Clinical update on the management of adrenal hemorrhage.

Adrenal hemorrhage is a rare yet potentially life-threatening event that occurs both in traumatic conditions and in a variety of nontraumatic conditions. Clinical manifestations of adrenal hemorrhage can vary widely depending on the degree and rate of hemorrhage, as well as the amount of adrenal cortex compromised by hemorrhage. Although an isolated focal unilateral adrenal hemorrhage may present subclinically, massive bilateral adrenal hemorrhage may lead to rapid cardiovascular collapse and ultimately death if not diagnosed appropriately and treated quickly. Diagnosis of adrenal hemorrhage is often complicated by its nonspecific presentation and tendency to occur in the setting of acute illness and other complicating medical conditions. This article outlines the variety of clinical situations in which adrenal hemorrhage can occur, summarizes the appropriate diagnostic tests available, and reviews the appropriate management of adrenal hemorrhage.

Noninvasive adrenal imaging in hyperaldosteronism.

Proper management of primary aldosteronism requires localization of excess aldosterone production. Partial or radical adrenalectomy may cure cases of aldosterone-producing adenomas; however, pharmacologic management is indicated in cases of bilateral adrenal hyperplasia. Differentiating among the causes of primary aldosteronism can be a diagnostic challenge. Adrenal vein sampling, the gold standard for diagnosing subtypes of primary aldosteronism, is an invasive and often difficult procedure. Advancements in CT and MRI have improved their adrenal-imaging capabilities, but accuracy in identifying aldosterone-producing adenomas remains inferior to adrenal vein sampling. Radionuclide scintigraphy has been used for many years and can also provide functional information for diagnosis. No diagnostic test, however, distinguishes with complete accuracy aldosterone-producing adenomas from bilateral adrenal hyperplasia in primary aldosteronism. Therefore, a combination of diagnostic techniques may most effectively guide medical management.

Outcomes of hand-assisted laparoscopic nephrectomy in technically challenging cases.

OBJECTIVES: To evaluate the outcomes of hand-assisted laparoscopic nephrectomy in patients with significant complicating clinical factors. METHODS: We performed a retrospective review of 322 hand-assisted laparoscopic nephrectomy cases that were completed at a single institution from 1998 to 2004. Patients with a history of extensive abdominal surgery or prior procedures on the affected kidney, evidence of perirenal inflammation, renal lesions 10 cm or more in diameter, or level I renal vein thrombus were included. RESULTS: A total of 42 patients were included in this series. Of these, 16 patients had a lesion 10 cm or larger, 10 had a renal vein thrombus, and 10 had undergone prior major abdominal surgery. Many patients had more than one complicating factor. Another 6 patients had a history of prior renal procedures or chronic inflammatory processes involving the affected kidney. One Stage T4 renal tumor with paraspinous muscle invasion was successfully managed without conversion. The overall mean operative time and estimated blood loss was 235 minutes and 439 mL, respectively, with a mean hospital stay of 4 days. Four patients (9.5%) required open conversion (one renal hilar injury, two failure to progress, and one persistent bleeding from the renal fossa). Postoperative complications included pulmonary embolism in 1, ileus in 1, and chronic obstructive pulmonary disease exacerbation in 1 patient. One patient developed an incarcerated port site hernia requiring reoperation. CONCLUSIONS: Hand-assisted laparoscopic nephrectomy is an attractive minimally invasive option in the setting of significant complicating factors. This technique may facilitate the successful laparoscopic completion of these challenging cases with reasonable operative times, blood loss, and complication rates.