Robot-assisted transperitoneal and retroperitoneal adrenalectomy for huge adrenal tumors in 45 cases / 现代泌尿外科杂志

【Objective】 To compare the outcomes of robot-assisted laparoscopic transperitoneal and retroperitoneal operation for huge (>6 cm) adrenal tumors. 【Methods】 The clinical data of 45 patients with huge adrenal tumors who underwent robotic surgery during Jan.2017 and Dec.2021 were retrospectively analyzed, including 28 cases via the transperitoneal approach and 17 cases via the retroperitoneal approach. 【Results】 No patients were converted to open operations. There were no significant differences in postoperative drainage time (2.24±0.44 vs. 2.36±0.49) d, operation time (130.88±5.96 vs. 136.61±8.39) min, blood loss (189.41±13.91 vs. 192.5±12.36) mL and postoperative hospital stay (7.06±0.56 vs. 7.46±0.69) d between the retroperitoneal and transperitoneal approaches. Retroperitoneal approach was better than transperitoneal approach in early postoperative feeding [(38.82±6.75 vs. 74.14±6.57) h, P<0.01] . 【Conclusion】 Robotic surgery is safe and effective in the treatment of large adrenal tumors. The choice of surgical approach should be based on patients’ condition, tumor volume and location.

Enfermedad de Cushing recurrente con hipercortisolismo catastrófico: reporte de caso y revisión de literatura / Catastrophic hypercortisolism and recurrence in Cushing´s disease: a case report and literature review / Doença de Cushing recorrente com hipercortisolismo catastrófico: relato de caso e revisão da literatura

Resumen: Presentamos un caso de una paciente femenina de 27 años, con síndrome de Cushing ACTH dependiente con hipercortisolismo severo, causado por un macroadenoma hipofisario recurrente y resistente pese a dos cirugías transesfenoidales, radioterapia y terapia médica. Dada la falla en las diferentes terapias se realiza una adrenalectomía bilateral como tratamiento definitivo. La paciente fallece en el posoperatorio por causa no clara. Si bien la adrenalectomía bilateral ha sido reportada como un tratamiento efectivo en pacientes con enfermedad de Cushing, se ha relacionado con una mortalidad significativa vinculada con la severidad del hipercortisolismo y las comorbilidades presentes. En este caso la adrenalectomía izquierda se tuvo que convertir a cielo abierto, asociada con mayor morbimortalidad.

Abstract: The study presents the case of a 27-year-old female patient with adrenocorticotropic hormone (ACTH) dependent Cushing's disease and severe hypercortisolism caused by recurrent pituitary macroadenoma that was resistant to treatment despite two transsphenoidal surgeries, radiotherapy and medical treatment. Upon failure of the different therapies a bilateral adrenalectomy was performed as the final treatment. The patient died in after surgery although the case of death was not clear. Despite bilateral adrenalectomy having been reports as an effective treatment in patients with Cushing's disease, it has been related to significant mortality rates in connection with the severity of hypercortisolism and existing comorbilities. In this case the left adrenalectomy ended up being an open surgery, which is associated to a higher mortality rate.

Resumo: Apresentamos o caso de uma paciente de 27 anos com síndrome de Cushing ACTH-dependente com hipercortisolismo grave causado por macroadenoma hipofisário, recorrente e resistente, apesar de haver sido submetida a duas cirurgias transesfenoidal, radioterapia e terapia medicamentosa. Diante do fracasso das diferentes terapias, foi realizada adrenalectomia bilateral como tratamento definitivo. A paciente faleceu no pós-operatório por causa não esclarecida. Embora a adrenalectomia bilateral tenha sido relatada como tratamento eficaz em pacientes com doença de Cushing, ela tem sido associada a mortalidade significativa relacionada à gravidade do hipercortisolismo e às comorbidades presentes. Neste caso, a adrenalectomia esquerda teve que ser convertida para cirurgia aberta, associada a maior morbimortalidade.

Feocromocitoma adrenal gigante derecho. Reporte de un caso / Right giant adrenal pheochromocytoma. A case report

Introducción. El feocromocitoma es una neoplasia endocrina productora de catecolaminas, poco común, que generalmente se origina en la medula suprarrenal, y rara vez en el tejido cromafín extraadrenal, dándosele el nombre de paraganglioma. Existe una gran variedad de signos y síntomas secundarios a la secreción excesiva de catecolaminas por lo que su diagnóstico y tratamiento oportunos son fundamentales para evitar complicaciones potencialmente fatales. Caso clínico. Paciente femenina de 54 años, con dolor abdominal intermitente y con aumento progresivo, localizado en el cuadrante superior derecho. Por estudios imagenológicos se diagnosticó una gran masa suprarrenal derecha, con pruebas de laboratorio que encontraron niveles de metanefrinas y catecolaminas en orina normales. Discusión. Debido al tamaño del tumor y al íntimo contacto con las estructuras adyacentes, se realizó la resección por vía abierta, sin complicaciones y con una buena evolución postoperatoria. El informe anatomopatológico confirmó el diagnóstico de feocromocitoma suprarrenal derecho. Conclusión. Aunque poco frecuente, el feocromocitoma es una patología que se debe sospechar ante la presencia de masas suprarrenales y alteraciones relacionadas con la secreción elevada de catecolaminas. Se debe practicar el tratamiento quirúrgico de forma oportuna.

