Adrenal Insufficiency following Stereotactic Ablative Radiotherapy (SAbR) of Adrenal Gland Metastases.

BACKGROUND: Adrenal metastases are often treated with stereotactic ablative radiation (SAbR). We aimed to assess the incidence, timing, and factors associated with the development of primary adrenal insufficiency (PAI) following SAbR. METHODS: A retrospective cohort study comprised 66 consecutive patients (73% men, median age 61 years) who underwent SAbR for adrenal metastasis. RESULTS: The series encompassed metastases from renal cell carcinoma (41%), lung tumors (38%), colorectal adenocarcinoma (9%), melanoma (5%), and others (7%). Median follow-up was 17 months from SAbR. Nine (14%) patients developed PAI at a median of 4.3 months (range, 0.7-20.2). The incidence of PAI was 44% in patients with prior adrenalectomy receiving unilateral SAbR, 44% with bilateral SAbR, 2% with unaffected contralateral gland, and 0% with bilateral metastases treated with unilateral SAbR. PAI was associated with prior adrenalectomy (odds ratio [OR] 32) and bilateral SAbR (OR 8.2), but not age, sex, metastasis size, or biological effective dose. Post-SAbR 6-month and 1-year local control rates were 82% and 75%, respectively. CONCLUSIONS: Patients undergoing SAbR for adrenal metastasis are at high risk of developing PAI. PAI is associated with bilateral SAbR and contralateral adrenalectomy. PAI is unlikely with a remaining unaffected adrenal gland or in the setting of bilateral adrenal metastases with unilateral SAbR.

A New Disease Severity Score for Measuring Treatment Response to Adrenalectomy in Patients With Primary Aldosteronism.

OBJECTIVE: Cure after adrenalectomy for primary aldosteronism has been reported in only 15% to 40% of patients, with no disease severity score available to measure response objectively. Furthermore, the criteria used to define cure are outdated. This study aims to determine the rate of cure based on the current definition of normal blood pressure and develop a disease severity score to measure clinical improvement after adrenalectomy for primary aldosteronism. METHODS: This was a retrospective single-center study that included patients who underwent adrenalectomy for primary aldosteronism between 2000 and 2023. Blood pressure, a defined daily dose of antihypertensives, and potassium supplementation were incorporated into a new Primary Aldosteronism Disease Severity Score (PADSS), which was calculated with preoperative and 6-month postoperative parameters. RESULTS: The study included 201 patients. Adrenalectomy was guided by adrenal venous sampling in 86.1% of patients. The cure rate per the new definition of normal blood pressure was 7.5% (n = 15). The median PADSS was 16.3 (13.6-19.9) preoperatively and decreased to 10 (4.5-13.3) postoperatively. An improvement of the PADSS was observed in 90% (n = 180) of patients at 6 months of adrenalectomy. The median rate of improvement in PADSS was 33.3% (13.8% to 56.6%). CONCLUSIONS: Although complete cure rates are low after adrenalectomy in primary aldosteronism, especially based on the new definition of normal blood pressure, a clinical improvement is seen in the vast majority of patients postoperatively. The newly introduced PADSS can be used to assess the clinical benefit achieved with adrenalectomy.

Adrenal Schwannoma Presenting as an Incidentaloma in a Patient with Uterine Fibroids and Cholelithiasis: a Rare Case Report.

Schwannomas, which are benign mesenchymal tumors derived from Schwann cells, are common in the central nervous system. While they are commonly seen in the extremities and head-neck area, their presence in visceral organs, particularly the adrenals, is uncommon. Adrenal schwannomas are frequently discovered incidentally, offering a diagnostic difficulty because of their uncommon presentation. A 46-year-old woman initially sought treatment for symptoms related to uterine fibroids and biliary stones. Diagnostic imaging uncovered an adrenal incidentaloma, necessitating a laparoscopic right adrenalectomy. The mass was determined to be an adrenal schwannoma based on its spindle-shaped cells and S-100 immunohistochemistry positivity. The patient's symptoms improved, and she was discharged with stable vital signs. Preoperative diagnosis of adrenal schwannomas is difficult and requires histological confirmation. When diagnosing non-secreting adrenal tumors with unusual radiology, surgeons should investigate for schwannoma. Post-resection adrenal schwannoma follow-up studies are scarce; however, they imply a low risk of recurrence or metastasis.

