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PubMed2002

Does adrenal mass size really affect safety and effectiveness of laparoscopic adrenalectomy?

OBJECTIVES: To evaluate the effectiveness and safety of laparoscopic adrenalectomy with regard to adrenal mass size, as well as to consider its clinical and pathologic patterns. Laparoscopy is today considered the first-choice treatment of many adrenal diseases, although its use is still controversial for large adrenal masses and incidentally found adrenal cortical carcinoma. METHODS: A total of 125 patients underwent lateral transperitoneal laparoscopic adrenalectomy. The indications were either functioning or nonfunctioning adrenal masses, without any radiologic evidence of involvement of the surrounding structures. The correlation between the size and the operative times, estimated blood loss, incidence of intraoperative and postoperative complications, and length of hospital stay were studied with Pearson's correlation coefficient, Fisher's exact test, and the chi-square test. The analysis of variance test was used to evaluate any possible correlation between the size and clinicopathologic features and the results. RESULTS: A slight correlation was observed between the size and operative time (P = 0.004), but no correlation was observed between the size and the other parameters. Statistical analysis showed a significant correlation between the clinicopathologic patterns (nonfunctioning benign adrenal masses, Conn's adenoma, Cushing's adenoma, pheochromocytoma, adrenal cortical cancer, and other tumor metastasis) and the operative time (P = 0.011), but not with the other parameters. CONCLUSIONS: Laparoscopic adrenalectomy is also effective and safe for large lesions. The results of our series confirms that the risk of encountering an incidental adrenal cortical cancer is significantly increased for large lesions, and therefore, in these cases, additional attention is required to observe oncologic surgical principles.

Adolescent↗
PubMed1997

Adrenal metastases from renal cell carcinoma: role of ipsilateral adrenalectomy and definition of stage.

OBJECTIVES: We undertook this study to establish criteria for adrenalectomy in patients with renal cell carcinoma. METHODS: We retrospectively reviewed the records of 162 patients undergoing radical nephrectomy from 1979 to 1993 at University Hospitals of Cleveland. Simultaneous ipsilateral adrenalectomy was performed in 57 patients (35%). RESULTS: Three of these 57 patients (5.3%) had ipsilateral adrenal metastases. All 3 patients had large, left-sided, upper-pole tumors that extended through the renal capsule (Stage T3a). All 3 patients with adrenal metastases had progression to disseminated disease, with an average time to progression of 7.2 months, whereas only 13 (24%) of the 54 patients without adrenal metastases developed metastatic disease (none to adrenal), with an average time to progression of 27.6 months. No patient with organ-confined disease (Stage T1 or T2) or extracapsular disease in the midkidney or lower pole had adrenal metastases identified histologically. CONCLUSIONS: The prognosis is poor for renal cell carcinoma with ipsilateral adrenal involvement, even with complete removal. Because of this poor prognosis, we believe that adrenal involvement should constitute a separate stage category. We propose that patients with ipsilateral adrenal metastases via direct extension should be classified as having pathologic Stage pT3d. If the patient has an ipsilateral adrenal metastasis not via direct extension, contralateral adrenal metastasis, or bilateral adrenal metastases, the pathologic stage should be M1. Ipsilateral adrenalectomy should only be performed if a lesion is seen preoperatively on computed tomographic scan or if gross disease is seen at the time of nephrectomy although its removal may not benefit the patient.

Adrenal Gland Neoplasms↗
PubMed1997

Laparoscopic adrenalectomy: a new standard of care.

