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Current Opinion in Endocrinology,... Jun 2020The current review provides a summary on the most recent developments regarding the cause, work-up and management of bilateral adrenal incidentalomas (BAI). (Review)
Review
PURPOSE OF REVIEW
The current review provides a summary on the most recent developments regarding the cause, work-up and management of bilateral adrenal incidentalomas (BAI).
RECENT FINDINGS
The recent ENS@T/ESE guidelines provide comprehensive directions on the evaluation and management of patients with adrenal incidentalomas with special focus on those with bilateral tumours. Intraadrenal ACTH synthesis that may locally stimulate cortisol secretion challenging the traditionally used term 'ACTH-independent'. Inactivating mutations of a new tumour suppressor gene, armadillo repeat containing 5 (ARMC5), are implicated in a number of patients, especially those with multiple macronodules (bilateral macronodular hyperplasia) and evidence of hypercortisolism. Loss-of-function mutations of the glucocorticoid receptor gene (NR3C1) consist a new possible genetic cause of BAIs. Regarding management an increasing number of studies provide data on the benefits and safety of unilateral rather than bilateral adrenalectomy. There is also emerging data on the beneficial use of steroidogenesis inhibitors in a dosing schedule that aims to mimic the normal cortisol rhythm with promising short-term results, but the long-term clinical benefits of this approach remain to be demonstrated.
SUMMARY
The diagnostic approach consists of imaging and hormonal evaluation. Imaging characterization should be done separately for each lesion. Hormonal evaluation includes testing for primary aldosteronism, pheochromocytoma and evaluation for autonomous cortisol secretion, using the 1-mg overnight dexamethasone suppression test. Midnight cortisol or 24-h urinary-free cortisol may aid in establishing the degree of cortisol excess. In patients with hypercortisolism ACTH levels should be measured to establish ACTH-independency. The appropriate management of BAI associated with cortisol excess remains controversial. Bilateral adrenalectomy results in lifetime steroid dependency and is better reserved only for patients with overt and severe hypercortisolism. Unilateral adrenalectomy might be considered in selected patients. Medical therapy is not an established approach yet but it may be considered when control of hypercortisolism is desired, but surgery is not an option.
Topics: Adrenal Gland Neoplasms; Adrenalectomy; Humans; Practice Guidelines as Topic
PubMed: 32209820
DOI: 10.1097/MED.0000000000000536 -
Endocrinology and Metabolism Clinics of... Jun 2018Recent advances in the molecular pathogenesis and the natural history of Cushing's syndrome have improved the understanding of the management of this disease. The... (Review)
Review
Recent advances in the molecular pathogenesis and the natural history of Cushing's syndrome have improved the understanding of the management of this disease. The long-term efficacy of several cortisol-lowering medical treatments is currently under evaluation. However, adrenalectomy is a safe option for the treatment of patients affected by Cushing's syndrome. Unilateral adrenalectomy is the gold standard for treatment of adrenocortical adenomas associated with hypercortisolism. Bilateral adrenalectomy has been widely used in the past as definitive treatment of bilateral macronodular hyperplasia and persistent or recurrent Cushing's disease. The indication and the potential applications of this technique have been recently critically analyzed.
Topics: Adrenalectomy; Cushing Syndrome; Humans
PubMed: 29754639
DOI: 10.1016/j.ecl.2018.01.004 -
Chirurgie (Heidelberg, Germany) Sep 2022Today, adrenalectomy can be performed by a variety of laparoscopic and retroperitoneoscopic approaches. Of particular importance are the lateral transperitoneal and the... (Review)
Review
Today, adrenalectomy can be performed by a variety of laparoscopic and retroperitoneoscopic approaches. Of particular importance are the lateral transperitoneal and the posterior retroperitoneoscopic access routes. Comparative studies of transperitoneal and retroperitoneal procedures still demonstrate heterogeneous results. Nevertheless, retroperitoneal access techniques seem to enable less postoperative pain and a faster recovery. Robotic procedures are gaining in popularity but the final importance cannot yet be determined. All minimally invasive techniques are considered to be so safe and reliable that open approaches are only justified in exceptional cases.