Successful laparotomic ethanol ablation for an adrenal tumour in a dog.

Adrenalectomy is the gold standard for canine adrenal tumours, but not always recommended due to patient age, underlying conditions and perioperative mortality. Ethanol ablation is an alternative in human medicine for poor surgical candidates. A 13-year-old neutered female toy-poodle with hypercortisolism presented with severe haematuria. Ultrasonography revealed left adrenal and right kidney tumours. Due to high surgical risk, simultaneous laparotomic right nephroureterectomy and ethanol ablation of the left adrenal tumour were performed. Post-ethanol injection complications included transient hypertension and arrhythmia, which resolved spontaneously. The adrenal tumour size decreased within 2.5 months, and cortisol levels normalised within 8 days, remaining stable for 12 months. No hypercortisolism signs were observed without trilostane until death from renal insufficiency. Autopsy showed that the ablated left adrenal gland was an adrenocortical tumour and had shrunk. Ethanol ablation may be a feasible alternative to adrenalectomy for high-risk canine patients.

Robotic and Laparoscopic Adrenalectomy for Pheochromocytoma: An International Multicenter Study.

BACKGROUND AND OBJECTIVE: Robotic adrenalectomy (RA) has attracted interest as an alternative to laparoscopic adrenalectomy (LA) for patients with pheochromocytoma, although its beneficial effects are uncertain. Our aim was to compare RA and LA outcomes for these patients. METHODS: Data for patients who underwent RA or LA for pheochromocytoma in 46 international centers between 2012 and 2022 were reviewed. We analyzed baseline characteristics and postoperative complications at discharge, 90 d, and 1 yr. We conducted propensity score matching (PSM; 1:1 ratio) and multivariable analyses to evaluate outcomes and risk factors for the occurrence of complications and higher Comprehensive Complication Index (CCI). KEY FINDINGS AND LIMITATIONS: Of 1755 patients, 1613 (91.9%) underwent LA and 142 (8.1%) underwent RA. Estimated blood loss, conversion rate, complication rate, and CCI at discharge, 90 d, and 1 yr were similar between the groups. However, RA was associated with a longer operative time in comparison to LA (100 vs 123 min; p < 0.001), but not after PSM (p = 0.120). Multivariable analysis revealed that Charlson comorbidity index (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.07-1.29; p = 0.001), and tumor size per 1-cm increment (OR 1.13, 95% CI 1.07-1.21; p < 0.001) were independently associated with the incidence of complications, but there was no significant difference in complication rates between the LA and RA groups (OR 1.09, 95% CI 0.63-1.87; p = 0.767). After PSM, RA was associated with a lower rate of severe (grade ≥3a) complications in comparison to LA (p = 0.023). CONCLUSIONS AND CLINICAL IMPLICATIONS: RA is a safe alternative to LA and yields similar outcomes for patients with pheochromocytoma. RA may be associated with a lower likelihood of severe complications. Further studies are warranted to determine the role of robotic surgery in pheochromocytoma. PATIENT SUMMARY: Pheochromocytoma is a rare tumor in the adrenal gland and the gold-standard treatment is surgical removal. We assessed patient outcomes after robot-assisted surgery compared with laparoscopic surgery and found that outcomes are similar, but the rate of severe complications may be lower if a surgical robot is used.

Androgen and Cortisol Cosecreting Adrenal Adenoma and Tuberculous Lymphadenitis.