Introduction. Pheochromocytoma is a rare catecholamine-producing endocrine neoplasm that generally originates in the adrenal medulla, and rarely in extra-adrenal chromaffin tissue, giving it the name of paraganglioma. There is a wide variety of signs and symptoms secondary to excessive secretion of catecholamines, so its timely diagnosis and treatment are essential to avoid potentially fatal complications. Clinical case. A 54-year-old female patient with intermittent abdominal pain and progressive increase, located in the right upper quadrant. By imaging studies, a large right adrenal mass was diagnosed, with laboratory tests that found normal levels of metanephrines and catecholamines in urine. Discussion. Due to the size of the tumor and the intimate contact with the adjacent structures, the resection was performed by open approach, without complications and with a good postoperative evolution. The pathology report confirmed the diagnosis of right adrenal pheochromocytoma. Conclusion. Although rare, pheochromocytoma is a pathology that should be suspected in the presence of adrenal masses and changes related to elevated catecholamine secretion. Surgical treatment should be performed in a timely manner.

Outcomes after laparoscopic adrenalectomy for unilateral primary aldosteronism / Resultados luego de adrenalectomía laparoscópica en hiperaldosteronismo primario unilateral

Abstract Unilateral primary aldosteronism (PA) is the most common surgically correctable cause of hypertension. Determination of success after laparoscopic adrenalectomy (LA) is limited by the lack of standardized criteria. We sought to evaluate the surgical recurrence and functional outcomes of LA in patients with Conn's syndrome applying the primary aldosteronism surgical outcome (PASO) Criteria. Descriptive obser vational analysis of patients treated with LA due to confirmed u nilateral Conn's syndrome between May 2007 and August 2020: Twenty patients were included in the cohort; 16 patients had TLA and other four PLA [58% male, median age 47 (IQR: 44-59.5) years and median follow-up of 64 (IQR: 2-156) ] months. Median tumor size was 1.2 (0.8-1.8) cm. No conversions to open surgery were recorded and the overall morbidity of the series was 1/20. No surgical or biochemical recurrence was observed. Five patients were excluded from the analysis of functional results due to lack of follow-up. According to the PASO criteria, complete, partial, and no success were observed in 8/15, 6/15, and 1/15, respectively. The surgical treatment of the disease is supported by the literature, and we were able to reproduce the results of other series. The use of standardized and reproducible criteria to assess its functional results would be essential for a more complete and integrated evaluation of adrenal surgery.

Resumen El hiperaldosteronismo primario es la causa más frecuente de hipertensión secundaria pasible de tratamiento quirúrgico. La determinación del éxito de la adrenalectomía laparoscópica (AL), actualmente, está limitada por la falta de criterios estandarizados. Buscamos evaluar la tasa de recurrencia quirúrgica y los resultados funcionales de la AL en pacientes con Síndrome de Conn aplicando los criterios PASO (primary aldosteronism surgical outcome). Análisis descriptivo y observacional de pacientes tratados con AL en contexto de síndrome de Conn unilateral confirmado, entre Mayo-2007 y Agosto-2020. Se incluyeron 20 pacientes en el estudio; 16 pacientes tratados mediante AL total y 4 con AL parcial (55% hombres, edad mediana de 47 (IQR: 44-59.5) años y mediana de seguimiento 64 (IQR: 2-156) meses. La mediana de tamaño tumoral fue de 1.2 (0.8-1.8) cm. No se registraron conversiones a cirugía abierta y la morbilidad global de la serie: 1/20. No se observó recurrencia quirúrgica o bioquímica. Se excluyeron 5 pacientes en el análisis de resultados funcionales por falta de seguimiento. Según los criterios PASO, se observó un éxito completo, parcial y ausente en 8/15, 6/15 y 1/15, respectivamente. El tratamiento quirúrgico de la enfermedad es avalado por la literatura y pudimos reproducir los resultados de otras series. El uso estandarizado y reproducible de criterios para valorar sus resul tados funcionales sería fundamental para una evaluación más completa e integrada de la cirugía suprarrenal.

Selection of treatment and surgical methods of a patient with primary aldosteronism / 中华内分泌外科杂志

Primary aldosteronism (PA) is a kind of disease caused by excessive aldosterone secretion from the adrenal cortex, the reason of which include bilateral adrenal hyperplasia, aldosteronoma, unilateral adrenal hyperplasia, etc. Surgical treatment is the first choice for unilateral adrenal lesions. In this article, we report a patient who underwent left adrenal surgery but did not achieve the expected results. This case suggests that clinicians need to further improve the level of diagnosis and treatment of primary aldosteronism, especially the surgical methods.

Analysis of adrenalectomy for the treatment of adrenal diseases performed by the Public Health Service in São Paulo between 2008 and 2019 / Análise da adrenalectomia para tratamento de doenças adrenais realizadas pelo Serviço Público de Saúde de São Paulo entre 2008 e 2019

ABSTRACT Introduction: treating benign (hormonally active or nonfunctional) and malignant adrenal cancer includes adrenalectomy. The expertise of surgeons and surgery performed by high-volume surgeons were associated with fewer complications and lower cost. We aimed to describe and compare the number of surgeries, mortality rate, and length of hospital stay for adrenalectomies performed between 2008 and 2019 in the public health system of São Paulo. Methods: this was an ecological study. The data were collected using the TabNet Platform of the Unified Health System Department of Informatics. Outcomes analyzed included the number of surgeries performed, mortality rate during hospital stay, and length of hospital stay. Public hospitals in Sao Paulo were divided into three subgroups according to the surgical volume of adrenalectomies performed as well as hospitals with and without a residency program in Urology, and the results were compared among them. Results: a total of 943 adrenalectomies were performed in Sao Paulo between 2008 and 2019. Mortality rates during hospital stay according to hospital surgical volume were no reported deaths in low-volume, 0.015% in intermediate-volume, and 0.004% in high-volume hospitals. The average length of the ICU stay was 1.03 days in low-volume, 2.8 in intermediate-volume, and 1.12 in high-volume hospitals (analysis between intermediate and high volume centers with statistical significance, p=0.016). Conclusions: despite no statistically significant differences among the groups analyzed, mortality rates were very low in all groups. ICU stay was shorter in high-volume centers than in intermediate-volume centers.

