Diagnostic Delay and Disease Burden in Primary Aldosteronism: An International Patient Survey.

BACKGROUND: Primary aldosteronism (PA) is a common but underdiagnosed cause of hypertension. Many patients experience preventable end-organ injury due to delayed or missed diagnosis but data on the experience of patients are limited. METHODS: We evaluated the lived experience of PA and determines factors associated with diagnostic delay through an international anonymous online cross-sectional survey, codesigned by researchers and PA consumers. We distributed the survey through academic medical centers, Amazon Mechanical Turk, Twitter, PA patient advocacy groups, and hypertension support groups on Facebook between March 21 and June 5, 2022. RESULTS: Of 684 eligible respondents, 66.5% were women. Diagnostic delay (defined as ≥5 years between the diagnosis of hypertension and PA) was reported in 35.6%. Delay was more likely in women than in men (odds ratio, 1.55 [95% CI, 1.10-2.20]) and respondents with ≥3 comorbidities versus none (odds ratio, 1.77 [95% CI, 1.05-3.02]), ≥10 symptoms versus none (odds ratio, 2.73 [95% CI, 1.74-4.44]), and on ≥4 antihypertensive medications versus none (odds ratio, 18.23 [95% CI, 6.24-77.72]). Three-quarters of patients (74.4%) experienced reduced symptom burden following targeted PA treatment. Quality of life improved in 62.3% of patients, and greater improvement was associated with being a woman (odds ratio, 1.42, [95% CI, 1.02-1.97]), receiving adrenalectomy (odds ratio, 2.36 [95% CI, 1.67-3.35]), and taking fewer antihypertensive medications following diagnosis (odds ratio, 5.28 [95% CI, 3.55-7.90]). CONCLUSIONS: One-third of patients with PA experienced prolonged diagnostic delays. Targeted treatment led to reduced symptom burden and improved quality of life. Gender differences in diagnostic delay and symptom burden are prominent. These findings suggest that routine screening for PA at the onset of hypertension may reduce diagnostic delay and facilitate timely diagnosis.

Cost Analysis of Radiofrequency Ablation for Adrenal Adenoma in Patients with Primary Aldosteronism and Hypertension: Results from the ADERADHTA Pilot Study and Comparison with Surgical Adrenalectomy.

PURPOSE: Primary Aldosteronism (PA) is increasingly considered as a common disease affecting up to 10% of the hypertensive population. Standard of care comprises laparoscopic total adrenalectomy but innovative treatment such as RadioFrequency Ablation (RFA) constitutes an emerging promising alternative to surgery. The main aim of this study is to analyse the cost of RFA versus surgery on aldosterone-producing adenoma patient from the French National Health Insurance (FNHI) perspective. METHODS: The ADERADHTA study was a prospective pilot study aiming to evaluate both safety and efficacy of the novel use of adrenal RFA on the patients with PA. This study conducted on two French sites and enrolled adult patients, between 2016 and 2018, presenting hypertension and underwent the RFA procedure. Direct medical (inpatient and outpatient) and non-medical (transportation, daily allowance) costs were calculated over a 6-month follow-up period. Moreover, the procedure costs for the RFA were calculated from the hospital perspective. Descriptive statistics were implemented. RESULTS: Analysis was done on 21 patients in RFA groups and 27 patients in the surgery group. The difference in hospital costs between the RFA and surgery groups was €3774 (RFA: €1923; Surgery: €5697 p < 0.001) in favour of RFA. Inpatient and outpatient costs over the 6-month follow-up period were estimated at €3,48 for patients who underwent RFA. The production cost of implementing the RFA procedure was estimated at €1539 from the hospital perspective. CONCLUSION: Our study was the first to show that RFA is 2 to 3 times less costly than surgery. The trial is registered at ClinicalTrials.gov under the number NCT02756754.

Assessment of performance of stratum-specific likelihood ratios of the aldosteronoma resolution score for predicting hypertension cure after adrenalectomy for primary aldosteronism: a systematic review and meta-analysis.

