Historical Contribution: 1919, HH Young, Mercurochrome

1919

Young HH, White EC, Swartz EO. A New Germicide for the Use in the Genitourinary Tract: "Mercurochrome-220". JAMA. 1919;73:20:1483-91.


At the turn of the 20th Century, one of the urologists biggest tasks was the treatment of urinary tract  and sexually transmitted infections; and their sequelae (including abscess, strictures, etc.).  Hugh Hampton Young and other urologists were in search of a sufficient urinary antiseptic, especially after World War I where venereal disease accounted for an estimated 7 million person-days lost and 10,000 discharges in the US army; and 416,891 hospital admissions among British troops accounting nearly 5% of the entire British force.[1]

mercurochrome-220

In 1919, HH Young reported results from Johns Hopkins in the Journal of the American Medical Association (JAMA), where mercurochrome-220 was used to sterilize the bladder.  Dr. Young wrote:

"The speed with which some old infections of the bladder and kidney pelvis have disappeared after its use is striking, and the absence of irritating and toxic qualities, together with the ability of the patient to retain a 1 per cent, solution for hours without discomfort, are sufficiently proved to establish the possibilities of the drug in these conditions." 

This work earned Young and colleagues a grant from the Interdepartmental Social Hygiene Board.

Young detailed the important properties needed for a new "urinary germicide":

1. ready penetration of the tissues in which the infection exists
2. lack of irritation of the drug to tissues
3. high germicidal activity
4. ready solubility in water and stability of the solution
5. freedom from precipitation in urine
6. sufficiently low toxicity to avoid systemic effects from the small amount of the drug that may be absorbed. 

Young and colleagues then demonstrated the ability of mercurochrome to kill a variety of bacteria including Balantidium Coli and Staphylococcus aureus; and compared its efficacy to other, known antimicrobial compounds.

In Dr. Young's typical meticulous fashion, the authors report the outcomes of 10 patients treated for cystitis, 14 treated topically for chancroid and comment on the outcomes of 51 patients treated for gonorrheal urethritis - all of which responded to treatment.

Read the entire manuscript using the link above or here.


HISTORICAL CONTRIBUTIONS highlight the greatest academic manuscripts from the Brady Urological Institute over the past 100 years.  As the Brady Urological Institute approaches its centennial, we will present a HISTORICAL CONTRIBUTION from each of the past 100 years.  In the most recent experience, the most highly cited article from each year is selected; older manuscripts were selected based on their perceived impact on the field.  We hope you enjoy! 

[1] Mitchell, T.J, & Smith, G.M. (1931) Medical Services: Casualties and Medical Statistics of the Great War, History of the Great War, Based on Official Documents (London: HMSO).

Stone Disease: Minimizing Recurrence Through a Comprehensive Approach

The lifetime prevalence of kidney stones is estimated to be 10-15% in the United States.[1-2]  While kidney stones are more common in men, caucasians, and in warmer climates; the most common risk factor for a kidney stone is a prior stone.  After one episode, the risk of recurrence is 50% in the next 5-10 years.[3-5]

Brian Matlaga, MD, is the Director of Stone Disease at the Brady Urological Institute at Johns Hopkins,

"If you have one stone, you have a 50% lifetime recurrence risk, which is pretty high.  Patients with a stone have two problems: [the first is treating the stone, then] we need to figure out why the stone formed and how to lower those risk factors." 

For the majority of first-time stone formers, dietary and behavioral modifications are enough to reduce the risk of a second stone.  It is estimated that of patients with a first-time stone, 60% or greater are idiopathic stone formers (or stone formers without a particular cause).[6]  Therefore, making simple dietary modifications can help most people who form a stone, without subjecting them to a plethora of diagnostic tests.
These modifications include:

1. hydration
2. minimizing salt intake
3. normal calcium in the diet
4. low animal protein

     See the blog entry: Classic Manuscripts in Urology: Borghi, NEJM 2002 to learn more about dietary modifications in stone disease. 

However, other studies demonstrate that 50% of stone formers will have hypercalciuria or hyperuricosuria (elevated amounts of common components of kidney stones in the urine) and 20% of patients will have a systemic disease that contributes to stone formation.[7,8]  Therefore the decision to undergo a complete metabolic stone work-up should be based on an assessment and discussion of patient risk factors and evaluation of the obstructing kidney stone when it has been removed.

