Wednesday, April 9, 2014

Adrenal Tumors: Minimally-Invasive Considerations

The paired adrenal glands sit above the kidneys bilaterally.
Adrenal tumors are common entities, with incidental adrenal masses found in 3.4-7% of patients on imaging studies[1].  After appropriate imaging and endocrine workup, the majority of functional adrenal masses, masses over 4 cm, and masses with concerning radiographic features are candidates for surgical resection. Once the decision is made to undergo surgery, an adrenal tumors can be removed via a traditional “open” approach or through a minimally-invasive approach -- either laparoscopic or robotic.

Many patients with adrenal masses wonder if there are minimally-invasive options for adrenal surgery and if minimally-invasive surgery is a good idea?  

The following blog reviews the data and outcomes for minimally-invasive adrenal surgery.

Laparoscopic adrenalectomy was initially described by Gagner et al in 1992.[2]  Since its introduction, it has become the gold standard for the surgical treatment of benign adrenal neoplasms and is increasingly used for malignant tumors [3-6].  Multiple study have demonstrated decreased pain, lower blood loss, faster convalescence, less ileus, and shorter hospital stays.[4, 7-14]  Regardless of underlying pathology, the best outcomes for adrenal resection have been associated with high volume surgeons.[15]  While the majority of studies have focused on outcomes in adults, emerging literature also supports safety and feasibility of a laparoscopic approach in children also. [16, 17]

Laparoscopy for Specific Adrenal Tumors

Primary Hyperaldosteronoma

In patients with symptomatic primary hyperaldosteronism, laparoscopic adrenalectomy was associated with few postoperative complications, shorter hospital stay and equivalent improvement of hypertension and hypokalemia compared to patients treated with an open approach. [7, 18]

Pheochromocytoma

Similarly, the resection of pheochromocytomas, though to be more difficult both to catecholamine release during manipulation as well as increased vascularity, is aided by a laparoscopic approach. Compared to open surgery, laparoscopy was associated with lower blood loss [19-22] and shorter length of stay. [11, 19, 20, 23-25] Additionally, episodes of intraoperative hypertension or hypotension were either less [20, 25] or similar during laparoscopic procedures.

Adrenocortical Carcinoma (ACC)

The use of laparoscopy for adrenocortical carcinoma (ACC) is debated.  While no prospective, comparative series have been reported, retrospective series have reported increased recurrence, peritoneal carcinomatosis, positive margins and local recurrence rates for laparoscopic cases compared to open. [26-30] Conversely, in a matched-comparison of laparoscopic and open adrenalectomy for ACC less than 10 cm, no difference in cancer-specific survival, tumor capsule violation of carcinomatosis was noted. [31] Taken together, while a laparoscopic approach may be feasible for select cases of ACC without adjacent organ invasion, an open surgical approach remains the gold standard.

Considering Laparoscopic or Open Adrenal Surgery

Laparoscopic resection of “large” adrenal masses is not well studied, due to both inconsistency of what size constitutes a large mass and a dearth of studies addressing this question. It is well established, however, that size is correlated with the risk of ACC. Using a size cutoff of 4 cm, the sensitivity for ACC is 93%, though the specificity is only 42%.[32] As previously described, tumors with preoperative concern for ACC are most safely resected by an open approach. For benign tumors, however, most series describe similar outcomes across size ranges, with similar morbidity [24, 33, 34]. However, resection of adrenal masses greater than 8 cm are associated with longer operative, increased blood loss and longer hospital stay.[34] Moreover, larger tumors may be associated with a higher risk of open conversion.[35]  For larger tumors found to be locally invasive or otherwise concerning for ACC during laparoscopy, most authors recommend an open conversion [36, 37]

Robotic Adrenalectomy

Robotic surgery is increasingly utilized as an alternative to laparoscopic surgery. Multiple feasibility studies have demonstrated the safety and feasibility of robotic adrenalectomy. [38-44] The perceived advantage of robotics over traditional laparoscopy includes stereoscopic vision, improved magnification, and greater range of motion.[45]  A recent systematic review and meta-analysis, including 1 randomized clinical trial and 8 observational studies demonstrated lower blood loss and hospital stay in robotic cases, and similar operative times, conversion rates, and complication rates.


This blog was written by Mark W. Ball, MD, urology resident at the Brady Urological Institute at Johns Hopkins.  It is extracted from a publication written with Mohamad E. Allaf, MD, Associate Professor and Director of Robotic Surgery at the Brady, for the ICUD-EAU Consultation on Minimally Invasive Surgery in Urology, 2014 Guidelines.











