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Current Opinion in Endocrinology,... Jun 2023Review the literature on the surgical management of adrenal diseases, highlighting the various surgical approaches and their respective pros and cons. (Review)
Review
PURPOSE OF REVIEW
Review the literature on the surgical management of adrenal diseases, highlighting the various surgical approaches and their respective pros and cons.
RECENT FINDINGS
Minimally invasive adrenalectomy is commonly used for small and benign adrenal tumors, whereas open adrenalectomy is preferred for larger tumors and primary adrenal malignancy. Although minimally invasive adrenalectomy results in shorter recovery and fewer complications compared with open, the latter offers better oncologic outcomes in the setting of primary adrenal malignancy. Adrenalectomy is performed transabdominally or retroperitoneoscopically, both yielding equivalent results and recovery. Traditional laparoscopic or robotic equipment can be utilized for either minimally invasive approach. Subtotal adrenalectomy may be appropriate for patients with genetically associated pheochromocytoma to preserve cortical function and reduce the risk of adrenal insufficiency. However, the potential benefits of sparing adrenal function must be weighed against the risk of recurrence.
SUMMARY
Adrenalectomy is becoming increasingly common worldwide. For benign and small adrenal tumors, minimally invasive adrenalectomy is generally considered the standard approach, while open adrenalectomy is preferred for primary adrenal malignancy and larger tumors. Subtotal adrenalectomy may be appropriate for patients with bilateral adrenal pheochromocytoma, as it can reduce the need for lifelong glucocorticoid dependency.
Topics: Humans; Pheochromocytoma; Adrenal Gland Neoplasms; Adrenal Glands; Laparoscopy; Adrenalectomy
PubMed: 37057653
DOI: 10.1097/MED.0000000000000810 -
Updates in Surgery Jun 2017The history of adrenal surgery is longstanding. Firstly described in 1889 by Thornton, the open adrenalectomy has been for decades the only surgical approach to adrenal... (Review)
Review
The history of adrenal surgery is longstanding. Firstly described in 1889 by Thornton, the open adrenalectomy has been for decades the only surgical approach to adrenal diseases. Nowadays, instead, several approaches to adrenal glands have been described in the literature, such as laparoscopic adrenalectomy, robotic-assisted procedure and single-incision technique. Actually, laparoscopic adrenalectomy is considered as the gold standard treatment for adrenal lesions. In fact, all functional tumors, including pheochromocytoma, are candidates for a laparoscopic approach in the absence of other contraindications. In the adrenal gland surgery, it is important to consider that a multidisciplinary approach which comprises surgeons, anesthesiologists, endocrinologists, and oncologists plays an important role in the management of patients and that the success of the procedure is related also to surgeon experience and hospital volume. This review aims to discuss the indications for adrenalectomy and to describe the different techniques options for the adrenal gland surgery.
Topics: Adrenal Gland Diseases; Adrenalectomy; Combined Modality Therapy; Humans; Laparoscopy; Minimally Invasive Surgical Procedures; Robotic Surgical Procedures
PubMed: 28421470
DOI: 10.1007/s13304-017-0441-0 -
Journal of Laparoendoscopic & Advanced... Feb 2019Over the last few decades, robotic surgery with the da Vinci system has become increasingly prevalent. Endocrine surgeons are witnessing a rapid growth in enthusiasm for... (Review)
Review
BACKGROUND
Over the last few decades, robotic surgery with the da Vinci system has become increasingly prevalent. Endocrine surgeons are witnessing a rapid growth in enthusiasm for robotic approaches for treating thyroid, parathyroid, and adrenal disease. For carefully selected patients, the robotic system may be the preferred technique, although its use remains controversial and indications are in evolution. The goal of this article is to review current robotic procedures for thyroidectomy, parathyroidectomy, and adrenalectomy, and scrutinize the existing literature for application of these approaches.
METHODS
We systematically searched and reviewed relevant articles on PubMed and MEDLINE databases for robotic or robot-assisted thyroidectomy, parathyroidectomy, or adrenalectomy.
RESULTS
The safety and feasibility for robotic thyroidectomy, parathyroidectomy, and adrenalectomy have been repeatedly demonstrated. Although robotic thyroid and parathyroid surgery offers better cosmetic results compared to the conventional open operation, remote-access techniques introduce new risks. Similar outcomes have been reported for laparoscopic and robotic adrenalectomy, but robot-assisted techniques may extend the capabilities of minimally invasive surgery, particularly performing subtotal adrenalectomy.
CONCLUSIONS
While robotic procedures offer better ergonomics for the endocrine surgeon and improved cosmesis for the patient, the major drawback to the robot system almost universally is the higher cost. With new robotically assisted surgical devices on the way that could drive down costs and speed up innovation, the indications for robotic endocrine surgery may greatly expand.
