AIPOUPTIKH, ‘ANAQUETA XEIPOUPTIKH. ANAVU
WORLD Journal of SURGERY @ 2004 by the Société Internationale de Chirurgie
BIOT
Partial versus Total Adrenalectomy by the Posterior Retroperitoneoscopic Approach: Early and Long-term Results of 325 Consecutive Procedures in Primary Adrenal Neoplasia
Martin K. Walz, M.D.,1 Klaus Peitgen, M.D.,1 Daniela Diesing1 Stephan Petersenn, M.D.,2 Onno E. Janssen, M.D.,2 Thomas Philipp, M.D.,3 Klaus A. Metz, M.D.,4 Klaus Mann, M.D.,2 Kurt W. Schmid, M.D.,4 Hartmut P. H. Neumann, M.D.5
1Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Akademisches Lehrkrankenhaus der Universität Essen, Henricistrasse 92, D-45136 Essen, Germany
2Abteilung für Endokrinologie, Universitätsklinikum Essen, Hufelandstrasse 55, D-45122 Essen, Germany
3 Abteilung für Nieren-und Hochdruckkrankheiten, Universitätsklinikum Essen, Hufelandstrasse 55, D-45122 Essen, Germany
4Institut für Pathologie, Universitätsklinikum Essen, Hufelandstrasse 55, D-45122 Essen, Germany
5Medizinische Klinik und Poliklinik, Abteilung für Innere Medizin IV, Universitätsklinikum Freiburg, Hugstetter Strasse 55, D-79106 Freiburg, Germany
Published Online: November 11, 2004
Abstract. The retroperitoneoscopic approach is a standardized operative procedure for primary adrenal gland tumors. It allows direct access with a detailed view of the adrenal gland. Thereby, a clear differentiation between normal and neoplastic adrenal tissue is often possible, which permits a planned partial resection of the gland in selected cases. Between July 1994 and November 2003 325 posterior retroperitoneoscopic adrenalectomies were performed for primary benign adrenal gland tumors (106 Conn’s ad- enomas, 83 pheochromocytomas, 76 Cushing’s adenomas, 60 nonfunction- ing tumors; size: 2.8 ± 1.5 cm; site: 160 right, 165 left) in 318 patients (122 M, 196 F, age: 49.0 ± 14.3 years). In 96 patients 100 tumors were removed by partial adrenalectomy (30 Conn’s adenomas, 33 pheochromocytomas, 20 Cushing’s adenomas, 17 nonfunctioning tumors; site: 61 right, 59 left) maintaining tumor-free parts of the adrenal gland. Of this group, 15 pa- tients suffered from bilateral adrenal neoplastic diseases. During the same period, 225 total adrenalectomies (76 Conn’s adenomas, 50 pheochromo- cytomas, 56 Cushing’s adenomas, 34 nonfunctioning tumors; site: 109 right, 116 left) were performed in 224 patients. There was no mortality. Major complications were seen in 1.8%, minor complications in 14.5%. Three conversions were necessary to an open or a laparoscopic approach (2 patients and 1 patient, respectively). There are no differences between the two groups (total versus partial adrenalectomy) with regard to tumor size (2.8 ± 1.6 cm versus 2.8 ± 1.5 cm), operating time (80 ± 44 minutes versus 79 ± 42 minutes), and blood loss (33 ± 71 ml versus 29 ± 31 ml). In all patients with partial adrenalectomy, biochemical healing was proven. Fourteen of 15 patients with bilateral diseases had preservation of adreno- cortical function. After a mean follow up of 51 months (range: 7-120 months) local recurrence or relapse of the initial diseases was noticed in 6 patients after total adrenalectomy: in 4 patients with Conn’s syndrome and bilateral hyperplasia, and in 2 patients with malignant pheochromocytoma and adrenocortical carcinoma, respectively. Our data demonstrate that
partial adrenalectomy is a safe procedure not only perioperatively but also in the long-term follow-up.