RESUMO Introdução: o tratamento do câncer de adrenal benigno (hormonalmente ativo ou não funcional) e maligno inclui a adrenalectomia. A experiência dos cirurgiões e a cirurgia realizada por cirurgiões de alto volume foram associadas a menos complicações e menor custo. O objetivo do estudo foi descrever e comparar o número de cirurgias, a taxa de mortalidade e o tempo de internação para adrenalectomias realizadas entre 2008 e 2019 na rede pública de saúde de São Paulo. Métodos: trata-se de um estudo ecológico. Os dados foram coletados da Plataforma TabNet do Departamento de Informática do Sistema Único de Saúde. Os hospitais foram divididos em três subgrupos de acordo com o volume cirúrgico e hospitais com e sem programa de residência médica em Urologia. Os resultados foram comparados entre os grupos. Resultados: no período estudado, 943 adrenalectomias foram realizadas em São Paulo. As taxas de mortalidade durante a internação de acordo com o volume cirúrgico hospitalar foram: não foram relatados óbitos em hospitais de baixo volume; 0,015% em hospitais de volume intermediário e 0,004% em alto volume. O tempo médio de permanência na UTI foi de 1,03 dias nos hospitais de baixo volume; 2,8 nos de médio volume e 1,12 nos de alto volume (análise entre centros de médio e alto volume com significância estatística, p=0,016). Conclusão: as taxas de mortalidade foram muito baixas em todos os grupos. A permanência na UTI foi menor em centros de alto volume do que em centros de volume intermediário.

Comparison of the da Vinci Si and Xi surgical systems in robot-assisted laparoscopic adrenalectomy / 中华泌尿外科杂志

Objective:To compare the clinical efficacy and cost of robot-assisted laparoscopic adrenalectomy with da Vinci Xi and Si surgical system in the treatment of adrenal tumors.Methods:The clinical data of 99 patients performing robotic-assisted laparoscopic adrenalectomy in our hospital between June 2019 and December 2020 were retrospective analyzed. Among them, 57 cases were Si system robot assisted laparoscopic adrenalectomy (group Si), 35 male, 22 female; age (45.6±14.0)years; BMI(21.0±1.2); 6 with diabetes, 10 hypertension, 14 with abdominal surgery; 28 left, 29 right; 9 ASA score ≥3; tumor diameter (3.9±1.2)cm. There were 42 cases of Xi system robot-assisted laparoscopic adrenalectomy (group Xi), 21 male, 21 female; age(44.8±14.5)years; BMI(21.4±1.8); 2 with diabetes, 12 hypertension, 11 with abdominal surgery; 15 left, 27 right; 7 with ASA score ≥3; tumor diameter (3.7±1.1) cm. Sex, age, BMI, comorbidities, history of abdominal surgery, lateral division, ASA score, and tumor diameter were not significantly different between the two groups ( P>0.05). Operation method: except for the different docking procedures, the same surgical procedures were roughly performed in the two groups. The docking method of the Si group was the doctor holding the attractor as the guide. The operating room nurse introduced the robot cart under the guidance of the attractor, and then completed the docking.Group Xi docking adoptd the own laser positioning system of the robot system, without manual positioning and guidance; the mechanical arm of the Xi system was also more flexible. Complications were graded according to the Clavien-Dindo grading system. Comparing the treatment effect, safety, and cost of the two groups were compared. Results:The anesthesia times in the Si and Xi groups were (140.0±24.3) min and (125.6±26.4) min ( P=0.006), respectively. The surgical times in the Si and Xi groups were (109.0±18.8) min and (98.8±20.7) min (P=0.013), respectively. The docking times between the Si and Xi groups were (7.8±1.4) min and (5.0±0.9) min ( P<0.001), respectively. The estimated intraoperative blood loss in the Si and Xi groups was (121.5±70.8) ml and (124.7±68.9) ml ( P=0.824), respectively. The postoperative indwelling times of the drainage tube in the Si and Xi groups were (3.4±1.2) d and (3.4±1.3) d ( P=0.892), respectively. Postoperative bed times in the Si and Xi groups were (2.3±1.0) d and (2.5±1.2) d ( P=0.419), respectively. Postoperative hospitalization times in the Si and Xi groups were (6.4±1.5) d and (6.2±1.5) d ( P=0.484), respectively. Post Clavien ≥ grade 3 complications were four and two in groups Si and Xi, respectively ( P=0.642). The total cost during hospitalization in the Si and Xi groups was (51 975.2±7 320.8) Yuan and (56 830.9±8 392.5) Yuan, respectively ( P=0.003). The surgery and consumables costs for the Si and Xi groups were (23 785.3±4 063.1) Yuan and (28 021.2±6 066.8) Yuan ( P<0.001), respectively. Conclusions:Compared with the Si system, the Xi system robot-assisted laparoscopic adrenalectomy can provide similar perioperative results and safety, and shorten the time of anesthesia and surgery, but the total cost of hospitalization is increased.

