Robot-assisted adrenalectomy:Step-by-step technique and surgical outcomes at a high-volume robotic center

Objective In the last years,robotic surgery was introduced in several different settings with good perioperative results.However,its role in the management of adrenal masses is still debated.In order to provide a contribution to this field,we described our step-by-step technique for robotic adrenalectomy(RA)and related modifications according to the type of adrenal mass treated.Methods We retrospectively analyzed 27 consecutive patients who underwent RA at Onze-Lieve-Vrouw hospital(Aalst,Belgium)between January 2009 and October 2022.Demographic,intra-and post-operative,and pathological data were retrieved from our prospectively maintained institutional database.Continuous variables are summarized as median and interquartile range(IQR).Categorical variables are reported as frequencies(percentages).Results Twenty-seven patients underwent RA were included in the study.Median age,body mass index,and Charlson's comorbidity index were 61(IQR:49-71)years,26(IQR:24-29)kg/m^(2),and 2(IQR:0-3),respectively,and 16(59.3%)patients were male.Median tumor size at computed tomography scan was 6.0(IQR:3.5-8.0)cm.Median operative time and blood loss were 105(IQR:82-120)min and 175(IQR:94-250)mL,respectively.No intraoperative complications were recorded.Overall postoperative complications rate was 11.1%,with a postoperative transfusion rate of 3.7%.A total of 10(37.0%)patients harbored malignant adrenal masses.Among them,3(11.1%)had adrenocortical carcinoma,6(22.2%)secondary metastasis,and 1(3.7%)malignant pheochromocytoma on final pathological exam.Only 1(10.0%)patient had positive surgical margins.Conclusion We described our step-by-step technique for RA,which can be safely performed even in case of high challenging settings as malignant tumors,pheochromocytoma,and large masses.The standardization of perioperative protocol should be encouraged to maximize the outcomes of this complex surgical procedure.

Effect of adrenalectomy and hydrocortisone on ventral prostate of rats

Aim: To study the effects of adrenalectomy and hydrocortisone on the ventral prostate of SD rats. Methods: Inadrenalectomised (ADX) and ADX + hydrocortisone (1, 2, or 4 mg) treated rats, the prostatic histology and thecholesterol, protein, zinc, and copper levels and the enzymic profile (acid phosphatase, alkaline phosphatase, aryl sul-phatase, lactic dehydrogenase, and leucine aminopeptidase) in the prostatic tissue were determined; the serum hormon-al profile (testosterone, FSH and LH) was also assayed. Results; Adrenalectomy caused a progressive degenerationin prostatic structure that was not reversed by hydrocortisone treatment. The serum testosterone were significantly lowerin ADX than in sham operated rats and lower in ADX + hydrocortisone than in ADX-C rats (P < 0.01). The serumFSH and LH were below the detection limit of 1 mIU/mL. The enzymatic activity was higher in ADX than in sham op-erated rats and higher in ADX + hydrocortisone than in ADX-C rats (P<0.05-0.01). The prostatic zinc levels weresignificantly higher in sham operated than in ADX, and higher in ADX-C than in ADX + hydrocortisone rats (P < 0.05-0.01). The prostatic copper level was significantly lower in sham operated than in ADX, and lower in ADX-C thanin the ADX + hydrocortisone rats (P <0.01). Conclusion; In rats, adrenalectomy leads to pathological and func-tional changes of the prostate. Hydrocortisone treatment at the doses employed did not reverse these changes. (Asian JAndrol 2001 Dec; 3: 289 - 300)

Effect of adrenalectomy on rat epididymidis

AIM: To investigate the effect of adrenalectomy (ADX) on the epididymidis of Sprague-Dawley rats. METHODS: The histological, biochemical (cholesterol protein, zinc, copper, alkaline and acid phosphatase aryl sulphatase, lactic dehydrogenase and leucine amino peptidase) and hormonal (FSH, LH and testosterone) changes of caput and cauda epididymis in ADX rats were observed. RESULTS: Organ wet weight, histological studies and morphometric measurements indicated a cellular degeneration in caput and cauda epididymis of ADX rats. Serum testosterone level was significantly lower in ADX than in sham-operated rats, while the serum FSH and LH were below the detection limit of 1 mIU/mL. The enzymatic activity was higher in ADX than in sham-operated rats. Epididymal zinc level increased whereas copper level decreased in ADX rats compared to the sham-operated. CONCLUSION: Adrenalectomy leads to degeneration of caput and cauda epididymidis epithelial cells as a result of decreased supply of testosterone.

