-
European Journal of Endocrinology Oct 2023To assess (1) comorbidities associated with and (2) treatment strategies for patients with adrenal incidentalomas and mild autonomous cortisol secretion (MACS; >... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To assess (1) comorbidities associated with and (2) treatment strategies for patients with adrenal incidentalomas and mild autonomous cortisol secretion (MACS; > 1.8 µg/dL (>50 nmol/L) cortisol level cut-off following the 1 mg dexamethasone suppression test).
DESIGN
Systematic review and meta-analysis.
METHODS
Seven databases were searched up to July 14, 2022. Eligible studies were (randomized) trials, cohort studies, and cross-sectional studies assessing comorbidities potentially attributable to cortisol excess or mortality in patients with adrenal incidentaloma with or without MACS or the effects of conservative or surgical management of MACS. Random-effects meta-analysis was performed to estimate pooled proportions (with 95% CIs).
RESULTS
In 30 cross-sectional and 16 cohort studies (n = 17 156 patients in total), patients with MACS had a higher prevalence of diabetes (relative risk [RR] 1.44 [1.23-1.69]), hypertension (RR = 1.24 [1.16-1.32]), and dyslipidemia (RR = 1.23 [1.13-1.34]). All-cause mortality (adjusted for confounders) in patients with MACS, assessed in 4 studies (n = 5921), was increased (hazard ratio [HR] = 1.54 [1.27-1.81]). Nine observational studies (n = 856) and 2 randomized trials (n = 107) suggest an improvement in glucometabolic control (RR = 7.99 [2.95-21.90]), hypertension (RR = 8.75 [3.99-19.18]), and dyslipidemia (RR = 3.24 [1.19-8.82]) following adrenalectomy.
CONCLUSIONS
The present systematic review and meta-analysis highlight the relevance of MACS, since both cardiometabolic morbidities and mortality appeared to have increased in patients with MACS compared to patients with non-functioning incidentalomas. However, due to heterogeneous definitions, various outcomes, selective reporting, and missing data, the reported pooled estimates need to be interpreted with caution. The small number of patients in randomized trials prevents any strong conclusion on the causality between MACS and these comorbidities.
Topics: Humans; Adrenal Gland Neoplasms; Hydrocortisone; Cross-Sectional Studies; Hypertension; Dyslipidemias
PubMed: 37801655
DOI: 10.1093/ejendo/lvad134 -
Wideochirurgia I Inne Techniki... Mar 2022The application of robotic adrenalectomy (RA) has been increasing. However, there is still controversy about whether RA is more feasible than laparoscopic adrenalectomy...
INTRODUCTION
The application of robotic adrenalectomy (RA) has been increasing. However, there is still controversy about whether RA is more feasible than laparoscopic adrenalectomy (LA) for pheochromocytoma (PHEO).
AIM
To evaluate the efficacy and safety of RA vs. LA for PHEO.
MATERIAL AND METHODS
A literature search of the PubMed, Ovid, and Scopus databases was performed to identify eligible studies up to April 2021. All studies comparing RA versus LA for PHEO were included. Data were analysed using the Cochrane Collaboration's Review Manager (RevMan) 5.4 software.
RESULTS
Overall, 4 studies including 386 patients (RA 155; LA 231) were included. RA might have larger tumour size (WMD = 0.72 cm, 95% CI: 0.31 to 1.13; p < 0.001). There were no statistically significant differences in operative time (WMD = -12.49 min, 95% CI: -29.50 to 4.52; p = 0.15), estimated blood loss (EBL) (WMD = -28.48 ml, 95% CI: -58.92, 1.95; p = 0.07), transfusion rate (OR = 0.70, 95% CI: 0.07 to 7.07; p = 0.77), or conversion rate (OR = 0.44, 95% CI: 0.07 to 2.88; p = 0.39). There were no significant differences between the 2 groups in terms of postoperative complications (OR = 1.06, 95% CI: 0.62 to 1.82; p = 0.84) and Clavien Dindo score ≥ 3 complications (OR = 1.15, 95% CI: 0.39 to 3.41; p = 0.80). Patients from the RA group could benefit from shorter length of hospital stay (WMD = -0.51 days, 95% CI -0.91 to -0.12; p = 0.01).