The Aldosteronoma Resolution Score (ARS) is the most studied scoring system for predicting the high likelihood of hypertension cure after adrenalectomy for unilateral primary aldosteronism (PA). However, the ARS's accuracy in PA patients worldwide is uncertain. We aimed to perform a meta-analysis of the accuracy, discrimination, and calibration of the ARS using stratum-specific likelihood ratios (SSLR) by organizing available data from cohort studies. We searched PubMed, Embase (Ovid), the Cochrane CENTRAL, Web of Science to November 2021 according to PRISMA statement. The quality assessment used adapted TRIPOD and PROBAST criteria. Thirteen studies comprising 2158 PA patients from North America (43%), Europe (32%), Asia (22%), and other continents, were included. The pooled estimate of the area under the receiver operating characteristic curve for all studies was 0.77 (95% CI: 0.73-0.81), and the ratio of the observed to expected complete resolution of hypertension (CRH) for all studies was 0.9 (95% CI: 0.8-1.0). The summary estimates of the SSLR for all studies were 0.31, 0.89, and 3.1, for the low (ARS 0-1), medium (ARS 2-3), and high-likelihood group (ARS 4-5) of CRH, respectively. However, substantial heterogeneity existed among studies. Follow-up period, and adrenalectomy AVS (adrenal vein sampling)-guided served as potential sources of heterogeneity for quantitative studies, which were measurement and reference standard for qualitative studies selection. In conclusion, in patients with unilateral PA, the ARS is currently an accurate prediction tool, the easiest and cheapest, for identifying long-term high likelihood of CRH after adrenalectomy, particularly when the adrenalectomy is AVS-guided.

Intraprocedural cortisol testing improves adrenal vein cannulation success and diagnostic accuracy in assessment of primary aldosteronism, in a medium throughput centre.

Primary aldosteronism is the most common cause of secondary hypertension. Identifying individuals who have unilateral secretion from aldosterone secreting adenomas allows adrenalectomy. Surgical treatment when feasible may be superior to medical management with improved cardiovascular outcomes and reduced medication dependence. Adrenal vein sampling (AVS) is required to biochemically lateralise aldosterone secretion prior to adrenalectomy. However, diagnostic success of AVS is variable and can be poor even at tertiary centres; failure is largely due to unsuccessful adrenal vein cannulation. Intra-procedural rapid semiquantitative cortisol testing (RCT) identifies correct catheter placement in real time. We compared diagnostic success rates of AVS before and after the introduction of intraprocedural cortisol testing at the Royal Adelaide Hospital-a medium throughput tertiary centre (average 6.2 procedures a year over the last 8 years). We observed an increase in success rate from 63% to 94%. Intraprocedural cortisol testing also led to a net financial saving of ~$100 AUD per procedure. RCT is likely to be cost effective if pre-RCT success rate is less than 78%. Procedure time and number of samples collected, however, were increased with RCT. This suggests that intraprocedural cortisol testing will improve success in low to medium throughput centres and may make AVS feasible in less specialised centres.

Cost-effectiveness of adrenal vein sampling- vs computed tomography-guided adrenalectomy for unilateral adrenaloma in primary aldosteronism.

PURPOSE: Adrenalectomies performed for the treatment of primary aldosteronism due to unilateral adenoma are traditionally confirmed with, and guided by, results from adrenal vein sampling (AVS). However, the usefulness of AVS at the expense of cost and complications is debated, and many institutions have independent protocols that use AVS to varying degrees. METHODS: Cost-effectiveness of AVS- vs computed tomography (CT)-based adrenalectomy was calculated using decision tree models. The tree was populated with values describing biochemical post-operative outcomes from the published literature; patients were placed into AVS- or CT-dependent treatment arms. Biochemical outcomes were defined based on patients' potassium levels and aldosterone-renin ratios. Patients underwent adrenalectomies and received medical management dosed based on surgical outcomes. Costs were represented by Medicare (FY2021) reimbursement rates (US$) and quality-adjusted life-years (QALYs) were calculated using published morbidity and survival data. A willingness-to-pay of $100,000 per QALY gained was set to determine the most cost-effective strategy. The primary outcome was the incremental cost-effectiveness ratio (ICER) associated with biochemical outcomes. RESULTS: The base case analyses favored the use of AVS-guided care, which cost $307.65 more but yielded 0.78 more QALYs, resulting in an ICER of $392.57. These results were upheld by all one-way and two-way sensitivity analyses. In 100,000 random-sampling simulations, AVS-guided care was favored 100% of the time. CONCLUSIONS: For patients with primary aldosteronism receiving adrenalectomies with curative intent, the more cost-effective method based on biochemical outcomes is AVS-based care. Recent literature suggests biochemical resolution should be favored over clinical resolution, due to long-term detriments of increased aldosterone independent of clinical symptoms.