The differential diagnosis between malignant and benign adrenal cortical tumors is challenging, and concurrent androgen and cortisol production should raise  suspicion of a malignant tumor. We present the case of a 36-year-old woman who exhibited pronounced hirsutism, clitoromegaly, and secondary amenorrhea. A contrast-enhanced computed tomography (CT) scan revealed a 35 × 27 mm right adrenal mass with unenhanced CT attenuation of 40 Hounsfield units (HUs). The mass exhibited absolute and relative washout rates of 50% and 28%, respectively, and was accompanied by a 25 × 20 mm adenopathy located in the hepatogastric space. Total testosterone was elevated by 247 ng/dL (8.56 nmol/L) (normal reference range, 10-75 ng/dL; 0.34-2.6 nmol/L). A 1-mg dexamethasone suppression test revealed an elevated serum morning cortisol concentration of 10.57 µg/dL (291.58 nmol/L) (reference range, <1.8 µg/dL; < 49.66 nmol/L). A fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) scan revealed increased uptake in both the adrenal mass and the adenopathy. Subsequently, the patient underwent an open right adrenalectomy and lymphadenectomy. Histological examination revealed the presence of an adrenal adenoma with myelolipomatous metaplasia, as well as a positive polymerase chain reaction (PCR) for Mycobacterium tuberculosis in the adenopathy.

Feasibility of outpatient laparoscopic adrenalectomy for primary aldosteronism.

OBJECTIVE: Laparoscopic adrenalectomy (LA) has emerged as the gold standard for the management of adrenal diseases. Despite its low complication rate, the utilization of LA in outpatient settings remains limited. This study explored the feasibility of outpatient LA for primary aldosteronism (PA). DESIGN & METHODS: A retrospective analysis was conducted by reviewing the medical records of consecutive LA procedures performed for PA in our department from 2013 to 2021. A successful outpatient procedure was defined as same-day discharge, less than 12 hours after admission, with no readmission within 48 hours. A postoperative day one (D1) follow-up call by a nurse assessed complications, pain, and patient satisfaction (Numeric Rating Scale [0-10]). Follow-up visits were scheduled at one, three, and six months. RESULTS: During the study period, 76 LAs were performed for PA, with 60 (78.9%) being outpatient procedures. Sixteen patients (21.9%) were not selected for outpatient procedures. The main reasons for contraindicating outpatient procedures were anesthetic or social issues. The success rate of the outpatient procedures was 95% (57/60), with no reported surgical complications. Prolonged hospitalization occurred due to medical reasons such as pain or vomiting. There were no readmissions within 48 hours after discharge. The mean pain and patient satisfaction, evaluated at D1, were 2.1/10 and 9.4/10, respectively. At 6 months, 32 patients (59.2%) were cured without any antihypertensive drugs, and 15 (27.8%) were improved (reduction of their antihypertensive treatment). CONCLUSION: Outpatient LA for PA has demonstrated feasibility with a high success rate, no readmissions, low postoperative pain, and a high level of patient satisfaction.

A case of adrenal cavernous hemangioma resected due to tumor growth accompanied by intratumoral hemorrhage.

Introduction: We describe a case of an adrenal cavernous hemangioma that was surgically resected because of tumor growth and intratumoral hemorrhage. Case presentation: A 73-year-old woman presented with an enlarged adrenal tumor and intratumoral hemorrhage during the follow-up of an incidental adrenal tumor. A computed tomography showed that the left adrenal tumor had grown from 23 to 44 mm over 1 year. Blood tests revealed a normal metabolic profile. Paragangliomas and metastatic tumors were suspected on imaging. Laparoscopic adrenalectomy was performed to prevent tumor rupture due to further bleeding. No adhesions or bleeding were observed around the tumor during surgery. Pathological diagnosis was adrenal cavernous hemangioma. Conclusion: Adrenal cavernous hemangioma is difficult to distinguish preoperatively from other adrenal tumors, including malignant tumors. The intraoperative findings of this case suggest that laparoscopic adrenalectomy is a safe treatment option for relatively small adrenal cavernous hemangioma.

Trainee-initiated dictations of endocrine surgeries: Implications for education and reimbursement.

