Retroperitoneoscopic Adrenalectomy Research Articles

A novel method of tunneling retroperitoneoscopic adrenalectomy: a prospective study.

To introduce the surgical technique and our team's extensive experience with tunnel method in laparoscopic adrenalectomy. From July 2019 to June 2022, we independently designed and conducted 83 cases of " Tunnel Method Laparoscopic Adrenalectomy," a prospective study. There were 45 male and 38 female patients, ages ranged from 25 to 73 years(mean: 44.6 years).The cases included 59 adrenal cortical adenomas, 9 pheochromocytomas, 6 cysts, 4 myelolipomas, 1 ganglioneuroma, and 4 cases of adrenal cortical hyperplasia. In terms of anatomical location, there were 39 cases on the left side, 42 on the right side, and 2 bilateral cases. Tumor diameters ranged from 0.6 to 5.9cm(mean: 2.9cm). Utilizing ultrasound monitoring, percutaneous puncture was made either directly to the target organ or its vicinity, and the puncture path was manually marked. Then, under the direct view of a single-port single-channel laparoscope, the path to the target organ in the retroperitoneum or its vicinity was further delineated and separated. This approach allowed for the insertion of the laparoscope and surgical instruments through the affected adrenal gland, thereby separating the surface of the target organ to create sufficient operational space for the adrenalectomy. All 83 surgeries were successfully completed. A breakdown of the surgical approach reveals that 51 surgeries were done using one puncture hole, 25 with two puncture holes, and 7 with three puncture holes. The operation time ranged from 31 to 105min (mean: 47min), with a blood loss of 10 to 220mL (mean: 40 mL). Notably, there were no conversions to open surgery and no intraoperative complications. Postoperative follow-up ranged from 6 to 28 months, during which after re-examination using ultrasound, CT, and other imaging methods, there were no recurrences or other complications detected. The completion of the tunnel method laparoscopic adrenalectomy represents a breakthrough, transitioning from the traditional step-by-step separation of retroperitoneal tissues to reach the target organ in conventional retroperitoneoscopic surgery. This method directly accesses the target organ, substantially reducing the damage and complications associated with tissue separation in retroperitoneoscopic surgery, As a result, it provides a new option for minimally invasive surgery of retroperitoneal organs and introduces innovative concepts to retroperitoneoscopic surgery.

A prospective case series to evaluate subcostal nerve injury with high-resolution ultrasound in posterior retroperitoneoscopic adrenalectomy

Abstract Background Posterior retroperitoneoscopic adrenalectomy has several advantages over transabdominal laparoscopic adrenalectomy regarding operating time, blood loss, postoperative pain, and recovery. However, postoperatively several patients report chronic pain or hypoesthesia. We hypothesized that these symptoms may be the result of damage to the subcostal nerve, because it passes the surgical area. Methods A prospective single-center case series was performed in adult patients without preoperative pain or numbness of the abdominal wall who underwent unilateral posterior retroperitoneoscopic adrenalectomy. Patients received pre- and postoperative questionnaires and a high-resolution ultrasound scan of the subcostal nerve and abdominal wall muscles was performed before and directly after surgery. Clinical evaluation at 6 weeks was performed with repeat questionnaires, physical examination, and high-resolution ultrasound. Long-term recovery was evaluated with questionnaires, and photographs from the patients were examined for abdominal wall asymmetry. Results A total of 25 patients were included in the study. There were no surgical complications. Preoperative visualization of the subcostal nerve was possible in all patients. At 6 weeks, ultrasound showed nerve damage in 15 patients, with no significant association between nerve damage and postsurgical pain. However, there was a significant association between nerve damage and hypoesthesia (p = 0.01), sensory (p < 0.001), and motor (p < 0.001) dysfunction on physical examination. After a median follow-up of 18 months, 5 patients still experienced either numbness or muscle weakness, and one patient experienced chronic postsurgical pain. Conclusion In this exporatory case series the incidence of postoperative damage to the subcostal nerve, both clinically and radiologically, was 60% after posterior retroperitoneoscopic adrenalectomy. There was no association with pain, and the spontaneous recovery rate was high. Graphical Abstract

Adrenal fast-track and enhanced recovery in retroperitoneoscopic surgery for primary aldosteronism improving patient outcome and efficiency

