Unilateral Laparoscopic Adrenalectomy Research Articles

Feasibility of laparoscopic adrenalectomy in adrenal masses greater than 5 centimeters: a systematic review and meta-analysis.

Laparoscopic adrenalectomy (LA) has emerged as the primary treatment for adrenal masses. This systematic review and meta-analysis assessed LA's feasibility, safety, effectiveness, and complications for adrenal masses exceeding 5 cm. The study was conducted using PRISMA guidelines with PROSPERO registration No. CRD42023462901. Adults with unilateral adrenal masses >5 cm who underwent unilateral LA were included. Intraoperative and postoperative measurements and complications were assessed. A systematic literature review employed a comprehensive search strategy which was last searched on September 8, 2023, through PubMed, Google Scholar, Web of Science, and ProQuest databases. Meta-analysis was utilized to analyze the outcomes. Risk of bias was assessed using the Newcastle-Ottawa scale. This systematic review encompassed 25 studies involving 963 patients who underwent LA. Tumor size varied 7.05 cm [95% confidence interval (CI): 6.24-7.70], with 50% on the right and 45% on the left. The subgroup meta-analysis comparing the transperitoneal and retroperitoneal approaches revealed the transperitoneal approach h was utilized for the largest tumor size with a mean of 12.10 cm (95% CI: 11.30-12.96), compared to the retroperitoneal approach 5.83 cm (95% CI: 5.52-6.14). Notably, the mean operative time across studies was 137.4 minutes (95% CI: 113.36-150.94), bleeding prevalence was 0.02% (95% CI: 0.01-0.03%), and average blood loss was 110.6 mL (95% CI: 78.2-156.3). Postoperative complications such as pulmonary edema, pulmonary embolism, gastric dysfunction, and wound infection were very low, ranging from 0.03% to 0.4%. Out of 963 patients, only 49 were converted to open surgery. Patient hospital stay averaged 3.72 days (95% CI: 2.97-4.66); blood transfusion was required in 1.3% (95% CI: 0.30-8.88%). The feasibility and safety of LA for tumors exceeding 5 cm in size have notable implications for intraoperative and postoperative outcomes. Underreporting in the included studies may impact the generalizability of findings.

Laparoscopic Bilateral Adrenalectomy with the Transabdominal Lateral Approach

Background: Laparoscopic adrenalectomy (LA) is a widely accepted method for most adrenal lesions. However, bilateral LA is performed less often than unilateral adrenalectomy. The most common indication for bilateral LA is adrenocorticotropin hormone (ACTH)-dependent Cushing’s syndrome, including persistent Cushing’s disease following unsuccessful transsphenoidal surgery and ectopic ACTH syndrome. Objectives: This retrospective study was conducted to assess the indications, safety, efficacy, and outcomes for bilateral LA with the transabdominal lateral approach. Methods: This retrospective study was conducted between January 2004 and February 2022. During the study period, transperitoneal LA was performed on 279 patients, among whom, 258 cases were unilateral LA. Therefore, our analysis included 21 consecutive patients who underwent laparoscopic bilateral LA with the transabdominal lateral approach. The surgery indication, tumor side and weight, operation time, conversion to open surgery, need for an additional trocar, complications, hospital stay, and follow-up information were analyzed. Results: Indications of bilateral LA were refractory Cushing’s disease (n=14), occult ectopic primary bilateral macronodular adrenal hyperplasia (n=5), ACTH secretion (n=1), and bilateral pheochromocytoma (n=1). The mean operative time was 207.8±21.3 min, including repositioning time. Intraoperative and postoperative complications were seen in 3 (14%) and 4 (19%) patients, respectively. No conversion to open surgery was observed. Median hospital stay was 7 (range, 5-10) days and median follow-up was 81 (range, 55-94.5) months. Three patients died at 62, 64, and 88 months after adrenalectomy due to heart failure, renal failure, and myocardial infarction, respectively. No adrenal insufficiency or signs of recurrent hypercortisolism was observed. Conclusion: Our results demonstrated that laparoscopic bilateral LA was safe and effective, allowing acceptable morbidity and hospital stay. The most common surgical indication was ACTH-dependent Cushing's syndrome, followed by ACTH-independent Cushing's syndrome. The lateral transperitoneal approach obtains an excellent anatomical view. In our series, operative time and conversion to open surgery rate were in line with the literature.