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[3] Nehs MA, Ruan DT. Minimally invasive adrenal surgery: an update. Current opinion in endocrinology, diabetes, and obesity. 2011;18(3):193-7.
[4] Wang HS, Li CC, Chou YH, Wang CJ, Wu WJ, Huang CH. Comparison of laparoscopic adrenalectomy with open surgery for adrenal tumors. The Kaohsiung journal of medical sciences. 2009;25(8):438-44.
[5] Ariyan C, Strong VE. The current status of laparoscopic adrenalectomy. Advances in surgery. 2007;41:133-53.
[6] Hall DW, Raman JD. Has laparoscopy impacted the indications for adrenalectomy? Curr Urol Rep. 2010;11(2):132-7.
[7] Shen WT, Lim RC, Siperstein AE, Clark OH, Schecter WP, Hunt TK, et al. Laparoscopic vs open adrenalectomy for the treatment of primary hyperaldosteronism. Archives of surgery (Chicago, Ill : 1960). 1999;134(6):628-31; discussion 31-2.
[8] Hallfeldt KK, Mussack T, Trupka A, Hohenbleicher F, Schmidbauer S. Laparoscopic lateral adrenalectomy versus open posterior adrenalectomy for the treatment of benign adrenal tumors. Surg Endosc. 2003;17(2):264-7.
[9] Kim HH, Kim GH, Sung GT. Laparoscopic adrenalectomy for pheochromocytoma: comparison with conventional open adrenalectomy. J Endourol. 2004;18(3):251-5.
[10] Ramachandran MS, Reid JA, Dolan SJ, Farling PA, Russell CF. Laparoscopic adrenalectomy versus open adrenalectomy: results from a retrospective comparative study. The Ulster medical journal. 2006;75(2):126-8.
[11] Humphrey R, Gray D, Pautler S, Davies W. Laparoscopic compared with open adrenalectomy for resection of pheochromocytoma: a review of 47 cases. Canadian journal of surgery Journal canadien de chirurgie. 2008;51(4):276-80.
[12] Kirshtein B, Yelle JD, Moloo H, Poulin E. Laparoscopic adrenalectomy for adrenal malignancy: a preliminary report comparing the short-term outcomes with open adrenalectomy. Journal of laparoendoscopic & advanced surgical techniques Part A. 2008;18(1):42-6.
[13] Lubikowski J, Uminski M, Andrysiak-Mamos E, Pynka S, Fuchs H, Wojcicki M, et al. From open to laparoscopic adrenalectomy: thirty years' experience of one medical centre. Endokrynologia Polska. 2010;61(1):94-101.
[14] Mir MC, Klink JC, Guillotreau J, Long JA, Miocinovic R, Kaouk JH, et al. Comparative outcomes of laparoscopic and open adrenalectomy for adrenocortical carcinoma: single, high-volume center experience. Ann Surg Oncol. 2013;20(5):1456-61.
[15] Park HS, Roman SA, Sosa JA. Outcomes from 3144 adrenalectomies in the United States: which matters more, surgeon volume or specialty? Archives of surgery. 2009;144(11):1060-7.
[16] Lopes RI, Denes FT, Bissoli J, Mendonca BB, Srougi M. Laparoscopic adrenalectomy in children. Journal of pediatric urology. 2012;8(4):379-85.
[17] Yankovic F, Undre S, Mushtaq I. Surgical technique: Retroperitoneoscopic approach for adrenal masses in children. Journal of pediatric urology. 2013.
[18] Duncan JL, 3rd, Fuhrman GM, Bolton JS, Bowen JD, Richardson WS. Laparoscopic adrenalectomy is superior to an open approach to treat primary hyperaldosteronism. The American surgeon. 2000;66(10):932-5; discussion 5-6.
[19] Tiberio GA, Baiocchi GL, Arru L, Agabiti Rosei C, De Ponti S, Matheis A, et al. Prospective randomized comparison of laparoscopic versus open adrenalectomy for sporadic pheochromocytoma. Surg Endosc. 2008;22(6):1435-9.
[20] Lang B, Fu B, OuYang JZ, Wang BJ, Zhang GX, Xu K, et al. Retrospective comparison of retroperitoneoscopic versus open adrenalectomy for pheochromocytoma. J Urol. 2008;179(1):57-60; discussion
[21] Ichikawa T, Mikami K, Komiya A, Suzuki H, Shimizu A, Akakura K, et al. Laparoscopic adrenalectomy for functioning adrenal tumors: clinical experiences with 38 cases and comparison with open adrenalectomy. Biomed Pharmacother. 2000;54 Suppl 1:178s-82s.
[22] Hemal AK, Kumar R, Misra MC, Gupta NP, Chumber S. Retroperitoneoscopic adrenalectomy for pheochromocytoma: comparison with open surgery. Jsls. 2003;7(4):341-5.
[23] Davies MJ, McGlade DP, Banting SW. A comparison of open and laparoscopic approaches to adrenalectomy in patients with phaeochromocytoma. Anaesthesia and intensive care. 2004;32(2):224-9.