OBJECTIVES: Adrenalectomy is the mainstay of treatment for adrenal tumors. A variety of surgical approaches to the adrenal gland have been described. We studied the feasibility of laparoscopic adrenalectomy (LA), compared laparoscopic with open adrenalectomy (OA), and studied the hemodynamic changes in patients with pheochromocytoma. METHODS: Our early experience with 20 consecutive LAs is compared with a contemporaneous, matched control cohort of 20 patients who underwent OA via a flank or subcostal incision. LA was performed via a transperitoneal approach, following a standardized surgical technique. RESULTS: LA was successfully completed in 18 of 20 cases. Average operating time in the first 5 cases was 261 minutes, but, with further experience, a significant decrease in operative time was seen in the last cohort of 4 patients (155 minutes) (P = 0.0018). There was no significant difference in operative time or degree of blood loss between LA and OA groups. Patients who underwent LA required lower doses of postoperative parenteral narcotics (P = 0.0169), had a shorter hospital stay (mean 3.2 days) (P < 0.0001), and had a shorter convalescent period (mean 3.1 weeks) (P < 0.0001). Complications in the laparoscopic group (chronic port site pain in 1 patient, intra-abdominal fluid collection in another) occurred in the 2 patients who required open conversion. These 2 patients had large adrenal tumors (9 and 7 cm in diameter, respectively). LA resulted in similar hemodynamic changes as OA in patients with pheochromocytoma. CONCLUSIONS: LA is a safe and effective approach in most patients with adrenal pathology. Benefits include excellent operative exposure and visualization, less postoperative pain, shorter hospital stay and convalescent period, and improved cosmetic result. Pheochromocytoma is not a contraindication to LA. Patients with large adrenal tumors (larger than 6 cm), evidence of venous involvement, or invasion into surrounding tissue should be approached cautiously.

Adrenal Gland Neoplasms↗
PubMed2001

Transperitoneal laparoscopic adrenalectomy.

Laparoscopic adrenalectomy has been demonstrated by many institutions to be a safe and effective approach to benign adrenal lesions. As surgical skills improve, it will most likely be comparable with open adrenalectomy in overall cost. Although it is technically demanding and takes slightly longer than open surgery, the benefits to the patient in terms of hospital stay, convalescence, and cosmetic results have been conclusively reported. The decision to use a transperitoneal or retroperitoneal access is mostly a function of surgeon preference, with similar outcomes by either approach. It is more important that the surgeon be comfortable with the selected approach. Laparoscopic adrenalectomy has become the gold standard for benign adrenal lesions.

Adrenalectomy↗
PubMed1986

The effect of adrenalectomy on the proteinuria of spontaneously hypertensive rats and normotensive controls.

Urinary proteins were studied by quantitative and electrophoretic methods in 6-month-old spontaneously hypertensive rats and normotensive controls. Protein analysis was carried out before and after adrenalectomy and during gluco- or mineralocorticoid treatment. Urinary protein excretion was significantly diminished after adrenalectomy both in the hypertensive and control groups. The original level of protein excretion was restored only by glycocorticoid treatment. Normal or pathologic electrophoretic pattern of urinary proteins was not influenced by the experimental procedure. Moderately non-selective glomerular proteinuria persisted in the spontaneously hypertensive rats referring to a definitely damaged glomerular barrier. One protein fraction of about 130,000 dalton molecular weight disappeared from the urine of hypertensive animals after adrenalectomy and reappeared after glucocorticoid treatment only. This fraction probably represents the dimeric form of albumin. Quantitative changes of urinary protein excretion can be explained by haemodynamic factors.

Adrenal Cortex Hormones↗
PubMed2001

Cause of residual hypertension after adrenalectomy in patients with primary aldosteronism.