İnsidental Adrenal Kitlelerin Değerlendirilmesinde Manyetik Rezonans ve Bilgisayarlı Tomografinin Direkt ve Dolaylı Maliyetlerinin Karşılaştırılması

Objective: It was planned to compare the direct and indirect costs of computed tomography (CT) and magnetic resonance (MR) methods in the differentiation of adrenal adenoma and non adenoma.
 
 Material and Methods: CT, MR, pathology, laboratory and other information of the patients were obtained from the patient files. Radiological examination and unilateral laparoscopic adrenalectomy cost information was obtained from the accounting department. For cost calculation; the scenario was used in which 500 patients were referred equally to CT and MR, individuals diagnosed with non-adenoma were referred to the operation after the first control, individuals diagnosed with adenoma were followed, and standard follow-up was done every 6 months for 4 years.
 
 Results: A total of 31 patients (8 males and 23 females) were eligible for the study. The mean age of the patients was 48.1+17.7 years. In the CT group, an excess cost of 609,0 ₺ per person for 1 year and 2435,9 ₺ per person for 4 years was incurred. In the diagnosis of adenoma and non-adenoma, CT was inaccurate in 24.4% of patients, whereas MR was inaccurate in 5.2%. When used for the diagnosis of pheochromocytoma, it was found that in the CT group, 609,0 ₺ per person for 1 year and 2435,9 ₺ per person for 4 years resulted in an excess cost, whereas CT was erroneous in 17.6% of patients and MR in 15.8% of patients. In the diagnosis of malignancy, in the CT group, an excess cost of 522,2 ₺ per person for 1 year and 2088,7 ₺ per person for 4 years was incurred. It was determined that correct decision could not be made in 33.2% of the patients in the CT group and in 5.8% of the patients in the MR group.
 
 Conclusion: The use of contrast-enhanced MR in patients of adrenal masses reduces unnecessary interventions and the resulting expenditures.

ODP060 Treatment of Aldosterone-producing adenoma by CT-guided radiofrequency ablation in a high surgical risk patient: biochemical and clinical outcomes.

Abstract Background Primary aldosteronism (PA) is a leading cause of secondary hypertension and harness a much higher cardiovascular risk than essential hypertension. About 30% of PA cases are due the existence of an aldosterone-producing adenoma (APA). Although the current guidelines recommend unilateral laparoscopic adrenalectomy as the standard treatment of APA, some patients might no be suited for the procedure. Clinical Case A 66-year man was referred to our institution following a 14-year history of resistant hypertension. His past history included a stage III chronic kidney disease, type 2 diabetes mellitus, dyslipidemia, obstructive sleep apnea (OSA), hypothyroidism, grade I obesity, and rheumatoid arthritis. Initial tests were consistent with PA: elevated serum aldosterone (26 ng/dL), suppressed plasma renin activity (PRA: 0. 07 ng/ml/H) and a high aldosterone/renin ratio (RAR: 65) with concomitant hypokalemia (3,4 mEq/L). Abdominal CT-scan demonstrated a 11×8 mm left adrenal nodule with an absolute washout of 60%. A diagnosis of an APA was confirmed by an adrenal vein sampling. Since the patient had multiple comorbidities and an unequivocal high surgical risk, laparoscopic adrenalectomy was contraindicated, and pharmacologic treatment was started with spironolactone. Despite the use of high doses of spironolactone, blood pressure (BP) control was not achieved. Moreover, severe side effects were experienced, notably sexual dysfunction and painful gynecomastia. In this setting, a decision for a CT-guided radiofrequency ablation was made. The procedure underwent under general anesthesia and had no adverse events. Three days after the ablation, biochemical analysis demonstrated a significant reduction of aldosterone (10 ng/dL) and RAR (10), whereas the PRA was notably higher (1,45 ng/mL/h). He transitioned from 6 different classes of anti-hypertensives drugs to only one and his blood pressure was well controlled in an appointment 30 days after the procedure. On the other hand, his glomerular filtration rate had decayed from 44 mL/min to 31 mL/h due to a rapid blood pressure control. Despite no changes in anthropometric measures and OSA related symptoms were observed, an expressive reduction in microalbuminuria (191 mg/dL to 28,6 mg/dL) was noticed. Conclusion The CT-guided radiofrequency ablation is a suitable minimally invasive treatment for PA in high surgical risk patients. For patients with high surgical risk and intolerance to clinical treatment, radiofrequency should be offered as an option for treatment in a specialized center. Presentation: No date and time listed