Topics: Adrenal Gland Neoplasms; Adrenal Glands; Adrenalectomy; Humans; Laparoscopy; Retroperitoneal Space
PubMed: 35927340
DOI: 10.1007/s00104-022-01682-z -
International Journal of Surgery... Apr 2016Nowadays robotic assisted adrenalectomy has become an alternative to conventional laparoscopic adrenalectomy. However, evidence on the possible advantages and drawbacks... (Review)
Review
Nowadays robotic assisted adrenalectomy has become an alternative to conventional laparoscopic adrenalectomy. However, evidence on the possible advantages and drawbacks of robotic assisted adrenalectomy remains still limited. This manuscript aimed to review evidence on robotic assisted adrenalectomy in terms of surgical technique, feasibility, indications, oncological outcome and safety. Existing evidence, although limited, suggests that robotic assisted adrenalectomy is feasible and safe. However, the number of patients submitted to robotic assisted adrenalectomy is limited with the majority of them being operated for benign disease. There are only a few case reports of robotic assisted adrenalectomy performed for adrenocortical carcinoma, oncocytoma or metastasis. Partial adrenalectomy seems to be a promising application of robotic assisted adrenalectomy especially for the treatment of hereditary pheocromocytomas. Robotic assisted adrenalectomy overcoming the technical limitations of laparoscopic surgery could possibly elicit a mild surgical response instead of the well described surgical response. Surgical response affects surgical morbidity and mortality as well as oncological outcome of malignant disease. If this hypothesis is proved correct, robotic assisted adrenalectomy could be possibly indicated in the treatment of disease. In conclusion, robotic assisted adrenalectomy is feasible and safe. Further research is needed on the oncological outcome of this minimally invasive technique as well as on its effect on surgical stress response.
Topics: Adrenal Cortex Neoplasms; Adrenalectomy; Female; Humans; Laparoscopy; Middle Aged; Robotic Surgical Procedures
PubMed: 26926087
DOI: 10.1016/j.ijsu.2016.02.089 -
International Journal of Surgery... Sep 2022To compare the safety and effectiveness of robot-assisted adrenalectomy (RA) and laparoscopic adrenalectomy (LA). (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To compare the safety and effectiveness of robot-assisted adrenalectomy (RA) and laparoscopic adrenalectomy (LA).
METHODS
We performed a systematic review and cumulative meta-analysis of the primary outcomes of interest according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the Methodological Quality of Systematic Reviews) Guidelines. Five databases, including Medline, PubMed, Cochrane Library, Scopus, and Web of Science, were systematically searched. The search timeframe was set from the creation of the database to December 2021.
RESULTS
There were 26 studies including 2985 patients. Our study found that the robotic technique was superior to conventional laparoscopy for estimated blood loss (WMD = -18.25, 95% CI [-27.85, -8.65], P < 0.01), length of stay (WMD = -0.45, 95% CI [-0.57, -0.33], P < 0.01), and conversion to open (OR = 0.31, 95% CI [0.12, 0.78], P = 0.01), while complications and readmissions were comparable. Interestingly, there was no difference in operative time between the two surgical modalities, but subgroup analysis found that the retroperitoneal route robotic technique took longer (WMD = 14.64, 95% CI [0.04, 29.24], P < 0.05), whereas the study of the mixed surgical modality (RA versus LA with mixed transabdominal and retroperitoneal surgical routes) found that the robot required less time (WMD = -12.29, 95% CI [-22.86, -1.72], P < 0.05). For pheochromocytoma, RA was superior to LA in terms of length of stay (WMD = -0.49, 95% CI [-0.83, -0.15], P < 0.01), with no difference in other indicators.
CONCLUSION
robotic-assisted adrenalectomy is a superior technique to conventional laparoscopy in managing adrenal tumors, even in the case of a specific adrenal tumor - pheochromocytoma.
Topics: Adrenal Gland Neoplasms; Adrenalectomy; Humans; Laparoscopy; Length of Stay; Operative Time; Pheochromocytoma; Robotic Surgical Procedures; Treatment Outcome
PubMed: 36075556
DOI: 10.1016/j.ijsu.2022.106853 -
Surgical Endoscopy Mar 2024Laparoscopic adrenalectomy is recognized as the "gold standard" approach for benign adrenal tumors. The majority of surgeons opt for laparoscopic transabdominal...
BACKGROUND
Laparoscopic adrenalectomy is recognized as the "gold standard" approach for benign adrenal tumors. The majority of surgeons opt for laparoscopic transabdominal adrenalectomies (LTA), while retroperitoneoscopic adrenalectomies (RPA) in the prone position have certain advantages for patients. The aim of this study was to compare the effectiveness and safety of the transabdominal and retroperitoneoscopic laparoscopic adrenalectomies.
MATERIALS AND METHODS
Between 2000 and 2021, our clinic performed 472 laparoscopic adrenalectomies. The age ranged from 19 to 79 years, with a mean age of 50.5 ± 10.2 years. The patient pool consisted of 315 women and 157 men. Tumor sizes ranged from 1 to 10 cm.