A combination of laparoscopic approach and ERAS pathway optimizes outcomes and cost for adrenalectomy.

Enhanced recovery after surgery (ERAS) pathway comprises a set of comprehensive elements which have been reported to enhance patient postoperative prognosis. In the current study, we aimed to evaluate the effectiveness of the ERAS in patients undergoing laparoscopic adrenal resection. A retrospective review was performed to compare the outcomes of patients undergoing adrenalectomy for primary aldosteronism between the pre-ERAS period and the ERAS era. Data was generated from the traditional surgical period (September 1, 2019, to December 31, 2019) and the ERAS period (September 1, 2020, to December 31, 2020), respectively. Forty-seven adrenalectomy patients were enrolled (pre-ERAS, n = 21; ERAS, n = 26) in analysis. The results revealed that both total length of hospital stay and postoperative length of stay decreased in the ERAS period compared with the pre-ERAS period (14.19 ± 4.96 vs 11.27 ± 4.37, p = 0.015; 5.43 ± 1.08 vs 3.31 ± 0.97, p < 0.001). The medical expenses decreased significantly in the ERAS group (p < 0.05). While, the surgery-related complications, including urinary retention, retroperitoneal effusion and gastrointestinal discomfort, possessed no statistical difference. The ERAS pathway was safe and feasible for adrenalectomy in patients with primary aldosteronism. The ERAS could promote patients to quickly recover from the postoperative status to a physiological state, and decrease the length of hospitalization and medical cost after surgery.

Factors associated with postoperative complications and costs for adrenalectomy in benign adrenal disorders.

BACKGROUND: The incidence of adrenal incidentaloma has been increasing, and indications of and approaches to adrenalectomy are diverse. Drivers of complications and costs are not well identified. METHODS: The 2016 National Inpatient Sample data were used to identify patients who underwent adrenalectomy for benign adrenal disorders, such as Cushing syndrome, primary hyperaldosteronism, pheochromocytoma, and other benign neoplasms defined using the 10th Revision of the International Classification of Diseases. The primary outcome was determining the factors associated with clinical outcomes, perioperative complications, and hospitalization costs. RESULTS: Using weighted estimates of the national sample data, 5,140 patients were identified. The mean age was 55 years. The majority of adrenalectomies were performed laparoscopically (48.5%) followed by a robotic approach (32.7%). The postoperative complication rate was 7.6%. In adjusted multivariable analyses, independent risk factors for perioperative complications included Hispanic race (odds ratio, 2.5; P = .01), and perioperative comorbid heart failure (odds ratio, 6.3; P < .001) and respiratory failure (odds ratio, 9.9; P < .001). The mean cost was $18,122. Independent risk factors associated with decrease of cost were female sex and primary hyperaldosteronism; factors associated with increased cost were pheochromocytoma, intraoperative complications, perioperative underlying comorbid respiratory failure and heart failure, and postoperative complications (P < .001). CONCLUSION: Among patients undergoing adrenalectomy for benign adrenal disorders, underlying comorbidities, including heart and respiratory failure, should be considered when recommending adrenalectomy, as these may increase the postoperative complication rates and hospitalization costs.

Subtyping of Primary Aldosteronism in the AVIS-2 Study: Assessment of Selectivity and Lateralization.