ODP639 The Occurrence and Predictors of Postoperative Adrenal Insufficiency for Patients With Subclinical Cushing's Syndrome

Abstract Objective To identify the occurrence and predictive factors of postoperative adrenal insufficiency in patients with subclinical Cushing's syndrome (SCS), and try to provide evidence for decision-making in SCS management. Methods The present retrospective analysis included 77 patients who underwent unilateral laparoscopic adrenalectomy for SCS between December 2011 and April 2021. Among them, 59 patients with complete follow-up data were included. We compared clinical characteristics of patients with and without postoperative adrenal insufficiency. The logistic regression model was used to find the potential risk factors in predicting the occurrence of postoperative adrenal insufficiency. The receiver operating characteristic (ROC) curve was used to evaluate the predictive values. Results We included 59 patients, of whom the incidence of postoperative adrenal insufficiency is 42.37%. The circadian rhythms of adrenocorticotropic hormone (ACTH) and cortisol disappeared in both two groups. Compared patients without postoperative adrenal insufficiency, patients with postoperative adrenal insufficiency were characterized by suppressed plasma ACTH level [1.11(1.11, 1.83) pmol/L vs 2.56(1.16, 4.63) pmol/L], elevated midnight cortisol level [268. 00(164. 00, 347.50) nmol/L vs 181.50(156.32, 227. 00) nmol/L] and increased cortisol level after 1 mg overnight dexamethasone suppression test (DST) [281. 00(241. 00, 396.64) nmol/L vs 172.50(144. 05, 215.25) nmol/L] (all P < 0. 05). Multivariate logistic regression analysis showed that the serum cortisol after a 1 mg-DST was the only independent predictive factor for the occurrence of postoperative adrenal insufficiency. The ROC curve showed that the best cut-off value of the serum cortisol after a 1 mg-DST was 233 nmol/L, with a sensitivity of 80. 00% and a specificity of 82.35%. The combination of the serum cortisol after a 1 mg-DST, plasma ACTH and midnight cortisol had the highest predictive accuracy (83. 05%). Conclusion Patients who underwent unilateral laparoscopic adrenalectomy for SCS had a risk of postoperative adrenal insufficiency. The pre-surgical assessment of the serum cortisol after a 1 mg-DST plus elevated midnight cortisol and suppressed plasma ACTH had predictive value for the occurrence of postoperative adrenal insufficiency. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Monday, June 13, 2022 1:00 p.m. - 1:05 p.m.

Risk factors for hemodynamic instability during laparoscopic resection of pheochromocytoma