PurposeNo data exist on perioperative strategies for enhancing recovery after posterior retroperitoneoscopic adrenalectomy (PRA). Our objective was to determine whether a multimodality adrenal fast-track and enhanced recovery (AFTER) protocol for PRA can reduce recovery time, improve patient satisfaction and maintain safety.MethodsThirty primary aldosteronism patients were included. Fifteen patients were treated with ‘standard-of-care’ PRA and compared with 15 in the AFTER protocol. The AFTER protocol contains: a preoperative information video, postoperative oral analgesics, early postoperative mobilisation and enteral feeding, and blood pressure monitoring at home. The primary outcome was recovery time. Secondary outcomes were length of hospital stay, postoperative pain and analgesics requirements, patient satisfaction, perioperative complications and quality of life (QoL).ResultsRecovery time was much shorter in both groups than anticipated and was not significantly different (median 28 days). Postoperative length of hospital stay was significantly reduced in AFTER patients (mean 32 vs 42 h, CI 95%, p = 0.004). No significant differences were seen in pain, but less analgesics were used in the AFTER group. Satisfaction improved amongst AFTER patients for time of admission and postoperative visit to the outpatient clinic. There were no significant differences in complication rates or QoL.ConclusionDespite no difference in recovery time between the two groups, probably due to small sample size, the AFTER protocol led to shorter hospital stays and less analgesic use after surgery, whilst maintaining and even enhancing patient satisfaction for several aspects of perioperative care. Complication rates and QoL are comparable to standard-of-care.

Exploring the Benefits of a Reduced-Port Approach in Robotic Posterior Retroperitoneoscopic Adrenalectomy: A Comparative Study of the Two-Port and Three-Port Techniques.

Background: Robotic adrenalectomy has become a surgical treatment option for benign and selected malignant adrenal diseases. We aimed to evaluate the eligibility of two-port robotic posterior retroperitoneoscopic adrenalectomy (PRA) as an alternative to the conventional three-port technique by comparing their surgical outcomes. Materials and Methods: This retrospective cohort study compared the clinicopathological factors and surgical outcomes among 197 patients who underwent two-port or three-port robotic adrenalectomy between 2016 and 2020 in a single tertiary center. For further evaluation, propensity score matching was performed to reduce the selection bias in population characteristics. Results: Patients were categorized by the number of ports (two-port group, 87; and three-port group, 110). The two-port group compared with the three-port group was significantly older (P = .006) and had a smaller mean tumor size (P = .003) and shorter mean operation time (P = .001). Upon comparing clinicopathologic characteristics according to adrenal disorders, for pheochromocytoma, the three-port group had a larger tumor size and a longer operation time. For Cushing's syndrome, the operation time was short and numeric rating scale pain score was significantly low in the two-port group. After propensity score matching, the two-port group had a short operation time and a significantly low postoperative pain score (P < .05). Predictive factors associated with prolonged operation time included male gender, an increased number of ports, and large tumor size. Conclusions: The two-port technique resulted in a shorter operation time and lower pain score compared with the three-port technique. The two-port technique may be a safe alternative to the conventional three-port technique for robotic PRA.

Single-Plane Retroperitoneoscopic Adrenalectomy Guided by Indocyanine Green Dye: An Optimized Step.

Background: The objective of this study was to explore the perioperative outcomes of single-plane posterior retroperitoneoscopic adrenalectomy (SPRA) guided by indocyanine green dye (ICG) fluorescence imaging. Methods: A retrospective analysis of patients who underwent SPRA from April to September 2023 in our center was conducted. Patients were divided into the ICG group and the non-ICG group, based on whether they received intraoperative ICG fluorescence guided or not. Baseline and perioperative data were recorded and analyzed by R software (R 4.3.1). Results: A total of 23 patients were enrolled in the study, with 12 in the ICG group and 11 in the non-ICG group. The demographics including age, gender, body mass index, or American Society of Anesthesiologists classification showed no significant differences between groups. There were obvious advantages in shortening adrenal gland localization time and total operative time, as well as reducing estimated blood loss in the ICG group compared with the non-ICG group (5.58 ± 0.36 minutes vs 7.55 ± 0.62 minutes, p < 0.001; 27.50 ± 5.46 minutes vs 45.00 ± 10.99 minutes, p < 0.001; 22.91 ± 7.57 mL vs 54.54 ± 18.90 mL, p < 0.001; respectively). Furthermore, patients in the ICG group exhibited significantly lower visual analog pain scale scores at 24 hours postoperatively and at discharge (p = 0.001 and p = 0.006, respectively). The oral intake intervals, hospital stays, and perioperative complications were comparable between groups. Conclusions: ICG-guided SPRA could be a safe and effective procedure for patients with adrenal tumors. This technique improves the accuracy and efficacy of adrenal gland localization and has shown benefits in perioperative outcomes. The use of ICG fluorescence guidance represents a promising clinical application.