Early Identification and Diagnosis of Adrenal Crisis after Retroperitoneal Laparoscopic Unilateral Adrenalectomy

The occurrence of adrenal crisis after retroperitoneal laparoscopic unilateral adrenalectomy is usually concealed.If not timely diagnosis and treatment,it may cause shock,and even lead to death.It is very difficult to distinguish the clinical manifestations of adrenal crisis from nausea,vomiting,fatigue,gas separation from the lower diaphragm,abdominal pain,hypotension,hypertension,fever and hypothermia after operation.This makes it very difficult to identify and diagnose adrenal crisis early.This article mainly discusses the early recognition,diagnosis and treatment of adrenal crisis after unilateral adrenalectomy by retroperitoneoscope.

Retroperitoneoscopic adrenalectomy in semilateral supine position

Objective To discuss semilateral supine position for retroperitoneoscopic adrenalectomy. Methods From Jan. 2006 to Dec. 2008,36 patients ( 20 males and 16 females with mean age of 43 years) underwent retroperito-neoscopic adrenalectomy in 60° - 70°semilateral

Role of adrenalectomy in treating recurrent Cushing's disease:A report of 43 cases

Objective To evaluate the efficacy of laparoscopic adrenalectomy and open adrenalectomy in treating recurrent Cushing ’s disease. Methods Forty-three patients ( 29 females and 14 males) with recurrent Cushing’s disease treated with laparoscopic adrenalectomy ( LA,n = 32) or open ( OA,n = 11) adrenalectomy from 2000

Role of adrenalectomy in recurrent Cushing＇s disease

Background Cushing＇s disease is a pituitary-dependent type of Cushing＇s syndrome. Treatment consists of pituitary surgery or radiotherapy, but the recurrence rate at 10 years is as high as 40%. Adrenalectomy is considered an effective treatment to refractory Cushing＇s disease. The objective of this study was to examine the efficacy of laparoscopic adrenalectomy and open adrenalectomy in Cushing＇s disease, focusing on reversing the sequelae of hypercortisolism and improving patients＇ quality of life. Methods Forty-three patients （29 women, 14 men） with recurrent Cushing＇s disease after transsphenoidal operation underwent laparoscopic （n=32） or open （n=11） adrenalectomy from 2000 to 2008. Surgical results were evaluated for all the 43 patients. Patients completed a follow-up survey, including the short-form 36-item （SF-36） health survey. Results All the 43 patients achieved clinical reversal of hypercortisolism after adrenalectomy. Time to symptom resolution varied from a few weeks to up to 3 years. Most physical changes had resolved by a mean of 8 months after surgery. These conditions were not significantly different between the laparoscopy and open groups. Median length of hospital stay was shorter in the laparoscopy group （4 vs. 9 days; P 〈0.001）. Median follow-up was 48.5 months. Of the 34 （79%） patients available for follow-up, 22 （65%） had adrenocorticotropic hormone levels 〉200 ng/ml and 6 （27%） had clinical Nelson syndrome. Four patients died by 75 months after surgery. Using SF-36, 30 （88%） patients reported they felt their health status was good to excellent compared with 1 year before adrenalectomy; however, they showed significantly lower scores in all the 8 SF-36 parameters compared with the general population. No significant difference emerged in SF-36 scores between the laparoscopy and open groups. Conclusions Adrenalectomy showed high survival and clinical benefits in recurrent Cushing＇s disease patients. Despite patient-reported improvement in health after adrenalectomy, patients continue to experience poor health status compared with the general population.

Investigation on the indication of ipsilateral adrenalectomy in radical nephrectomy： a meta-analysis

Background With a trend that renal tumors are being detected at an earlier stage, classical radical nephrectomy is being reconsidered. More conservative techniques are being proposed. To clarify the indication for synchronous adrenalectomy in radical nephrectomy for renal cell carcinoma which has been questioned since the 1980s, this study evaluates the role of adrenalectomy and recommends a new indication for adrenalectomy in renal cell carcinoma.