Topics: Adrenalectomy; Humans; Laparoscopy; Parathyroidectomy; Robotic Surgical Procedures; Thyroidectomy
PubMed: 30133339
DOI: 10.1089/lap.2018.0308 -
Medicina (Kaunas, Lithuania) Nov 2022Nelson's syndrome is a potentially severe condition that may develop in patients with Cushing's disease treated with bilateral adrenalectomy. Its management can be... (Review)
Review
Nelson's syndrome is a potentially severe condition that may develop in patients with Cushing's disease treated with bilateral adrenalectomy. Its management can be challenging. Pituitary surgery followed or not by radiotherapy offers the most optimal tumour control, whilst pituitary irradiation alone needs to be considered in cases requiring intervention and are poor surgical candidates. Observation is an option for patients with small lesions, not causing mass effects to vital adjacent structures but close follow-up is required for a timely detection of corticotroph tumour progression and for further treatment if required. To date, no medical therapy has been consistently proven to be effective in Nelson's syndrome. Pharmacotherapy, however, should be considered when other management approaches have failed. A subset of patients with Nelson's syndrome may develop further tumour growth after primary treatment, and, in some cases, a truly aggressive tumour behaviour can be demonstrated. In the absence of evidence-based guidance, the management of these cases is individualized and tailored to previously offered treatments. Temozolomide has been used in patients with aggressive Nelson's with no consistent results. Development of tumour-targeted therapeutic agents are an unmet need for the management of aggressive cases of Nelson's syndrome.
Topics: Humans; Adrenocorticotropic Hormone; Nelson Syndrome; Adrenalectomy; Temozolomide
PubMed: 36363537
DOI: 10.3390/medicina58111580 -
Current Opinion in Urology Mar 2015Total adrenalectomy has been the standard treatment for small adrenal masses for years. In recent times, however, partial adrenalectomy and cortex-preserving strategies... (Review)
Review
PURPOSE OF REVIEW
Total adrenalectomy has been the standard treatment for small adrenal masses for years. In recent times, however, partial adrenalectomy and cortex-preserving strategies are gaining more importance. Therefore, we evaluated indications, techniques and outcome of partial adrenalectomy.
RECENT FINDINGS
With more small adrenal masses identified through the widespread use of imaging modalities, partial adrenalectomy and cortical-preserving strategies were applied in various indications and techniques. In all original papers published on this topic during the review period of the last 18 months, minimal invasive approaches were used with satisfying surgical and functional outcomes.
SUMMARY
There is a definitive trend towards the use of partial adrenalectomy in the treatment of small adrenal masses. In bilateral disease, steroid replacement can be avoided in most cases, whereas successful normalization of pathological endocrine levels was reported in various indications. Therefore, minimal invasive partial adrenalectomy may become the recommended standard treatment of small benign and hormonal active adrenal tumours.
Topics: Adrenal Cortex Neoplasms; Adrenal Gland Neoplasms; Adrenalectomy; Adrenocortical Adenoma; Catheter Ablation; Humans; Laparoscopy; Organ Sparing Treatments; Pheochromocytoma; Robotic Surgical Procedures
PubMed: 25581540
DOI: 10.1097/MOU.0000000000000147 -
Current Hypertension Reports Aug 2022In this narrative review, we aim to summarize the latest data on the association between primary aldosteronism and resistant hypertension, as well as to emphasize the... (Review)
Review
PURPOSE OF REVIEW
In this narrative review, we aim to summarize the latest data on the association between primary aldosteronism and resistant hypertension, as well as to emphasize the necessity for screening for primary aldosteronism all patients with resistant hypertension.
RECENT FINDINGS
Epidemiological data suggests that up to one out of five patients with resistant hypertension suffer from primary aldosteronism. Patients with primary aldosteronism have increased incidence of renal disease, diabetes mellitus, atrial fibrillation, and obstructive sleep apnea, as well as they are characterized by an extended target organ damage and increased cardiovascular morbidity and mortality. Specific treatments for primary hyperaldosteronism (adrenalectomy and mineralocorticoid receptor antagonists) have significant impact on blood pressure, can reverse target organ damage, and mitigate cardiovascular risk. All patients with resistant hypertension should be evaluated for primary aldosteronism. Patients diagnosed with the disease may further undergo lateralization with adrenal vein sampling in order to receive the optimal therapeutic option which results in significant improvements in quality of life and cardiovascular profile.