In general, a complete metabolic stone evaluation includes:

• a thorough history and physical
• medication review
• blood work (basic metabolic panel, calcium , parathyroid hormone, uric acid)
• stone analysis
• 24-hour urinalysis (a patient may be required to do one or several repeat tests)

Patients at high-risk of stone recurrence (and therefore those that should undergo complete metabolic evaluation at the time of their first stone) include:

• family history of stones
• those with intestinal disease (particularly when causing chronic diarrheal states)
• pathologic skeletal fractures/osteoporosis
• urinary tract infection
• gout
• stones composed of: 
• cystine
• uric acid
• struvite 
• all children (children have a much higher risk of underlying systemic disease or metabolic derangement leading to recurrent stones)[9-13]

At the Brady Urological Institute, Dr. Matlaga helps coordinate a Comprehensive Stone Clinic, in which a patient can be seen, evaluated and managed by a urologist, nephrologist and nutritionist.  This "team approach" often helps determine who needs a complete metabolic evaluation and how often do patients need to be seen.  Using 24-hour urine tests, Dr. Matlaga and colleagues can "back-calculate" a patient's metabolic risk factors to see whether "it's too much calcium, too much oxalate or not enough inhibitors of stone formation, and then we can say,

"Your recurrence risk is now 50 percent; let's try and get it down to about 10% (the general population's risk)."

This works particularly well in the pediatric population where "[urologists] are used to taking care of complex surgical problems, we have a pediatric nephrologist who is used to taking care of complex medical problems, and the nutritionist manages the dietary issues."

If you, a loved one, or a patient has stone disease and would like to be evaluated by Dr. Matlaga and colleagues at Johns Hopkins, please call 410 955 6100 (adults) or 410-955-6108 (children).

Part of this blog was extracted from "A Comprehensive Approach to Stone Disease" in Johns Hopkins Urology News for Physicians, Spring 2014.

[1] Johnson CM, Wilson DM, O’Fallon WM,et al: Renal stone epidemiology: a 25-year study in Rochester, Minnesota. Kidney Int 1979; 16: 624-631
[2] Sierakowski R, Finlayson B, Landes R,et al: The frequency of urolithiasis in hospital discharge diagnoses in the United States. Invest Urol 1978; 15: 438-441
[3] Uribarri J, Oh MS, Carroll HJ,et al: The first kidney stone. Ann Intern Med 1989; 111: 1006-1009
[4] Ljunghall S, Danielson BG: A prospective study of renal stone recurrences. Br J Urol 1984; 56: 122-124
[5] Ljunghall S, Backman U: Calcium and magnesium metabolism during long-term treatment with thiazides. Scand J Urol Nephrol 1981; 15: 257-262
[6] Hosking DH, Erickson SB: The stone clinic effect in patients with idiopathic calcium urolithiasis. J Urol 1983; 130: 1115-1118
[7] Pak CY: Should patients with single renal stone occurrence undergo diagnostic evaluation?. J Urol 1982; 127: 855-858
[8] Strauss AL, Coe FL: Factors that predict relapse of calcium nephrolithiasis during treatment: a prospective study. Am J Med 1982; 72: 17-24
[9] Bartosh SM: Medical management of pediatric stone disease. Urol Clin North Am 2004; 31: 575-587x–xi
[10] Coward RJ, Peters CJ: Epidemiology of paediatric renal stone disease in the UK. Arch Dis Child 2003; 88: 962-965
[11] Pietrow PK, Pope JC: Clinical outcome of pediatric stone disease. J Urol 2002; 167: 670-673
[12] Polito C, Manna ALa: Clinical presentation and natural course of idiopathic hypercalciuria in children. Pediatr Nephrol 2000; 15: 211-214
[13] Tekin A, Tekgul S: Ureteropelvic junction obstruction and coexisting renal calculi in children: role of metabolic abnormalities. Urology 2001; 57: 542-545discussion 545–6

Is a DMSA Scan Necessary for UTI in Children?

The classic teaching in the evaluation of children with febrile, culture-proven urinary tract infections (UTI) is to order a DMSA (dimercaptosuccinic acid) Scan to look for scarring of the kidney.  If the kidney is scarred, it indicates a serious infection that warrants treatment to prevent long-term damage to the kidney.