CONTEXT: Adrenal venous sampling (AVS) is the key test for subtyping primary aldosteronism (PA), but its interpretation varies widely across referral centers and this can adversely affect the management of PA patients. OBJECTIVES: To investigate in a real-life study the rate of bilateral success and identification of unilateral aldosteronism and their impact on blood pressure outcomes in PA subtyped by AVS. DESIGN AND SETTINGS: In a retrospective analysis of the largest international registry of individual AVS data (AVIS-2 study), we investigated how different cut-off values of the selectivity index (SI) and lateralization index (LI) affected rate of bilateral success, identification of unilateral aldosteronism, and blood pressure outcomes. RESULTS: AVIS-2 recruited 1625 individual AVS studies performed between 2000 and 2015 in 19 tertiary referral centers. Under unstimulated conditions, the rate of biochemically confirmed bilateral AVS success progressively decreased with increasing SI cut-offs; furthermore, with currently used LI cut-offs, the rate of identified unilateral PA leading to adrenalectomy was as low as <25%. A within-patient pairwise comparison of 402 AVS performed both under unstimulated and cosyntropin-stimulated conditions showed that cosyntropin increased the confirmed rate of bilateral selectivity for SI cut-offs ≥ 2.0, but reduced lateralization rates (P < 0.001). Post-adrenalectomy outcomes were not improved by use of cosyntropin or more restrictive diagnostic criteria. CONCLUSION: Commonly used SI and LI cut-offs are associated with disappointingly low rates of biochemically defined AVS success and identified unilateral PA. Evidence-based protocols entailing less restrictive interpretative cut-offs might optimize the clinical use of this costly and invasive test. (J Clin Endocrinol Metab XX: 0-0, 2020).

Assessment of postoperative renal function after adrenalectomy in patients with primary aldosteronism.

OBJECTIVE: To investigate kidney function change during adrenalectomy in patients with primary aldosteronism and assess predictors of kidney function decline. METHODS: The present study included 90 patients who underwent adrenalectomy for primary aldosteronism between 2004 and 2017. Kidney function was evaluated 1 month after surgery. Predictors associated with a ≥10% decline in the estimated glomerular filtration rate were investigated. Kidney parenchymal volume was compared before and after surgery in 10 patients using volumetric studies. RESULTS: The mean estimated glomerular filtration rate decline in the total cohort at 1 month after surgery was 13.3% (before: 72.9 mL/min/1.73 m2 , after: 64.9 mL/min/1.73 m2 , P < 0.0001). The mean serum plasma aldosterone concentration (before: 373 pg/mL vs after: 78 pg/mL, P < 0.0001) and potassium level (before: 3.7 mEq/L vs after: 3.9 mEq/L, P = 0.0001) were also significantly different after surgery. Age (odds ratio 6.37, P = 0.0006), preoperative plasma aldosterone concentration (odds ratio 3.12, P = 0.0209) and preoperative serum potassium level (odds ratio 2.87, P = 0.0010) were independent predictors of a ≥10% decline in estimated glomerular filtration rate. Volumetric studies in 10 patients showed that mean postoperative parenchymal volume was significantly decreased compared with the preoperative volume (263 cc vs 312 cc, P = 0.0003), with decreases in estimated glomerular filtration rate from 63 to 56 mL/min/1.73 m2 (P = 0.0146). CONCLUSIONS: Kidney function deterioration after adrenalectomy can be detected in patients with primary aldosteronism. Age, preoperative plasma aldosterone concentration and preoperative potassium level are significant predictors of a decrease in the estimated glomerular filtration rate. Normal parenchymal volume decreases in line with renal functional deterioration.

Laparoscopic Adrenalectomy for Conn's Syndrome is Beneficial to Patients and is Cost Effective in England.