Primary adrenal Ewing sarcoma:A systematic review of the literature

BACKGROUND Ewing sarcoma(ES)is a malignant neoplasm of neuroectodermal origin and is commonly observed in children and young adults.The musculoskeletal system is the main body system impacted and ES is rarely seen in the visceral organs particularly the adrenal gland.AIM To present a comprehensive review of primary adrenal ES,with emphasis on diagnosis,therapy and oncological outcomes.METHODS A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020.PubMed/MEDLINE,EMBASE and Google Scholar bibliographic databases were searched to identify articles from 1989 to 2022 and included patients with ES/primitive neuroectodermal tumor(PNET)of the adrenal gland.PubMed,Google Scholar and EMBASE medical databases were searched,combining the terms“adrenal”,“ES”and“PNET”.Demographic,clinical,pathological and oncological data of patients were analyzed by SPSS version 29.0.RESULTS A total of 52 studies were included for review(47 case reports and 5 case series)with 66 patients reported to have primary adrenal ES.Mean age at diagnosis was 26.4±15.4 years(37.9%males,57.6%females,sex not reported in 3 cases).The most frequent complaint was abdominal/flank pain or discomfort(46.4%)followed by a palpable mass(25.0%),and the average duration of symptoms was 2.6±3.1 mo.The imaging modality of choice was computed tomography scan(81.5%),followed by magnetic resonance imaging(20.4%).Preoperative staging revealed that 17 tumors(27.9%)were metastatic and 14 patients had inferior vena cava or renal vein neoplastic thrombus at initial diagnosis.Open adrenalectomy was performed in the majority of cases(80.0%),of which 27.9%required more extensive resection.Minimally invasive surgery was attempted in 8.2%of tumors.Complete surgical resection was achieved in 89.4%of the patients.Adjuvant therapy was administered to 32 patients,in the form of chemotherapy(62.5%),radiotherapy(3.1%)or combination(34.4%).Median overall survival was 15 mo and 24-mo overall survival was 40.5%.Median disease-free survival was 10 mo and 24-mo disease-free survival was 33.3%.CONCLUSION The significant progress in molecular biology and genetics of ES does not reflect on patient outcomes.ES remains an aggressive tumor with a poor prognosis and high mortality.

Surgical treatment of large pheochromocytoma(>6 cm):A 10-year single-center experience

Objective:Clinical practice guidelines recommend open adrenalectomy(OA)for large pheochromocytoma(LPCC)>6 cm in size.Although laparoscopic adrenalectomy(LA)for the treatment of LPCC has been reported,its role remains unclear.This study aimed to compare the effectiveness of LA and OA,and summary the surgical treatment experience.Methods:Data concerning LPCC,from January 2010 to June 2019 of a single institution,were retrospectively reviewed.Altogether 82 patients with a tumor larger than 6 cm were included(52 patients in LA group and 30 patients in OA group).Groups were balanced by propensity score matching(PSM)into 15 pairs.Patients’demographics,preoperative characteristics,and prognosis were analyzed.Results:Before PSM,the OA group had larger tumor sizes(median[interquartile range,IQR]:8.9[7.3-10.3]vs.7.2[6.7-8.0]cm;p=0.000)and higher vanillylmandelic acid level(median[IQR]:114.3[67.8-326.4]vs.66.6[37.8-145.8]μmol/24 h;p=0.004)and needed a higher cumulative dose of prazosin(median[IQR]:83.5[37.0-154.0]vs.38.0[21.0-81.0]mg;p=0.028).After PSM,the baseline data showed no significant differences between both groups.The LA group had relatively more stable blood pressure in surgery,with a lower fluctuation of systolic blood pressure(mean±standard deviation[SD]:70.9±25.1 vs.107.4±46.2 mmHg,p=0.012)and a lower percentage of hemodynamic instability(46.7%vs.86.7%,p=0.020).The LA group had shorter postoperative hospital stays(mean±SD:6.4±2.7 vs.10.1±3.4 days;p=0.003)than the OA group.Differences regarding metastasis rate(6.7%vs.0,p=1.000)were not statistically significant between LA and OA groups.The median(IQR)follow-up time of 82 patients was 72.5(47.0-103.5)months.Binary logistic regression showed that right-side tumors or those>8 cm in size were independent risk factors of OA.Conclusion:LA is a safe,minimally invasive procedure for LPCC and has relatively better perioperative characteristics in large medical centers.Patients with tumors on the right side or larger than 8 cm are more likely to undergo OA initially.