CONCLUSIONS
RA is a feasible, safe, and comparable treatment option for PHEO.
PubMed: 35251386
DOI: 10.5114/wiitm.2021.107764 -
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 -
The Journal of Urology Oct 2023Incidental adrenal masses are common and require a multidisciplinary approach to evaluation and management that includes family physicians, urologists, endocrinologists,...
PURPOSE
Incidental adrenal masses are common and require a multidisciplinary approach to evaluation and management that includes family physicians, urologists, endocrinologists, and radiologists. The purpose of this guideline is to provide an updated approach to the diagnosis, management, and follow-up of adrenal incidentalomas, with a special focus on the areas of discrepancy/controversy existing among the published guidelines from other associations.
MATERIALS AND METHODS
This guideline was developed by the Canadian Urological Association (CUA) through a working group comprised of urologists, endocrinologists, and radiologists and subsequently endorsed by the American Urological Association (AUA). A systematic review utilizing the GRADE approach served as the basis for evidence-based recommendations with consensus statements provided in the absence of evidence. For each guideline statement, the strength of recommendation was reported as weak or strong, and the quality of evidence was evaluated as low, medium, or high.
RESULTS
The CUA working group provided evidence- and consensus-based recommendations based on an updated systematic review and subject matter expertise. Important updates on evidence-based radiological evaluation and hormonal testing are included in the recommendations. This guideline clarifies which patients may benefit from surgery and highlights where short term surveillance is appropriate.
CONCLUSION
Incidentally detected adrenal masses require a comprehensive assessment of hormonal function and oncologic risk. This guideline provides a contemporary approach to the appropriate clinical, radiographic, and endocrine assessments required for the evaluation, management, and follow-up of patients with such lesions.
Topics: Humans; Adrenal Gland Neoplasms; Follow-Up Studies; Canada; Incidental Findings
PubMed: 37556768
DOI: 10.1097/JU.0000000000003644 -
European Journal of Endocrinology Dec 2022In patients with primary aldosteronism (PA), long-term cardiovascular and mortality outcomes after adrenalectomy vs mineralocorticoid receptor antagonist (MRA) have not... (Meta-Analysis)
Meta-Analysis
BACKGROUND
In patients with primary aldosteronism (PA), long-term cardiovascular and mortality outcomes after adrenalectomy vs mineralocorticoid receptor antagonist (MRA) have not been compared yet. We aim to compare the clinical outcomes of these patients after treatment.
DESIGN AND METHODS
A systematic review and meta-analysis was conducted by searching PubMed, Cochrane library, and Embase from no start date restriction to 18 December 2021. Our composite primary outcomes were long-term all-cause mortality and/or major adverse cardiovascular events (MACE), including coronary artery disease (CAD), stroke, arrhythmia, and congestive heart failure. We adopted the random-effects model and performed subgroup analyses, meta-regression, and trial sequential analysis (TSA).
RESULTS
A total of 9 studies with 8473 adult patients with PA (≥18 years) were enrolled. A lower incidence of composite primary outcomes was observed in the adrenalectomy group (odds ratio (OR): 0.46 (95% CI: 0.38-0.56), P < 0.001). We found a lower incidence of all-cause mortality (OR: 0.33 (95% CI: 0.15-0.73), P = 0.006) and MACE (OR: 0.55, (95% CI: 0.40-0.74), P = 0.0001) in the adrenalectomy group. The incidence of CAD (OR: 0.33 (95% CI: 0.15-0.75), P = 0.008), arrhythmias (OR: 0.46 (95% CI: 0.27-0.81), P = 0.007), and congestive heart failure (OR: 0.52 (95% CI: 0.33-0.81), P = 0.004) was also lower in adrenalectomy group. The metaregression showed patient's age may attenuate the benefits of adrenalectomy on composite primary outcomes (coefficient: 1.084 (95% CI: 1.005-1.169), P = 0.036). TSA demonstrated that the accrued sample size and effect size were sufficiently large to draw a solid conclusion, and the advantage of adrenalectomy over MRA was constant with the chronological sequence.