PURPOSE: Adrenalectomy has the potential to cure or improve the control of hypertension in patients with primary hyperaldosteronism due to unilateral adrenal adenoma (Conn's syndrome). This study assesses the patients' perception of, and costs associated with, laparoscopic adrenalectomy for Conn's syndrome. MATERIALS AND METHODS: Clinical, radiological, operative, and pathological data were collected on patients undergoing adrenalectomy for Conn's syndrome over 8-years period in a UK tertiary referral center. RESULTS: Thirty-eight patients (17M:21F, age 34-79 yrs, median 54 yrs) operated between Jan2005-Sept2012 had lateralization based on CT scans (n = 30) and/or MRI scans (n = 18) and confirmed on selective adrenal venous sampling (n = 25). Laparoscopic adrenalectomy was performed in all patients, with two cases requiring conversion to open operation. Median operative time was 105 min (range: 27-315). Costs were estimated as £19k for preoperative investigations, £20k for in-hospital stay, £53k for operating theatre use and £29k for disposable surgical instruments, with average £3499/patient (national tariff for adrenalectomy in 2015/2016 £3624). Follow-up at a mean of 30 months postoperatively using a visual analogue scale and a standardized questionnaire showed significantly improved quality of life (QoL) post-operatively. Majority of patients (85%) reported taking none or fewer anti-hypertensive medications (median reduction of 2 antihypertensive drugs). All patients stated that they would definitely have the operation again in preference to anti-hypertensive medications and they would recommend the operation to friends/relatives. CONCLUSIONS: Laparoscopic adrenalectomy for Conn's syndrome has a positive impact on hypertension control, leads to improved QoL and its costs are covered in the NHS financial model.

Risk of new-onset diabetes mellitus in primary aldosteronism: a population study over 5 years.

OBJECTIVE: Abnormal glucose metabolism due to insulin resistance has been linked to aldosterone overproduction. However, the long-term incidence of new-onset diabetes mellitus (NODM) among patients with primary aldosteronism after targeted treatment has not been well documented. METHODS: The diagnosis of primary aldosteronism and essential hypertension were identified, and then the occurrence of NODM, all-cause mortality among these patients, was ascertained by a validated algorithm from a 23-million population insurance registry. RESULTS: From 1999 to 2007, 2367 primary aldosteronism patients without previously diabetes mellitus were identified and propensity score-matched with 9468 patients with essential hypertension. Among those primary aldosteronism patients, 754 aldosterone-producing adenomas patients were identified and matched with 3016 essential hypertension controls. After a mean 5.2 years of follow-up, primary aldosteronism patients who underwent adrenalectomy had an attenuated NODM incidence (hazard ratio = 0.60, P < 0.01, versus essential hypertension); whereas those treated with mineralocorticoid receptor antagonist had augmented risk of NODM (hazard ratio = 1.16, P < 0.001, versus essential hypertension). Among the aldosterone-producing adenoma patients, adrenalectomy is also protective from developing NODM (hazard ratio = 0.61, P < 0.001, versus essential hypertension), however, mineralocorticoid receptor antagonist treatment did not alter the risk of NODM (P = 0.10, versus essential hypertension). Adjusted hazard ratios for long-term risk of mortality from this analysis revealed that adrenalectomy is protective, but NODM and major cardiovascular disease are deleterious. CONCLUSION: The primary aldosteronism patients who underwent adrenalectomy had reduced risk for incident NODM and all-cause of mortality, compared with matched hypertensive controls. This observation adds more evidence on the association of primary aldosteronism with a higher risk of metabolic syndrome and long-term mortality.

Assessment of the Aldosteronona resolution score as a predictive resolution score of hypertension after adrenalectomy for aldosteronoma in French patients.