SAT335 Bilateral Pheochromocytomas In Multiple Endocrine Neoplasia Type 2B: A Frozen Abdomen, A Slow Growing Mass, And A Backdoor Solution

Abstract Disclosure: O.A. Shariq: None. T.J. McKenzie: None. W.F. Young: None. Background: Multiple endocrine neoplasia type 2B (MEN2B) is most commonly caused by a germline methionine-to-threonine substitution at codon 918 (M918T) of the RET proto-oncogene. The syndrome is characterized by medullary thyroid carcinoma, pheochromocytoma, and extra-endocrine manifestations (intestinal ganglioneuromas, mucosal neuromas, and skeletal and ophthalmic abnormalities). We describe a patient with MEN2B and bilateral pheochromocytomas, in whom the slow-growing nature of the lesions, and previous history of an extra-endocrine manifestation, precluded the typical approach to surgical resection. Clinical Case: A 58-year-old-male with MEN2B, diagnosed at age 15, presented with a 6-month history of episodic palpitations and labile blood pressures. His past surgical history included a total abdominal colectomy and ileorectal anastomosis at age 7 years for megacolon, secondary to intestinal ganglioneuromatosis. He subsequently required multiple laparotomies and adhesiolysis procedures for recurrent small bowel obstructions. During his most recent laparotomy at age 44, he was noted to have a ‘frozen’ abdomen with dense adhesions involving the small bowel. CT abdomen revealed bilateral adrenal masses, measuring 2.9 cm and 1.5 cm on the right and left, respectively. Review of previous imaging revealed that the right adrenal mass had been present 16 years prior, measuring 1.0 cm at that time, while the left-sided mass was not seen. Biochemical workup was negative previously, but now showed elevated plasma metanephrine (4.1 nmol/L [N&amp;lt;0.5 nmol/L ]) and normetanephrine 2.3 nmol/L [N&amp;lt;0.9 nmol/L ]) levels. In the setting of extensive intra-abdominal adhesions and the slow-growing nature of both masses, the decision was made to perform a unilateral right adrenalectomy through a retroperitoneoscopic, rather than a transabdominal, approach. Pathology confirmed a 4.4 cm pheochromocytoma. The patient was discharged on postoperative day 1 and was symptom free at 1 year follow-up. His most recent plasma metanephrine and normetanephine levels were 0.7 nmol/L and 0.5 nmol/L, respectively. Clinical Lessons: Patients with MEN2B have a 50% lifetime risk of developing pheochromocytoma. Unlike medullary thyroid cancer, which exhibits an aggressive phenotype in this syndrome, MEN2B-associated pheochromocytomas may be slow growing, thereby avoiding the need for an initial bilateral adrenalectomy. Many patients with MEN2B develop gastrointestinal manifestations, including megacolon during infancy, for which multiple surgical interventions may be required. These procedures carry a risk of adhesion formation, which presents a challenge if further abdominal surgery is required later in life for pheochromocytoma. Retroperitoneoscopic adrenalectomy provides a safe approach in such patients, as the need to perform risky adhesiolysis and mobilize adjacent organs is obviated. Presentation: Saturday, June 17, 2023

Retroperitoneoscopic adrenalectomy may be superior to laparoscopic transperitoneal adrenalectomy in terms of costs and profit: a retrospective pair-matched cohort analysis

