ipsilateral adrenalectomy (HR 1.23, 1.00-1.50). Ipsilateral adrenalectomy was not predictive of cancer-specific survival (HR 1.18, 0.78-1.79). We demonstrated a significant association between ipsilateral adrenalectomy and overall survival. Our findings further support the importance of adrenal-sparing approaches at the time of RN.

52 DOES IPSILATERAL ADRENALECTOMY AT THE TIME OF RADICAL NEPHRECTOMY IMPACT OVERALL SURVIVAL?

You have accessJournal of UrologyAdrenal: Surgery + Tumors/Benign and Malignant Disease (Physiology and Pharmacology)1 Apr 201252 DOES IPSILATERAL ADRENALECTOMY AT THE TIME OF RADICAL NEPHRECTOMY IMPACT OVERALL SURVIVAL? Stanley Yap, Shabbir Alibhai, Robert Abouassaly, Narhari Timilshina, David Margel, and Antonio Finelli Stanley YapStanley Yap Toronto, Canada More articles by this author , Shabbir AlibhaiShabbir Alibhai Toronto, Canada More articles by this author , Robert AbouassalyRobert Abouassaly Cleveland, OH More articles by this author , Narhari TimilshinaNarhari Timilshina Toronto, Canada More articles by this author , David MargelDavid Margel Toronto, Canada More articles by this author , and Antonio FinelliAntonio Finelli Toronto, Canada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.096AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Despite current evidence supporting ipsilateral adrenal gland-sparing approaches during radical nephrectomy (RN), such practices remain underutilized. The long-term consequences of an iatrogenic solitary adrenal gland are poorly understood. We performed a population-level analysis to assess the impact of ipsilateral adrenalectomy on overall survival. METHODS Using the Ontario Cancer Registry (OCR), we identified 1,651 patients in the province of Ontario, Canada undergoing RN for T1a renal tumors between 1995 and 2004. We linked individual patient information with pathologic data from abstracted pathology reports and determined whether the ipsilateral adrenal gland was removed at the time of RN. We also determined overall and cancer-specific survival in this cohort. Further variables analyzed include age, gender, tumor size, and tumor grade. We utilized univariable and multivariable Cox proportional hazards models and Kaplan-Meier curves to assess predictors of overall and cancer-specific survival. RESULTS The overall rate of ipsilateral adrenalectomy at the time of RN was 30%. Median follow-up for the cohort was 9.1 years. Adrenal removal was associated with worse overall survival with 10-year mortality of 26%, compared to 20% for those in which the adrenal gland was left in situ. Factors predictive of worse overall survival on multivariable analysis were advanced age â€′′ 70 to 79 years-old (hazard ratio (HR) 9.38, CI 5.89-14.94), high-grade tumors (HR 1.43, 1.04-1.97), and having undergone ipsilateral adrenalectomy (HR 1.23, 1.00-1.50). Ipsilateral adrenalectomy was not predictive of cancer-specific survival (HR 1.18, 0.78-1.79). CONCLUSIONS We demonstrate a significant association between performing ipsilateral adrenalectomy and overall survival. Our findings further support the importance of adrenal-sparing approaches at the time of RN. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e22 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Stanley Yap Toronto, Canada More articles by this author Shabbir Alibhai Toronto, Canada More articles by this author Robert Abouassaly Cleveland, OH More articles by this author Narhari Timilshina Toronto, Canada More articles by this author David Margel Toronto, Canada More articles by this author Antonio Finelli Toronto, Canada More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Effective Therapy of Insulinoma by Using Long-Acting Somatostatin Analogue. A Case Report and Literature Review