The cause of residual hypertension after adrenalectomy for primary aldosteronism (PA) is unknown. The purpose of this study is to investigate the characteristic pathological kidney features associated with PA. Between 1977 and 1999 at our hospital, 26 patients with PA caused by a unilateral adrenal cortical adenoma (Conn's syndrome) underwent unilateral adrenalectomy with concurrent open-wedge renal biopsy. Patients were categorized into two groups: (1) those with normotension with diastolic blood pressure less than 90 mm Hg who were not administered antihypertensive drugs, and (2) those with residual hypertension with diastolic blood pressure of 90 mm Hg or greater who were administered medication for 6 months after surgery. Thirteen patients were cured of hypertension postoperatively, and 12 patients were administered antihypertensive medications. Glomerulosclerosis, renal arteriolosclerosis, and preoperative left ventricular mass (LVM) index were worse in the group with residual hypertension than in that with normotension (17.8% +/- 7.8% versus 9.6% +/- 3.8%; P = 0.01; 2.5 +/- 0.5 versus 1.6 +/- 0.4, Bader's grade; P = 0.005; and 165 +/- 31 versus 139 +/- 24 g/m(2); P = 0.02, respectively). Severity of tubulointerstitial injury, preoperative duration of hypertension, preoperative severity of proteinuria, plasma aldosterone level, and serum potassium concentration were not significantly different between the two groups. In conclusion, severity of glomerulosclerosis and arteriolosclerosis and LVM are related to blood pressure after adrenalectomy in patients with PA.

Adenoma↗
PubMed2003

Posterior retroperitoneoscopic partial adrenalectomy: clinical experience in 47 procedures.

OBJECTIVES: We evaluated posterior retroperitoneoscopic partial adrenalectomy with regard to operative complications, operation time, intraoperative blood loss. PATIENTS AND METHODS: Between January 1997 and April 2002, we performed 47 posterior retroperitoneoscopic partial adrenalectomies. There were 18 males and 29 females with a mean age of 48 years (range 28-82 years). The average adrenal tumor size was 26 mm (range 10-50mm). All procedures required three trocars. RESULTS: There was no mortality and conversion rate to open surgery was 2.1%. Average operative time and average blood loss was 198.0 ml (range 71-420 ml) and 40.8 ml (range 0-1100 ml), respectively. There was a significant correlation of operative time with the number of procedures performed. However, no significant correlation was observed between intraoperative blood loss and the number of procedures. Tumor size did not correlate with intraoperative blood loss and operative time. No significant correlation was found between body mass index and operative time. The operative time in the initial 20 cases was significantly longer than that in the subsequent 26 cases. CONCLUSION: Posterior retroperitoneoscopic partial adrenalectomy is a safe and less invasive method for treatment of adrenal tumors. With improved operative technique, the time required for this procedure has been decreased.

Adenoma↗
PubMed2003

The effects of long-term adrenalectomy on 5-HT1B receptors mRNA expression in cerebellum, striatum, frontal cortex and hippocampus of rats.

The brain serotonin (5-HT) system and circulating corticosteroids are in close interaction and both implicated in the pathogenesis of affective disorders. We evaluated the effects of adrenalectomy (ADX) on 5-HT(1B) receptors mRNA expression in cerebellum, frontal cortex, striatum and hippocampus in rats, using the RNase protection assay technique. Eight weeks after bilateral adrenalectomy, 5-HT(1B) receptor mRNA levels were decreased in the cerebellum and in the frontal cortex. The expression of 5-HT(1B) receptors mRNA was unchanged in the hippocampus and in the striatum. This data indicates regional differences in the effects of long term adrenalectomy on the expression of 5-HT(1B) receptors.

Adrenalectomy↗
PubMed1998

Altered expression of the cell cycle regulatory protein cyclin D1 in the rat dentate gyrus after adrenalectomy-induced granular cell loss.

The loss of dentate gyrus (DG) granular cells after removal of the rat adrenal glands (ADX) is mediated by a process that is apoptotic in nature. The present study was initiated to compare changes in the immunocytochemical distribution of the cell-cycle regulatory protein cyclin D1, which has been implicated in apoptosis, with the loss of DG granular cells after ADX. Our data indicate that cyclin D1-immunoreactivity (cyclin D1-ir) is enhanced in the rat dentate gyrus after adrenalectomy. The enhanced cyclin D1-ir shows a close relationship, both in time and space, with granular cell loss in the rat dentate gyrus that occurs after adrenalectomy. However, the enhanced cyclin D1-immunoreactivity was present in microglia and radial glia rather than in the dentate gyrus granular cells. This suggests that cyclin D1 is not directly involved in apoptosis of granular cells in the rat dentate gyrus after adrenalectomy.