DMSA is injected intravenously, taken up by the kidney over the next two to four hours during which repeat imaging is taken.  It requires that child get an IV, stay in the hospital for a few hours, are often given general anesthesia, and has a small, but not negligible, radiation exposure.  Areas of decreased uptake on a DMSA Scan represent pyelonephritis or scarring. In a systematic review of 33 studies, approximately 60 percent of children with initial UTI had DMSA scans consistent with acute pyelonephritis in the acute phase of illness, but only 15 percent had renal scarring at follow-up [1].  Many children are given one or more repeat DMSA Scans as follow-up to monitor their infections.

Ming-Hsien Wang, MD, Assistant Professor of Pediatric Urology at the Brady Urological Institute at Johns Hopkins challenges the use of DMSA as a first-line study of children with UTI,

"A baseline ultrasound can tell you whether there's significant scar, and it can do so without exposing children to the side effects of a test that has minimal clinical benefit."

Dr. Wang and colleagues investigated 126 Johns Hopkins Children's Center patients (age 1 month to 5 years) and found that DMSA did not improve the diagnosis when ultrasound was used as the initial test to evaluate for renal scarring and infection.  This research will be presented at the upcoming American Urological Association (AUA) Annual Meeting in Orlando, Florida; and the European Society for Pediatric Urology (ESPU) Annual Meeting in Innsbruck, Austria.

Dr. Wang and colleagues see approximately 200 children each year with fever and culture-proven UTI.  "Our protocol for these children is baseline ultrasound, and we do not order a DMSA unless the ultrasound shows evidence of scar."  Dr. Wang is a co-principle investigator for an ongoing NIH study of UTI in children and is working to develop evidence-based clinical decision rules to improve diagnosis and avoid unnecessary tests in children.


Portions of this blog entry are extracted from "Rethinking the DMSA Scan" in the Johns Hopkins Urology Newsletter for Physicians.


[1] Shaikh N, Ewing AL, Bhatnagar S, Hoberman A.  Risk of renal scarring in children with a first urinary tract infection: a systematic review.  Pediatrics. 2010 Dec;126(6):1084-91. doi: 10.1542/peds.2010-0685. Epub 2010 Nov 8.

Historical Contribution: 1918, HH Young, High Frequency Current for Extraction of Calculi

Hugh Hampton Young

1918

Young HH.  The Employment of the High Frequency Current for the Extraction of Calculi Incarcerated in the Lower End of the Ureter.  Journal of Urology. 1918;2:35-38

At the turn of the century, the management options for ureteral stones were limited and most were treated with open surgery.  In this 1918 manuscript, HH Young describes an "exhaustive study," in which one distal stone was able to be freed from the distal ureter by manipulating it with a ureteral catheter, but most stones were removed by suprpubic cystotomy with use of "dilating instruments, forceps or scissors."

Known for his innovation, HH Young developed an instrument and "[t]he technique which is presented herewith consists in the employment of high frequency spark to incise the mucous membrane covering the incarcerated calculus, thus enlarging the ureteral orifice to a degree sufficient to permit its passage into the bladder."

Using a device similar to our modern day bugbee electrocautery, HH Young incised the distal ureter in three patients, described their clinical presentation, treatment and outcomes.  He describes one of the first endoscopic operations on the upper tract that involved more than a catheter, wire or simple dilation.  This opened the possibilities of the wide variety of endoscopic operations urologists perform on a daily basis.  In HH Young's words, "this operation is simple, can be carried out without anesthetia, and does not produce more than a slight hemorrhage."

Read the entire manuscript using the link above or here.

HISTORICAL CONTRIBUTIONS highlight the greatest academic manuscripts from the Brady Urological Institute over the past 100 years.  As the Brady Urological Institute approaches its centennial, we will present a HISTORICAL CONTRIBUTION from each of the past 100 years.  In the most recent experience, the most highly cited article from each year is selected; older manuscripts were selected based on their perceived impact on the field.  We hope you enjoy! 

Classic Manuscript in Urology: Schoor et al, Testicular Biopsy & Infertility, 2002

Azoospermia is the condition in which there are no sperm in the semen (ejaculate fluid).
In the past, almost all men with azoospermia underwent a diagnostic testicular biopsy to distinguish obstructive (blockage) from non-obstructive (sperm production) causes; normal sperm production found in the tissue suggests obstructive causes. Previously, most men with non-obstructive azoospermia had no options to father biologically related children. However, with the emergence of assisted reproductive techniques (ART) such as in-vitro fertilization  (IVF) and intracytoplasmic sperm injection (ICSI), a pregnancy could be initiated using very low numbers of sperm.