INTRODUCTION: Our university-based surgery department recently transitioned to attending-only authorship of operative reports. We performed a mixed-methods investigation to determine if trainee-initiated endocrine surgical reports were associated with under-coding of specific procedures. METHODS: Endocrine operations performed from July 2020 to June 2022 were identified from billing data. Pre- and post-policy RVU distributions and note modification history were reviewed to determine how often trainees captured billable differentiators over attending note modification. RESULTS: 714 operations and 1138 billed procedures were identified. Parathyroidectomy alone showed greater mean RVUs with attending-only reports attributable to attending practice change in coding for intraoperative parathyroid hormone monitoring. Trainees were more likely to miss coding modifier 22 but RVU losses were prevented by attending note modification. CONCLUSION: Trainee-initiated operative reports were not associated with RVU losses for endocrine operations compared to attending-only reports. Trainee dictation can be improved by emphasizing education on procedural billing differences and surgical reasoning.

Presentation, Management, and Outcomes of Patients with Giant Pheochromocytoma: Retrospective Cohort Study.

CONTEXT: Data on giant pheochromocytomas (PHEO), defined based on size ≥ 10 cm, are scarce. OBJECTIVE: to compare presentation, management, and outcomes of patients with giant vs non-giant PHEOs. DESIGN: retrospective cohort study, 2000-2023. SETTING: referral center. PATIENTS: consecutive patients with giant PHEO and randomly chosen patients with non-giant PHEO (referents) at a 1:6 ratio. OUTCOMES: perioperative complications, metastases, mortality. RESULTS: Of 828 patients with PHEO, 31 (3.7%) had giant PHEO (median size 12 cm, IQR 10.0-13.5). In comparison to referents (n=186, median size 4 cm, IQR, 2.9-5.0), patients with giant PHEO had more symptoms of catecholamine excess (median of 2 vs 1, P=.04) and presented with a higher prevalence of severe catecholamine excess (76% vs 30%, P<.0001).Adrenalectomy was performed in 94% of patients with giant PHEOs and 100% referents. In addition to preoperative alpha-adrenergic blockade (89%), metyrosine was used in 14 (7%) patients, mostly in patients with giant PHEO (26% vs 3%, P<.0001). Patients with giant PHEO had a higher perioperative complication rate (31% vs 10%, P=.004).During a median follow-up of 3 years, metastases developed at a higher rate in patients with giant PHEOs (45% vs 4% in referents, P<.0001). Disease-specific mortality was 7% in patients with giant PHEOs and 0% in referents (P=.02). CONCLUSION: Patients with giant PHEO as compared to referents were more symptomatic, had a higher degree of catecholamine excess, and had a higher rate of perioperative complications. Almost half of patients with giant PHEO developed metastases, warranting a close follow-up.

Management of patients with adrenal myelolipoma: experience from a tertiary referral centre.

BACKGROUND: Adrenal myelolipomas are rare, benign, tumours of the adrenal cortex. AIMS: This study reports the experience of a tertiary adrenal surgery referral centre's approach to the management of patients with adrenal myelolipoma. METHODS: A retrospective observational cohort study was conducted on all adult patients (> 18 years age) diagnosed with adrenal myelolipoma from January 1, 2014, to December 30, 2022. Demographics, imaging characteristics, histological diagnosis (where applicable) and follow-up data were compared between patients undergoing surgery and those referred to surveillance. Indications for operative intervention were recorded at the time of multidisciplinary team discussion, consisting of surgeons, endocrinology physicians, radiologists, pathologists and specialist nursing representatives. RESULTS: Of the 522 patients with an adrenal lesion discussed in adrenal tumour meeting between 2014 and 2022, n = 15 (2.8%) were diagnosed with adrenal myelolipoma. Of the 15 patients, 4 underwent adrenalectomy at first presentation (27%), while 1 patient underwent adrenalectomy after interval follow-up. Indications for operative intervention were as follows: 'indeterminate lesion' (n = 3), 'abdominal pain and size (> 4 cm)' (n = 1) and 'mass effect on adjacent organs' (n = 1). The mean rate of lesion growth in patients referred for surveillance (n = 10) was 0.13 cm/year. Histology confirmed adrenal myelolipoma as the diagnosis in all resected tumours. CONCLUSIONS: For patients with adrenal myelolipoma, the presence of symptoms and/or indeterminate features on imaging may be more clinically useful indications for operative intervention over size alone. The surveillance of adrenal myelolipomas, even in patients with adrenal lesions > 4 cm, is a safe clinical strategy, provided the imaging characteristics are benign and patients remain asymptomatic.

