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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 -
European Urology Jun 2014Over the last decade, robot-assisted adrenalectomy has been included in the surgical armamentarium for the management of adrenal masses. (Comparative Study)
Comparative Study Meta-Analysis Review
CONTEXT
Over the last decade, robot-assisted adrenalectomy has been included in the surgical armamentarium for the management of adrenal masses.
OBJECTIVE
To critically analyze the available evidence of studies comparing laparoscopic and robotic adrenalectomy.
EVIDENCE ACQUISITION
A systematic literature review was performed in August 2013 using PubMed, Scopus, and Web of Science electronic search engines. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria.
EVIDENCE SYNTHESIS
Nine studies were selected for the analysis including 600 patients who underwent minimally invasive adrenalectomy (277 robot assisted and 323 laparoscopic). Only one of the studies was a randomized clinical trial (RCT) but of low quality according to the Jadad scale. However, the methodological quality of included nonrandomized studies was relatively high. Body mass index was higher for the laparoscopic group (weighted mean difference [WMD]: -2.37; 95% confidence interval [CI], - 3.01 to -1.74; p<0.00001). A transperitoneal approach was mostly used for both techniques (72.5% of robotic cases and 75.5% of laparoscopic cases; p=0.27). There was no significant difference between the two groups in terms of conversion rate (odds ratio [OR]: 0.82; 95% CI, 0.39-1.75; p=0.61) and operative time (WMD: 5.88; 95% CI, -6.02 to 17.79; p=0.33). There was a significantly longer hospital stay in the conventional laparoscopic group (WMD: -0.43; 95% CI, -0.56 to -0.30; p<0.00001), as well as a higher estimated blood loss (WMD: -18.21; 95% CI, -29.11 to -7.32; p=0.001). There was also no statistically significant difference in terms of postoperative complication rate (OR: 0.04; 95% CI, -0.07 to -0.00; p=0.05) between groups. Most of the postoperative complications were minor (80% for the robotic group and 68% for the conventional laparoscopic group). Limitations of the present analysis are the limited sample size and including only one low-quality RCT.
CONCLUSIONS
Robot-assisted adrenalectomy can be performed safely and effectively with operative time and conversion rates similar to laparoscopic adrenalectomy. In addition, it can provide potential advantages of a shorter hospital stay, less blood loss, and lower occurrence of postoperative complications. These findings seem to support the use of robotics for the minimally invasive surgical management of adrenal masses.
Topics: Adrenalectomy; Blood Loss, Surgical; Conversion to Open Surgery; Humans; Laparoscopy; Length of Stay; Operative Time; Robotic Surgical Procedures
PubMed: 24079955
DOI: 10.1016/j.eururo.2013.09.021 -
International Journal of Surgery... Apr 2015Partial adrenalectomy is typically performed for the treatment of hereditary and sporadic bilateral tumours, to reduce the risk of adrenal failure, particularly in... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Partial adrenalectomy is typically performed for the treatment of hereditary and sporadic bilateral tumours, to reduce the risk of adrenal failure, particularly in younger patients. Partial adrenalectomy proposes a postoperative steroid-free course nevertheless, is associated with the risk of local recurrence. In this study we evaluate the recurrence and functional outcomes of partial adrenalectomy.
METHODS
A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. The search identified 60 relevant articles reporting on patients who underwent partial adrenalectomy. Data was extracted from each study and used to calculate a pooled event rate and 95% confidence interval (95% CI).
RESULTS
The overall recurrence rate was 8% (95% CI: 0.05-0.12) and the 85% (95% CI: 0.78-0.9) of the patients were steroid free. The recurrence rates were the least in the retroperitoneoscopic group 1% (95% CI: 0-0.04) and Conn's syndrome group 2% (95% CI: 0.01-0.05) and highest in open group 15% (95% CI: 0.07-0.28) and Pheochromocytoma group 10% (95% CI: 0.07-0.16). Steroid independence rates were best in the Conn's syndrome group 97% (95% CI: 0.85-0.99) and laparoscopic group 88% (95% CI: 0.75-0.95).
CONCLUSIONS
Partial adrenalectomy can obviate the need for steroid replacement in the majority of patients and local recurrence rates appear to be infrequent. For patients with hereditary and bilateral adrenal tumours, partial adrenalectomy should be recommended as a primary surgical approach whenever possible.