Management of hypertension in primary aldosteronism

Hypertension causes significant morbidity and mortal-ity worldwide, owing to its deleterious effects on the cardiovascular and renal systems. Primary hyperaldo-steronism(PA) is the most common cause of revers-ible hypertension, affecting 5%-18% of adults with hypertension. PA is estimated to result from bilateral adrenal hyperplasia in two-thirds of patients, and from unilateral aldosterone-secreting adenoma in approxi-mately one-third. Suspected cases are initially screened by measurement of the plasma aldosterone-renin-ratio, and may be confirmed by additional noninvasive tests. Localization of aldostosterone hypersecretion is then determined by computed tomography imaging, and in selective cases with adrenal vein sampling. Solitary adenomas are managed by laparoscopic or robotic re-section, while bilateral hyperplasia is treated with min-eralocorticoid antagonists. Biochemical cure following adrenalectomy occurs in 99% of patients, and hemo-dynamic improvement is seen in over 90%, prompting a reduction in quantity of anti-hypertensive medica-tions in most patients. End-organ damage secondary to hypertension and excess aldosterone is significantly improved by both surgical and medical treatment, asmanifested by decreased left ventricular hypertrophy, arterial stiffness, and proteinuria, highlighting the im-portance of proper diagnosis and treatment of primary hyperaldosteronism. Although numerous independent predictors of resolution of hypertension after adrenalec-tomy for unilateral adenomas have been described, the Aldosteronoma Resolution Score is a validated multifac-torial model convenient for use in daily clinical practice.

Adrenal ganglioneuroma:What you need to know

Adrenal ganglioneuromas(GNs) constitute rare,differentiated tumors which originate from neural crest cells. GNs are usually hormonally silent and tend to be discovered incidentally on imaging tests. Adrenalectomy is the gold standard for the treatment of primary adrenal GNs. Nevertheless,preoperative differential diagnosis of GNs remains extremely challenging,and thus histopathological examination is required in order to confirm the diagnosis of GN. Overall,prognosis after surgical resection seems to be excellent,without any recurrences or need for adjuvant therapy.

Robotic renal and adrenal oncologic surgery:A contemporary review

Robot-assisted surgery has evolved over time.Radical nephrectomy with inferior vena cava thrombectomy is feasible and safe for level I,II and III thrombus in high volume centers.Though it is feasible for level IV thrombus,this procedure needs a multi-departmental cooperation.However,the safety of robot-assisted procedures in this subset is still unknown.Robot-assisted partial nephrectomy has been universally approved and found oncologically safe.Robotic adrenalectomy has been increasingly utilized for select cases,especially in bilateral tumors and for retroperitoneal adrenalectomy.

Minimally invasive techniques in benign and malignant adrenal tumors

Minimally invasive adrenalectomy has become the main treatment modality for most adrenal lesions.Both laparoscopic transabdominal and retroperitoneoscopic approaches are safe and feasible options,each with respective advantages,including better surgical outcomes,fewer complications,and faster recovery over open adrenalectomy.While open surgery remains a valid modality in treatment of adrenocortical cancer in the presence of some findings such as invasion,robotic platforms,and minimally invasive surgery have gained popularity as technology continues to evolve.Organ preservation during adrenalectomy is feasible in some conditions to prevent adrenal insufficiency.Ablative technologies are increasingly utilized in benign and malignant tumors,including the adrenal gland,with various outcomes.A multidisciplinary team,an experienced surgeon,and a highvolume center are recommended for any surgical approaches and management of adrenal lesions.This review article evaluated recent findings and current evidence on minimally invasive adrenalectomy.