Comparison of Laparoendoscopic Single-Site Adrenalectomy with the Aid of Intracavitary Retractors and Multiport Laparoendoscopic Adrenalectomy.

Objective: To evaluate the operative outcome of the use of intracavitary retractors in transumbilical laparoendoscopic single-site (LESS) adrenalectomy in comparison with the conventional multiport laparoendoscopic procedure. Methods: Between July 2021 and December 2023, 34 patients underwent transumbilical LESS adrenalectomy with intracavitary retractors, while 47 patients underwent conventional multiport laparoscopic adrenalectomy. Comprehensive data were compared, including demographics, intraoperative outcomes, perioperative complications, postoperative visual analog pain scale score, analgesic requirement, and short-term measures of convalescence. Results: Baseline characteristics were similar between the groups. All procedures were successfully completed without additional access or open conversion. The mean operative time and estimated blood loss for LESS adrenalectomy were comparable with multiport adrenalectomy. The LESS group had significantly shorter incision length (3.07 cm versus 5.16 cm, P < .01), lower postoperative pain scores (3.29 versus 4.91, P < .01), less analgesic drug use (29% versus 53%, P = .03), and better cosmetic scores (9.29 versus 7.28, P < .01). No significant differences were observed in time to resume oral intake, time to ambulation, or postoperative hospital stay. Complication rates were similar between the groups. Conclusion: The utilization of intracavitary retractors in transumbilical LESS adrenalectomy has demonstrated feasibility, effectiveness, and the potential to reduce technical complexities with satisfactory cosmetic effects. This technique enhances visualization of the surgical field without the need for extra ports.

PRAP study-partial versus radical adrenalectomy in hereditary pheochromocytomas.

OBJECTIVE: Hereditary pheochromocytoma (hPCC) commonly develops bilaterally, causing adrenal insufficiency when standard treatment, radical adrenalectomy (RA), is performed. Partial adrenalectomy (PA) aims to preserve adrenal function, but with higher recurrence rates. This study compares outcomes of PA versus RA in hPCC. METHODS: Patients with hPCC due to pathogenic variants in RET, VHL, NF1, MAX, and TMEM127 from 12 European centers (1974-2023) were studied retrospectively. Stratified analysis based on surgery type and initial presentation was conducted. The main outcomes included recurrence, adrenal insufficiency, metastasis, and mortality. RESULTS: The study included 256 patients (223 RA, 33 PA). Ipsilateral recurrence rates were 9/223 (4%) after RA versus 5/33 (15%) after PA (P = 0.02). Metastasis and mortality did not differ between groups. Overall, 103 patients (40%) underwent bilateral adrenalectomy either synchronously or metachronously (75 RA, 28 PA). Of these, 46% developed adrenal insufficiency after PA.In total, 191 patients presented with initial unilateral disease, of whom 50 (26%) developed metachronous contralateral disease, most commonly in RET, VHL, and MAX. In patients with metachronous bilateral disease, adrenal insufficiency developed in 3/4 (75%) when PA was performed as the first operation followed by RA, compared to 1/7 (14%) when PA was performed as the second operation after prior RA (P = 0.09). CONCLUSION: In patients with hPCC undergoing PA, local recurrence rates are higher than after RA, but metastasis and disease-specific mortality are similar. Therefore, PA seems a safe method to preserve adrenal function in patients with hPCC, in cases of both synchronous and metachronous bilateral disease, when performed as a second operation.

Primary aldosteronism and hypokalemia-induced rhabdomyolysis in a patient with aldosterone-producing adenoma: A case report and literature review.