Topics: Adrenal Gland Neoplasms; Adrenalectomy; Global Health; Humans; Incidence; Laparoscopy; Neoplasm Recurrence, Local; Pheochromocytoma; Postoperative Period
PubMed: 25681039
DOI: 10.1016/j.ijsu.2015.01.015 -
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 -
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 -
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 -
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 -
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 -
JSLS : Journal of the Society of... 2015Adrenocortical cancer (ACC) is a rare disease that is difficult to treat. Laparoscopic adrenalectomy (LA) is performed, even for large adrenocortical carcinomas.... (Review)
Review
BACKGROUND
Adrenocortical cancer (ACC) is a rare disease that is difficult to treat. Laparoscopic adrenalectomy (LA) is performed, even for large adrenocortical carcinomas. However, the oncological effectiveness of LA remains unclear. This review presents the current knowledge of the feasibility and oncological effectiveness of laparoscopic surgery for ACC, with an analysis of data for outcomes and other parameters.
DATABASE
A systematic review of the literature was performed by searching the PubMed and Medline databases for all relevant articles in English, published between January 1992 and August 2014 on LA for adrenocortical carcinoma.
DISCUSSION
The search resulted in retrieval of 29 studies, of which 10 addressed the outcome of LA versus open adrenalectomy (OA) and included 844 patients eligible for this review. Among these, 206 patients had undergone LA approaches, and 638 patients had undergone OA. Among the 10 studies that compared the outcomes obtained with LA and OA for ACC, 5 noted no statistically significant difference between the 2 groups in the oncological outcomes of recurrence and disease-free survival, whereas the remaining 5 reported inferior outcomes in the LA group. Using a paired t test for statistical analysis, except for tumor size, we found no significant difference in local recurrence, peritoneal carcinomatosis, positive resection margin, and time to recurrence between the LA and OA groups. The overall mean tumor size in patients undergoing LA and OA was 7.1 and 11.2 cm, respectively (P = .0003), and the mean overall recurrence was 61.5 and 57.9%, respectively. The outcome of LA is believed to depend to a large extent on the size and stage of the lesion (I and II being favorable) and the surgical expertise in the center where the patient undergoes the operation. However, the present review shows no difference in the outcome between the 2 approaches across all stages. A poor outcome is likely to result from inadequate surgery, irrespective of whether the approach is open or laparoscopic.
Topics: Adrenal Cortex Neoplasms; Adrenalectomy; Adrenocortical Carcinoma; Humans; Laparoscopy
PubMed: 26175553
DOI: 10.4293/JSLS.2015.00036 -
Langenbeck's Archives of Surgery May 2023No randomised clinical trials (RCTs) have simultaneously compared the safety of open (OA), transperitoneal laparoscopic (TLA), posterior retroperitoneal (PRA), and... (Meta-Analysis)
Meta-Analysis
BACKGROUND
No randomised clinical trials (RCTs) have simultaneously compared the safety of open (OA), transperitoneal laparoscopic (TLA), posterior retroperitoneal (PRA), and robotic adrenalectomy (RA) for resecting adrenal tumours.
AIM
To evaluate outcomes for OA, TLA, PRA, and RA from RCTs.
METHODS
A NMA was performed according to PRISMA-NMA guidelines. Analysis was performed using R packages and Shiny.
RESULTS
Eight RCTs with 488 patients were included (mean age: 48.9 years). Overall, 44.5% of patients underwent TLA (217/488), 37.3% underwent PRA (182/488), 16.4% underwent RA (80/488), and just 1.8% patients underwent OA (9/488). The mean tumour size was 35 mm in largest diameter with mean sizes of 44.3 mm for RA, 40.9 mm for OA, 35.5 mm for TLA, and 34.4 mm for PRA (P < 0.001). TLA had the lowest blood loss (mean: 50.6 ml), complication rates (12.4%, 14/113), and conversion to open rates (1.3%, 2/157), while PRA had the shortest intra-operative duration (mean: 94 min), length of hospital stay (mean: 3.7 days), lowest visual analogue scale pain scores post-operatively (mean: 3.7), and was most cost-effective (mean: 1728 euros per case). At NMA, there was a significant increase in blood loss for OA (mean difference (MD): 117.00 ml (95% confidence interval (CI): 1.41-230.00)) with similar blood loss observed for PRA (MD: - 10.50 (95% CI: - 83.40-65.90)) compared to TLA.
CONCLUSION
LTA and PRA are important contemporary options in achieving favourable outcomes following adrenalectomy. The next generation of RCTs may be more insightful for comparison surgical outcomes following RA, as this approach is likely to play a future role in minimally invasive adrenalectomy.
PROSPERO REGISTRATION
CRD42022301005.
Topics: Humans; Middle Aged; Adrenal Gland Neoplasms; Adrenalectomy; Laparoscopy; Length of Stay; Network Meta-Analysis; Retroperitoneal Space; Treatment Outcome; Randomized Controlled Trials as Topic
PubMed: 37145303
DOI: 10.1007/s00423-023-02911-7