Cancer risk in adrenalectomy: are adrenal lesions equal or more than 4 cm a contraindication for laparoscopy?

BACKGROUND: Some authors consider adrenal lesions size of less than 4 cm as a positive cut-off limit to set the indications for minimally invasive surgery due to a lower risk of malignancy. Aim of this study is to report the risk of cancer for adrenal lesions measuring 4 cm or more in diameter, assessed as benign at preoperative workup (primary outcome), and to evaluate the feasibility and safety of laparoscopic adrenalectomy (LA) in these cases (secondary outcome). METHODS: From January 1994 to February 2019, 579 patients underwent adrenalectomy. Fifty patients with a preoperative diagnosis of primary adrenal cancer or metastases were excluded. The remaining 529 patients were included and divided in five subgroups based on adrenal lesion size at definitive histology: group A, 4-5.9 cm (137 patients); group B, 6-7.9 cm (64 patients); group C, 8-9.9 cm (13 patients); group D, ≥ 10 cm (11 patients); group E, < 4 cm (304 patients). Each group was further divided based on diagnosis of benign or malignant lesions at definitive histology. RESULTS: Four (2.9%) malignant lesions were observed in group A, 5 (7.8%) in group B, 2 (15.4%) in Groups C and D (18.2%) and 13 (4.3%) in Group E. Comparing the cancer risk among the groups, no statistically significant differences were observed. Operative time increased with increasing lesion size. However, no statistically significant differences were observed between benign and malignant lesions in each group comparing operative time, conversion and complication rates, postoperative hospital stay and mortality rate. CONCLUSIONS: Adrenal lesions measuring 4 cm or more in diameter are not a contraindication for LA neither in terms of cancer risk nor of conversion and morbidity rates, even if the operative time increases with increasing adrenal lesion diameter. Further prospective studies with a larger number of patients are required to draw definitive conclusions.

Effects of low and standard intra-abdominal pressure on systemic inflammation and immune response in laparoscopic adrenalectomy: A prospective randomised study.

BACKGROUND: The advantages of laparoscopic adrenalectomy (LA) over open adrenalectomy are undeniable. Nevertheless, carbon dioxide (CO2) pneumoperitoneum may have an unfavourable effect on the local immune response. The aim of this study was to compare changes in the systemic inflammation and immune response in the early post-operative (p.o.) period after LA performed with standard and low-pressure CO2 pneumoperitoneum. MATERIALS AND METHODS: We studied, in a prospective randomised study, 51 patients consecutively with documented adrenal lesion who had undergone a LA: 26 using standard-pressure (12-14 mmHg) and 25 using low-pressure (6-8 mmHg) pneumoperitoneum. White blood cells (WBC), peripheral lymphocyte subpopulation, human leucocyte antigen-DR (HLA-DR), neutrophil elastase, interleukin (IL)-6 and IL-1, and C-reactive protein (CRP) were investigated. RESULTS: Significantly higher concentrations of neutrophil elastase, IL-6 and IL-1 and CRP were detected p.o. in the standard-pressure group of patients in comparison with the low-pressure group (P < 0.05). A statistically significant change in HLA-DR expression was recorded p.o. at 24 h, as a reduction of this antigen expressed on the monocyte surface in patients from the standard group; no changes were noted in low-pressure group patients (P < 0.05). CONCLUSIONS: This study demonstrated that reducing the pressure of the pneumoperitoneum to 6-8 mmHg during LA reduced p.o. inflammatory response and averted p.o. immunosuppression.

Propensity score-matched analysis examining the role of obesity on outcomes in retroperitoneal laparoscopic adrenalectomy: a cohort study.

Background: There is inconsistent evidence regarding obesity's effect on surgical outcomes following retroperitoneal laparoscopic adrenalectomy (RLA). This study aimed to investigate the influence of obesity on surgical outcomes in patients undergoing RLA, with an emphasis on operative time, drainage tube removal time, postoperative hospital stays and perioperative complications. Methods: In this retrospective, single-center, observational study, all consecutive cases of unilateral RLA for adrenal disease from January 2012 to December 2021 were incorporated. The patients were divided into two groups based on their body mass index (BMI) of 28 kg/m2. To mitigate selection bias, propensity score matching (PSM) was conducted, using logistic regression to calculate propensity scores for balancing baseline characteristics. A multivariate logistic regression analysis was performed to assess how obesity affects operative time and intraoperative blood loss as well. The linear correlation between BMI and surgical outcomes, including prolonged operative time and increased intraoperative blood loss, was also examined using restricted cubic spline (RCS) analysis. Results: A total of 569 patients who underwent RLA were included. After PSM, 122 patients were apportioned to each group. Statistically significant differences were observed between the obese and non-obese group in operative time (97.5 vs. 115 min, P<0.001). There were no statistically significant differences between the two groups regarding hospital stay (6.7 vs. 6.8 days, P=0.58), drainage tube removal time (3.0 vs. 3.0 days, P=0.19), nor postoperative complications (9.0% vs. 12.3%, P=0.41). Furthermore, univariate logistic regression analysis revealed that, obese patients undergoing RLA were linked to prolonged operative time and increased intraoperative blood loss. After adjusting for potential confounders, the obese group showed a 67% increased risk of prolonged operative time and a 69% increased intraoperative blood loss. The RCS analysis revealed that BMI had a linear relationship with operative time (P for nonlinearity =0.47) and blood loss during surgery (P for linearity =0.89). Conclusions: In patients undergoing RLA, obesity exerts a significant influence on surgical outcomes, particularly with regard to operative time and intraoperative blood loss, as shown in multivariable logistic regression analysis and PSM to balance baseline characteristics.