CONCLUSIONS
In conclusion, adrenalectomy could be preferred over MRA for patients with PA in reducing the risk of all-cause mortality and/or MACE and should be considered as the treatment of choice. That patients with PA could get less benefit from adrenalectomy as they age warrants further investigation.
Topics: Adult; Humans; Adrenalectomy; Heart Failure; Hyperaldosteronism; Mineralocorticoid Receptor Antagonists
PubMed: 36315466
DOI: 10.1530/EJE-22-0375 -
Journal of Clinical Medicine Jul 2023To summarize the existing knowledge about adrenal gland abscesses, including etiology, clinical presentation, common laboratory and imaging findings, management and... (Review)
Review
To summarize the existing knowledge about adrenal gland abscesses, including etiology, clinical presentation, common laboratory and imaging findings, management and overall morbidity and mortality. Systematic literature review. We performed a search in the PubMed database using search terms: 'abscess and adrenal glands', 'adrenalitis', 'infection and adrenal gland', 'adrenal abscess', 'adrenal infection' and 'infectious adrenalitis'. Articles from 2017 to 2022 were included. We found total of 116 articles, and after applying exclusion criteria, data from 73 articles was included in the final statistical analysis. Of 84 patients included in this review, 68 were male (81%), with a mean age of 55 years (range: 29 to 85 years). Weight loss was the most frequent symptom reported in 58.3% patients, followed by fever in 49%. Mean duration of symptoms was 4.5 months. The most common laboratory findings were low cortisol (51.9%), elevated ACTH (43.2%), hyponatremia (88.2%) and anemia (83.3%). Adrenal cultures were positive in 86.4% cases, with (37.3%) being the leading causative agent. Blood cultures were positive in 30% of patients. The majority of the adrenal infections occurred through secondary dissemination from other infectious foci and abscesses were more commonly bilateral (70%). A total of 46.4% of patients developed long-term adrenal insufficiency requiring treatment. Abscess drainage was performed in 7 patients (8.3%) and adrenalectomy was performed in 18 (21.4%) patients. The survival rate was 92.9%. Multivariate analysis showed that the only independent risk factor for mortality was thrombocytopenia ( = 0.048). Our review shows that adrenal abscesses are usually caused by fungal pathogens, and among these, is the most common. The adrenal glands are usually involved in a bilateral fashion and become infected through dissemination from other primary sources of infection. Long-term adrenal insufficiency develops in 46% of patients, which is more common than what is observed in non-infectious etiology of adrenal gland disorders. Mortality is about 7%, and the presence of thrombocytopenia is associated with worse prognosis. Further prospective studies are needed to better characterize optimal testing and treatment duration in patients with this relatively rare but challenging disorder.
PubMed: 37510716
DOI: 10.3390/jcm12144601 -
Wideochirurgia I Inne Techniki... Mar 2022Due to more complex anatomical features, right laparoscopic adrenalectomy (RLA) could be more challenging than left laparoscopic adrenalectomy (LLA). However, this...
INTRODUCTION
Due to more complex anatomical features, right laparoscopic adrenalectomy (RLA) could be more challenging than left laparoscopic adrenalectomy (LLA). However, this opinion remains elusive.
AIM
To evaluate the perioperative and postoperative outcomes of RLA versus LLA.
MATERIAL AND METHODS
A systematic literature research of the PubMed, Ovid, Scopus databases (up to March 2021) and citation lists were performed to identify eligible studies. All studies comparing RLA versus LLA were included. Data were analysed using RevMan 5.4 software.