Today, laparoscopic adrenalectomy and retroperitoneoscopic ad- renalectomy have become standard approaches in adrenal surgery. These endoscopic accesses are recommended mainly for benign adrenal tumors and for hyperplasia. It is still debated whether total adrenalectomy is necessary in all cases or whether there may be indications for partial adrenalectomy in selected situations. For adrenal tumors, the latter concept has been introduced by Irvin et al. in the era of the open approach [1] and by our group in the laparoscopic phase of treatment [2]. Meanwhile, many surgeons have adopted this policy demonstrating feasibility and safety of par- tial endoscopic adrenalectomy [3, 4, 5, 6, 7, 8, 9], but long-term results are still missing. Having earlier described our initial experi- ence with partial adrenalectomy in 22 patients [10] and our learning curve of posterior retroperitoneoscopic adrenalectomy in 142 pa- tients [11], we will now present a comparative study of 318 patients with total versus partial adrenalectomy for primary adrenal neopla- sia operated by the posterior retroperitoneoscopic approach. In- cluded are 15 patients with bilateral adrenal diseases.
Patients and Methods
Patients
Between July 1994 and November 2003 a prospective study was performed on 342 patients (132 male, 210 female, age: 49.0 ± 14.0 years; range: 10-80 years) with 366 posterior retroperitoneoscopic adrenalectomies. Of this group, 318 patients (122 male, 196 female,
| Adrenalectomy | All | Partial | Total |
|---|---|---|---|
| Patientsª | 318 | 96 | 224 |
| Gender | 122 M/196 F | 38 M/58 F | 86 M/138 F |
| Age (years) | 49.0 ± 14.3 | 44.5 ± 15.3 | 51.0 ± 13.5 |
| Adrenal tumors (no.) | 325b | 100 | 225 |
| Conn's adenoma | 106 | 30 | 76 |
| Pheochromocytoma | 83 | 33 | 50 |
| Cushing's adenoma | 76 | 20 | 56€ |
| Nonfunctioning tumor | 60 | 17 | 43 |
| Site of tumor | |||
| Right | 160 | 51 | 109 |
| Left | 165 | 49 | 116 |
| Size of tumor (cm) | 2.8 ± 1.5 | 2.8 ± 1.5 | 2.8 ± 1.6 |
| Operating time (min) | 80 ± 43 | 79 ± 42 | 80 ± 44 |
| Right | 84 ± 46 | 71 ± 37 | 90 ± 48 |
| Left | 76 ± 40 | 88 ± 45 | 70 ± 37 |
| Blood loss (ml) | 33 ± 61 | 29 ± 31 | 33 ± 71 |
ª2 Patients (No. S.R. and S.A., Figure 2) with bilateral pheochromocy- tomas had synchronously total and partial adrenalectomy, respectively. b6 Patients with bilateral pheochromocytomas, 1 patient with bilateral Cushing’s adenoma.
“One carcinoma in final histology.
age: 49.0 ± 14.3 years; range 10-80 years) suffered from primary adrenal tumors. Patients with ACTH-dependent bilateral hyper- plasia (n = 15) or with adrenal metastases (n = 9) as well as patients with laparoscopic adrenalectomy operated during the same period (n = 26) were excluded from this study. All patients gave their in- formed consent. Indications for adrenalectomy were all hormon- ally active tumors or in nonfunctioning tumors, a size of 4-7 cm or with proven growth. For patients with Conn’s syndrome adrenalec- tomy was performed if a unilateral tumor could be identified by computed tomography or magnetic resonance tomography. Adre- nal venous sampling was used in selected patients with Conn’s syn- drome if nondetectable lesions or bilateral adrenal neoplasias were presented.