The efficacy and safety comparison of transperitoneal laparoscopic adrenalectomy and retroperitoneal laparoscopic adrenalectomy for adrenocortical carcinoma / 中华泌尿外科杂志

Objective:To compare the efficacy and safety of retroperitoneal laparoscopic adrenalectomy (RLA) and transperitoneal laparoscopic adrenalectomy (TLA) in the treatment of localized adrenocortical carcinoma (ACC).Methods:The data of 22 patients with stage Ⅰ/Ⅱ ACC underwent laparoscopic adrenalectomy in our institution from January 2009 to December 2018 were retrospectively analyzed. According to the different surgical approaches, these patients were divided into RLA and TLA groups. Eleven patients underwent RLA and 11 patients underwent TLA. There were no significant differences between the RLA group and the TLA group in terms of age at first diagnosis[44 (35, 54) vs. 46(41, 55) years, P= 0.793], sex (male/female: 3/8 vs. 4/7, P = 1.00), secreting tumor ratio (3/11 vs. 4/11, P = 1.00), tumor location (left/right: 6/6 vs. 7/4, P = 1.00), with hypertension or diabetes mellitus (4/11 vs. 3/11, P = 1.00). However, RLA has significantly smaller tumor size [3.0(2.5, 8.4) cm vs. 7.7(5.2, 8.4)cm, P= 0.001], and more stage Ⅰ patients [90.9%(10/11) vs. 18.2%(2/11), P=0.002], compared with those in TLA group. The perioperative indicators and oncology prognosis outcomes were collected and compared between the two groups. The Kaplan-Meier method was performed to calculate the overall survival (OS) and disease-free survival (DFS). Results:Compared with TLA, RLA had shorter operation time[90(70, 100) vs. 110 (90, 120) min, P = 0.005] and postoperative drainage tube removal time [2 (2, 3) vs. 3 (2, 6) day, P = 0.002), and the difference was statistically significant. In the TLA group, one patient was converted to open operation due to intraoperative tumor capsule rupture. For postoperative complications, one patient in the TLA group suffered with wound infection. There were no perioperative deaths in either group. All postoperative pathological examinations confirmed ACC, and there was no significant difference in Ki-67 index between the two groups [10%(3%, 35%) vs. 10%(9%, 25%), P = 0.484]. The median follow-up was similar in the two groups [48(26, 98) vs. 31(18, 49) months, P=0.237]. The local recurrence and metastasis rates were 36.4% for RLA group and 63.6% for TLA group ( P = 0.395). Survival analysis showed no statistically significant difference in DFS [5-year DFS rate: 33.6% vs. 73.2%, P = 0.118] between the two groups. The 5-year OS rates for RLA group versus TLA group were 58.3% vs. 45.5% ( P=0.485). Conclusions:For localized (stage Ⅰ/Ⅱ) ACC, both RLA and TLA seem safe and feasible, based on the similar long-term oncological prognosis. However, compared with TLA, RLA has the advantage of shorter operation time and postoperative drainage tube removal time. Due to the small number of cases included in this study, further multi-center, large-sample studies are required to demonstrate clear benefit of one surgical approach in the future.

Neoplasia endocrina múltiple IIA: feocromocitoma bilateral. A propósito de un caso y revisión de la literatura / Multiple Endocrine Neoplasia IIA: Bilateral Pheochromocytoma. About a Case and Literature Review

Resumen: Presentamos el caso de una paciente del sexo femenino, de 54 años de edad, con antecedente familiar de neoplasia endocrina múltiple tipo II, con estudio genético positivo para NEM 2 IIA EXON 11, c634 CGCIB. Inició padecimiento con cardiopatía hipertensiva y disfunción diastólica, hallazgo to mográfico de tumor suprarrenal bilateral por imagenología, se realizó adrenalectomía convencional transabdominal, se encontró tumor derecho con cápsula correspondiente a feo cromocitoma con un peso de 1,100 g de 14.5 cm de diámetro mayor con invasión a cápsula sin romperla, tumor suprarrenal izquierdo correspondiente a feocromocitoma con un peso de 950 g de 15 cm de diámetro mayor.

Abstract: We present the case of a 54-year-old female patient with a family history of multiple endocrine neoplasia type II, with a genetic study for MEN 2 IIA EXON 11, CG6B c634, onset with hypertensive heart disease and diastolic dysfunction, tomographic finding of bilateral adrenal tumor by imaging. A conventional transabdominal adrenalectomy was performed, finding a right tumor with a capsule corresponding to pheochromocytoma with a weight of 1,100 g of 14.5 cm of greater diameter with invasion of the capsule without breaking it, and a left adrenal tumor corresponding to pheochromocytoma with a weight of 950 g of 15 cm of greater diameter.