BackgroundA direct comparison of the cost–benefit analysis of retroperitoneoscopic adrenalectomy (RPA) versus the minimally invasive transperitoneal access (LTA) approach is currently lacking. We hypothesized that RPA is more cost effective than LTA; promising significant savings for the healthcare system in an era of ever more limited resources.MethodsWe performed a monocentric retrospective observational cohort study based on data from our Endocrine Surgery Registry. Patients who were operated upon between 2019 and 2022 were included. After pair-matching, both cohorts (RPA vs. LTA) were compared for perioperative variables and treatment costs (process cost calculation), revenue and profit.ResultsTwo homogenous cohorts of 43 patients each (RPA vs. LTA) were identified following matching. Patient characteristics between the cohorts were comparable. In terms of both treatment-associated costs and profit, the RPA procedure was superior to LTA (costs: US$5789.99 for RPA vs. US$6617.75 for LTA, P = 0.043; profit: US$1235.59 for RPA vs. US$653.33 for LTA, P = 0.027). The duration of inpatient treatment and comorbidities significantly influenced the cost of treatment and the overall profit.ConclusionsRPA appears not only to offer benefits over LTA in terms of perioperative morbidity and length of hospital stay, but also has a superior financial cost/benefit profile.Graphical abstract

The Impact of Obesity on Mortality and Complications in Posterior Retroperitoneoscopic Adrenalectomy.

Background Obesity is a global epidemic. It influences surgical technique, ergonomics, safety, and outcomes. However, there is a paucity of evidence of obesity-related impact in posterior retroperitoneoscopic adrenalectomy (PRA). This study compared perioperative outcomes of obese and non-obese participants undergoing PRA. Methodology This is a multi-center retrospective cohort study of elective PRA from March 2014 to December 2022. Patient demographics, surgical techniques, clinicopathological parameters, and outcomes, including overall complication rate, were analyzed using SPSS version 27 (IBM Corp., Armonk, NY, USA). Results Seventy-five patients underwent a PRA, of which 97.3% were completed retroperitoneoscopically. The overall complication rate was (9.3%), and on subgroup analysis, the obese cohort had a lower percentage complication profile at 6.5%. Male participants comprised 52%, with a median age of 55 (IQR=19). The median BMI was 29.0 (IQR=8), of which 41% were obese, and 40% were overweight. Univariate analysis showed that being obese was not significantly associated with a higher complication rate (p=0.471). In addition, there was no significant increase in conversion (p=0.508), bleeding/transfusion (p=0.508), surgical site infection (SSI; p=1.000), incisional hernia (p=1.000), ICU or high dependency unit admission (p=0.292) and any-cause mortality (p=1.000). No sentinel deaths directly related to PRA were recorded. Procedure duration was longer in obese (117 mins) vs. non-obese participants (88.9 mins, p=0.022). However, there was no significant difference in the length-of-hospital stay (p=0.592). The cohort conversion rate was (2.7%), and tumor size was associated with a higher conversion rate (35.4 vs. 62.5mm, p=0.040). Conclusion Posterior retroperitoneoscopic adrenalectomy can be a safe procedure in obese populations, and obesity does not increase perioperative morbidity or mortality.

Anesthetic support of aldosterom surgery (literature review)

Introduction . In 2016, M. Forero published data on the successful application of a new method of analgesia for chest pain – blockade of the fascial space of the erector spinae muscle, which was given the name Erector Spinae Planeblock (ESP). With the accumulation of clinical experience in the use of this blockade, it became obvious that the range of indications for its use can be significantly expanded. We propose a technique for using ESP blockade as a component of anesthesia in retroperitoneoscopic adrenalectomy for aldosteroma. Research . The authors conducted a systematic literature review in accordance with the principles of the PRISMA Statement. A bibliographic search was carried out in September–November 2021 in the MEDLINE, EMBASE, Cochrane Library databases. The search terms were: ‘ESP – blocks’, ‘postoperative analgesia’, ‘retroperitoneoscopic adrenalectomy’, ‘preoperative preparation before adrenalectomy’.

Minimally invasive adrenalectomy: a cohort study of surgical approach and outcomes.