Kidney in primary aldosteronism: A key determinant of treatment outcome

Recently, it has been suggested that primary aldosteronism(PA) is associated with a variety of cardiac,vascular, metabolic, and renal sequelae that reflect the capability of elevated aldosterone to induce organ damage beyond that induced by hypertension itself. The evidence supporting of these views has been obtained from experiments conducted in rodents and clinica studies conducted in patients with this endocrine disorder. It has been suggested that untoward effects of high-salt intake are dependent on activation of mineralocorticoid receptors that might result from increased oxidative stress and changes in the intracellular redox potential. Unilateral adrenalectomy or treatment with mineralocorticoid receptor antagonists are the current options for treating an aldosterone-producing adrena adenoma or idiopathic adrenal hyperplasia. Treatments are largely effective in correcting hypertension and hypokalemia, and currently available information on their capability to prevent deterioration of renal function indicates that surgery and medical treatment are equallybeneficial in the long term. This editorial review will focus on the renal aspects of PA and highlights the role of the kidney as a key determinant of both adaptation to aldosterone-induced volume retention and response of blood pressure to treatment.

Bilateral Macronodular Adrenal Hyperplasia

Cushing’s syndrome is the set of clinical manifestations secondary to a chronic excess of glucocorticoids. Bilateral macronodular adrenal hyperplasia with subclinical cortisol secretion is the most common, but its prevalence remains unknown. We describe a case of bilateral macronodular adrenal hyperplasia. This is a 36-year-old female patient who had been consulting for secondary amenorrhea and developing asthenia for 4 months. The clinical examination noted an overweight patient with high blood pressure, facio-trunk obesity, hirsutism and purple stretch marks in the abdomen and thighs. Biologically, hypokalemia at 2.9 meq/l (3.5 - 5.4), normal calcemia at 90 mg/l (85 - 104), fasting blood sugar was 0.84 g/l (0.7 - 1), the tests for minute, low and high dexamethasone suppression test revealed insufficient suppression of cortisol. The cortisoluria collected from the second day to the third day of the high dexamethasone suppression test was at 186 μg/24 h (<60), the ACTH (Pg/ml) was undetectable (6.4 - 49.8). The diagnosis of an independent adrenocorticotrophin (ACTH) Cushing syndrome was made and the adrenal CT scan revealed bilateral macronodular hyperplasia. A bilateral adrenalectomy was performed and a complete remission of Cushing syndrome was achieved. We prescribed to her, hydrocortisone 20 mg/day and alpha-fludrocortisone 25 to 50 μg/day, This medical observation showed that macro-nodular adrenal hyperplasia with overt Cushing syndrome can occur in the third decade of life. Bilateral adrenalectomy has resulted in a complete cure for Cushing’s syndrome, but may be fraught with complications.

NOTES new frontier:Natural orifice approach to retroperitoneal disease

AIM: To develop a pure transvaginal access to the retroperitoneum, that is simple, reproducible and uses endoscopic material available on the market. METHODS: From February 2008 to April 2009, 31 pigs were operated on, with 17 as an acute experiment and 14 with a survival protocol. The animals were placed in a supine position and a 12-mm double-channel endoscope (Karl StorzTM, Tuttlingen) was used for vision and dissection. During the same time period, the access experiment was reproduced on 3 human cadavers using material similar to that used in the animal model. RESULTS: In the animal model, 37 interventions were done on the kidney, adrenal gland and pancreas. The mean time to fashion the access was 10 min (range 5 to 20 min). No intraoperative death was observed. Two major (5%) intraoperative complications occurred: one hemorrhage on the aorta and one tearing of the right renal vein. Peritoneal laceration was encountered in 5 cases without impairing the planned task. In the survival group, good clinical outcome was observed at a mean follow-up of 3 wk (range 2 to 6 wk). In the 3 cadavers, access was performed correctly. The mean time to fashion the access was 52 min (range 40 to 60 min). All the anatomical landmarks described in the pig model were clearly identified in the same sequence. CONCLUSION: A retroperitoneal natural orifice translumenal surgical transvaginal approach is feasible in both animal and human models and allows performance of a large panel of interventions.