Feasibility of laparoscopic adrenalectomy in adrenal masses greater than 5 centimeters: a systematic review and meta-analysis.

Background: Laparoscopic adrenalectomy (LA) has emerged as the primary treatment for adrenal masses. This systematic review and meta-analysis assessed LA's feasibility, safety, effectiveness, and complications for adrenal masses exceeding 5 cm. Methods: The study was conducted using PRISMA guidelines with PROSPERO registration No. CRD42023462901. Adults with unilateral adrenal masses >5 cm who underwent unilateral LA were included. Intraoperative and postoperative measurements and complications were assessed. A systematic literature review employed a comprehensive search strategy which was last searched on September 8, 2023, through PubMed, Google Scholar, Web of Science, and ProQuest databases. Meta-analysis was utilized to analyze the outcomes. Risk of bias was assessed using the Newcastle-Ottawa scale. Results: This systematic review encompassed 25 studies involving 963 patients who underwent LA. Tumor size varied 7.05 cm [95% confidence interval (CI): 6.24-7.70], with 50% on the right and 45% on the left. The subgroup meta-analysis comparing the transperitoneal and retroperitoneal approaches revealed the transperitoneal approach h was utilized for the largest tumor size with a mean of 12.10 cm (95% CI: 11.30-12.96), compared to the retroperitoneal approach 5.83 cm (95% CI: 5.52-6.14). Notably, the mean operative time across studies was 137.4 minutes (95% CI: 113.36-150.94), bleeding prevalence was 0.02% (95% CI: 0.01-0.03%), and average blood loss was 110.6 mL (95% CI: 78.2-156.3). Postoperative complications such as pulmonary edema, pulmonary embolism, gastric dysfunction, and wound infection were very low, ranging from 0.03% to 0.4%. Out of 963 patients, only 49 were converted to open surgery. Patient hospital stay averaged 3.72 days (95% CI: 2.97-4.66); blood transfusion was required in 1.3% (95% CI: 0.30-8.88%). Conclusions: The feasibility and safety of LA for tumors exceeding 5 cm in size have notable implications for intraoperative and postoperative outcomes. Underreporting in the included studies may impact the generalizability of findings.

Establishment and validation of a nomogram for predicting the surgical difficulty of lateral retroperitoneal laparoscopic adrenalectomy.

Background: Lateral retroperitoneal laparoscopic adrenalectomy (LRLA) is widely performed for the resection of adrenal disorders, but when larger and more malignant lesions are involved, the difficulty of LRLA increases. We aimed to develop and evaluate a predictive model for the surgical difficulty of LRLA. Methods: A retrospective, observational, single-center study was performed involving all consecutive cases of unilateral RLA for adrenal disease from 2012.01 to 2021.12. Cases were randomly divided into training and validation cohorts (split ratio =7:3), then the least absolute shrinkage and selection operator (LASSO) regression was applied to reduce data dimension and select predictors. Multivariate logistic regression followed to develop the prediction nomogram for the surgical difficulty of LRLA. Finally, receiver operating characteristic (ROC) curve, calibration curve plot and decision curve analysis (DCA) were used to evaluate the nomogram's discrimination, calibration, and clinical usefulness, respectively. Results: A total of 621 cases were enrolled with a median age of 53 years and a median tumor diameter of 1.7 cm. After LASSO regression analysis, surgeon's experience, tumor diameter, resection procedure, histological type, patient's sex and body mass index (BMI) were identified to establish the nomogram. The model displayed good discrimination with area under the curve (AUC) in both the training cohort (0.754, 95% CI: 0.701-0.806) and validation cohort (0.742, 95% CI: 0.646-0.838). Additionally, excellent calibration curves were revealed for surgical difficulty evaluation in both the training cohort (P=0.999) and validation cohort (P=0.444). DCA results indicated the prediction model was clinically useful. Conclusions: Our novel and effective predictive model can be used to assess the individual surgical difficulty of LRLA. By stratifying patients at risk of having a difficult LRLA for adrenal disease, the model could contribute to improvements in perioperative strategy and therapy.

The role of laparoscopic resection of metastases to adrenal glands.

BACKGROUND: The potential role of the laparoscopic approach for metastases to the adrenal gland is debated. We review here a series of patients consecutively submitted to laparoscopic adrenalectomy (LA) for suspected adrenal metastasis (AM). METHODS: Retrospective study (consecutive series) of LA for AM. We measured parameters associated to primary tumor and metastasis. Statistical analysis: stepwise regression model. RESULTS: Thirty-seven LA were performed on 36 patients. The mean age was 62.1 yrs. The side was right in 13 cases. Primary tumor was in the lung (n=22), breast (n=4), colon-rectum (n=4), kidney (n=3), thyroid, melanoma and ovary (n=1 each). Thirty-three out of 37 were confirmed to be AM (mean diameter 50 mm). Twenty-five were single metastasis. One LA was converted due to cava vein infiltration. Mean operative time was 142 min', median p.o. hospital stay was 3 days. After a mean follow-up of 33 months, 9 patients (25%) were alive free of disease, 6 (17%) were alive with disease. Mean post-adrenalectomy DFI was 19 months (range, 0-97 months), and it was the most predictive variable for survival (P<0.001). CONCLUSIONS: The dimensions and absence of invasion on imaging, the evolutive status of the disease and the performance status of the patient are key factors for LA, which is associated with adequate oncologic results, a quicker postoperative recovery, and potential survival benefits.