BackgroundLaparoscopic adrenalectomy for pheochromocytoma is associated with high risk of intraoperative hemodynamic instability. Our study aimed to identify predictive factors for hemodynamic instability during laparoscopic resection of pheochromocytoma.MethodsBetween January 2011 and December 2021, 136 patients underwent unilateral laparoscopic adrenalectomy for pheochromocytoma. The patients were divided into 2 groups depending on the presence or absence of hemodynamic instability during surgery. Intraoperative hemodynamic parameters were compared between the 2 groups. Patient demographic characteristics and preoperative evaluations were assessed for their prognostic relevance with respect to intraoperative hemodynamic instability via both univariate analysis and multivariate logistic regression analysis.ResultsThere was greater blood pressure fluctuations and higher maximum blood pressure and heart rate in the hemodynamic instability group. More patients need intraoperative administration of vasoactive drugs in the hemodynamic instability group. In the univariate analysis, presence of coronary artery disease, tumour size, and previous hypertension history were significantly associated with intraoperative hemodynamic instability. The multivariate logistic regression analysis showed that tumour size and previous hypertension history were independent risk factors for intraoperative hemodynamic instability.ConclusionTumour size and previous hypertension history were associated with hemodynamic instability during laparoscopic resection of pheochromocytoma.

Factors associated with renal function change after unilateral adrenalectomy in patients with primary aldosteronism.

Decreased glomerular filtration rate has been reported in patients with primary aldosteronism after unilateral adrenalectomy. Glomerular hyperfiltration has been assumed to mask the preoperative subtle renal impairment. In this study, we investigated predictors for decreased estimated glomerular filtration rate after adrenalectomy in patients with primary aldosteronism. From January 2006 through September 2018, 328 patients with confirmatory diagnoses of primary aldosteronism received unilateral laparoscopic adrenalectomy and subsequent follow-up for 12 months. We prospectively collected related parameters of the clinical outcomes and renal function to identify predictors of renal function impairment at 12 months after surgery. Patients were stratified into three groups by preoperative estimated glomerular filtration rate level: 144 (43.9%) with estimated glomerular filtration rate ≥90, 130 (39.6%) with estimated glomerular filtration rate within 60-89.9, and 54 (16.5%) with estimated glomerular filtration rate <60 mL/min/1.73 m2 . The estimated glomerular filtration rate decreased significantly at the 6th month and remained stable at the 12th month, postoperatively. Patients with estimated glomerular filtration rate ≥90 had better clinical outcome with 59.6% success rate (P = 0.006) among three groups. Multivariate logistic regression analysis indicated that preoperative estimated glomerular filtration rate (odds ratio 1.012, P = 0.02) and hypokalemia (odds ratio 2.018, P = 0.024) were associated with renal impairment at 12th month after adrenalectomy. Multivariate linear regression analysis revealed high preoperative estimated glomerular filtration rate (β = 0.261, P < 0.001), high preoperative systolic blood pressure (β = 0.168, P = 0.003), high level of microalbuminuria (β = 0.024, P = 0.001), and low level of serum potassium (β = -4.883, P = 0.007) were associated with estimated glomerular filtration rate percentage decline at 12th month after adrenalectomy. Estimated glomerular filtration rate declined significantly after adrenalectomy in patients with estimated glomerular filtration rate ≥90. The study provided important information to identify primary aldosteronism patients with higher risk of estimated glomerular filtration rate decline after adrenalectomy and might help to adopt early interventions to improve the outcomes.

High-Volume Center Experience with Laparoscopic Adrenalectomy over Two Decades.

Background: Study aims to demonstrate single-institution two decades experience with lateral transperitoneal laparoscopic adrenalectomies. Methods: Retrospective study involved 991 operations grouped into 4 cohorts. Data was collected on the patients’ age, sex, side and size of the lesion, histopathological type, hormonal activity, conversion to open adrenalectomy, operating time, length of hospital stay, perioperative complications. Results: The operations were right-sided (n = 550), left-sided (n = 422), bilateral (n = 19). Mean tumor size was 41.9 mm. Histopathological examination revealed 442 adenomas, 191 nodular hyperplasias, 218 pheochromocytomas, 33 malignancies and 126 other lesions. 541 patients had hormonally active tumors. Mean operating time for unilateral laparoscopic adrenalectomy was 141 min. Mean length of hospital stay was 5.27 days. Intraoperative complications rate was 2.3%. Conversion rate was 1.5%. 54 of patients had 70 postoperative complications. Reoperation rate was 1%. Mortality rate was 0.1%. Statistically significant differences were found in all factors, apart from age, sex, side and size of the lesion, reoperations rate (p > 0.05). Conversions rate, complications rates, length of hospital stay were highest in the first group (p < 0.05). Operating time shortened in the first decade. Conclusions: Laparoscopic adrenalectomy is a safe procedure with negligible mortality. Conversions rate, perioperative complications rate, and length of hospital stay, significantly decreased over time.