RESULTS
In a study of 316 patients undergoing LTA versus 156 with RPA, the TLA averaged 82.5 min (70-98), while the RPA took 56.4 min (46-62) (P < 0.001). Intraoperative blood loss was 110 cc for the LTA group and 80 cc for the RPA group (P < 0.05) Conversion rates stood at 2.5% for transabdominal and 4.5% for retroperitoneoscopic procedures (P = 0.254). At 24 h post-operation, pain scores were 3.6 and 1.6, respectively (P < 0.001). Time to resume solid oral intake was 15.2 h for TLA and 8 h for RPA, with hospital stays at 4.5 days and 3 days respectively (P < 0.001). Short-term complications occurred in 8.9% of transabdominal and 12.2% of retroperitoneoscopic patients (P = 0.257).
CONCLUSIONS
For small tumors, RPA offers advantages over the transabdominal method in surgery time, blood loss, post-op pain, and recovery. These benefits are enhanced for patients with prior abdominal surgeries. However, large tumors present challenges in the retroperitoneal approach due to limited space and anatomical orientation. If complications emerge, surgeons can seamlessly switch to the LTA.
Topics: Male; Humans; Female; Adult; Middle Aged; Young Adult; Aged; Adrenalectomy; Laparoscopy; Retroperitoneal Space; Adrenal Gland Neoplasms; Pain
PubMed: 38092972
DOI: 10.1007/s00464-023-10533-9 -
The Surgical Clinics of North America Aug 2019Without the overt clinical signs and symptoms associated with Cushing's syndrome, the diagnosis of subclinical Cushing's syndrome (SCS) is primarily based on biochemical... (Review)
Review
Without the overt clinical signs and symptoms associated with Cushing's syndrome, the diagnosis of subclinical Cushing's syndrome (SCS) is primarily based on biochemical evaluation. Despite being labeled as "subclinical," SCS is associated with significant morbidity that can be improved with adrenalectomy. Minimally invasive adrenalectomy is associated with low morbidity in the hands of experienced adrenal surgeons and is recommended as the treatment of choice for SCS patients with SCS-associated comorbidities.
Topics: Adrenalectomy; Cushing Syndrome; Decision Making; Humans; Hydrocortisone; Minimally Invasive Surgical Procedures
PubMed: 31255204
DOI: 10.1016/j.suc.2019.04.011 -
BJS Open Nov 2023Bilateral pheochromocytomas are rare and often heritable. Total adrenalectomy leads to a definitive oncological cure, with subsequent definitive hypocortisolism.... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Bilateral pheochromocytomas are rare and often heritable. Total adrenalectomy leads to a definitive oncological cure, with subsequent definitive hypocortisolism. Subtotal adrenalectomy is a possible alternative. The aim of this study was to assess the effects of total adrenalectomy and subtotal adrenalectomy on bilateral pheochromocytoma in terms of post-surgical rate of recurrence, metastatic disease, and steroid dependence.
METHODS
Systematic searches in the bibliographic databases PubMed, Embase, and Europe PMC were performed for 1945 to 1 June 2023. PRISMA guidelines were followed and the PICO strategy was applied to English-language studies comparing subtotal adrenalectomy with total adrenalectomy. A random-effects model was used to assess the different outcomes for studies with high heterogeneity. The Newcastle-Ottawa scale and the Risk Of Bias In Non-randomized Studies of Interventions ('ROBINS-I') tool were used to assess quality and risk of bias.
RESULTS
From a total of 12 909 studies, 1202 patients (from 10 retrospective studies) were eligible for the meta-analysis. In six studies, including 1176 patients, the recurrence rate after subtotal adrenalectomy and total adrenalectomy was 14.1 versus 2.6 per cent respectively (OR 4.91, 95 per cent c.i. 1.30 to 18.54; P = 0.020; I2 72 per cent). In nine studies, including 1124 patients, the rate of post-surgical steroid dependence was 93.3 versus 11.6 per cent after total adrenalectomy and subtotal adrenalectomy respectively (OR 0.003, 95 per cent c.i. 0.0003 to 0.03; P < 0.00001; I2 66 per cent). Based on two studies, including 719 patients, no differences were evident regarding the occurrence of post-surgery metastatic disease.
CONCLUSION
Subtotal adrenalectomy leads to less post-surgical primary adrenal insufficiency, but leads to a higher postoperative recurrence rate. Future prospective randomized studies, with clear eligibility criteria, are needed to confirm these results.