For men with non-obstructive azoospermia, we typically offer microsurgical-dissection testicular sperm extraction (microTESE), which gives the best chance of finding sperm within the testis that can be used with ART. In contrast, men with obstructive azoospermia can seek reconstruction to relieve the obstruction and attempt natural conception, or they can use surgically retrieved sperm with similar assisted reproductive techniques. To plan for the most appropriate treatment, it is highly valuable to be able to characterize the cause of azoospermia without a diagnostic biopsy.

Schoor RA, Elhanbly S, Niederberger CS, Ross LS.  The Role of Testicular Biopsy in the Modern Management of Male Infertility.  J Urol 2002; 167(1):197-200.

PubMed.
Journal of Urology.

In this study, Dr. Schoor and colleagues retrospectively reviewed the records of 153 azoospermic men.  The authors recognized that classic texts of infertility described men with obstructive azoospermia having “normal” endocrine profiles, testicular volumes and long axis length, while men with nonobstructive azoospermia will have an abnormality in 1 or more of these parameters.  However, the importance of these abnormalities had not been defined in the modern era of infertility.

They investigated a number of parameters including follicle stimulating hormone (FSH), leutenizing hormone (LH), prolactin, and testicular size, were analyzed as predictors for obstructive vs. non-obstructive azoospermia.  FSH and testicular long axis were found to be the best individual diagnostic predictors:

• 96% of men with obstructive azoospermia had:
• FSH <7.6 mIU/mL
• Testicular Long Axis > 4.6cm
• 89% of men with nonobstructive azoospermia had: 
• FSH >7.6 mIU/mL
• Testicular Long Axis < 4.6cm 

Take Home: Not only did this study define clinical parameters to distinguish obstructive and nonobstructive azoospermia, but is also implies that testicular biopsy is generally unnecessary in the initial evaluation of azoospermia.  Avoiding testicular biopsy reduced the cost and risk associated with evaluation of azoospermia for many men.

For the majority of patients with findings suggesting non-obstructive azoospermia, we now proceed directly to microTESE. Diagnostic biopsy is still performed for a small subset of patients whose findings suggest obstructive azoospermia, as a significant fraction of them may still have a sperm production problem within the testis. For more information, see: http://malefertility.jhu.edu/fertility_evaluation.php

This blog entry was written by Pravin Rao, MD, Director of Reproductive Medicine and Surgery at the Brady Urological Institute at Johns Hopkins.

Classic Manuscripts in Urology will be posted on this blog on regular basis.  These articles are meant to highlight the achievements of our predecessors, recognize the work from which we build our careers and stimulate new conversations and discussion on a variety of urological topics.  Please feel free to comment on this manuscript, help point out its strengths and weaknesses, or suggest a new manuscript and topic. 

Renal Cysts: Cause for Concern?

A cyst is a thin-walled, cell-lined collection of fluid.  They can occur in nearly every tissue type and many places in the body including the brain, lung, nerve tissue and skin. Renal cysts are incredibly common, affecting up to 50% of 50-year olds in the United States and increasing in prevalence with age.[1]  Renal cysts represent upwards of 70% of the asymptomatic, benign renal masses discovered incidentally.[2]  Risk factors for cyst formation include:

• increasing age
• male gender
• hypertension
• chronic kidney disease (renal insufficiency) [3]

The main concern of patients and physicians is that renal cysts are cancerous or will develop into a cancer.  In an excellent study of the natural history of renal cysts, with increasing time cysts are demonstrated to grow slowly (average 1.9mm/year), increase in number and only rarely develop into cancers.[4]  Predicting which cysts are potentially malignant is a tough task.

The Bosniak Classification System

Bosniak I

In 1986, Dr. Bosniak, radiologist at New York University in New York City, defined the characteristics of simple and complex renal cysts to reduce unnecessary surgery on benign lesions.  Thus the Bosniak System was created, categorizing each renal cyst into four (and then five in 1993) categories that predict malignant behavior.[5] The single-most important imaging characteristic that predicts malignancy is enhancement (brightening) on contrast-based CT imaging.