In the context of minimally invasive adrenal surgery, there remains debate about whether the transperitoneal adrenalectomy (TPA) and posterior retroperitoneoscopic adrenalectomy (PRA) approach have equivalent indications. This study aims to examine complication and conversion rates associated with three surgical approaches for adrenal tumours over the last 17 years in a specialized endocrine surgical unit. All adrenalectomy cases performed in the period 2005-2021 were identified within a prospectively maintained surgical database. A retrospective cohort study was undertaken with patients divided into two cohorts (2005-2013 and 2014-2021). Surgical approach (open adrenalectomy (OA), TPA, PRA), tumour size, histopathology, complication and conversion rates were compared. During the study period, 596 patients underwent adrenalectomy with 31 and 40 cases each year per cohort. The dominant surgical approach per cohort significantly changed from TPA (79% versus 17%) to PRA (8% versus 69%, P < 0.001), whilst the frequency of OA remained stable (13% versus 15%). TPA removed larger tumours (3.0 ± 2.9 cm) than PRA (2.8 ± 2.2 cm, P = 0.02), with the median size increasing from 3.0 ± 2.5 to 4.5 ± 3.5 cm per cohort (P < 0.001). The maximum tumour sizes treated by TPA and PRA were 15 and 12 cm, respectively. Adrenocortical adenoma was the commonest pathology treated by either laparoscopic technique. Complication rates were greatest for OA (30.1%) with no significant difference between minimally invasive approaches (TPA 7.3%, PRA 8.3%, P = 0.7). Both laparoscopic techniques had equivalent conversion rates (3.6%). PRA was preferably converted to TPA (2.8%) over OA (0.8%). This study demonstrates the transition from TPA to PRA, offering similarly low complication and conversion rates.

PD03-07 PREDICTORS OF SUCCESSFUL OUTCOME AFTER ADRENALECTOMY FOR UNILATERAL PRIMARY ALDOSTERONISM (UPA)

You have accessJournal of UrologyCME1 Apr 2023PD03-07 PREDICTORS OF SUCCESSFUL OUTCOME AFTER ADRENALECTOMY FOR UNILATERAL PRIMARY ALDOSTERONISM (UPA) Ahmed Saadi, Mohamed Ali Bedoui, Selim Zaghbib, Seif Mokaddem, Ibtissem Ben Nacef, Hamza Boussaffa, Haroun Ayed, Amine Derouiche, Karima Khiari, Marouene Chakroun, and Riadh Ben Slama Ahmed SaadiAhmed Saadi More articles by this author , Mohamed Ali BedouiMohamed Ali Bedoui More articles by this author , Selim ZaghbibSelim Zaghbib More articles by this author , Seif MokaddemSeif Mokaddem More articles by this author , Ibtissem Ben NacefIbtissem Ben Nacef More articles by this author , Hamza BoussaffaHamza Boussaffa More articles by this author , Haroun AyedHaroun Ayed More articles by this author , Amine DerouicheAmine Derouiche More articles by this author , Karima KhiariKarima Khiari More articles by this author , Marouene ChakrounMarouene Chakroun More articles by this author , and Riadh Ben SlamaRiadh Ben Slama More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003220.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: UPA is the most common surgically curable form of endocrine hypertension. The underlying cause of resistant hypertension after surgery remains controversial. The aim of this study was to identify preoperative factors predictive of complete clinical success after laparoscopic adrenalectomy for UPA. METHODS: Between 2000 and 2021 patients treated by laparoscopic adrenalectomy for UPA were enrolled in this retrospective study. Preoperative data were divided into 3 categories: clinical, biological and radiological variables and follow up data was recorded. For determining factors influencing surgical outcome patients were divided into 3 groups: 1) complete clinical success (CS): normal blood pressure(BP) (≤140/90 mmHg) without antihypertensive medications (AHM). 2) Partial CS: the same BP as before surgery with less AHM or a reduction in BP with either the same amount or less AHM. 3) Absent CS: unchanged or increased BP with either the same amount or an increase in AHM. We performed an univariate and multivariate regression analysis. Statistical significance was defined as a P value of <0.05. RESULTS: Our study included 71 patients (59% female, mean age 46 years, median follow up 21 months). The mean duration of hypertension before surgery was 82.9±75.9 months. Preoperative mean DDD was 2.8±1.1 with 66% of patients having poorly controlled hypertension. Retroperitoneoscopic adrenalectomy was performed in 47 patients (66%). Four patients (6%) underwent partial adrenalectomy. Only 2 patients required conversion to open adrenalectomy. Complication rate (Clavien-Dindo ≥3a) was 4%. No mortality was registered. After adrenalectomy complete plus partial CS occured in 64 patients (91%).The following factors were associated with a complete clinical success by univariate analysis : absence of diabetes (p=0.007), low BMI (p=0.001), lower levels of preoperative AHM (p=0.01), controlled preoperative BP (p=0.024), higher levels of plasma aldosterone-to-renin ratio (ARR) (p=0.001), adenoma classification (p<0.001) and aldosteronoma resolution score (ARS) (p=0.002). Multivariate regression analysis revealed that the main determinants of complete clinical success were : absence of diabetes (OR: 5.205, 95% CI 1.411-19.206), low BMI (OR: 0.904, 95% CI 0.820-0.997), plasma ARR >332 (OR: 1.003, 95% CI 1.001-1.004) and ARS score ≥3 (OR: 2.056, 95% CI 1.210-3.491). CONCLUSIONS: The majority of our patients (91%) experienced clinical benefit from adrenalectomy.The main determinants of cured hypertension were absence of diabetes, low BMI, high levels of plasma ARR and high ARS score. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e77 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ahmed Saadi More articles by this author Mohamed Ali Bedoui More articles by this author Selim Zaghbib More articles by this author Seif Mokaddem More articles by this author Ibtissem Ben Nacef More articles by this author Hamza Boussaffa More articles by this author Haroun Ayed More articles by this author Amine Derouiche More articles by this author Karima Khiari More articles by this author Marouene Chakroun More articles by this author Riadh Ben Slama More articles by this author Expand All Advertisement PDF downloadLoading ...