Topics: Humans; Pheochromocytoma; Adrenalectomy; Retrospective Studies; Adrenal Gland Neoplasms; Steroids
PubMed: 37945270
DOI: 10.1093/bjsopen/zrad109 -
Urologia Aug 2022Minimal invasive surgeries (MIS) for large size adrenal tumors are still debatable. The objective is to evaluate the contemporary peri- and post-operative outcomes of...
INTRODUCTION
Minimal invasive surgeries (MIS) for large size adrenal tumors are still debatable. The objective is to evaluate the contemporary peri- and post-operative outcomes of patients undergoing (open = OA, laparoscopic = LA, and robotic = RA) adrenalectomies in three institutions.
MATERIALS AND METHODS
Retrospectively gathered peri- and post-operative data of 235 patients, underwent adrenalectomy at three Institutions over a 7-year period (2013-2020) were analyzed. All patients underwent thorough radiological and endocrine workup.
RESULTS
Two hundred and thirty five patients who underwent adrenalectomy (OA ( = 29), LA ( = 146), and RA ( = 60)) were assessed. OA ( = 29) versus Minimally invasive surgery ( = 206) showed significant differences (median, value) in larger tumour size, cm (9.4 vs 5, ( = 0.0001)), longer operative time, mins (240 vs 100, ( = 0.0001)), longer hospital stay, days (8 vs 3,( = .0001)), Higher readmission rates (14% vs 1.9%), higher blood loss, ml (400 vs 100, ( = 0.0001)) requiring blood transfusion (14% vs 4.3%) ( = 0.03), higher intraoperative complication (21% vs 6%) ( = 0.0004), and post op complications (17% vs 5.3%) ( = 0.01). Amongst the MIS (RA vs LA), RA appeared be have better outcomes in terms of shorter operative time, less blood loss and less intra operative complications with a value <0.05. These results were consistent for the assessment of patients who had ⩾6 cm tumor size. The postoperative complication rates were lowest with RA (3.3%) compared to OA (17%) and LA (6.1%).
CONCLUSIONS
Contemporary practice of adrenalectomy shows that robotic adrenalectomy is safe and effective irrespective of the tumor size.
Topics: Adrenal Gland Neoplasms; Adrenalectomy; Humans; Intraoperative Complications; Laparoscopy; Length of Stay; Retrospective Studies; Robotics; Treatment Outcome
PubMed: 35634982
DOI: 10.1177/03915603221097166 -
International Journal of Surgery... Feb 2017The benefit of robotic adrenalectomy (RA) compared to laparoscopic adrenalectomy (LA) is still debatable. The purpose of this paper was to systematically review and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The benefit of robotic adrenalectomy (RA) compared to laparoscopic adrenalectomy (LA) is still debatable. The purpose of this paper was to systematically review and synthesize all available evidence comparing RA to LA so as to evaluate which procedure provides superior clinical outcomes.
METHODS
A systematic literature search of PubMed and Scopus databases was performed with respect to the PRISMA statement (end-of-search date: January 31, 2016). Data on perioperative variables were extracted by three independent reviewers. Data were pooled using a random-effects model.
RESULTS
Twenty-seven studies were included in this review (13 comparative and 14 non-comparative). Overall, 1162 patients underwent adrenalectomy (747 treated with RA and 415 with LA). There was no significant difference between the robotic and the laparoscopic groups for intraoperative complications (OR: 1.20; 95%CI, 0.33-4.38), postoperative complications (OR: 0.69; 95% CI, 0.36-1.31), mortality (OR: 0.42; 95%CI, 0.07-2.72), conversion to laparotomy (OR: 0.51; 95%CI, 0.21-1.23), conversion to laparotomy or laparoscopy (OR: 0.73; 95%CI, 0.32-1.69) and blood loss (WMD: -9.78; 95%, -22.10 to 2.53). For patients treated with RA, there was a significantly shorter hospital stay (WMD: -0.40; 95% CI, -0.64 to -0.17) and a significantly longer operating time (WMD: 15.60; 95%CI, 2.12 to 29.08).
CONCLUSIONS
Robotic adrenalectomy is a safe and feasible procedure with similar clinical outcomes as the laparoscopic approach in selected patient populations. High quality RCTs as well as uniform and detailed reporting of outcomes are needed to determine the role and cost-effectiveness of robotic adrenal surgery in the years to come.
Topics: Adrenalectomy; Humans; Intraoperative Complications; Laparoscopy; Length of Stay; Operative Time; Postoperative Complications; Robotics
PubMed: 28043926
DOI: 10.1016/j.ijsu.2016.12.118