[24] Hemal AK, Singh A, Gupta NP. Whether adrenal mass more than 5 cm can pose problem in laparoscopic adrenalectomy? An evaluation of 22 patients. World J Urol. 2008;26(5):505-8.
[25] Edwin B, Kazaryan AM, Mala T, Pfeffer PF, Tønnessen TI, Fosse E. Laparoscopic and open surgery for pheochromocytoma. BMC surgery. 2001;1(1):2.
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[27] Leboulleux S, Deandreis D, Al Ghuzlan A, Auperin A, Goere D, Dromain C, et al. Adrenocortical carcinoma: is the surgical approach a risk factor of peritoneal carcinomatosis? European Journal of Endocrinology. 2010;162(6):1147-53.
[28] Lombardi CP, Raffaelli M, De Crea C, Bellantone R. Role of laparoscopy in the management of adrenal malignancies. Journal of surgical oncology. 2006;94(2):128-31.
[29] Miller BS, Gauger PG, Hammer GD, Doherty GM. Resection of adrenocortical carcinoma is less complete and local recurrence occurs sooner and more often after laparoscopic adrenalectomy than after open adrenalectomy. Surgery. 2012;152(6):1150-7.
[30] Porpiglia F, Fiori C, Daffara F, Zaggia B, Bollito E, Volante M, et al. Retrospective evaluation of the outcome of open versus laparoscopic adrenalectomy for stage I and II adrenocortical cancer. European urology. 2010;57(5):873-8.
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[32] Mantero F, Terzolo M, Arnaldi G, Osella G, Masini AM, Ali A, et al. A survey on adrenal incidentaloma in Italy. Study Group on Adrenal Tumors of the Italian Society of Endocrinology. J Clin Endocrinol Metab. 2000;85(2):637-44.
[33] Bittner JGt, Gershuni VM, Matthews BD, Moley JF, Brunt LM. Risk factors affecting operative approach, conversion, and morbidity for adrenalectomy: a single-institution series of 402 patients. Surg Endosc. 2013;27(7):2342-50.
[34] Castillo OA, Vitagliano G, Secin FP, Kerkebe M, Arellano L. Laparoscopic adrenalectomy for adrenal masses: does size matter? Urology. 2008;71(6):1138-41.
[35] Parnaby C, Chong P, Chisholm L, Farrow J, Connell J, O’Dwyer P. The role of laparoscopic adrenalectomy for adrenal tumours of 6 cm or greater. Surgical endoscopy. 2008;22(3):617-21.
[36] Henry J-F, Sebag F, Iacobone M, Mirallie E. Results of laparoscopic adrenalectomy for large and potentially malignant tumors. World journal of surgery. 2002;26(8):1043-7.
[37] Shen WT, Sturgeon C, Duh QY. From incidentaloma to adrenocortical carcinoma: the surgical management of adrenal tumors. Journal of surgical oncology. 2005;89(3):186-92.
[38] Ludwig AT, Wagner KR, Lowry PS, Papaconstantinou HT, Lairmore TC. Robot-assisted posterior retroperitoneoscopic adrenalectomy. J Endourol. 2010;24(8):1307-14.
[39] Park JH, Kim SY, Lee CR, Park S, Jeong JS, Kang SW, et al. Robot-assisted posterior retroperitoneoscopic adrenalectomy using single-port access: technical feasibility and preliminary results. Ann Surg Oncol. 2013;20(8):2741-5.
[40] Park JH, Walz MK, Kang SW, Jeong JJ, Nam KH, Chang HS, et al. Robot-assisted posterior retroperitoneoscopic adrenalectomy: single port access. Journal of the Korean Surgical Society. 2011;81 Suppl 1:S21-4.
[41] D'Annibale A, Lucandri G, Monsellato I, De Angelis M, Pernazza G, Alfano G, et al. Robotic adrenalectomy: technical aspects, early results and learning curve. The international journal of medical robotics + computer assisted surgery : MRCAS. 2012;8(4):483-90.
[42] Pineda-Solis K, Medina-Franco H, Heslin MJ. Robotic versus laparoscopic adrenalectomy: a comparative study in a high-volume center. Surg Endosc. 2013;27(2):599-602.
[43] Agcaoglu O, Aliyev S, Karabulut K, Mitchell J, Siperstein A, Berber E. Robotic versus laparoscopic resection of large adrenal tumors. Ann Surg Oncol. 2012;19(7):2288-94.
[44] Dickson PV, Alex GC, Grubbs EG, Jimenez C, Lee JE, Perrier ND. Robotic-assisted retroperitoneoscopic adrenalectomy: making a good procedure even better. The American surgeon. 2013;79(1):84-9.
[45] Hyams ES, Stifelman MD. The role of robotics for adrenal pathology. Curr Opin Urol. 2009;19(1):89-96.

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