Adrenal Glands↗
PubMed1999

Electroshock seizures protect against apoptotic hippocampal cell death induced by adrenalectomy.

Seizures evoked by electroshock induce rapid changes in the expression of several genes in the adult brain, including those encoding for neurotrophic factors. Some of the neurotrophic factors induced by brief seizures such as basic fibroblast growth factor and nerve growth factor have been shown to have neuroprotective action. We reasoned therefore that these seizures may protect against neural injury. To test this hypothesis, we examined the effect of electroshock-induced seizures on the vulnerability to cell death in the hippocampus. Cell death was induced by adrenalectomy, which results in a highly selective apoptotic neuronal death in the dentate granule cell layer of the hippocampus. Daily electroshock seizures were administered for seven days to sham-operated and adrenalectomized rats. Neuronal degeneration was evaluated by the highly sensitive and reliable cupric-silver impregnation method. Animals experiencing electroshock seizures were completely protected against adrenalectomy-induced cell death, whereas adrenalectomized animals not exposed to electroshock seizures exhibited substantial neuronal cell degeneration in the dentate granule cell layer. Daily restraint stress did not prevent the adrenalectomy-induced neuronal death, indicating that the neuroprotective effect of the seizure treatment is not accounted for by stress. We conclude that brief controlled seizure-evoked neural activation may allow the sparing of otherwise vulnerable neuronal populations in the injured adult brain. This prompts a need to explore the possibility that controlled administration of electroshock seizures may have therapeutic potential in treating neurodegenerative disorders.

Adrenalectomy↗
PubMed2000

Catecholamine and cytokine response to laparoscopic adrenalectomy in patients with pheochromocytoma.

This study assesses the surgical stress of laparoscopic adrenalectomy (LA) in patients with pheochromocytoma using catecholamine and cytokine. The study was conducted on one patient who had laparoscopic adrenalectomy performed for pheochromocytoma, and three patients as controls who had undergone laparoscopic cholecystectomy (LC) for cholecystolithiasis. Catecholamines, tumor necrosis factor alpha (TNFalpha) and interleukin 6 (IL-6) were measured at 30-minute intervals intraoperatively, and on the first, third and fifth postoperative days (POD) respectively. Plasma TNFalpha and IL-6 were measured by a commercially available sandwich enzyme-linked immunosorbent assay test. During the operation. changes of catecholamine concentration in LA were far larger than those in LC. The changes of TNFalpha concentration in LA were also larger than those in LC. TNFalpha returned to basal value at the end of the operation in LC, but it did not in LA. TNFalpha concentration in LC changed a little after the surgery, whereas that in LA sharply increased and was maintained at a high level from 1 POD until 5 POD. Enhanced cytokine responses were observed in LA compared to LC during and after the surgery. We concluded that laparoscopic adrenalectomy may give those patients with pheochromocytoma more surgical stress than laparoscopic cholecystectomy for cholecystolithiasis, during and after the operation.

Adrenal Gland Neoplasms↗
PubMed2000

Laparoscopic adrenalectomy: lateral transabdominal approach vs posterior retroperitoneal approach.

Laparoscopic adrenalectomy has been used to remove a wide variety of adrenal neoplasms. Although several laparoscopic approaches to the adrenal gland have been described, the lateral transabdominal approach has several advantages when compared with other approaches for laparoscopic adrenalectomy. From October 1995 to July 1999, we performed laparoscopic adrenalectomies on 16 patients, including eight posterior retroperitoneal approaches and eight lateral transabdominal approaches. Sixteen patients, ranging in age from 23 to 69 years, were treated for the following conditions: non-functioning adenoma, four patients; aldosteronoma, seven patients; pheochromocytoma, three patients; Cushing's adenoma, two patients. The average tumor size was 2.5 +/- 0.5 cm (1.8-3.0 cm, median 2.4 cm) in the lateral transabdominal approach, 1.2 +/- 0.8 cm (0.8-3.2 cm, median 1.75 cm) in the posterior retroperitoneal approach. Average operative time of lateral transabdominal approach was significantly shorter than that of the posterior retroperitoneal approaches (mean 129 min vs 269 min, P = 0.0005). Conversion to laparotomy was required in one patient in the posterior approach. Postoperative complication occurred in one pneumothorax in the lateral transabdominal approach and two subcutaneous emphysemas in the posterior retroperitoneal approach. There was no statistical difference in blood loss during the operation in the two groups. There was no mortality in either group. The lateral transabdominal approach is a safe and efficient technique for the removal of the adrenal neoplasms. Compared with other approaches, this technique has a wider working space and also good exposure for removing the adrenal gland.