Total adrenalectomy was performed in 223 patients with unilat- eral neoplasias and one patient with bilateral Cushing’s adenomas. In 92 patients with unilateral neoplasias partial adrenalectomy was carried out. In 4 patients with bilateral pheochromocytomas partial adrenalectomy was performed on both sides. In addition, for 2 pa- tients with bilateral pheochromocytoma a complete resection was performed unilaterally and a partial resection contralaterally. In these procedures 225 tumor-bearing adrenal glands were removed totally and 100 partially. Twenty-two patients with pheochromocy- tomas had inherited diseases: 5 multiple endocrine neoplasia (MEN) type 2A, 3 MEN type 2B, 8 von Hippel-Lindau disease (VHL), 2 von Recklinghausen’s disease, 2 succinate dehydroge- nase subunit D gene mutations. Six patients suffered from recur- rent adrenal neoplasias. These patients each had pheochromocy- tomas, and one had apparent sporadic disease, while VHL was present in 5 cases. Recurrent tumors were extirpated by total adre- nalectomy in 4 patients and by partial resection in two cases. The intervals between the initial and the recurrent operation were 1, 9, 9, 11, 12, and 26 years. Further details of patients (age, gender, type of tumor, and tumor size) are described in Table 1. Patients with pheochromocytoma were pretreated with high-dose a-blockage (phenoxybenzamine: usually 2-4 mg per kg body weight) orally; in
patients with Conn’s syndrome potassium-sparing diuretics and oral potassium replacement therapy served preoperatively.
For long-term results, the patients, their general practitioners, and in most cases, the endocrinologists providing ongoing care, were contacted by telephone or had clinical follow-up. If possible, data were demonstrated as mean values ± standard deviation. For group comparison, the Mann-Whitney U-test was performed. Sig- nificance was accepted for p < 0.05. The statistical analyses were performed by a commercially available program for personal com- puters (StatView 5.0; Abacus Concepts, Berkeley, CA).
Operative Technique
Since our earlier descriptions [2, 10, 11, 12] owing to increasing experience, we have modified the retroperitoneoscopic technique slightly: after induction of total intravenous anesthesia, a central venous catheter and an arterial line are inserted if indicated. The procedure is performed with the patient in the prone position lying on a rectangular support that allows the ventral abdominal wall to hang through. Initially, a 1.5 cm transverse incision just below the tip of the twelfth rib is performed. The retroperitoneal space is reached by blunt and sharp dissection of the abdominal wall. A small cavity is prepared digitally for insertion of two 5 mm trocars 4 to 5 cm lateral and medial to the initial incision site respecting the subcostal nerve. Thus safe trocar placement is possible without vi- sual control. A blunt trocar with an inflatable balloon and an ad- justable sleeve is introduced into the initial incision site and blocked. The capnoretroperitoneum is created by maintaining a CO2 pressure of 20 to 25 mmHg. Retroperitoneoscopy is usually performed by a 5 mm 30-degree endoscope, which is introduced into the trocar nearest to the spine.
After creation of the retroperitoneal space underneath the dia- phragm by pushing down the fatty tissue, mobilization of the upper pole of the kidney is performed. Thereby, the area of the adrenal gland is exposed. The upper pole of the kidney is then retracted by one of the instruments in the medial or lateral trocar. Sometimes it is necessary to place a fourth trocar below the first line of ports for pulling the kidney down with a retractor. Mobilization of the adre- nal gland begins medially and caudally between the crus of the dia- phragm and the adrenal gland. In this area on the right side the adrenal gland arteries cross the vena cava posteriorly. These vessels are separated by electrocoagulation or clip application. By lifting the adrenal gland, the inferior vena cava is demonstrated posteri- orly in its retroperitoneal-cranial segment. The short suprarenal vein thus becomes clearly visible running posterolaterally. This ves- sel is followed to a length of 1 cm and divided between clips. Prepa- ration of the right adrenal gland is completed by lateral and cranial dissection. For the left-sided retroperitoneoscopic adrenalectomy, the adrenal gland vein must be prepared in the space between the adrenal gland and the crus of the diaphragm medial to the upper pole of the kidney. After dissection of the main vein preparation of the adrenal gland is continued medially, laterally, and cranially. All adrenal gland manipulations are performed carefully using blunt palpation probes to prevent injury to the adrenal gland tissue.
If a subtotal adrenalectomy is planned, the margin of the neo- plasm must be identified. Therefore, it may be necessary to resect parts of the surrounding fatty tissue. Additionally, retroperitoneo-
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scopic ultrasonography by a 10 mm flexible 10 MHz probe is ap- plied, especially in cases with bilateral or inherited pheochromocy- tomas. After clear identification, the adrenal tumor is resected with a margin of 0.5 to 1.0 cm of normal tissue. These resections are regularly performed by electrocoagulation, ultrasonic scalpel, or clip application. Preservation of the adrenal vessels depends on the individual situation.