Follow-up of second adrenal tumor after remission of Cushing syndrome

Bilateral adrenal tumors (BAT) represent a vast domain of endocrinology and connected medical and surgical fields. Our purpose is to introduce several key points in relationship with long time management on a 56-year old female case who is currently admitted for reassessment of a left adrenal tumor with potential autonomous cortisol secretion. She is also known with pituitary incidentaloma since 2014, cerebral meningioma which was partially removed in 2015, uncontrolled diabetes mellitus under metformin and insulin therapy since 2017, and high blood pressure since 2021. Her medical history includes right adrenalectomy for Cushing syndrome in 2014. At that moment, she was first admitted for BAT, a tumor of 2 centimeters (cm) on the left gland according to computed tomography, respective of 3.5 cm maximum diameter on the right adrenal. The hormonal panel confirmed adrenal Cushing syndrome. After 6 months of non-interventional follow-up, the right tumor increased to 4 cm, also associating small areas of necrosis, thus a decision of unilateral laparoscopic adrenalectomy was done with good clinical post-operatory outcome. She did not develop adrenal insufficiency at any point in time, moreover, a low-normal ACTH (Adrenocorticotropic Hormone) with intermittent elevation of morning plasma cortisol levels after Dexamethasone suppression test showed a possible autonomous cortisol secretion of the left adrenal tumor during a 7-year follow-up. In 2014, the female patient received the confirmation of an adrenocortical adenoma which was consistent with cortisol over-secretion. Particular gene contributions are attributed to protein kinase A (PKA) defects (or B) that usually induce bilateral adrenocortical hyperplasia; however, they are not routinely tested in daily endocrine practice, neither had we performed it. Interestingly, the patient was detected with a cerebral meningioma after years of intermittent, mild headache. The diagnostic was established during initial endocrine evaluations. The headache was not associated with uncontrolled high blood pressure, as first expected due to excessive cortisol amount. Recently, it was identified that mutations of ARMC5 (armadillo repeat containing 5) gene are responsible for macronodular adrenal hyperplasia, but also meningioma. They may be also responsible for severe diabetes mellitus as seen here. The key points of following a patient with bilateral adrenal tumors include the timing of uni/bilateral adrenalectomy, the multidisciplinary management of associated complications, as well as the need of understanding the genetic rational behind it.

Conn's syndrome-Frequent and still too rarely diagnosed to underdiagnosed

Conn's syndrome represents the most common cause of endocrine hypertension and is associated with an increased cardiovascular risk, a series of comorbidities (including type 2 diabetes mellitus) and with their frequent occurrence. Therefore, acorrect and rapid diagnosis is of essential importance. Measurement of the aldosterone-renin ratio is used as afirst screening test for primary aldosteronism. This should ideally be evaluated under optimized conditions (e.g. at rest), after adjustment of the blood pressure medication and with an equilibrated potassium balance. In cases of elevated aldosterone to renin ratio, further confirmatory testing as well as imaging of the adrenal glands is needed. After confirmation of Conn's syndrome a differentiation between a unilateral and bilateral adrenal disease is necessary for further treatment planning. The current gold standard is still selective adrenal vein catheterization. Promising alternatives to an adrenal vein catheter, such as functional imaging techniques and measurement of steroid profiles are currently being investigated in clinical trials. In cases of lateralization of aldosterone production, unilateral laparoscopic adrenalectomy of the affected side is the treatment of choice. In contrast, patients with bilateral disease or patients with contraindications for adrenalectomy should receive life-long treatment with mineralocorticoid receptor antagonists.