Chronic kidney disease after adrenalectomy in a patient with primary aldosteronism / 北京大学学报(医学版)

We report one case of estimated glomerular filtration rate (eGFR) decline after taking unilateral adrenalectomy due to aldosterone adenoma. A 60-year-old male with 23-year history of hypertension was reported to the endocrinologist due to hypokalemia (serum potassium 3.01 mmol/L). Urine microalbumin/creatinine (ALB/CR) was 70.15 mg/g, serum creatinine was 82 μmol/L and eGFR was 89.79 mL/(min·1.73 m2). Random serum aldosterone was 172.2-203.5 ng/L, and random plasma rennin activity was 0-0.17 μg/(L·h). His captopril challenge test suggested that his aldosterone le-vels were suppressed by 8% (< 30%) and the adrenal enhanced computed tomography scan revealed a left adrenal tumor. The patient was diagnosed with primary hyperaldosteronism (PA), aldosterone adenoma and underwent left laparoscopic adrenalectomy. Histological examination confirmed adrenal cortical adenoma. One week after the operation, his serum creatinine was increased to 127 μmol/L compared with preoperative level; eGFR was 32.34 mL/(min·1.73 m2). His systolic blood pressure (SBP) was 110 mmHg and diastolic blood pressure (DBP) was 60 mmHg (hypotensive drugs discontinued), and serum potassium level was 5.22 mmol/L. At the end of the 2-year follow up, the serum creatinine of this patient remained at 109-158 μmol/L and eGFR fluctuated from 63.28-40.12 mL/(min·1.73 m2). PA is one of the most common causes of secondary hypertension. Several studies have reported renal function deterioration of PA patients after unilateral adrenalectomy, like the patient in this article. Age, preoperative plasma aldosterone concentration, albuminuria and preoperative potassium level might be significant predictors of a decrease in the eGFR. Growing evidence suggests that aldosterone could contribute to structural kidney damage, arterial injury and hemodynamic disorder. At the same time, patients with PA exhibit glomerular hyperfiltration and glomerular vascular hypertension, leading to the misinterpretation of renal function in PA patients as subtle kidney damage may be masked by the glomerular hyperfiltration before treatment. After a unilateral adrenalectomy, glomerular hyperfiltration by aldosterone excess is resolved and renal damage can be unmasked. In conclusion, kidney function deterioration after adrenalectomy can be detected in some patients with PA. Thus, accurate evaluation of kidney function in patients with PA may be essential, especially for those with preoperative risk factors for postoperative renal impairment. After unilateral adrenalectomy, close monitoring of renal function and adequate management are required for PA patients.

Adrenal cavernous hemangioma: A case report and literature review / 北京大学学报(医学版)

A 57-year-old male patient was referred to our department with complaints of his right adrenal gland occupancy and hypertension about 6 months. When admitted to the hospital, the blood pressure was about 160/100 mmHg, and the heart rate was 110 beats/min. He was no obvious obesity, acne, abnormal mood, without weakness of limbs, acral numbness, palpitation and headache. He presented with type 2 diabetes for more than 3 years, with oral administration of metformin enteric coated tablets and subcutaneous injection of insulin glargine to control blood glucose, and satisfied with blood glucose control. Enhanced CT showed that: the right adrenal gland showed a kind of oval isodense, slightly hypodense shadow, the edge was clear, lobular change, the size was about 5.8 cm×5.4 cm, uneven density, there were nodular and strip calcification, round lipid containing area and strip low density area, and the CT value of solid part was about 34 HU. Enhanced scan showed heterogeneous nodular enhancement in the solid part of the right adrenal gland, nodular enhancement could be seen inside. The CT values of solid part in arterial phase, venous phase and delayed phase were 45 HU, 50 HU and 81 HU, respectively. Considering from the right adrenal gland, cortical cancer was more likely. No obvious abnormality was found in his endocrine examination. After adequate preoperative preparation, retroperitoneal laparoscopic adrenalectomy was performed under general anesthesia. During the operation, the 6 cm adrenal tumor was closely related to the inferior vena cava and liver, and after careful separation, the tumor was completely removed and normal adrenal tissue was preserved. The operation lasted 180 min and the blood loss was 100 mL, and the blood pressure was stable during and after the operation. There was no obvious complication. The results of pathological examinations were as follows: the size of the tumor was 7.5 cm×6.0 cm×3.5 cm, soft, with intact capsule and grayish-red cystic in section. Pathological diagnosis: (right adrenal gland) cavernous hemangioma, secondary intravascular thrombosis, old hemorrhagic infarction with calcification and ossification. After 6 months of observation, no obvious complications and tumor recurrence were found. In summary, cavernous hemangioma of adrenal gland is a rare histopathological change. Its essence is a malformed vascular mass. Blood retention is the cause of thrombosis and calcification in malformed vessels. The imaging findings were inhomogeneous enhancement of soft tissue masses, and the adrenal function examination showed no obvious abnormalities. Retroperitoneal laparoscopic surgery is feasible after adequate preoperative preparation. It is difficult to diagnose the disease preoperatively and needs to be confirmed by postoperative pathology.