RESULTS
Overall, 5 studies including 780 patients (RLA 361; LLA 419) were included. The operative time was similar in both groups (WMD -9.38 min, 95% CI: -21.04 to 2.28; p = 0.11). Compared with LLA, RLA showed greater volume of estimated blood loss (EBL) (WMD 13.82 ml, 95% CI: 3.77, 23.88; p = 0.007) and higher conversion rate (OR = 3.45, 95% CI: 1.12 to 10.57; p = 0.03). RLA had comparable complications (OR = 0.88, 95% CI: 0.44 to 1.76; p = 0.71), Clavien Dindo score ≥ 3 complications (OR = 0.38, 95% CI: 0.09 to 1.65; p = 0.20), and length of hospital stay (WMD -0.07 days, 95% CI: -0.35 to 0.21; p = 0.61). The transperitoneal approach analysis showed consistent results.
CONCLUSIONS
RLA is associated with a higher risk of bleeding and higher conversion rate.
PubMed: 35251387
DOI: 10.5114/wiitm.2021.108212 -
Frontiers in Endocrinology 2023In patients with bilateral pheochromocytoma, partial adrenalectomy offers the chance to preserve adrenal function and avoid the need for lifelong steroid... (Meta-Analysis)
Meta-Analysis
BACKGROUND
In patients with bilateral pheochromocytoma, partial adrenalectomy offers the chance to preserve adrenal function and avoid the need for lifelong steroid supplementation. However, the risk of tumour recurrence raises questions about this procedure. The aim of our study was to compare partial and total adrenalectomy in bilateral pheochromocytoma through a systematic review with meta-analysis.
METHODS
A systematic search was carried out using databases (MEDLINE, EMBASE, Scopus, Web of Science, CENTRAL) and registers of clinical trials (ClinicalTrials.gov, European Trials Register, WHO International Trials Registry Platform). This meta-analysis included studies up to July 2022 without language restrictions. A random effects model meta-analysis was performed to assess the risk of tumor recurrence, steroid dependence and morbidity in these patients.
RESULTS
Twenty-five studies were included in the analysis involving 1444 patients. The relative risk (RR) of loss of adrenal hormone function during follow-up and the need for steroid therapy was 0.32 in patients after partial adrenalectomy: RR 0.32, 95% Confidence Interval (CI): 0.26-0.38, P < 0.00001, I2 = 21%. Patients undergoing partial adrenalectomy had a lower odds ratio (OR) for developing acute adrenal crisis: OR 0.3, 95% CI: 0.1-0.91, P=0.03, I2 = 0%. Partial adrenalectomy was associated with a higher risk of recurrence than total adrenalectomy: OR 3.72, 95% CI: 1.54-8.96, P=0.003, I2 = 28%.
CONCLUSION
Partial adrenalectomy for bilateral pheochromocytoma is a treatment that offers a chance of preserving adrenal hormonal function, but is associated with a higher risk of local tumor recurrence. There was no difference for the risk of metastasis and in overall mortality among the group with bilateral pheochromocytomas undergoing total or partial adrenalectomy. This study is in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (A Measurement Tool to Assess Systematic Reviews) Guidelines (10, 11).
SYSTEMATIC REVIEW REGISTRATION
https://osf.io/zx3se.
Topics: Humans; Pheochromocytoma; Neoplasm Recurrence, Local; Adrenalectomy; Adrenal Gland Neoplasms
PubMed: 36998480
DOI: 10.3389/fendo.2023.1127676 -
International Journal of Surgery... May 2023The effectiveness and safety of laparoscopic adrenalectomy (LA) under different routes for the treatment of large pheochromocytomas (PCCs) is unknown. (Meta-Analysis)
Meta-Analysis
BACKGROUND
The effectiveness and safety of laparoscopic adrenalectomy (LA) under different routes for the treatment of large pheochromocytomas (PCCs) is unknown.
MATERIALS AND METHODS
This meta-analysis and systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) Guidelines. Three databases were systematically searched, including Medline, PubMed, and Web of Science. The time frame of the search was set from the creation of the database to October 2022. Perioperative outcomes were divided into two groups according to tumor size: SMALL group (≤6 cm in diameter), LARGE group (>6 cm in diameter).