Aldosterone and Primary Aldosteronism: Star Performers in Hypertension Research

Aldosterone and Primary Aldosteronism: Star Performers in Hypertension Research

Preoperative Renin Status Indicate the Clinical Outcome of Aldosterone-Producing Adenoma

Primary aldosteronism is widely recognized as renin-independent hypersecretion of aldosterone and aldosterone-producing adenoma(APA) represents the typical clinical subtype. Plasma renin below detection levels was considered as an important indicator for PA, and the suppressed renin level after confirmatory tests was considered to be a prerequisite when interpreting the results of confirmatory tests, before making the diagnosis of PA. Strictly, there is no specific definition of suppressed renin level in patients with PA. Clinically, the renin level of patients with APA varied greatly within the low to normal range. However, the clinical characteristics and outcomes in patients with APA having different renin status remain unclear. This retrospective study included 274 patients with APA who underwent unilateral laparoscopic adrenalectomy with at least a 12-month follow-up postoperatively. Patients were classified into the following 2 groups: low renin and non-low renin groups measured at 8.2 mU/L, according to the widely used criteria(defined as plasma renin activity<1ng/ml/h≈PRC 8.2 mU/L). Only patients with two consecutive PRC less than 8.2 mU/L could be classified into the low renin group. For the screening test and the confirmatory tests, antihypertensive medication was withheld or changed according to the guideline. Chemiluminescence immunoassays showed the range of the plasma renin concentration as 0.4–41.5mU/L. Non-low renin APA patients (n=26) had higher presurgical SBP(p=0.028), DBP(p=0.001) and PRC post confirmatory tests(p<0.001), compared with low renin APA patients(n=248). There was no significant difference in baseline PAC(p=0.507) and serum potassium(p=0.348) between the two groups. Intriguingly, non-low renin APA patients had higher PAC(p<0.001) and PRC(p<0.001) and lower serum potassium(p<0.001) at follow-up. For non-low renin APA patients, the rate of complete clinical success after surgery was 42.3%, 25% lower than that of low renin APA patients. APA patients with PRC<0.5mU/L had the highest rate of complete clinical success(75%), followed by PRC 0.5~8.2 mU/L(65%) and 8.2~20 mU/L(50%), with the lowest rate in patients with PRC>20 mU/L(33%). Multivariable logistic regression showed that the presence of baseline PRC>8.2 mU/L was a strong independent predictor for the lack of complete clinical success[OR 3.7(1.5–8.9),p=0.004]. Plasma renin concentration is closely related to the clinical outcome of APA patients postoperatively. APA patients with higher baseline renin status are at high likelihood of persistent hypertension after surgery, in whom strengthened monitoring of blood pressure is necessary.

Higher risk of chronic kidney disease and progressive kidney function impairment in primary aldosteronism than in essential hypertension. Case-control study.

To study the differences in the prevalence, risk, and grade of control of different cardiometabolic comorbidities in patients with primary aldosteronism (PA) and essential hypertension (EH) matched by age, sex, and blood pressure levels at diagnosis. Case-control study of a secondary base (PA patients in follow-up in a tertiary hospital between 2018 and 2020). Controls were patients with non-functioning adrenal incidentalomas and EH, matched by age, sex, and baseline diastolic blood pressure (DBP) and systolic blood pressure (SBP). Fifty patients with PA and 50 controls were enrolled in the study. At diagnosis, PA patients had a higher prevalence of chronic kidney disease (CKD) than controls (18.4% vs. 2.1%, P = 0.008). No differences were detected in the prevalence of other cardiometabolic comorbidities nor in their degree of control (P > 0.05). All patients received antihypertensive medical treatment and 10 PA patients underwent unilateral laparoscopic adrenalectomy. After a median follow-up of 31.9 [IQR = 1.0-254.8] months, PA patients presented a greater degree of declination of kidney function than controls (average decrease in glomerular filtration rate (MDRD-4) -17.6 ± 3.1 vs. -2.8 ± 1.8 ml/min/1.73 m2, P < 0.001). There were no differences in the grade of SBP (P = 0.840) and DBP control (P = 0.191), nor in the risk of developing other comorbidities or in their degree of control. PA patients have a higher prevalence of CKD at the time of diagnosis when compared to EH matched by age, sex, and blood pressure levels. Furthermore, the risk of kidney function impairment throughout the follow-up is significantly greater in PA patients and is independent of the degree of blood pressure control.