Renal‑rotation techniques in retroperitoneoscopic adrenalectomy for giant pheochromocytomas: a clinical intervention study with historical controls

BackgroundDealing with the giant pheochromocytomas (maximum diameter ≥ 6 cm) has long been a tough challenge for urologists. We introduced a new retroperitoneoscopic adrenalectomy method modified with renal-rotation techniques to treat giant pheochromocytomas.Methods28 diagnosed patients were prospectively recruited as the intervention group. Meanwhile, by referring to the historical records in our database, matched patients who had undergone routine retroperitoneoscopic adrenalectomy (RA), transperitoneal laparoscopic adrenalectomy (TA), or open adrenalectomy (OA) for giant pheochromocytomas were selected as controls. Perioperative and follow-up data were collected for comparative assessment.ResultsAmong all the groups, the intervention group had the minimal bleeding volume (28.93 ± 25.94 ml, p < 0.05), the least intraoperative blood pressure variation (59.11 ± 25.68 mmHg, p < 0.05), the shortest operation time (115.32 ± 30.69 min, p < 0.05), the lowest postoperative ICU admission rates (7.14%, p < 0.05), and shortest drainage time length (2.57 ± 0.50 days, p < 0.05). Besides, compared with TA and OA groups, intervention group was also characterized by lower pain scores (3.21 ± 0.63, p < 0.05), less postoperative complications (p < 0.05), earlier diet initiation time (1.32 ± 0.48 postoperative days, p < 0.05) and ambulation time (2.68 ± 0.48 postoperative days, p < 0.05). Follow-up blood pressure and metanephrine and normetanephrine levels in all intervention group patients remained normal.ConclusionCompared with RA, TA, and OA, retroperitoneoscopic adrenalectomy with renal-rotation techniques is a more feasible, efficient, and secure surgical treatment for giant pheochromocytomas.Trial registrationThis study has been prospectively registered on the Chinese Clinical Trial Registry website (ChiCTR2200059953, date of first registration: 14/05/2022).

An abrupt decrease in arterial blood pressure may predict a high level carbon dioxide embolism in retroperitoneoscopic surgery: case report and a literature review

BackgroundCarbon dioxide (CO2) embolism is the primary suspect in most cases of intraoperative “cardiovascular” collapse. However, there are few reports about CO2 embolism in retroperitoneal laparoscopy.Case presentationAn abrupt decrease in arterial blood pressure was noted in time of retroperitoneoscopic adrenalectomy in a 40 years old male patient with adrenal adenoma. The end-tidal carbon dioxide (EtCO2) and saturation of oxygen were stable with normal cardiography until anesthesiologists found the change of resistant of peripheral circulation, then they gave us a hint of hemorrhage. However, the blood pressure had no reaction to one bolus of epinephrine administration when trying to improve the circulation. Five minutes later, a sudden fall of blood pressure was noted, and then we stopped the processing of cutting tissue and trying to coagulate any bleeding in the operation field. Further vasopressor support proved to be completely ineffective. With the help of transesophageal echocardiography, we found the bubbles in the right atrium, which confirmed the diagnosis of an intraoperative gas embolism (Grade IV). We stopped the carbon dioxide insufflation and deflated the retroperitoneal cavity. All the bubbles in the right atrium totally disappeared and the blood pressure, resistance of peripheral circulation and cardiac output returned to normal 20 min later. We continued the operation and completed it in 40 min with the 10 mmHg air pressure.ConclusionCO2 embolism may occour during retroperitoneoscopic adrenalectomy, and an acute decrease in arterial blood pressure should alert both the urologists and anesthesiologists to this rare and fatal complication.