Giant androgen-producing adrenocortical carcinoma with atrial flutter: A case report and review of the literature

BACKGROUND Adrenocortical carcinoma(ACC),the second most aggressive malignant tumor,lacks epidemiological data worldwide;therefore,every new case can improve the understanding of the pathology and treatment of this malignancy.CASE SUMMARY We present the case of a 66-year-old Caucasian woman with a giant androgenproducing ACC(21 cm×17 cm×12 cm;2100 g),without metastases,which unusually presented with an acute onset of atrial flutter and congestive heart failure.The cardiac complications observed in our case support the hypothesis that androgen excess in women is a cardiovascular risk factor.Androgen excess in women can be a rare cause of reversible dilated cardiomyopathy,therefore a comprehensive approach to the patient is essential to improve the recognition of androgen-secreting ACC.The atrial flutter was remitted after initiation of drug treatment during admission.The severe heart failure was totally remitted at 6 mo after radical open surgery to remove the giant ACC.CONCLUSION Radical open surgery to remove a giant androgen-producing ACC was the firstline treatment to cure the excess of androgen,which determined the total remission of cardiac complications at 6 mo after surgery in the women of this case report.

Comparison of Cardiac Structural Improvement in Patients with Primary Aldosteronism after Surgical Therapy and Drug Therapy: A Meta-Analysis

Background: At present, in clinical practice, patients with primary hyperaldosteronism (PA) are mainly treated by surgery or medical drugs (spironolactone/spironolactone, epridone, etc.). Some studies show that the left ventricular hypertrophy of patients can be significantly improved after treatment. However, at present, the relevant research is very limited, and there is still controversy on the improvement of cardiac structure and function between the two treatment methods. No reliable conclusions have been drawn. Objective: We conducted this meta-analysis to compare the improvement of cardiac structure of patients after surgical treatment and drug treatment, so as to clarify the efficacy of surgical treatment and drug treatment for PA patients. Methods: In order to examine the cardiac color ultrasound data of PA patients receiving surgical treatment and drug therapy (spironolactone, antisterone), randomized or observational studies were searched through Pubmed, Cochrane Library, and Embase. Meta-analysis was then carried out on the comprehensive and individual outcomes. The ROINBS-I scale is utilized to assess the offset risk of study inclusion. Outcomes: A total of nine studies involving 799 patients with PA into meta analysis, according to the results of the surgery in the treatment of patients with PA, left ventricular mass index (LVMI) changes in value (drop range) is significantly higher than drug therapy (Mean difference IV: —2.32, P In 6 studies, after surgical treatment of interventricular septal thickness (IVSD), changes in value (drop range) are also higher than drug therapy (Mean difference IV: —0.35, P In 2 studies, the surgical treatment of plasma aldosterone concentration (PAC) drop degree is superior to drug therapy (Mean difference IV: —12.63, P < 0.05), and blood pressure to improve the degree of surgery and drug treatment has no obvious difference. Conclusions: This meta-analysis result confirmed that after medical and surgical treatment of PA can obviously improve the patient’s blood pressure, and no difference between the two treatments. But for the heart structure improvement, including left ventricular hypertrophy and interventricular septum thickness, surgical treatment effect is significantly better than the medicine treatment, so the adrenalectomy can be used as unilateral PA optimal choice of treatment.

Laparoendoscopic single site,laparoscopic or open surgery for adrenal tumors:Selecting the optimal approach

Numerous surgical modalities are available to treat adrenal lesions. Minimally-invasive approaches for adrenalectomy are indicated in most circumstances, and new evidence continues to be accumulated. In this context, current indications for open surgical adrenalectomy(OS-A), minimally-invasive adrenalectomy(MI-A), and laparoendoscopic single-site adrenalectomy(LESS-A) remain unclear. A comprehensive Englishlanguage literature review was performed using MEDLINE/Pub MED to identify articles and guidelines pertinent to the surgical management of adrenal tumors. A comprehensive chart review was performed for three illustrative cases. Clinical recommendations were generated based on relevant literature and the expertise of the investigator group. MI-A offers advantages over OS-A in properly selected patients, who experience fewer complications, lower blood loss, and shorter hospital stays. Robot-assisted laparoscopic and retroperitoneoscopic adrenalectomy may offer advantages over transperitoneal surgery, and LESS-A may be an even less-invasive option that will require further evaluation. MI-A remains the surgical treatment of choice for most adrenal lesions. Tumor size and stage are the primary indications for selecting alternative treatment modalities. OS-A remains the gold standard for large tumors(> 10 cm) and suspected or known advanced stage malignancy. LESS-A appears to be an appropriate initial approach for small tumors(< 4-5 cm), including pheochromocytoma and isolated adrenal metastases.