Results
In this consecutive series of 325 posterior retroperitoneoscopic ad- renalectomies for primary adrenal tumors, mortality was zero. Three conversions occurred (0.9%), twice to the open posterior approach due to cardiac instability (patient no. 2) and technical problems (patient no. 21), and once to the lateral laparoscopic technique due to severe obesity (patient no. 205). The operating time for total and partial adrenalectomies decreased significantly: the first 50 total adrenalectomies needed 120 ± 52 minutes and the last 50 total procedures 55 ± 23 minutes (p < 0.001). The initial 50 partial adrenalectomies took 87 + 38 minutes, the last 71 ± 43 min- utes (p < 0.01). The learning curves are demonstrated in Figure 1. Operating time did not differ significantly between total and partial adrenalectomy (80 ± 44 minutes versus 79 ± 42 minutes, respec- tively), procedures took longer in male than in female patients (93 ± 43 minutes versus 71 ± 38 minutes, respectively; p < 0.001). In- traoperative blood loss was low in total and partial adrenalectomy (33 ± 71 ml and 29 ± 31 ml, respectively). No unit of blood was transfused in any patient.
Intraoperative and postoperative complications are listed in Table 2 showing no relevant differences between total and partial
| Adrenalectomy | All (n = 325) | Partial (n = 100) | Total (n = 225) |
|---|---|---|---|
| Intraoperative | |||
| Conversion to open procedure | 2 | – | 2 |
| Pleural tear | 4 | – | 4 |
| Hypertension (systolic pressure ≥ 200 mmHg) | 5 | 1 | 4 |
| Postoperative | |||
| Myocardial infarction | 1 | – | 1 |
| Myocardial insufficiency | 1 | – | 1 |
| Addisonian crisis | 1 | – | 1 |
| Pneumonia | 1 | 1 | – |
| Pneumothorax | 1 | 1 | |
| Bleeding (> 500 ml) | 3 | – | 3 |
| Incisional hernia | 1 | – | 1 |
| Relaxation of abdominal wall | 24 | 5 | 19 |
| (temporary) | |||
| Hypesthesia of abdominal wall (temporary) | 9 | 2 | 7 |
adrenalectomy. The parietal pleura was injured in four patients, none of which required conversion to the open procedure. In- creases of systolic blood pressure to more than 200 mmHg were seen in five patients with pheochromocytoma. One myocardial in- farction, one pneumonia, and one Addisonian crisis occurred and were treated conservatively. The latter complication was seen in a patient with Cushing’s syndrome who refused the oral corticoid medication postoperatively. Other complications included hypes- thesia and relaxation of the abdominal wall but were temporary and disappeared within a few months. Postoperative bleeding was seen three times: one hematoma spontaneously discharged one week postoperatively through the middle incision. In one case suctioning of the wound drainage collected more than 500 ml. Another retro- peritoneal hematoma was diagnosed by computed tomography, and conservative treatment was instituted. Finally, one incisional hernia developed and was surgically closed after two years.
Six patients underwent operation for a recurrent pheochromo- cytoma, 5 suffered from VHL, one from a sporadic disease. In one patient a tumor 2.5 cm in diameter was found 1 year after the lap- aroscopic partial procedure in another hospital. In this case, per- sistent disease is assumed. The other five patients had had open procedures 9-26 years earlier. Four of these patients had an open anterior approach and one an open posterior approach at the first procedure. Because of retroperitoneal scarring, operating time was increased (mean: 189 minutes, range: 80-255 minutes).
Bilateral adrenal diseases were diagnosed in 15 patients (Fig. 2). Fourteen patients suffered from bilateral pheochromocytomas and one patient showed a unilateral pheochromocytoma but had had a contralateral adrenalectomy with nephrectomy for renal carci- noma 12 years earlier. All patients underwent partial adrenalecto- my of at least one side with preservation of one third or more in all cases except the first. The main adrenal vein had to be dissected in most cases (Fig. 2). In the last 13 patients of this subgroup, partial adrenalectomy was guided by intraoperative ultrasound. Cortical function was preserved completely in all but the initial case.