Abdomen↗
PubMed2002

Laparoscopic bilateral adrenalectomy for Cushing's syndrome due to ACTH-independent macronodular adrenocortical hyperplasia.

We performed simultaneous bilateral laparoscopic total adrenalectomy in two patients with Cushing's syndrome due to ACTH-independent macronodular adrenocortical hyperplasia (AIMAH). Preoperative serum cortisol in the patients was 29.5 and 53.2 microg/dl, respectively. The clinical symptoms of the latter patient were advanced, and respiration was labored with orthopnea. Laparoscopic adrenalectomies were performed transabdominally in the sequential lateral decubitus positions with extension of the lateral abdominal wall of the affected side. Three 12-mm and three 5-mm trocars were positioned, and two trocar sites in the midline were used on both sides. The flexible fiberscope was inserted through the umbilical port. The adrenal glands were large, fragile, and multinodular. The maximal diameters of the removed glands were 7.8 and 8.7 cm, respectively. In both patients, the adrenal glands were successfully removed without fragmentation. The operation times were 505 and 320 min, and the estimated blood loss was 150 and 5 ml, respectively. Neither intraoperative nor postoperative complications occurred, although the latter patient required muscle training before ambulation on postoperative day 42. The procedures resulted in marked clinical improvements. Compliance with the substitutive therapy remained excellent, and the patients expressed a very high degree of satisfaction with the laparoscopic adrenal surgery. The procedures of bilateral laparoscopic adrenalectomy were successful, and provided increased experience with the laparoscopic techniques.

Adrenal Glands↗
PubMed2002

Retroperitoneal laparoscopic adrenalectomy.

Retroperitoneoscopic adrenalectomy is currently performed either by lateral flank approach or posterior lumbar approach. The retroperitoneal laparoscopic adrenalectomy avoids invading the intraperitoneal cavity and possible injury to the abdominal organs. The posterior lumbar approach allows direct access to the main adrenal vascular supply before the gland is manipulated. Retroperitoneal laparoscopic adrenalectomy by the posterior approach is technically feasible and most effective as regards the simplicity of vascular control. The lateral flank approach allows a more spacious working cavity, but a large tumor obscures the surgical plane to the adrenal vessels. The transection of the adrenal vein is performed at the end of the procedure. The operating time, perioperative morbidity and cost have been reduced with these retroperitoneal approaches. The retroperitoneal approach to the adrenal gland is technically simple and can be performed quickly, with a low postoperative morbidity and should be regarded as the routine approach for relatively small adrenal benign tumors that are less than 5 cm in diameter.

Adrenalectomy↗
PubMed2003

Consequences of adrenalectomy on small intestine trophic parameters in aged and young rats: evidence of defective adaptation by aging and lack of corticoids.

Previous study pointed to an important role of adrenals and glucocorticoids in the trophic status of the adult small intestine mucosa, with possible implications during stress events. Small intestine morphological and biochemical consequences of 10-day bilateral adrenalectomy and also sham-related laparotomy were determined in 23-month-old Sprague-Dawley rats. As described in young rats, adrenalectomy in old rats leads to partial atrophy and disorganization of the proximal small intestine epithelium, with an increase in the number of Paneth cells and reduced crypt cell proliferation. We also observed a decrease of goblet cell number and a reduction of all enzyme activities including disaccharidases, in contrast with the specific induced response shown in young rats. A number of marked biochemical effects have also been noted in aged rats subjected to solely laparotomy, suggesting age-related adaptation impairments. In conclusion, adrenalectomy modified the differentiation processes of the small intestinal mucosa in both young and aged rats, and some parameters underlined that the lack of corticoid-mediated adaptive process are exacerbated by cumulative surgical stress (event) and aging.