The learning curve of retroperitoneoscopic urologic surgery: A systematic review

INTRODUCTION@#Retroperitoneal laparoscopic (RPL) urologic surgery offers comparable surgical and functional outcomes to the traditional transperitoneal approach, with the advantage of circumventing the need to enter the intraabdominal space. This precludes the necessity to encounter small intestinal and colonic segments, encounter abdominal adhesions, and mobilize adjacent organs, translating to better peri-operative and post-operative conditions. However, RPL demands a strong knowledge of the retroperitoneal anatomy coupled with a level of laparoscopic dexterity, this results in a steep learning curve. Unfortunately, the evidence on the learning curve for RPL is diverse and scarce. The aim of this systematic review was to consolidate the available literature and determine the minimum required number of cases to efficiently and safely perform RPL.@*METHODS@#This is a systematic review of the literature via PubMed, EBSCO and Science Direct of all studies published since 2000 to 2019. The search was conducted by combining the following terms, “Retroperitoneoscopy”, “Retroperitoneoscopic”, “posterior laparoscopy”, “Learning”, “Nephrectomy”, “Adrenalectomy”, and “Ureterolithotomy”. Outcomes of interest were learning curve, mean operative time, mean intra-operative blood loss and mean hospital stay.@*RESULTS@#After the screening phase and application of the eligibility and exclusion criteria, the review included a total of 6 studies on the learning curve for RPL. The learning curve for retroperitoneoscopic adrenalectomy was 40 cases and 24 to 42 cases, based on the evidence from Uitert, et al. (2016) and Vrielink, et al. (2017), respectively. For retroperitoneoscopic nephrectomy, the minimum required number of cases is 30 – 70, based on the studies by Pal, et al. (2017), Zhu, et al. (2018) and Tokodai, et al. (2013). Ercil, et al. (2014) demonstrated the learning curve for retroperitoneoscpic ureterolithotomy to be at 30 cases. Review of each literature showed that completion of the learning curves translated to better peri-operative and post-operative conditions (i.e. shorter operative time, lesser intra-operative blood loss, shorter hospital stay). Overall, the evidence in this review suggests that for posterior retroperitoneal laparoscopy, a mean learning curve of 31 to 56 cases is required to safely and efficiently perform the procedure. @*CONCLUSION@#Retroperitoneal laparoscopic surgery is a valid alternative to the traditional transperitoneal approach. It offers comparable anatomic and functional results, albeit better peri-operative and post-operative outcomes. However, its performance requires a strong knowledge and familiarity of working within the retroperitoneum which can be achieved through progressive experience in RPL. The evidence consolidated by this review suggests a learning curve of 31 to 56 cases prior to effectively performing the procedure.

Advance in Surgical Treatment for Primary Aldosteronism / 中国医学科学院学报

Primary aldosteronism is the most common cause of secondary hypertension.This review focuses on the procedures related to surgical treatment and summarizes the available evidence.We analyzed the impact of primary aldosteronism on the body,the advantages of surgical treatment,the choice of patients and surgical methods,perioperative management,and surgical efficacy evaluation.Finally,we put forward the prospect of scientific research in this field,with a view to providing reference for clinical work.

Clevidipine as an antihypertensive drug in three pheochromocytoma surgeries: Case series / Clevidipino como fármaco antihipertensivo en tres cirugías de feocromocitoma: Serie de casos

Abstract Introduction Laparoscopic adrenalectomy is the treatment of choice of pheochromocytoma. During the first surgical phase (pneumoperitoneum insufflation, tumor and veins handling), there is a risk of hypertensive crisis due to catecholamine release. After tumor excision, patients can suffer relative vasodilation and the residual effect of antihypertensive drugs, which results in arterial hypotension. For that reason, antihypertensive drugs used in the first phase should have a rapid onset of action, short half-life and no residual effect. Methods We report a series of three cases of patients with pheochromocytoma who were treated with laparoscopic adrenalectomy. They all received clevidipine infusion from the beginning of the surgery, before they had presented hypertension, to treat and try to minimize hypertensive peaks. Results In all patients, hypertensive peaks were controlled in a few minutes. After tumor resection, clevidipine infusion was stopped in all cases, and any patient required infusion of vasopressors. Discussion Clevidipine could be a first choice antihypertensive drug in pheochromocytoma surgery. Starting the infusion of clevidipine before the hypertensive peaks could help to make them less pronounced.

Resumen Introducción La adrenalectomía laparoscópica es el tratamiento de elección del feocromocitoma. Durante la primera fase quirúrgica (insuflación de neumoperitoneo, manipulación del tumor y de las venas implicadas), existe el riesgo de que se desencadenen crisis hipertensivas debido a la liberación de catecolaminas. Después de la extirpación del tumor, los pacientes pueden sufrir una vasodilatación relativa y el efecto residual de los fármacos antihipertensivos usados previamente, lo que resulta en hipotensión arterial. Por esa razón, los fármacos antihipertensivos utilizados en la primera fase quirúrgica deben tener rápido inicio de acción, vida media corta y mínimo efecto residual. Métodos Se describe una serie de casos de tres pacientes con feocromocitoma que fueron tratados con adrenalectomía laparoscópica. Todos recibieron infusión de clevidipino desde el comienzo de la cirugía, antes de presentar hipertensión arterial, para así intentar minimizar y tratar rápidamente los posibles picos hipertensivos. Resultados En todos los pacientes los picos hipertensivos se controlaron en pocos minutos. Después de la resección del tumor, la infusión de clevidipino se detuvo en todos los casos y ningún paciente requirió perfusión de vasopresores. Discusión El clevidipino podría ser un fármaco antihipertensivo de primera elección en la cirugía de feocromocitoma. Iniciarlo antes de que ocurran los picos hipertensivos podría ayudar a que sean más leves.

A rare case of bilateral adrenal pheochromocytoma with unusual presentation: the case report

Here we report a 25 years old male patient came to our emergency department with chief complaints of headache from 3 months, blurring of vision 7 days, abdominal pain 7 days, and vomiting from 2 days. Young male, with no known comorbidities, presented to our casualty with headache since, 3 months, episodic in nature, increased over the last 1 week, holocranial, gradually progressive in severity. last recorded Blood pressure outside was 220/120 mmHg and papilledema were noted on fundoscopy. USG abdomen and pelvis, CECT abdomen done and diagnosed to have bilateral adrenal pheochromocytoma. Patient underwent bilateral adrenalectomy was performed with good intra op BP control. Right adrenals were enlarged and shows multiple nodular lesions, left adrenal noted shows nodular lesions. Surgery remains the first line of management in malignant pheochromocytoma. Norepinephrine, epinephrine, and dopamine all act on their target receptors, which causes a physiological change in the body. Increase in catecholamines cause severe hypertension and multiple systemic complications like (cardiovascular, cerebrovascular events) and can lead to death if untreated.