We are reporting a case of 68-year-old woman with insulinoma, after a non-successful tumor surgery and a long-term diazoxide treatment. She had a lot of hypoglycemia cases, and a weight gain of 50 kg. An abdominal CT scan demonstrated a tumor 28 mm in the diameter, in the head of the pancreas. The patient did not agree for the repeated insulinoma surgery. Furthermore, we found a lesion in the left adrenal gland (14 mm in the diameter) and in the right lung (8 mm in the diameter). Pheochromocytoma was diagnosed on the basis of hypertension, elevated levels of normetanephrine in the 24-h urine collection, and an elevated level of norepinephrine in a plasma sample. After the left adrenal gland removal we observed lower blood pressure. Since we had revealed the presence of somatostatin receptors by the somatostatin receptors scintigraphy, we decided to control hypoglycemia by a monthly subcutaneous administration of the long-acting lanreotide. Because of higher glucose levels (300-400 mg/dl) we started an intense insulin therapy. Nowadays, the patient feels better, she has lost 20 kg of her body weight, and we have observed normal blood glucose levels during the long-term lanreotide treatment. We have noticed neither side effects nor hypoglycemic episodes and we have reduced the dose of insulin. The presented case can be an evidence of the effective treatment of the pancreatic neuroendocrine tumor of insulinoma type, with somatostatin analogue.

Do We Continue to Unnecessarily Perform Ipsilateral Adrenalectomy at the Time of Radical Nephrectomy? A Population Based Study

Since the mid 1990s evidence has supported ipsilateral adrenal gland sparing radical nephrectomy unless the gland appears involved on imaging or the primary tumor is large and located in the upper pole. However, it is unclear whether this shift in surgical practice has been adopted at the population level. Using the Ontario Cancer Registry we identified 5,135 patients in the province of Ontario who underwent radical nephrectomy between 1995 and 2004. Ipsilateral adrenalectomy and tumor involvement of the adrenal gland were ascertained from pathology reports. Further variables analyzed included age, gender, pathology, surgeon year of graduation, academic status of hospital/surgeon, hospital and surgeon volume, and year of surgery. We used multivariable logistic regression to assess outcomes. The overall rate of adrenal gland involvement with cancer was 1.4%. The adrenal was involved in 3.2% of tumors larger than 7 cm vs only 0.89% of tumors 4 to 7 cm and 0.63% of tumors smaller than 4 cm. Factors predictive of adrenal involvement on multivariable analysis were tumor size greater than 7 cm and fat invasion. The overall adrenalectomy rate was 40.1%, which decreased slightly over time (40.6% in 1995 vs 34.8% in 2004). Variables predictive of adrenal removal on multivariable analysis included tumor size greater than 7 cm, presence of venous thrombus, upper pole location, higher hospital volume, and academic status of hospital or surgeon. Despite evidence to support preservation of the ipsilateral adrenal gland during radical nephrectomy, the rate of adrenalectomy decreased only slightly in 10 years. Adrenalectomy remains overused in populations that are unlikely to benefit from the procedure.

Single-port endoscopic retroperitoneal adrenalectomy: initial experience

Over the last decade, laparoendoscopic adrenalectomy has become the standard of care for adrenal removal. Elimination of a large incision and difficult exposure has decreased postoperative morbidity and length of stay. Single port access (SPA) surgery was developed as an alternative to traditional multi-port laparoscopy, potentially exploiting the already proven benefits of minimally invasive surgery. We applied the SPA technique to adrenalectomy using the posterior retroperitoneal approach. Between January 2010 and July 2010, a 52-year-old female with Conn’s adenoma and two females, aged 31 and 39, both diagnosed with pheochromocytoma, underwent single port endoscopic retroperitoneal adrenalectomies. Procedures were performed using two different commercially available specific access devices and conventional laparoscopic equipment. No conversions to open or conventional retroperitoneal approach were necessary. No perioperative or postoperative complications occurred. Operating time ranged from 120 min to 240 min. All patients were discharged from the hospital 2 days after surgery. The single port access technique has been successfully applied to adrenalectomy as an available alternative to multiport laparoendoscopic adrenalectomy. Exposure, visualization, and dissection are the same as in retroperitoneal endoscopic adrenalectomy. Single port access surgery offers the patient benefits such as faster convalescence, decreased postoperative scarring and better cosmetic effect.