RESULTS
Eight studies including 600 patients were included. In the LA group, complications was comparable in both groups (SMALL group and LARGE group), and the LARGE group had longer operative time [OT weighted mean difference (WMD)=32.55; 95% CI: 11.17, 53.92; P <0.01], length of stay (LOS WMD=0.82; 95% CI: 0.19, 1.44; P <0.05), more estimated blood loss (EBL WMD=85.26; 95% CI: 20.71, 149.82; P <0.05), hypertension [odds ratio (OR)=3.99; 95% CI: 1.84, 8.65; P <0.01], hypotension (OR=1.84; 95% CI: 1.11, 3.05; P <0.05), and conversion (OR=5.60; 95% CI: 1.56, 20.13; P <0.01). In the transabdominal LA group, OT, LOS, EBL, complications, hypertension, and hypotension were the same in both groups. In the retroperitoneal LA group, complications and hypotension were the same in both groups, while the LARGE group had longer OT (WMD=52.07; 95% CI: 26.95, 77.20; P <0.01), LOS (WMD=0.51; 95% CI: 0.00, 1.01; P <0.05), more EBL (WMD=92.99; 95% CI: 27.70, 158.28; P <0.01) and higher rates of hypertension (OR=6.03; 95% CI: 1.95, 18.61; P <0.01).
CONCLUSIONS
LA remains a safe and effective approach for large PCC. Transabdominal LA is superior to retroperitoneal LA.
Topics: Humans; Laparoscopy; Adrenalectomy; Pheochromocytoma; Adrenal Gland Neoplasms; Hypertension; Hypotension; Treatment Outcome; Length of Stay
PubMed: 37037515
DOI: 10.1097/JS9.0000000000000389 -
Wideochirurgia I Inne Techniki... Mar 2023To compare the efficacy and safety of retroperitoneal laparoscopic adrenalectomy (RLA) vs. transperitoneal laparoscopic adrenalectomy (TLA) for pheochromocytoma (PHEO).
INTRODUCTION
To compare the efficacy and safety of retroperitoneal laparoscopic adrenalectomy (RLA) vs. transperitoneal laparoscopic adrenalectomy (TLA) for pheochromocytoma (PHEO).
AIM
To perform a systematic review and meta-analysis to evaluate the efficacy and safety of RLA versus TLA for PHEO.
MATERIAL AND METHODS
A systematic research of PubMed, Ovid, Scopus (up to June 2022), and citation lists was performed for all comparative eligible studies of RLA versus TLA for PHEO. Statistical analysis was performed using RevMan 5.4.
RESULTS
Overall, six studies including 597 patients (RLA 243; TLA 354) were included. RLA was associated with lower BMI compared to TLA (WMD = -0.81 kg/m, 95% CI: -1.53 to -0.10; p = 0.03). RLA was associated with smaller tumor size (WMD = -0.90 cm, 95% CI: -1.59 to -0.20; p = 0.01). RLA was associated with shorter operative time (WMD = -34.58 min, 95% CI: -40.80 to -28.36; p < 0.001), lower EBL (WMD = -107.91 ml, 95% CI: -145.09, -70.74; p < 0.001), and a slightly higher HI rate (OR = 1.54, 95% CI: 1.03 to 2.29; p = 0.03). There were no statistically significant differences for complications (p = 0.71) and Clavien-Dindo score ≥ 3 complications (p = 0.19) for RLA compared to TLA. RLA was associated with shorter length of hospital stay (WMD = -1.94 days, 95% CI: -2.60 to -1.29; p < 0.001).
CONCLUSIONS
For selected PHEO patients, RLA has advantages in terms of operative time, EBL, and length of hospital stay, but the HI rate is higher. Since the lower BMI and smaller tumor size of RLA reduced the difficulty of surgery, these results need to be confirmed by further studies.
PubMed: 37064558
DOI: 10.5114/wiitm.2022.120419