Retroperitoneal laparoscopic adrenalectomy: its role in the management of adrenal tumour and tertiary care centre experience

Background: Laparoscopic adrenalectomy for adrenal tumour has gained increased popularity worldwide. To decrease the complications of commonly used transperitoneal approach, by not entering into peritoneal cavity the retroperitoneal laparoscopic adrenalectomy (RLA) has developed. It has several advantages over the transperitoneal approach and associated with reduced morbidity and excellent outcome. The objective of this study was to report our experience with RLA for treatment of adrenal tumour.Methods: The study was done from August 2014 and December 2017, data of 44 patients who underwent RLA for adrenal tumour in the institute were retrospectively reviewed. Patient’s demographical, clinical, diagnostic and procedural data were recorded. All patients were assessed by history, physical examinations, laboratory values with biochemical marker test and imaging by computed tomography/magnetic resonance imaging. Treatment outcome was assessed in terms of operative time, haemoglobin drop, conversion rate, hospital stay and complications.Results: In 44 adrenalectomy, 24 men and 20 women, with a mean age of 47.0±8.9 years were enrolled. Mean body mass index was 23.5±2.2 kg/m2. Right adrenal tumour was seen in 26 cases and left in 18 cases. Mean adrenal mass size was 2.6±0.85 cm. Mean operative time was 109.1±21.16 minutes, mean haemoglobin drop was 0.47±0.26 gram/L. Conversion to open surgery was necessary in 2 patients. Mean postoperative hospital stay was 4.0±0.91 days. Recovery time mean value was 12.18±1.7 days postoperatively. In final histopathology result adenoma was most prevalent (25 cases) and myelolipoma was least (1 case).  Conclusions: RLA appears to be safe and effective alternative to transperitoneal adrenalectomy for moderate size adrenal tumour in particular less than 6 cm. It is associated with less blood loss, shorter hospitalization, low conversion rate, fewer complications and early recovery. RLA offers an alternative method for treating adrenal tumour with improved surgical outcomes.

Functioning adrenocortical carcinoma causing virilisation: a case report

Adrenocortical carticnoma (ACC) is an uncommon tumor with an incidence of 1-2 cases/million/year. It has two peak incidences; the first one in the first decade and the second one in the fourth decade. Most patients present with features of steroid hormone excess or abdominal mass effects, but about 15% of ACC are diagnosed incidentally. It is hormonally functional in 80 - 100% patients and the predisposing lesions include congenital adrenal hyperplasia and adenoma. ACC has significant syndromic and genetic association. Surgery offers the best chance of cure, especially in localized disease. Here, we present the case of virilization in a young female child secondary to a functioning ACC. The child had classical hormonal and imaging features of functioning ACC and underwent resection of the tumor (Adrenalectomy) with good outcome.

Ganglioneuroma suprarrenal. Reporte de un caso / Adrenal ganglioneuroma. A case report / Ganglioneuroma suprarrenal. Relato de caso

Resumen: Introducción: el ganglioneuroma suprarrenal es un tumor benigno excepcional originado en las células nerviosas derivadas de la cresta neural. El objetivo de este trabajo es comunicar un caso clínico de un ganglioneuroma suprarrenal derecho sintomático. Caso clínico: paciente de 37 años, sexo femenino, que consultó por dolor abdominal inespecífico que luego de la valoración imagenológica y estudio funcional hormonal, se diagnosticó una tumoración suprarrenal derecha no funcionante. Con dicho diagnóstico se realizó la adrenalectomía por abordaje convencional retroperitoneal y el estudio anatomopatológico de la pieza diagnosticó un ganglioneuroma. Discusión: los ganglioneuromas habitualmente son asintomáticos y no funcionantes, por lo que su diagnóstico es incidental en un alto porcentaje de casos. Otros se presentan con una sintomatología inespecífica. Su diagnóstico etiológico preoperatorio raramente es realizado y su confirmación es anatomopatológica. Tienen indicación quirúrgica los sintomáticos, los que superan los 6 cm, o persisten dudas diagnósticas de malignidad. El pronóstico es bueno, siendo excepcional la recidiva.

Summary: Introduction: adrenal ganglioneuroma is an exceptional benign tumour which originates from neural crest cells. The study aims to inform about a clinical case of asymptomatic right adrenal ganglioneuroma. Clinical case: 37-year old patient, female, who consulted for non-specific abdominal pain which, after imaging assessment and functional and hormone test was diagnosed with non-functioning tumour of the right adrenal gland. Upon this diagnosis, adrenalectomy using the conventional retroperitoneal approach was performed, and the pathology study of the piece confirmed the diagnosis of ganglioneuroma. Discussion: ganglioneuromas are usually asymptomatic and non-functioning, so diagnosis is incidental in a large percentage of cases. Others present non-specific symptoms. Preoperative etiological diagnosis is rare, and confirmation is usually after pathology study. Symptomatic tumours over 6cm long have an indication of surgery, as well as those suspicious of malignancy. Prognosis is good, relapses being exceptional.