Adaptation, Physiological↗
PubMed2003

Effect of adrenalectomy on healing of indomethacin-induced gastric erosions in rats.

We studied the effects of adrenalectomy and replacement therapy on healing of gastric erosions in adult Sprague-Dawley rats developed 4 h after subcutaneous injection of indomethacin in a dose of 25 or 35 mg/kg. Adrenalectomy was performed 1 week before or 4 h after indomethacin administration. Healing was evaluated by changes in the area of erosions over 24 h after indomethacin administration at fixed time intervals. Plasma corticosterone was measured. Adrenalectomy (irrespective of the time of intervention) decelerated healing of gastric injuries. Injection of corticosterone in a physiological dose of 4 mg/kg at the initial stage of healing (4 h after indomethacin administration) improved healing of erosions.

Adrenalectomy↗
PubMed1984

Deficits in conditioned avoidance responding following adrenalectomy and central norepinephrine depletion are dependent on postsurgical recovery period and phase of the diurnal cycle.

Rats that had undergone combined dorsal noradrenergic bundle lesion (DNBL) and bilateral adrenalectomy were impaired in acquiring a conditioned avoidance response when tested 1 week following surgery. Normal acquisition was observed, however, when testing occurred 3 weeks or more after surgery despite low levels of both plasma corticosterone and brain norepinephrine at that time. Furthermore, neither neonatal systemic administration of 6-hydroxy-dopamine to deplete forebrain norepinephrine, combined with the corticosterone inhibitor metyrapone, nor the pharmacological blockade of noradrenergic receptors, combined with adrenalectomy, disrupted acquisition of the avoidance response. Thus, the combination of forebrain norepinephrine loss and low plasma corticosterone does not inevitably impair avoidance acquisition. Rather, the determining factor for such impairment seems to be the interval between surgery and testing. The impairment at 1 week following DNBL and adrenalectomy occurred only for rats tested during the dark phase of their light cycle. In addition, the DNBL abolished the effect of the light/dark cycle on posttraining plasma corticosterone. These results demonstrate the importance of the phase of the rat's diurnal rhythm on both the hormonal and the behavioral effects of altering the pituitary-adrenal axis and/or forebrain norepinephrine. Because adrenocorticotropin, corticosterone, and vasopressin all show diurnal patterns of release, it cannot be determined at this time which, if any, of these hormones is most important for the behavioral results reported here.

Adrenal Cortex Hormones↗
PubMedDate not supplied

Co-localization of corticotropin releasing factor and vasopressin mRNA in neurones after adrenalectomy.

The discrete anatomical distribution of arginine vasopressin and corticotropin releasing factor (CRF) immunoreactivity in the paraventricular nucleus (PVN) of the rat hypothalamus is altered after adrenalectomy. Not only is the immunostaining of both peptides enhanced, but vasopressin immunoreactivity, normally confined to the magnocellular subdivision, becomes clear in a large percentage of CRF neurones in the parvocellular subdivision. These changes in immunoreactivity may reflect changes in post-translational events, peptide metabolism or genomic activity that lead indirectly or directly to the enhanced expression of vasopressin. Here we report that levels of transcripts homologous to vasopressin messenger RNA increase in the PVN after adrenalectomy, in parallel with increases in vasopressin immunoreactivity. In fact, after adrenalectomy, vasopressin mRNA can be detected in CRF-immunoreactive neurones. These results indicate that a considerable degree of plasticity is retained by the adult neuronal genome of the rat and that this plasticity may be modulated by the endocrine environment.

Adrenalectomy↗