We saw 322 benign and 3 malignant neoplasias with a mean size of 2.8 + 1.5 cm. After a mean follow-up of 51 ± 31 months (range: 7-120 months; total adrenalectomy: 51 ± 32 months; partial adre- nalectomy: 53 ± 30 months), no local or locoregional recurrence
| Patient | Agel Gender | Diseño | Sile | Size | Pheochromocyloms primary/recurrent | Procedure total/partial adrenalactomy | Pari(s) preserved (dark area) | Main Voin Dissected | Timing | Follow-up {months) | Recurrence | Curtisol Supplementation |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| S.R. | 44 M | MEN 2A | right left | ti com | primary | total partial | yes yes | synchronous | 102 | no | 10 mg hydrocortisone per day | |
| 3 cm | primary | |||||||||||
| D.B. | right | 4 cm | primary | partial | yes | mecachroncosas, left years | ||||||
| 49 F | MEN 2A | lett | 3 cm | primary | total | adrenalectocay 9 before hy apen transperitoneal approach | 93 | no | none | |||
| A.G. | 38 M | VHL | right left | n.d. 2 cm | primary recurrent | total partial | yes | metacheccecus, rigt:s adren:'ecteeny and perial left adresalecomy 26 years before by' open transperitoneal approach | 54 | no | none | |
| S.J. | 31 M | VHL | right Infr | 6 cm 5 cm | primary primary | partial partial | yes yes | synchroncous | 47 | no | none | |
| S.T. | 33 M | VHL | right | 5 cam | primary | total partial | yes | metacheceeous, right | nune | |||
| loft | 3 cm | primary | adresalectomy I yese before by laparoscopic approach | 47 | nu | |||||||
| K.T. | 25 M | VHL | right loft | 2 cm 2 cm | primary recurrent | partial total | yes | synchroceous, let) partir] adrameleciomy 9 years before by open transabdominal approach | 44 | DO | nonc | |
| M.U. | 66 W | sporadic | right | total partial | yes | metachroneaus, right | 39 | no | ||||
| left | 2.5 cm | Ichrenalectoeny 9 years heforce de to renal | none | |||||||||
| primary | carcinoma | |||||||||||
| B.V. | 31 M | MEN 2B | right | 3 cm | primary | partial | yes | synchronsoas | 34 | 00 | none | |
| left | 6 cm | primary | partial | yes | ||||||||
| Z.N. | 18 ₩ | MEN 2D | right left | 1 cm | primary | partial partial | yes yes | synchronsons | 34 | Do | none | |
| 4 cm | ||||||||||||
| primary | ||||||||||||
| K.P. | 58 W | sparadic | righe let: | 12 cm 25 cm | primary primary | total partial | yes yes | merachroncous, right Kbencketomy S wocks before by laparoscopic approach | 25 | DIO | none | |
| W.T. | 30 M | SDID | rtglo. left | 25 cm | primary | partial | yes yes | metaclineous, lef: adrenalectomy 4 years before by open transalcinomal Eporcada | 22 | no | uone | |
| T.P. | 17 M | sporadic | rolex left | 25 cm | primary | partial | no | metachroneous, rigiy: adrenalectomy 4 years before by cpen transaldinomal approad: | 21 | no | none | |
| "TA | 39 M | SDHD | right kefr | 2 cza | primary | partial | yes | marachronoous, lafr ixtrennlactoeny 3 years beloce by opan transabdimboened approach | 17 | nu | none | |
| W.P. | 30 W | MEN 2A | right kauft | 3 ca 6 cm | primary primary | total partial | yes yes | synchronsous | 14 | no | none | |
| S.A. | 42 M | VHL | right ka | 1 cm 1.5 cm | primary recurrent | partial total | yes | synchrocceus, leal partial acron:)cclucy 12 years before by egen pasteriar appenach | 9 | no | none |
Fig. 2. Patients with partial adrenalectomies in bilateral adrenal diseases. MEN: multiple endocrine neoplasia; VHL: von Hippel-Lindau; SDHD: succinatdehydrogenase subunit D gene mutation.
occurred in any case of benign tumors. Biochemical healing was achieved in all patients after total or partial adrenalectomy with functioning lesions, except in 4 patients with Conn’s syndrome. In these patients a multinodular bilateral hyperplasia was diagnosed from the specimen; all four had total adrenalectomy.