Bosniak II: hyperdense cyst (right)

Bosniak I

Risk of Malignancy: 0-1.7%

Non-enhancing
Benign simple cyst
Water density
Hairline thin cyst wall
No septa, calcifications, or solid components

Bosniak II

Bosniak IIF

Risk of Malignancy: 0-18.5%

Non-enhancing

Benign cyst
May have a few thin septa
May have fine calcification in wall or septa
May be hyperdense (uniformly high attenutation lesions) if <3cm
Perceived enhancement may be present

Bosniak IIF

Bosniak III

Bosniak IV

Risk of Malignancy: 5-18.5%

Non-enhancing

May have a few thin septa
May have minimal wall thickening in wall or septa
May have thin or nodular calcifications
Perceived enhancement may be present
May be hyperdense (uniformly high attenutation lesions) if ≥3cm
Require follow-up studies to prove benignity

Bosniak III

Risk of Malignancy: 33-82%

Indeterminate cystic mass
Thickened and/or irregular walls/septa
Measurable enhancement
Surgical lesion

Bosniak IV

Risk of Malignancy: 92-93%

Clearly malignant cystic masses

Enhancing soft tissue components

Surgical lesion

Management of Renal Cysts

Most Bosniak I and II cysts do not require follow-up or treatment due to the low rate of documented progression to malignancy.  There is an association between renal cysts, chronic kidney disease and renal cell carcinoma; therefore it is reasonable to follow patients with Bosniak I and II lesions with serial ultrasounds and labs for renal function (creatinine, urinalysis) on an annual or biannual basis.  

Bosniak IIF cysts, however, should have repeat imaging on a regular basis to ensure they do not progress to malignant disease.  Progression of a cyst is defined by an increase in the Bosniak Classification Score.  In studies of Bosniak IIF cysts, 13-15% progress to Bosniak III lesions while under observation and 50-100% of the resected cysts were renal cancers.[6-8]

Bosniak III and IV cysts warrant consideration of surgical treatment.  Treatments may include partial nephrectomy (removal of the cyst only), radical nephrectomy (removal of the entire kidney) or ablative therapies.  While it is generally believed that most complex renal cysts are low-grade renal cell carcinomas, there is a significant proportion that are high-grade tumors.  

Summary

• Renal cysts are the most common benign lesion in the kidney.  
• The risk of malignancy increases with increasing complexity of the cyst.
• Bosniak I, II and IIF cysts have low-risk of malignancy and should be observed.
• Bosniak III and IV cysts have a higher risk of malignancy and therefore warrant surgical treatment.

  

This blog entry was written by Debasish Sundi, MD, Senior Assistant Resident at the Brady Urological Institute at Johns Hopkins University.  Dr. Sundi is pursuing a career in urological oncology.








[1] Torres VE, Grantham JJ. Cystic diseases of the kidney. In: Brenner BM, ed. Brenner & Rector’s The Kidney. Vol. 2. 8th ed. Philadelphia: Saunders Elsevier; 2008: 1451–1453.
[2] Terada N, Ichioka K: The natural history of simple renal cysts. J Urol 2002; 167: 21-2
[3] Terada N, Arai Y: Risk factors for renal cysts. BJU Int 2004; 93: 1300-1302
[4] Terada N, Arai Y: The 10-year natural history of simple renal cysts. Urology 2008; 71: 7-11discussion 11–12
[5] Israel GM, Bosniak MA: An update of the Bosniak renal cyst classification system. Urology 2005; 66: 484-488
[6] O'Malley RL, Godoy G, Hecht EM, Stifelman MD, Taneja SS.Bosniak category IIF designation and surgery for complex renal cysts.  J Urol. 2009 Sep;182(3):1091-5. doi: 0.1016/j.juro.2009.05.046. Epub 2009 Jul 18.
[7] Smith AD, Remer EM, Cox KL, Lieber ML, Allen BC, Shah SN, Herts BR.Bosniak category IIF and III cystic renal lesions: outcomes and associations.  Radiology. 2012 Jan;262(1):152-60. doi: 10.1148/radiol.11110888. Epub 2011 Nov 21.
[8] El-Mokadem I, Budak M, Pillai S, Lang S, Doull R, Goodman C, Nabi G.  Progression, interobserver agreement, and malignancy rate in complex renal cysts ( ≥ Bosniak category IIF).  Urol Oncol. 2014 Jan;32(1):24.e21-7. doi: 10.1016/j.urolonc.2012.08.018. Epub 2013 Feb 6.

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.











[1] Nieman LK. Approach to the patient with an adrenal incidentaloma. Journal of Clinical Endocrinology & Metabolism. 2010;95(9):4106-13.
[2] Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl j Med. 1992;327(14):1033.
[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.
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