Retroperitoneoscopic adrenalectomy – introducing a new surgical technique in South Africa

Retroperitoneoscopic adrenalectomy – introducing a new surgical technique in South Africa

Correction to: A Canadian centre's experience with prone peritoneoscopic adrenalectomy.

CJS has been made aware of an error that occurred in the article, “A Canadian centre’s experience with prone retroperitoneoscopic adrenalectomy,” published on October 25, 2022.[1][1] Dr. Adrienne Melk was listed as the second author on the paper; however, she was the study’s principal

Right Posterior Retroperitoneoscopic Adrenalectomy (PRA) for Adrenocortical Adenoma

Posterior retroperitoneoscopic adrenalectomy (PRA) allows the surgeon to approach the adrenal gland through the back rather than the more traditional laparoscopic transabdominal adrenalectomy (LTA) approach. This technique was popularized in Germany but is being used increasingly throughout the United States. Our institution was one of the early adopters of this technique in the US and we present such an operation here.

A Canadian centre's experience with prone retroperitoneoscopic adrenalectomy.

Minimally invasive adrenalectomy is the standard of care for the surgical management of benign adrenal disease. The transperitoneal laparoscopic approach (TLA) is the most common approach used worldwide; however, many centres have adopted a posterior retroperitoneoscopic approach (PRA), as it is reported to offer several advantages. We describe our experience with PRA. We performed a retrospective review of the charts of patients who underwent minimally invasive adrenalectomy via PRA or TLA performed by a single endocrine surgeon between September 2010 and December 2019 at a tertiary academic centre in British Columbia, Canada. Patient and tumour characteristics, operative times and postoperative outcomes were compared between the 2 groups. During the study period, 58 patients underwent adrenalectomy via PRA, and 41 underwent adrenalectomy via TLA. The median American Society of Anesthesiologists score was higher in the TLA group than the PRA group (3.0 v. 2.6, p = 0.02). Adrenal glands were heavier in the TLA group than the PRA group (mean 63.4 g v. 19.2 g, p < 0.001). The mean anesthesia preparation time was shorter with PRA than with TLA (51.5 min v. 63.7 min, p < 0.001), as was mean operative time (77.9 min v. 118.4 min, p < 0.001) and mean hospital length of stay (2 d v. 4 d, p < 0.001). There was no difference in the complication rate between the 2 groups. Our study shows that PRA offers shorter operative time and length of stay for appropriately selected patients. Thus, it has become the preferred approach at our centre for minimally invasive adrenalectomy.

Perception versus reality: A case-matched study assessing the intraoperative hemodynamics of minimally invasive retroperitoneal versus transperitoneal approach to pheochromocytomas