Three patients suffered from malignant adrenal diseases. Beside one adrenocortical carcinoma in a 27-year-old woman with Cush- ing’s syndrome (right adrenal gland; size: 7 cm) two patients had
malignant pheochromocytomas (both right side: size 6 and 7 cm, respectively). Initially, one patient had multiple skin metastases; the other patient developed an interaortocaval metastasis in a lymph node 42 months after the adrenalectomy. In the patient with the adrenocortical carcinoma, locoregional recurrence and mul- tiple liver and lung metastases were diagnosed 8 months after the primary procedure. She died after one year as the patient with the skin metastases did. The other patient with the malignant pheo-
chromocytoma developed multiple bone metastases and died 6 years after the adrenalectomy. Because of the size of the adrenal tumors, all three adrenal glands were removed completely. During follow-up one other patient died of cardiac arrest, and 6 patients died of metastatic bronchial carcinoma.
Discussion
The presented study describes 325 adrenalectomies by the poste- rior retroperitoneoscopic approach. To the best of our knowledge, this series represents the largest series of endoscopic adrenal pro- cedures published up to now. Since our early descriptions of the surgical technique, we have used that approach routinely for pri- mary adrenal tumors up to a size of 7 cm without suspicion of ma- lignancy, including for recurrent adrenal tumors. Up to now, about 93% of our endoscopic adrenalectomies have been performed by the posterior retroperitoneoscopic route. Mean operating time has decreased to less than 1 hour, demonstrating superior feasibility. Complications are rare and minor, showing safety convincingly, and biochemical cure in functioning tumors could almost always be achieved.
Based on our experience, contraindications for the posterior ret- roperitoneoscopic approach to the adrenal glands are tumors larger than 6-7 cm and extremely obese patients. Large tumors are difficult to manipulate in the relatively small space of about 300- 400 ml and have an increased rate of malignancy [13]. In very obese patients the retroperitoneum is compressed by the abdomen when the patient is in the prone position. In these cases even increased gas pressures of more than 20 mmHg do not create a sufficient retroperitoneal space to thwart gravity. From our point of view, primary adrenal tumors less than 5 cm in diameter are ideal indi- cations for the posterior retroperitoneoscopic approach. Probably because of the slightly reduced dimensions, the procedure is quicker and easier in female patients.
It is still controversial whether malignant tumors should be op- erated by endoscopic techniques [14, 15, 16]. In this study we tried to avoid the resection of malignant lesions in curative cases. This concept was successful except in two patients, one with an adreno- cortical carcinoma and the other with a malignant pheochromocy- toma. Whereas the patient with the cortical malignancy developed locoregional and distant metastases within a few months, the pa- tient with pheochromocytoma showed the first metastasis in a lo- coregional lymph node after more than three years. At least it re- mains open whether these neoplasms would have had a different course after a conventional open procedure. Our strategy for sepa- ration of non-benign adrenal tumors is still based predominantly on size and signs of local infiltration mainly by computed tomography. Other methods, such as chemical shift imaging in magnetic reso- nance tomography [17], were not used. Additional factors such as inherited disease, type of tumor, and type of hormonal secretion have also been taken into account. Large pheochromocytomas in MEN or VHL patients are usually benign; large corticoid-secreting tumors are suspicious for malignancy.
During the last several years, surgeons and urologists have in- creasingly adopted the concept of partial adrenalectomy by endo- scopic techniques. Bilateral pheochromocytomas and Conn’s ade- nomas have been the main indications [3, 4, 5, 6, 7, 8, 18]. These studies have proved the safety and feasibility of this approach, usu-
ally in small groups of patients. An exception is the recently pub- lished series with 47 adrenal tumors extirpated by partial adrenal- ectomy [7] with all patients cured via the posterior retroperito- neoscopic approach. For the first time our study includes 100 con- secutive partial adrenalectomies in primary adrenal tumors clearly showing equal results of total and partial procedures concerning operating time, blood loss, complication rate, and cure rate. No persistent or local recurrences were seen during follow-up for up to 120 months.
