Posterior retroperitoneoscopic adrenalectomy: a contemporary American experience.

BACKGROUND: Posterior retroperitoneoscopic adrenalectomy (PRA) is an excellent surgical option for adrenal gland removal. The operation requires that surgeons learn a new approach with few similarities to anterior adrenalectomy. This study reports a large series of PRAs incorporated into surgical care using a team-model approach. STUDY DESIGN: The prospective endocrine surgery database was queried to identify patients who underwent PRA during a recent 4-year period. Demographic, operative, and pathologic data were recorded. The authors' initial experiences with PRA (group 1) are compared with our contemporary experience (group 2). RESULTS: One hundred and eighteen PRAs were successfully performed (100 unilateral and 9 bilateral). Indications were pheochromocytoma in 21 patients, Cushing's syndrome or Cushing's disease in 22 patients, aldosteronoma in 22 patients, virilizing tumor in 3 patients, isolated metastasis in 28 patients, and nonfunctional mass in 19 patients. Forty-eight percent of patients had undergone earlier abdominal surgery. Forty-eight percent were obese (body mass index [calculated as kg/m(2)] ≥30). No significant differences were found in operative time (110 versus 118 minutes, p = 0.30), tumor size (2.59 versus 2.85 cm, p = 0.44), or body mass index (29.63 versus 29.93, p = 0.82) between groups 1 and 2. Both complications (15.9% versus 7.7%, p = 0.29) and conversion rates (9.5% versus 1.9%, p = 0.19) were lower in group 2, although this was not statistically significant. CONCLUSIONS: PRA is a technique safely performed for a variety of adrenal lesions, is ideal for patients who have undergone earlier abdominal surgery, and is feasible in obese patients. Proficiency can be obtained during a short period, leading to low conversion and complication rates. This technique should be incorporated into the armamentarium of the endocrine surgeon. A team approach to learning new surgical techniques is effective.

Posterior retroperitoneoscopic adrenalectomy.

PRA has become our preferred technique for resection of relatively small, benign adrenal masses and isolated metastases to the adrenal glands. PRA offers a direct, minimally invasive approach to the adrenal glands and avoids the need to enter the peritoneal cavity, deal with intraabdominal adhesions, and mobilize adjacent organs-steps necessary during anterior laparoscopic adrenalectomy. In addition, some patients tolerate retroperitoneal CO2 insufflation better than intraperitoneal CO2 insufflation from a hemodynamic and respiratory perspective. Finally, bilateral PRA can be performed without the need for patient repositioning. PRA requires the surgeon to become comfortable with the anatomy of the adrenal gland and surrounding structures from the posterior perspective. In addition, the surgeon must become adept at working in the retroperitoneal space, which is relatively restricted compared with the large cavity created by insufflation of the intraperitoneal space. However, in our experience, the learning curve can be overcome in a relatively short period, and the posterior approach is particularly advantageous in patients who have undergone prior open abdominal surgery or who are moderately obese. Proper patient positioning and trocar placement, high-pressure CO2 insufflation, and mobilization of the inferior aspect of the adrenal gland from the superior pole of the kidney before dividing its other attachments are critical technical details that greatly facilitate the procedure. In experienced hands, PRA is safe and is an ideal option for patients who are candidates for minimally invasive adrenalectomy.

Posterior retroperitoneoscopic adrenalectomy: preferred technique for removal of benign tumors and isolated metastases.

OBJECTIVE: Posterior retroperitoneoscopic adrenalectomy (PRA) is a minimally invasive approach to removal of the adrenal gland. This anatomically direct approach, popularized by Walz, minimizes dissection and affords early access to the adrenal vein. We report the largest experience to date of PRA in the United States. METHODS: The prospective endocrine surgery database at a tertiary care center was used to capture all patients who underwent PRA between October 2005 and February 2008. All PRA procedures were performed using a 3-trocar technique with the patient in a prone jackknife position. RESULTS: Sixty-eight PRAs were performed in 62 patients; there were 6 conversions (3 video-assisted and 3 open). Indications for adrenalectomy were functional tumors in 43 patients (20 pheochromocytomas, 13 Cushing disease or syndrome, and 10 others), nonfunctional cortical adenomas in 4, and isolated adrenal metastases in 15. Mean tumor size was 3.4 cm. Complications occurred in 11 patients (16%), with no perioperative deaths. In 34 (55%) patients, there was a relative contraindication to an anterior approach. Additionally, 20 patients (38%) had a body mass index greater than 30. Median operating time was 121 minutes. CONCLUSION: PRA is safe, avoids intra-abdominal adjacent organ mobilization, is unaffected by the presence of intra-abdominal adhesions, and is possible in obese patients. PRA may be the preferred technique for removing benign adrenal tumors and isolated metastases.