Resumo: Introdução: o ganglioneuroma suprarrenal é um tumor benigno excepcional originado nas células nervosas derivadas da crista neural. O objetivo deste trabalho é descrever o caso clínico de um ganglioneuroma suprarrenal direito sintomático. Caso clínico: paciente de 37 anos, sexo feminino que consultou por dor abdominal inespecífica que foi diagnosticado como uma tumoração suprarrenal direita não funcionante depois da avaliação de estudos de imagem e funcional hormonal. Com este diagnóstico realizou-se adrenalectomia por abordagem convencional retroperitoneal e o laudo anatomopatológico diagnosticou um ganglioneuroma. Discussão: os ganglioneuromas geralmente são assintomáticos e não funcionantes por isso seu diagnóstico é acidental em uma alta proporção dos casos. Outros se apresentam com sintomatologia inespecífica. O diagnóstico etiológico pré-operatório raramente é realizado e sua confirmação é feita pela anatomia patológica. Quando são sintomáticos, têm mais de 6 cm ou se persistem dúvidas sobre sua malignidade têm indicação cirúrgica. O prognóstico é bom, e a recidiva é excepcional.

Long-term outcome after bilateral adrenalectomy in Cushing's disease with focus on Nelson's syndrome

ABSTRACT Objective We analyzed the clinical, biochemical, and imaging findings of adrenalectomized patients with Cushing's disease (CD) in order to compare the characteristics of those who developed Nelson's syndrome (NS) versus those who did not develop this complication (NNS), aiming to identify possible predictive factors for its occurrence. Subjects and methods We performed a retrospective review of the clinical records of a group of patients with CD who underwent TBA between 1974 and 2011. Results Out of 179 patients with CD, 13 (7.3%) underwent TBA. NS occurred in 6 of them (46%) after a mean of 24 months from the total bilateral adrenalectomy (TBA). Age at diagnosis, duration of Cushing's syndrome (CS) until TBA, and steroid replacement doses were similar in both groups. Initial urinary cortisol levels (24-hour urinary free cortisol [UFC]) were significantly higher in the NS group than in the NNS group (p = 0.009). Four patients in the NS group and three of those in the NNS group received radiotherapy before TBA (p = 0.26). Three patients in the NS group presented residual tumors before TBA, compared with none in the NNS group (p = 0.04). At 1 year after TBA, the median ACTH level was 476 ng/L (240-1500 ng/L) in the NS group and 81 ng/L (48-330 ng/L) in the NNS group (p = 0.0007). Conclusion In conclusion, a residual tumor before TBA, higher 24-hour UFC at diagnosis, and increasing ACTH levels within 1 year after TBA emerged as predictive factors of development of NS.

Adrenalectomía laparoscópica en 40 pacientes para el tratamientodel feocromocitoma adrenal / Laparoscopic adrenalectomy in 40 patients for the treatment of adrenal pheochromocytoma

RESUMEN Introducción: D esde el año 1997 se comenzó a realizar la adrenalectomía laparoscópica en nuestro centro. Objetivo: Analizar los resultados de la adrenalectomía laparoscópica en el tratamiento quirúrgico del feocromocitoma en el servicio de cirugía general del Hospital Clínico Quirúrgico "Hermanos Ameijeiras". Métodos: Desde noviembre de 1997 a junio del año 2019 se realizaron 192 adrenalectomías por vía laparoscópica en 190 pacientes y en 41 fueron realizadas por feocromocitoma adrenal, en el servicio de cirugía general del Hospital Clínico Quirúrgico "Hermanos Ameijeiras". Se empleó la técnica laparoscópica con abordaje lateral intraperitoneal en la mayoría de los casos, y el abordaje en decúbito supino en un caso para la adrenalectomía bilateral. Resultados: Se realizaron 41 adrenalectomías laparoscópicas en 40 pacientes por feocromocitoma adrenal, en 1 pacientes se realizó adrenalectomía bilateral en un tiempo. La edad promedio fue de 44 años. Predominaron las lesiones del lado derecho en 26 pacientes, 14 del lado izquierdo y uno bilateral. Fueron convertidos a cirugía convencional 1 pacientes (0,41 por ciento). El tiempo quirúrgico promedio fue de 80 minutos. La estadía postoperatoria promedio fue de 2,5 días. Todos los pacientes se curaron de la hipertensión arterial. Conclusiones: La adrenalectomía laparoscópica es una técnica reproducible y segura en el tratamiento del feocromocitoma adrenal(AU)

ABSTRACT Introduction: Since 1997, laparoscopic adrenalectomy began to be performed in our center. Objective: To analyze the results of laparoscopic adrenalectomy in the surgical treatment of pheochromocytoma in the general surgery service of the "Hermanos Ameijeiras" Surgical Clinical Hospital. Methods: From November 1997 to June 2019, 192 adrenalectomies were performed laparoscopically in 190 patients and in 41 they were performed for adrenal pheochromocytoma, in the general surgery service of the "Hermanos Ameijeiras" Surgical Clinical Hospital. The laparoscopic technique with an intraperitoneal lateral approach was used in most cases, and the supine approach in one case for bilateral adrenalectomy. Results: 41 laparoscopic adrenalectomies were performed in 40 patients for adrenal pheochromocytoma, in 1 patients bilateral adrenalectomy was performed at one time. The average age was 44 years. Lesions on the right side predominated in 26 patients, 14 on the left side and one bilateral. 1 patients (0.41 pèrcent) were converted to conventional surgery. The average surgical time was 80 minutes. The average postoperative stay was 2.5 days. All patients were cured of high blood pressure. Conclusions: Laparoscopic adrenalectomy is a reproducible and safe technique in the treatment of adrenal pheochromocytoma(AU)