Today, the indications for partial adrenalectomy are still not clearly defined. The most accepted situations are bilateral pheo- chromocytomas in inherited diseases. Though the risk of a recur- rent tumor growing in the adrenal remnant is evident, a cortical- sparing surgical technique is increasingly demanded by well- informed patients to prevent corticoid supplementation and Addisonian crisis. As estimated by other investigators and us, cor- tical function can be preserved by sparing at least one-third of one gland [19]. Thereby, a main adrenal vein is not essential. In our subgroup of 15 consecutive patients with bilateral adrenal disease, complete cortical function could be preserved in all but one. As there were no other primary neoplastic bilateral diseases during the same period of time, the success rate is impressive. We believe that this is mainly based on the ideal exploration by the posterior retro- peritoneoscopic route that allows clear differentiation between normal and neoplastic tissue occasionally with the help of laparo- scopic ultrasound. Contraindications for partial adrenalectomy in bilateral inherited pheochromocytomas may be families with ma- lignant pheochromocytomas [20, 21, 22, 23]. As they are absent in our and other large series, they seem to be rare [24, 25]. Data of recurrences after partial adrenalectomy in inherited pheochromo- cytomas are inconsistent and range from 0 to 100% [19, 23, 26, 27]. The length of follow-up may explain these data, as recurrences are usually seen after one decade or later. This has also been demon- strated by the subgroup of recurrent pheochromocytomas in this study. Real recurrences were seen in 5 patients after a mean follow- up of 13 years.
Another increasingly frequent indication for partial adrenalec- tomy is Conn’s adenomas. They seem to be good candidates as they are usually small, often eccentric, and almost always benign. Pub- lished series with 5-26 patients show cure in all cases [5, 7, 8, 9, 28]. Persistent hyperaldosteronism after partial adrenalectomy has been reported once [29]. In this case with two well-known adrenal tumors in the gland the active nodule was left in place during partial adrenalectomy without intraoperative ultrasound. A second open procedure cured the patient. Our experiences in Conn’s adeno- mas-but also in Cushing’s adenomas-demonstrate that partial adrenalectomy cures the patients if a precise selection is per- formed. Clear differentiation of tumor and normal parenchyma is always essential. This possibility is offered especially by the endo- scopic methods with their excellent view of the adrenal gland and its surrounding area. If differentiation between tumor and normal parenchyma is impossible intraoperatively, complete adrenalecto- my becomes unavoidable. This situation may occur in the presence of an extreme amount of periadrenal fatty tissue or when a medul- lary tumor scatters the adrenal cortical tissue completely on its sur- face.
We conclude that total as well as partial adrenalectomy in pri- mary adrenal gland tumors can be safely and successfully carried out by the posterior retroperitoneoscopic approach. After a mean follow-up of about 4 years, all 96 patients with partial adrenalecto-
my are biochemically cured. Maintenance of cortical function was achieved in 14 of 15 patients with bilateral adrenal diseases.