BackgroundPheochromocytomas produce excess catecholamines that can result in intraoperative hemodynamic instability. Centers have reported variations in intraoperative hemodynamics with the retroperitoneoscopic versus the laparoscopic transperitoneal approach to adrenalectomies. When the retroperitoneoscopic approach was initiated for pheochromocytomas at our institution, the perception was of improved intraoperative hemodynamics, hypothesizing that increased retroperitoneoscopic insufflation pressures caused decreased venous return and less fluctuation in circulating catecholamines. The purpose of this study was to examine if a difference in intraoperative hemodynamics exists between a size-matched cohort of laparoscopic transperitoneal and retroperitoneoscopic pheochromocytoma patients. MethodsUnilateral adrenalectomies for pheochromocytoma performed via laparoscopic transperitoneal or retroperitoneoscopic approaches from 2015 to 2021 were identified from a surgical database. As larger tumors often underwent a laparoscopic transperitoneal approach, cases were matched 1:1 by tumor size. All patients received phenoxybenzamine. Groups were compared by patient characteristics, preoperative blockade, intraoperative hemodynamics and management, and early postoperative outcomes. ResultsThere were 13 laparoscopic transperitoneal adrenalectomy cases matched to 13 retroperitoneoscopic cases according to tumor size. Both groups (laparoscopic transperitoneal and retroperitoneoscopic) were similar for age (53 years), body mass index (28.5 vs 29.7), sex (69% female), and side (8 vs 7 right). There was no difference in preoperative 24-hour urine metanephrines/normetanephrines (9.9/8.0 vs 2.4/5.7 μmol/day). The phenoxybenzamine dose was similar in both groups (112 vs 114 mg/24 hours), as were baseline heart rate, blood pressure, and mean arterial pressure. There was no difference in any intraoperative hemodynamic parameters or vasoactive interventions. Operative time, length of stay, and 30-day emergency visits were similar between groups. ConclusionThis matched cohort study did not find a difference in intraoperative hemodynamics between laparoscopic transperitoneal and retroperitoneoscopic adrenalectomy approaches for pheochromocytoma in appropriately selected and blocked patients.

Pheochromocytoma recurrence in hereditary disease: does a cortical-sparing technique increase recurrence rate?

BackgroundPosterior retroperitoneoscopic adrenalectomy is an appealing approach for patients with hereditary pheochromocytoma and lends well to cortex preservation. We sought to examine pheochromocytoma recurrence in patients with hereditary pheochromocytoma in the era of posterior retroperitoneoscopic adrenalectomy and evaluate the predictors of recurrence. MethodsPatients with hereditary pheochromocytoma who underwent adrenalectomy for pheochromocytoma between 1995 and 2020 with biochemical cure and follow-up >1 year were identified. Recurrence was defined as plasma metanephrines above the upper limit of normal with radiographic evidence of disease in the ipsilateral adrenal bed. ResultsSeventy-eight hereditary pheochromocytoma patients (median age = 32.4 years; 60.3% women) underwent 114 adrenalectomies for pheochromocytoma. Of these patients, 40 had multiple endocrine neoplasia type 2A (51.3%), 10 had multiple endocrine neoplasia type B (12.8%), 17 had von Hippel-Lindau disease (21.8%), and 11 had neurofibromatosis type 1 (14.1%). Thirty-eight adrenalectomies (33.3%) were performed before the introduction of posterior retroperitoneoscopic adrenalectomy and 76 (66.7%) after. Cortical-sparing technique was performed in 62 (54.4%) adrenalectomies, with no difference in its use before and after posterior retroperitoneoscopic adrenalectomy introduction (P > .05). During a median follow-up of 80.7 months (interquartile range 43.4–151.2), 12 ipsilateral recurrences (10.5%) were identified. There was no difference in recurrence before and after the introduction of posterior retroperitoneoscopic adrenalectomy or by surgical technique or approach of the entire cohort (P > .05). Recurrence was more common in those with RET M918T mutation (23.5% vs 8.2%; P = .05). Patients with RET M918T mutations had a shorter recurrence-free survival (P = .013). On multivariate analysis, only RET M918T mutation was independently associated with an increased recurrence risk (hazard ratio = 4.30; 95% confidence interval, 1.26–14.66; P = .019). ConclusionThe introduction of posterior retroperitoneoscopic adrenalectomy did not influence the recurrence rate after adrenalectomy for hereditary pheochromocytoma patients. Patients with a RET M918T germline mutation are at increased risk for pheochromocytoma recurrence and may benefit from initial total adrenalectomy.

The learning curve of posterior retroperitoneoscopic adrenalectomy: a review of literature

Background and Objective: Posterior retroperitoneoscopic adrenalectomy has become an increasingly popular approach for removal of the adrenal gland. When compared to the transabdominal approach, it has several advantages including shorter operative time, less blood loss, less postoperative pain, faster recovery, improved cost-effectiveness, and abolished risk of trocar site herniation due to the direct approach to the adrenal gland. However, many surgeons still prefer the transabdominal approach, which is possibly a result of the uncommon anatomical view, limited working space and estimated longer learning curve of the retroperitoneal approach. The primary objective of this review was to evaluate the learning curve for posterior retroperitoneoscopic adrenalectomy and to propose a strategy for surgeons starting to learn this technique.