PURPOSE: Aldosteronoma Resolution Score (ARS) is a predictive score for cure of hypertension after adrenalectomy for hyperaldosteronism and has been validated in American patients. The aim of the study was to validate this score in a French population. METHOD: Data concerning patients operated from 2002 to 2015 in 7 French University Hospitals were retrospectively collected. Diagnosis of Aldosterone-producing adenoma (APA) was confirmed with clinical and biochemical hyperaldosteronism and adrenal nodule on CT scan. Adrenal venous sampling was performed when CT failed to identify laterality. ARS is based on four variables: female sex, BMI ≤25 kg/m2, duration of hypertension ≤6 years, number of antihypertensive medications ≤2. One point is attributed for the first three and 2 points for the last. Patients were considered as cured if they had no hypertension and no antihypertensive medications at least 6 months after surgery. Patients with bilateral adrenal hyperplasia were excluded. RESULTS: This multicenter study included 310 patients with APA. ARS and follow-up were obtained in 257 patients. 46.6% of patients were cured and potassium serum level was normalized in 97.7%. In multivariate analysis, odds ratio for female sex, BMI ≤25 kg/m2, duration of hypertension ≤6 years, and number of antihypertensive medications ≤2 were 1.60 (p = 0.09), 1.77 (p = 0.04), 1.28 (p = 0.4), 3.41 (p < 0.001), respectively. Cure rate were, respectively, 22.2, 41.4 and 74% for patients with a score ARS 0-1, 2-3, 4-5. The area under the curve (AUC) of ARS was 0.715. CONCLUSION: ARS is not a predictive score efficient enough in a French population maybe due to different metabolic data and genetic conditions.

Ventricular repolarization before and after treatment in patients with secondary hypertension due to renal-artery stenosis and primary aldosteronism.

A prolonged QT interval is a risk factor for ischemic heart disease in hypertensive subjects. Patients with renal-artery stenosis and primary aldosteronism (PA) are at increased risk of cardiovascular events. The objective of the present study was to evaluate the QT interval in patients with renovascular hypertension (RV) and PA before and after treatment. A total of 24 patients with RV and 38 with PA were studied; 89 patients with essential hypertension (EH) served as control group. Corrected QT intervals (QTcH) were measured from a 12-lead ECG. Basal QTcH was longer in RV (429±30 ms) and PA (423±23 ms) compared with EH controls (407±18 ms; P<0.001). The prevalence of QTcH >440 ms was higher in RV (29%) and PA patients (29%) compared with EH controls (4%; P<0.001). QTcH interval was evaluated after treatment in 19 RV and 15 PA patients. QTcH was reduced after renal-artery angioplasty in RV patients (419±14 ms; P=0.02), and after spironolactone or adrenalectomy in PA (403±12 ms; P=0.01). In conclusion, QT interval was prolonged in patients with RV and PA compared with controls with EH. After angioplasty of renal-artery stenosis in RV, and treatment with spironolactone or adrenalectomy in PA, the cardiovascular risk of such patients may be reduced by concomitant blood pressure lowering and QT duration shortening.

[Anaesthesia for patients with adrenal gland diseases]. / Anästhesie bei Erkrankungen der Nebennierenrinde--Effizientes Risikomanagement von der Prämedikation bis zum Aufwachraum.

Perioperative management of patients with adrenal gland diseases requires detailed information on the individual endocrine status and the potential complications. Typical signs of primary hyperaldosteronism (Conn's syndrome) comprise arterial hypertension, hypokalaemia and metabolic alkalosis. In such cases preoperative treatment with spironolactone is highly recommended. In patients with hypercortisolism (Cushing's syndrome) the following concomitant disorders must be considered particularly: arterial hypertension, osteoporosis, vulnerable skin, diabetes mellitus, and increased risk for infection and thromboembolism. In all patients with proven or suspected adrenocortical insufficiency (i.e. Addison's disease, after removal of a cortisol producing tumour or as the result of long-term therapy with glucocorticoids) consequent perioperative supplementation of hydrocortisone is mandatory. In patients with phaeochromcytoma hypertensive crisis and tachyarrhythmias may occur intraoperatively resulting from massive catecholamine release. Thus, preoperative treatment with the beta-antagonist phenoxybenzamine is obligatory. In contrast, nitroprusside is the substance of choice for intraoperative control of blood pressure. beta-blocking agents may be used in phaeochromocytoma but only under sufficient beta-blockade. Removal of a malignant tumour of the adrenal gland may induce massive haemorrhage, and thus anaesthetic management has to be modified.

Long-term follow-up and cost benefit of adrenalectomy in patients with primary hyperaldosteronism.