Many cases of primary aldosteronism (PA) in patients who developed hypokalemia-induced rhabdomyolysis and underwent adrenalectomy for aldosterone-producing adenoma (APA) have been reported; however, the immunohistopathological and molecular features remain unknown. We herein report the case of a 28-year-old woman with PA who presented with hypokalemia-induced rhabdomyolysis and underwent adrenalectomy for unilateral APA. An immunohistochemical analysis revealed that most adenoma cells were positive for steroidogenic enzymes, including CYP11B2. A genetic analysis revealed a somatic mutation in the KCNJ5. These findings suggest a strong aldosterone production capacity in our patient's adenoma, which was presumably related to her severe hyperaldosteronism and the resultant hypokalemia-induced rhabdomyolysis.

Evaluating the efficacy of surgical and conservative approaches in mild autonomous cortisol secretion: a meta-analysis.

Introduction: The management of Mild Autonomous Cortisol Secretion (MACS) remains a topic of debate among clinicians, with differing opinions on the effectiveness of surgical intervention compared to conservative treatment methods. This meta-analysis provides a comprehensive assessment of available literature to determine the most effective approach for treating this condition. Methods: On December 1, 2023, an exhaustive literature search of English databases Embase, PubMed, the Cochrane Library, Scopus, Web of Science, as well as the Chinese databases China HowNet, Wanfang Database, SinoMed Database, and Weipu Database using the keywords "Mild Autonomous Cortisol Secretion", "Subclinical Cushing's Syndrome", "Subclinical Hypercortisolism", "Mild Cortisol Autonomous Secretion", "Adrenal Incidentaloma", "Surgical Treatment" and "Adrenalectomy". The data were statistically analyzed using STATA version 15.0. Results: In this comprehensive analysis involving 629 patients with MACS, the therapeutic efficacy of adrenalectomy was evident. The meta-analysis results indicate that compared to conservative treatment, surgical intervention more effectively improves obesity indicators in patients: waist circumference (SMD=-0.62, 95% CI: -1.06 to -0.18), BMI (SMD=-0.41, 95% CI: -0.62 to -0.20), enhances glycemic control: fasting blood glucose (SMD=-0.47, 95% CI: -0.68 to -0.26), glycated hemoglobin (SMD=-0.66, 95% CI: -0.95 to -0.38), improves lipid metabolism: triglycerides (SMD=-0.45, 95% CI: -0.73 to -0.16), lowers blood pressure: systolic blood pressure (SMD=-1.04, 95% CI: -1.25 to -0.83), diastolic blood pressure (SMD=-0.89, 95% CI: -1.12 to -0.65), and ameliorates hormonal metabolic disorder: 24h urinary free cortisol (SMD=-1.10, 95% CI: -1.33 to -0.87), ACTH (SMD=2.30, 95% CI: 1.63 to 2.97). All these differences are statistically significant. Conclusion: This meta-analysis shows that, compared to conservative treatment, surgical treatment is more effective in improving obesity indicators, glycemic control, lipid metabolism, reducing blood pressure, and ameliorating hormonal metabolic disorders in patients with MACS. These statistically significant results highlight the importance of considering surgical intervention in the management of patients with MACS. Systematic review registration: https://www.crd.york.ac.uk/prospero, identifier CRD42023492527.

Reversible right-sided congestive heart failure secondary to primary hyperaldosteronism in a cat.

A 10-year-old male castrated Somali cat presented with neurologic signs, severe systemic hypertension, and hypokalemia. Abdominal ultrasonography demonstrated a left adrenal mass, and the serum aldosterone concentration was increased. Computed tomography and follow-up diagnostic testing confirmed a left adrenal mass consistent with functional adenocarcinoma; additional findings included chronic airway and parenchymal disease. Transthoracic echocardiography revealed biatrial enlargement, with abdominal and pericardial effusion, consistent with right-sided congestive heart failure. The cat was treated for congestive heart failure and adrenalectomy was performed. Cardiac structure and function returned to normal within 6 months postoperatively. This report highlights a case of reversible congestive heart failure secondary to primary hyperaldosteronism.

Improving adrenalectomies: Safe outcomes of partial adrenalectomies and suitable characteristics.