Percutaneous radiofrequency ablation of renal tumors: technique, complications, and outcomes.

PURPOSE: To report the safety, technical success, and effectiveness of percutaneous radiofrequency (RF) ablation for renal tumors. MATERIALS AND METHODS: The authors retrospectively reviewed the medical records and imaging studies of 29 consecutive patients (18 men, 11 women; mean age, 65 +/- 2.62 years) with 30 renal tumors (mean diameter, 3.5 +/- 0.24 cm) who underwent percutaneous RF ablation at their institution from September 2001 to March 2004. All procedures were performed with computed tomography guidance with general anesthesia, and all patients were admitted to the hospital for overnight observation. Technical success, complications, and their management were recorded. Technique effectiveness was assessed by imaging and clinical follow up. RESULTS: Overall, 88 overlapping ablations were performed (mean, 2.6 +/- 0.16 ablations per tumor per session) in 34 sessions. There were four major complications (12%). Three patients had gross hematuria and urinary obstruction, all were successfully treated. One patient had persistent anterior abdominal wall weakness. There were also two minor complications (6%) without significant clinical sequelae. One patient had gross hematuria which resolved spontaneously, another patient had transient paresthesia of the anterior abdominal wall. There were no significant changes in renal function after RF ablation. The intent of RF ablation was eradication of the primary tumor in 27 patients and treatment of gross hematuria in the other two. Technical success was achieved in all cases. Follow-up images were available for 26 patients. The primary tumor was completely ablated in 23 of 24 patients (96%) in whom eradication of the primary tumor was attempted (follow up period: mean, 10 months, median 7 months). The two patients treated for hematuria remained asymptomatic for 6 and 27 months each. CONCLUSION: Percutaneous RF ablation for renal tumors is safe and well tolerated. High technical success rates are expected. Early reports of the technique's effectiveness are promising.

Is extended hepatectomy for hepatobiliary malignancy justified?

BACKGROUND: Extended hepatectomy may be required to provide the best chance for cure of hepatobiliary malignancies. However, the procedure may be associated with significant morbidity and mortality. METHODS: We analyzed the outcome of 127 consecutive patients who underwent extended hepatectomy (resection of > or = 5 liver segments) for hepatobiliary malignancies. RESULTS: The patients underwent extended hepatectomy for colorectal metastases (n = 86; 67.7%), hepatocellular carcinoma (n =12; 9.4%), cholangiocarcinoma (n =14; 11.0%), and other malignant diseases (n =15; 11.5%). Thirty-two left and ninety-five right extended hepatectomies were performed. Eight patients also underwent caudate lobe resection, and 40 patients underwent a synchronous intraabdominal procedure. Twenty patients underwent radiofrequency ablation, and 31 underwent preoperative portal vein embolization. The median blood loss was 300 mL for right hepatectomy and 600 mL for left hepatectomy (P = 0.02). Thirty-six patients (28.3%) received a blood transfusion. The overall complication rate was 30.7% (n = 39), and the operative mortality rate was 0.8% (n = 1). Significant liver insufficiency (total bilirubin level > 10 mg/dL or international normalized ratio > 2) occurred in 6 patients (4.7%). Multivariate analysis showed that a synchronous intraabdominal procedure was the only factor associated with an increased risk of morbidity (hazard ratio [HR], 4.9; P = 0.02). The median survival was 41.9 months. The overall 5-year survival rate was 25.5%. CONCLUSIONS: Extended hepatectomy can be performed with a near-zero operative mortality rate and is associated with long-term survival in a subset of patients with malignant hepatobiliary disease. Combining extended hepatectomy with another intraabdominal procedure increases the risk of postoperative morbidity.