BACKGROUND: The purpose of this study was to evaluate the long-term efficacy of adrenalectomy on blood pressure control in patients with primary hyperaldosteronism (HA), and to analyse the cost of adrenalectomy compared with non-surgical management of HA over the patient's lifetime. METHODS: All patients who underwent an adrenalectomy for HA were recalled to the endocrine surgical clinic. Data gathered included blood pressure, aldosterone : renin ratios and medication. Total costs for adrenalectomy and ongoing medications were compared with the estimated costs of lifelong medical therapy alone. RESULTS: Twenty-four adrenalectomies were performed for HA, with one death. The mean follow-up was 42 (range 13-97) months. Long term, there was a significant decrease in both the mean diastolic and systolic blood pressure. The aldosterone : renin ratio decreased in 21 patients. Of these patients, 20 were either off all antihypertensives (eight) or had a reduction in medication (12). An increased aldosterone : renin ratio occurred in two patients, both of whom required an increase in antihypertensive medication. Using the predicted life expectancy, the mean estimated cost savings over the lifetime of each patient undergoing adrenalectomy compared with medication alone was Canadian $31 132. CONCLUSION: Adrenalectomy for HA resulted in significant long-term reduction in blood pressure. Adrenalectomy for HA is a significantly less expensive than long-term medical therapy alone.

The case for laparoscopic adrenalectomy.

PURPOSE: The current status of laparoscopic adrenal surgery was assessed. MATERIALS AND METHODS: A current MEDLINE search revealed 308 articles pertaining to laparoscopic surgery of the adrenal gland. Based on this literature review laparoscopic surgical anatomy, current indications and contraindications, and laparoscopic techniques were identified. The role of laparoscopic surgery for various adrenal disorders, including aldosteroma, pheochromocytoma, Cushing's syndrome, incidentaloma and adrenal cancer, were evaluated. Studies specifically comparing open versus laparoscopic adrenalectomy and the financial implications of laparoscopy were evaluated. Furthermore, newer advances in the minimally invasive management of surgical adrenal disease were identified. RESULTS: Available data from multiple institutions imply that laparoscopic adrenal surgery is safe and efficacious for aldosteroma, pheochromocytoma, Cushing's disease and incidentaloma. Compared to open surgery laparoscopy provides equally effective treatment, while minimizing patient morbidity. Laparoscopic adrenalectomy is financially superior to open adrenalectomy. For adrenal cancer open surgery currently remains the treatment of choice. CONCLUSIONS: In the majority of patients with surgical adrenal disease except those with adrenal cancer laparoscopy may now be considered an established treatment modality.

An assessment of diagnostic procedures preparatory to retroperitoneoscopic removal of adenoma in cases of primary hyperaldosteronism.

The goal of this study was to improve assessment of diagnostic measures for lateral localization of aldosterone-producing adrenal adenomas preparatory to retroperitoneoscopic removal, in view of the fact that this technique allows for only unilateral access. A retrospective study was carried out of the medical records of 64 patients (38 women, 26 men, average age 46.8+/-11.2) who underwent surgery at University Hospital, Münster, between 1969 and 1998. Seventeen of the 64 patients presented with hyperplasia and 47 had adrenal adenoma. In cases of hyperplasia, computerized tomography imaged a false-positive unilateral tumor 10 times, a false-negative 3 times, and a unilateral hyperplasia 1 time (ultrasonography: tumor 2 times, false-negative 3 times; 131I-Iodomethylnorcholesterol scintigraphy: tumor 5 times, false-negative 1 time, correct 1 time). In cases of adenoma, computerized tomography yielded accurate results 40 times, imaged a false-negative 2 times, and indicated the incorrect side 1 time (Ultrasonography: false-negative 12 times, correct side 9 times, incorrect side 1 time; 131I-Iodomethylnorcholesterol scintigraphy: correct side 19 times, false-positive (both sides) 5 times, negative 3 times, incorrect side 2 times). Venous sampling, which was carried out seven times, yielded accurate results six times, and failed technically one time. Venous sampling appears to be the method of choice for preoperative lateral localization. Thus, retroperitoneoscopic treatment of Conn's syndrome should not be carried out unless venous sampling is carried out first.