Résumé. L’approche endoscopique rétropéritonéale pour le traitement des tumeurs de la surrénale est un procédé standardisé. Elle permet l’abord direct et une vue en détails de la surrénale. Ainsi, on peut distinguer clairement entre les tissus normaux et pathologiques, ce qui est essentiel pour réaliser une résection partielle chez des patients sélectionnés. Entre juillet 1994 et novembre 2003, nous avons réalisé 325 surrénalectomies par voie endoscopique rétropéritonéale pour tumeur bénigne de la surrénale (106 adénomes de Conn, 83 phéochromocytomes, 76 syndromes de Cushing et 60 tumeurs non-fonctionnelles; taille: 2.8 ± 1.5 cm; côté: 160 à droite, 165 à gauche) chez 318 patients (122 hommes, 196 femmes, âge 49 ± 14.3 ans). Chez 96 patients, 100 tumeurs ont été réséquées partiellement: il s’agissait de 30 adénomes de Conn, 33 phéochromocytomes, 20 syndromes de Cushing et 17 tumeurs non-fonctionnelles; 61 du côté droit, 59 du côté gauche, permettant de conserver une partie de la glande surrenalienne fonctionnelle. Parmi ces patients, 15 avaient des tumeurs surrenaliennes bilatérales. Pendant cette même période, on a réalisé 225 surrénalectomies totales (76 adénomes de Conn, 50 phéochromocytomes, 56 syndromes de Cushing et 34 tumeurs non-fonctionnelles; 109 du côté droit, 116 du côté gauche) chez 224 patients. Il n’y avait aucune mortalité. Des complications majeures ont été observées chez 1.8% des patients, des complications mineures chez 14.5%. Trois conversions se sont avérées nécessaires (deux par laparotomie, une par laparoscopie transpéritonéale). Il n’y avait aucune différence entre les deux groupes (surrénalectomie partielle vs totale) en ce qui concernait la taille de la tumeur (2.8 ± 1.6 cm vs 2.8 ± 1.5 cm), la durée de l’intervention (80 ± 44 minutes vs 79 ± 42 minutes) ou les pertes sanguines (33 ± 71 ml vs 29 ± 31 ml). Une guérison biochimique a été obtenue chez tous les patients ayant eu une surrénalectomie partielle. La fonction adrénocorticale a été conservée chez 14 des 15 patients porteurs de tumeur bilatérale. Après un suivi moyen de 45 mois (extrêmes 1-114 mois), aucune récidive locale ou récidive de la maladie initiale n’a été observée sauf pour deux patients porteurs du syndrome de Conn et un patient porteur d’hyperplasie bilatérale. Ces résultats semblent indiquer que la surrénalectomie partielle est une technique sure, non seulement dans le court terme, mais aussi dans le long terme.
Resumen. El abordaje retroperitoneoscópico es un procedimiento operatorio estandarizado para el tratamiento de tumores suprarrenales primarios. Esta técnica hace posible el acceso directo con una visión detallada de la glándula suprarrenal, lo cual permite la diferenciación entre una lesión benigna y una maligna, y una resección parcial en casos seleccionados. Entre julio de 1994 y noviembre de 2003 se practicaron 325 adrenal- ectomías retroperitoneoscópicas posteriores por tumores suprarrenales benignos primarios (106 adenomas de Conn, 83 feocromocitomas, 76 adenomas de Cushing, 60 tumores no funcionantes; tamaño 2.8 ± 1.5 cm; ubicación: 160 derechos, 165 izquierdos) en 318 pacientes (122 masculinos, 196 femeninos; edad: 4.0 ± 14.3 años). Cien tumores fueron resecados por adrenalectomía parcial con preservación de las partes libres de tumor de la glándula en 96 pacientes (30 adenomas de Conn, 33 feocromocitomas, 20 adenomas de Cushing, 17 tumores no funcionantes; ubicación: 61 derechos, 59 izquierdos). En este grupo, 15 pacientes tenían neo- plasmas adrenales bilaterales. En el mismo periodo se practicaron 225 adrenalectomías totales (76 adenomas de Conn, 50 feocromocitomas, 50 adenomas de Cushing, 34 tumores no funcionantes; ubicación: 109 derechos, 116 izquierdos) en 224 pacientes. No hubo mortalidad. Se presentaron complicaciones mayores en 1.8% y menores en 14.5%. Fue necesario hacer tres conversiones al procedimiento abierto o al abordaje laparoscópico (2 y 1, respectivamente). No hubo diferencias entre los grupos de adrenalectomía total y parcial en cuanto a tamaño del tumor (2.8 ± 1.6 cm versus 2.8 ± 1.5 cm), tiempo operatorio (80 + 44 minutos versus 79 ± 42 minutos) y pérdida de sangre (33 ± 71 ml versus 29 ± 31 ml). En la totalidad de los pacientes con adrenalectomía parcial se comprobó curación bioquímica, y 14 de 15 pacientes con enfermedades bilaterales tuvieron preservación de la función adrenocortical. Luego de un seguimiento de 45 meses (rango 1-114 meses) no se registra recurrencia ni relapso de la enfermedad inicial excepto 2 pacientes con síndrome de Conn e hiperplasia bilateral. Nuestros hallazgos demuestran que la adrenalectomía parcial es un procedimiento seguro, no sólo en la fase perioperatoria sino también en el seguimiento a largo plazo.
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