Topics: Adrenalectomy; Humans; Hyperaldosteronism; Hypertension; Mineralocorticoid Receptor Antagonists; Quality of Life
PubMed: 35445928
DOI: 10.1007/s11906-022-01190-9 -
Updates in Surgery Jun 2017Adrenal tumors can vary from a benign adrenocortical adenoma with no hormonal secretion to a secretory adrenocortical malignancy (adrenocortical carcinoma) or a... (Review)
Review
Adrenal tumors can vary from a benign adrenocortical adenoma with no hormonal secretion to a secretory adrenocortical malignancy (adrenocortical carcinoma) or a hormone-secreting tumor of the adrenal medulla (pheochromocytoma). Currently, laparoscopic adrenalectomy is regarded as the preferred surgical approach for the management of most adrenal surgical disorders, although there are no prospective randomized trials comparing this technique with open adrenalectomy. However, widespread adoption of robotic technology has positioned robotic adrenalectomy as an option in some medical centers. Speculative advantages associated with the use of the robotic system have rarely been evaluated in clinical settings and cost increase remains an important drawback associated with robotic surgery. This review summarizes current available data regarding robotic transperitoneal adrenalectomy including its indications, advantages, limitations, and comparison with conventional laparoscopic adrenalectomy. We believe that the use of a robotic system seems to be useful especially in more difficult patients with larger tumors, truncal paragangliomas, and bilateral and/or partial adrenalectomies. Overall, we believe that overcosts due to robotic system use could be balanced by hospital stay decrease, patients' referral increase, improved postoperative outcomes in more difficult patients and ergonomics for the surgeon. However, we also believe that the current surgical intuitive business model is counterproductive, because there are no available strong clinical data that could balance overcosts associated with the use of the robotic system.
Topics: Adrenal Gland Neoplasms; Adrenalectomy; Humans; Laparoscopy; Robotic Surgical Procedures
PubMed: 28497219
DOI: 10.1007/s13304-017-0448-6 -
Chirurgie (Heidelberg, Germany) Sep 2022Despite the triumph of minimally invasive techniques in adrenal surgery, the indications for open adrenalectomy are indispensable in the canon of treatment options and... (Review)
Review
Despite the triumph of minimally invasive techniques in adrenal surgery, the indications for open adrenalectomy are indispensable in the canon of treatment options and must remain part of the repertoire of visceral surgery. Open adrenalectomy is indicated for advanced adrenal carcinoma (ENSAT stage III). In addition to the frequent local infiltration of these carcinomas which makes the en bloc resection of adjacent organs necessary, thromboses in the renal vein or the vena cava or multiple lymph node metastases can also necessitate an open procedure; however, open adrenalectomy is justified and must also be discussed for adrenocortical carcinoma ENSAT stages I-II (tumor size ≤ 5 cm or > 5 cm, NO). Furthermore, highly suspicious large adrenal tumors (6-8 cm, Hounsfield units > 20) without preoperative evidence of malignancy and other adrenal pathologies, such as neuroblastomas, large pheochromocytomas and also schwannomas can be an indication for open adrenalectomy.
Topics: Adrenal Cortex Neoplasms; Adrenal Gland Neoplasms; Adrenalectomy; Adrenocortical Carcinoma; Humans; Pheochromocytoma
PubMed: 35788865
DOI: 10.1007/s00104-022-01678-9 -
Chirurgia (Bucharest, Romania : 1990) 2017Laparoscopic adrenalectomy became the gold standard for adrenal disease, from incidentaloma to cancer. Partial adrenalectomy is difficult to accept due to its technical...
Laparoscopic adrenalectomy became the gold standard for adrenal disease, from incidentaloma to cancer. Partial adrenalectomy is difficult to accept due to its technical difficulties as well as hemorrhagic risk and a consensus has not been reached. On the other hand, in selected cases of benign adrenal tumors, adrenalectomy may be futile, partial resections being perfectly justified and with lower hemorrhagic risks. For functioning tumors smaller than 3 cm with an anterior or lateral location, partial adrenalectomy may be indicated. The key points reside in adenoma identification, preservation of the remaining glandular parenchyma and its blood supply with dissection in the space between the adenoma and the normal parenchyma. Laparoscopic partial adrenalectomy is feasible and effective for the treatment of benign tumors. Although partial resections have clear-cut advantages over conventional adrenalectomy especially for bilateral tumors, it remains a difficult intervention.
Topics: Adrenal Gland Diseases; Adrenal Gland Neoplasms; Adrenalectomy; Feasibility Studies; Humans; Laparoscopy; Treatment Outcome
PubMed: 28266298
DOI: 10.21614/chirurgia.112.1.77 -
Endocrinology and Metabolism Clinics of... Jun 2018During the last 20 years, a significant body of literature has accumulated regarding subclinical hypercortisolism in patients with adrenal incidentalomas. Retrospective... (Review)
Review
During the last 20 years, a significant body of literature has accumulated regarding subclinical hypercortisolism in patients with adrenal incidentalomas. Retrospective studies have indicated these patients have an increase in cardiovascular events and mortality. Current recommendations for patients with adrenal incidentalomas include an overnight low-dose dexamethasone suppression test and a thorough evaluation of cardiovascular and metabolic risk factors. Further hormonal testing and close monitoring are necessary in patients with incomplete suppression. Unilateral adrenalectomy may be beneficial in cases with abnormal suppression and comorbidities related to hypercortisolemia. Prospective studies are need for a better risk stratification and tailored therapy.
Topics: Adrenalectomy; Cushing Syndrome; Humans
PubMed: 29754638
DOI: 10.1016/j.ecl.2018.01.003