Primary aldosteronism: from diagnosis to therapy in clinical practice

Primary aldosteronism (PA) is the single most common cause of secondary hypertension and is associated with increased target organ injury. It can be can either surgically cured or treated with targeted pharmacotherapy. PA is frequently undiagnosed and untreated, leading to aldosterone-specific cardiovascular morbidity and nephrotoxicity. Thus, clinicians should perform case detection testing for PA at least once in all patients with hypertension. The diagnostic work-up of PA is a sequence of three phases comprising screening tests, confirmatory tests and the differentiation of unilateral from bilateral forms. With appropriate surgical expertise, laparoscopic unilateral adrenalectomy is safe, efficient and curative in patients with unilateral adrenal disease. In patients who have bilateral aldosterone hypersecretion, the optimal management is a low sodium diet and lifelong treatment with a mineralocorticoid receptor antagonist administered at a dosage to maintain a high-normal serum potassium concentration without the aid of oral potassium supplements. In patients with PA, specific treatment provides prognostic benefit over optimal antihypertensive therapy and is therefore crucial to reduce mortality and morbidity in this subgroup of patients with hypertension.

Thirty-six-month results of laparoscopic-based renal denervation plus unilateral laparoscopic adrenalectomy for the treatment of patients with resistant hypertension caused by unilateral aldosterone-producing adenoma.

The aim of this study was to explore the long‐term clinical results of Renal denervation (RDN) from the adventitia of the renal artery plus unilateral laparoscopic adrenalectomy to treat patients with resistant hypertension caused by unilateral aldosterone‐producing adenoma (APA). Sixty patients with resistant hypertension caused by APA who were treated at Henan Provincial People's Hospital from December 2016 to March 2018 were selected and randomly assigned to undergo RDN from the adventitia of the renal artery plus adrenalectomy (RDN group, n = 30) or adrenalectomy alone (control group, n = 30). Office blood pressure (BP), antihypertensive medication usage and other laboratory characteristics were followed every 6 months through 36 months. Follow‐up data were available at 36 months for 23 of 30 subjects in the RDN group and for 21 of 30 subjects who were in the control group. At 36 months postprocedure, the reduction in the RDN group was 42.2 ± 21.6 mmHg and that in the control group was 29.8 ± 13.5 mmHg (p = .029 between the groups). During the follow‐up to 36 months postprocedure, no patients in either the RDN group or the control group died due to surgical complications, and the RDN group had no procedural complications, including renal artery dissection, perforation, and renal artery stenosis. There was no change in the mean eGFR of the two groups, and no serious adverse events were reported. In conclusion, RDN from the adventitia of the renal artery plus unilateral laparoscopic adrenalectomy resulted in sustained lowering of BP at 3 years in a selected population of subjects with resistant hypertension caused by unilateral APA without serious safety concerns.

Early Identification and Diagnosis of Adrenal Crisis after Retroperitoneal Laparoscopic Unilateral Adrenalectomy

The occurrence of adrenal crisis after retroperitoneal laparoscopic unilateral adrenalectomy is usually concealed. If not timely diagnosis and treatment,it may cause shock, and even lead to death. It is very difficult to distinguish the clinical manifestations of adrenal crisis from nausea, vomiting, fatigue,gas separation from the lower diaphragm, abdominal pain, hypotension, hypertension, fever and hypothermia after operation. This makes it very difficult to identify and diagnose adrenal crisis early. This article mainly discusses the early recognition, diagnosis and treatment of adrenal crisis after unilateral adrenalectomy by retroperitoneoscope.

Hypertension Editors' Picks: Hyperaldosteronism.

Hypertension Editors' Picks: Hyperaldosteronism.