Background: Partial adrenalectomy (PA) is increasingly used to treat benign tumors to lower the probability of adrenal insufficiency and reduce need for lifetime hormone replacement therapy. Currently, two major concerns are increased bleeding and non-functioning adrenal remnants. This paper examines these concerns and compares surgical approaches with novel findings. Methods: Between 1993 and 2023, 72 patients underwent PA for primary adrenal disorders. Demographic, clinicopathologic and outcome data were analyzed for summary statistics, confidence intervals, and heteroscedastic t-test statistics. Results: The patients were 17-76 years-old and were 59.7 % female. The PA was on the left 54.2 % and bilaterally 4.2 %. The indications were adrenal adenoma, pheochromocytoma, cyst, hyperplasia, and other. The mean tumor diameter was 2.7 cm (range 0.7-10 cm). 23 were performed open, 43 laparoscopically, and 6 with an intended robotic approach. Median follow-up was 9.3 years.Robotic had the shortest length of stay (LOS) (p-value 0.01), then laparoscopic (p-value 0.00004), then open. The estimated blood loss (EBL) ranged from 5 to 500 mL (median 50 mL). The median LOS was two days.Intra-operative complication rate was 1.4 % and readmission within 30 days occurred in 2.8 %. Out of 72 patients, 6.8 % needed hormone replacement; of the 14 patients with contralateral adrenalectomy, 28.6 % needed replacement. Conclusion: PA appears to be safe with both laparoscopic and robotic-assisted techniques with superior perioperative outcomes. The functional results of PA prevent most patients from requiring ongoing steroid replacement treatment and recurrence rates were low. PA should be advised for more frequent use as the preferred treatment method of choice. Key message: Partial adrenalectomies' perioperative and long-term outcomes over a median 9.3 year follow-up emphasized its safety and efficacy with 95 % CI of (2.7 cm, 3.6 cm) for masses with adrenal sufficiency post-resection. Additionally, as healthcare institutions decide whether to invest in surgical robots, robotic approach's outperformance of laparoscopic and open on LOS may be counterbalanced by laparoscopic's strong performance in low EBL.

Laparoscopic adrenalectomy performed by a general surgeon on functioning adrenal tumors: Treatment outcomes and risk prediction of persistent hypertension.

Background: Functional adrenal tumors may contribute to poor hypertension control and electrolyte abnormalities, thus increasing the risk of cardiovascular mortality. Currently, laparoscopic adrenalectomy is an effective surgical option that contributes to improved treatment outcomes as compared to open surgery. The purpose of this study was to evaluate the outcomes of laparoscopic adrenalectomy performed by a general surgeon at a low-volume center and to identify clinicopathological risk factors for postoperative persistent hypertension. Methods: A retrospective study of patients with functional adrenal tumors who underwent laparoscopic adrenalectomy at Srinakharinwirot University, Thailand, between 2014 and 2022. Clinicopathologic and postoperative data were examined. Results: This study included twenty-five patients; the indications for laparoscopic adrenalectomy included primary aldosteronism in 19 (76%), pheochromocytoma in 4 (16%), and Cushing's syndrome in 2 (8%). The average time of surgery was 103.5 ± 19.7 min, and intraoperative complications occurred in three patients (12%), with one patient requiring conversion to open surgery (4%). The postoperative systolic (125 ± 15 vs. 158 ± 18 mmHg; p < 0.001) and diastolic (78.5 ± 6.7 vs. 95.3 ± 10 mmHg; p = 0.013) blood pressure significantly decreased compared to prior surgery, but only 19 patients (76%) achieved a cure for hypertension. Multivariate analysis revealed that the patient's physical status, as classified by the American Society of Anesthesiologists (odds ratio (OR) = 0.66, 95% confidence interval (CI) 0.43-1.32, p = 0.001), and the need for at least three antihypertensive medicines (OR = 0.7, 95% CI 0.36-1.2, p = 0.002), were independent predictive factors of persistent hypertension after surgery. Conclusion: Laparoscopic adrenalectomy is a safe and effective surgical treatment for functional adrenal tumors, even when performed in a low-volume center. According to the American Society of Anesthesiologists' physical categorization, the patient's physical condition and the necessity for at least three antihypertensive medications are predictors of postoperative hypertension. Trial registration: The study was registered with the Thai Clinical Registry Trials: TCTR20230707007.