Comparison of laparoscopic and open adrenalectomy.

This review compares the outcomes of patients who have undergone laparoscopic and open adrenalectomy. Records of all patients who underwent adrenalectomy between January 1993 and December 1996 at Cedars-Sinai Medical Center, Los Angeles, were reviewed. Ten patients underwent laparoscopic, and ten patients underwent open adrenalectomy. The average age in the laparoscopic group (LA) was 48 years (range, 23-64) and 47 years (range, 28-79) in the open group (OA). The LA had smaller tumor size (2.9 +/- 2.0 versus 6.1 +/- 2.8 cm; P = 0.01), longer operative times (164 +/- 47 versus 124 +/- 29 minutes; P = 0.03), shorter length of postsurgical stay (4.1 +/- 2.5 versus 5.9 +/- 1.1 days; P = 0.05), and fewer days of parenteral pain medication (1.9 +/- 1.8 versus 3.4 +/- 1.0 days; P = 0.04). Although the differences did not reach statistical significance, LA also had lower estimated blood loss (118 +/- 158 versus 210 +/- 172 cc; P = 0.23), less time to oral intake (1.8 +/- 2.2 versus 2.8 +/- 1.3 days; P = 0.24), and less direct cost ($3645 +/- 1502 versus $5752 +/- 2948; P = 0.07). Complications of LA included one patient who had a prolonged ileus and adrenal insufficiency and another patient who required readmission for adrenal insufficiency. Complications of OA included one patient who had a prolonged ileus and one patient who had a 20 per cent pneumothorax. Laparoscopic adrenalectomy is the preferred technique in nonmalignant adrenal lesions less than 6 cm in size.

Normal sympathetic vasomotor and cardiac parasympathetic activities in patients with primary aldosteronism: assessment by spectral analysis.

The role of the autonomic nervous system in hypertension due to mineralocorticoid excess remains unclear. To address this issue, we performed power spectral analysis of blood pressure (BP) and RR interval oscillations in 20 patients with primary aldosteronism (PA), 54 patients with essential hypertension (EH) and 45 normotensive (NT) subjects. Blood pressure and the degree of organ damage were similar between PA and EH groups. Age did not differ between the three groups. The Mayer wave power spectrum (MWP) of BP (approx. 0.1 Hz), an index of sympathetic vasomotor tone, was smaller in patients with PA than in patients with EH either while subjects were supine (systolic/diastolic; 3.9 +/- 3.2 (SD)/1.5 +/- 1.3 vs. 5.5 +/- 4.2/2.1 +/- 1.6 mmHg2, P < 0.05 for both) or standing (7.6 +/- 6.6/3.0 +/- 3.0 vs. 17.7 +/- 23.7/7.2 +/- 8.3 mmHg2, P < 0.05 for both). Supine respiratory-related power spectrum (RRP) of the RR interval (approx. 0.25 Hz), an index of cardiac parasympathetic tone, was greater in patients with PA than in patients with EH (545 +/- 574 vs. 302 +/- 464 ms2, P < 0.01). The MWP of BP and the RRP of the RR interval were similar between patients with PA and NT subjects. Adrenalectomy reduced the 24-h mean BP (-18 mmHg for systolic BP, P < 0.001; -12 mmHg for diastolic BP, P < 0.01) and increased the 24-h mean heart rate (+8 bpm, P < 0.001). Furthermore, the diastolic MWP increased mildly (+32%, P < 0.05) and the RRP of the RR interval decreased dramatically (-75%, P < 0.01) following adrenalectomy. These results suggest that both vascular sympathetic and cardiac parasympathetic regulatory systems have minor roles in the maintenance of hypertension in patients with PA. The autonomic nervous system contributes more to the maintenance of BP following than prior to adrenalectomy. This information may be useful for the management of hypertension still persists after removal of adrenal adenoma.