A randomized placebo controlled trial comparison of pre-incision infiltration of a local anaesthetic drug to reduce postoperative pain after laparoscopic adrenalectomy

Objective: To study the efficacy of pre-incision infiltration of a local anaesthetic drug in postoperative pain following laparoscopic adrenalectomy. Material and Method: In a randomized placebo controlled study, 52 patients listed for unilateral laparoscopic adrenalectomy were randomized into 2 groups. Group I (n=26) received subcuticular pre-incision infiltration with 0.5% bupivacaine and group II (n=26) received normal saline as a placebo; all the operations were performed with the same technique by only one experienced laparoscopic urologist. Postoperative pain was assessed using the Visual Analogue Scale at the 4th, 8th, 12th, 24th, and 48th hour postoperatively as primary outcomes. The secondary outcomes were the total postoperative analgesic consumption and time to the first analgesic demand. Results: The average pain scores were significantly different at the 4th, 12th, 24th, and 48th hour postoperatively (p=0.00, 0.00, 0.001, 0.00), but insignificantly different at the 8th hour (p=0.311). There was no significant difference in nausea/vomiting, bruising score and wound infection (p=0.223, 0.298, 0.313). Postoperative analgesic consumption was significantly lower in the bupivacaine group, but time to the first analgesic demand was not significantly longer in this study. Conclusion: Our study demonstrated that pre-incision infiltration of a local anaesthetic drug is highly effective for relief of postoperative pain after laparoscopic adrenalectomy in terms of pain perception and intravenous postoperative analgesic consumption without any effects on nausea/vomiting, bruising, and wound infection.

Primary aldosteronism: The Mayo Clinic approach

Primary aldosteronism (PA) is the most common reason of secondary hypertension, that can be cured surgically or treated with targeting medical treatment. In many cases PA is not diagnosed on time, leading to aldosterone-specific cardiovascular and nephritic lesions. Effective methods of treatment make it reasonable to perform case detection testing for PA at least once in all patients with hypertension. Mayo Clinic approach is aimed to simplify primary case detection testing. There is no need to use plasma aldosterone concentration/plasma renin activity ratio, all tests can be completed, whilst the patient is taking antihypertensive and other medications. The next step is confirmatory testing. The choice of pharmacological or surgical therapy depends on the results of computed tomography scans of the adrenal glands and adrenal venous sampling. The last one is performed only after discussing with patient the advantages and disadvantages of all therapy methods and positive intention to surgery. Laparoscopic unilateral adrenalectomy is the procedure of choice in patients with unilateral adrenal disease. In patients with bilateral aldosterone hypersecretion, the optimal is a low-sodium diet and lifelong treatment with a mineralocorticoid receptor antagonist administered at a dosage to reach a high-normal serum potassium concentration.

Enfermedades de la secreción de aldosterona

Hyper- and hypoaldosteronism are caused by an excessive or insufficient adrenal secretion of aldosterone, respectively. Idiopathic bilateral hyperplasia and aldosterone-producing adenoma are the commonest causes of primary hyperaldosteronism. Primary hyperaldosteronism is characterized by hypertension, hypokalemia and metabolic alkalosis; in turn, hypoaldosteronism presents hyperkalemia and metabolic acidosis. The aldosterone/plasma renin activity ratio (ARR) is routinely used as a screening test of primary hyperaldosteronism. Functional tests are recommended if ARR is high (salt-loading, intravenous or oral, and fludrocortisone or captopril suppression). Once diagnostic is confirmed, imaging studies (abdominal computed tomography —CT—) and adrenal vein catheterization (in patients for surgery) have to be performed. Plasma levels of aldosterone and renin activity have to be determined by stimulatory functional tests (response to posture and volume depletion tests). Unilateral laparoscopic adrenalectomy is recommended in primary hyperaldosteronism caused by unilateral hyperplasia or adenoma; mineralocorticoid (spironolactone) receptor antagonists are the first-choice treatment for bilateral cases and in patients considered unfit for surgery. Potassium restriction and mineralocorticoid replacement therapy with fludrocortisone is the treatment of hypoaldosteronism.