The effect of adrenalectomy on overall survival in metastatic adrenocortical carcinoma.

CONTEXT: Although complete surgical resection provides the only means of cure in adrenocortical carcinoma (ACC), the magnitude of the survival benefit of adrenalectomy in metastatic ACC (mACC) is unknown. OBJECTIVE: To assess the effect of adrenalectomy on survival outcomes in patients with mACC in a real-world setting. DESIGN AND SETTING: Patients with mACC were identified within the Surveillance, Epidemiology, and End Results database (SEER 2004-2020) and we tested for differences according to adrenalectomy status. PATIENTS: Patients aged ≥18 years with metastatic ACC at initial presentation who were treated between 2004-2020. INTERVENTION: Primary tumor resection status (Adrenalectomy vs no-adrenalectomy). MAIN OUTCOME AND MEASURES: Kaplan-Meier plots, multivariable Cox regression models and landmark analyses were used. Sensitivity analyses focused on use of systemic therapy, contemporary (2012-2020) vs. historical (2004-2011), single vs. multiple metastatic sites and assessable specific solitary metastatic sites (lung only and liver only). RESULTS: Of 543 patients with mACC, 194 (36%) underwent adrenalectomy. In multivariable analyses, adrenalectomy was associated with lower overall mortality without (hazard ratio [HR]: 0.39; p<0.001), as well as with three months' landmark analyses (HR: 0.57, p=0.002). The same association effect with three months' landmark analyses was recorded in patients exposed to systemic therapy (HR: 0.49, p<0.001), contemporary patients (HR: 0.57, p=0.004), historical patients (HR: 0.42 , p<0.001), and in those with lung only solitary metastasis (HR: 0.50, p=0.02). In contrast, no significant association was recorded in patients naïve to systemic therapy (HR: 0.68, p=0.3), those with multiple metastatic sites (HR: 0.55, p=0.07) and those with liver only solitary metastasis (HR: 0.98, p=0.9). CONCLUSIONS: The current results indicate a potential protective effect of adrenalectomy in mACC, particularly in patients exposed to systemic therapy and those with lung-only metastases.

Comparable cognitive impairment was detected in MACS and CS and alleviated after remission of hypercortisolism in MACS.

Context: Few studies have directly compared the cognitive characteristics of patients with mild autonomous cortisol secretion (MACS) and Cushing's syndrome (CS). The effect of surgical or conservative treatment on cognitive function in patients with MACS is still unclear. Objective: To compare the differences in cognitive function between patients with MACS and CS and evaluate the effect of surgery or conservative treatment on cognitive function. Methods: We prospectively recruited 59 patients with nonfunctional adrenal adenoma (NFA), 36 patients with MACS, and 20 patients with adrenal CS who completed the global cognition and cognitive subdomains assessments. Seventeen MACS patients were re-evaluated for cognitive function after a 12-month follow-up period; of these, eleven underwent laparoscopic adrenalectomy and six received conservative treatment. Results: Patients with MACS and CS performed worse in the global cognition and multiple cognitive domains than those with NFA (all P<0.05). No statistical difference was found in cognitive functions between patients with MACS and CS. Logistic regression analysis showed that patients with MACS (odds ratio [OR]=3.738, 95% confidence intervals [CI]: 1.329-10.515, P=0.012) and CS (OR=6.026, 95% CI: 1.411-25.730, P=0.015) were associated with an increased risk of immediate memory impairment. Visuospatial/constructional, immediate and delayed memory scores of MACS patients were significantly improved at 12 months compared with pre-operation in the surgical treatment group (all P<0.05), whereas there was no improvement in the conservative treatment group. Conclusion: Patients with MACS have comparable cognitive impairment as patients with CS. Cognitive function was partially improved in patients with MACS after adrenalectomy. The current data support the inclusion of cognitive function assessment in the clinical management of patients with MACS.