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PubMed1999

Laparoscopic vs open adrenalectomy for the treatment of primary hyperaldosteronism.

HYPOTHESIS: That the clinical presentations, biochemical profiles, and surgical outcomes of patients treated with laparoscopic vs open adrenalectomy for primary hyperaldosteronism are different. DESIGN, SETTINGS, PATIENTS, AND INTERVENTIONS: The medical records of 80 patients with primary hyperaldosteronism who underwent open adrenalectomy between 1975 and 1986 or laparoscopic adrenalectomy between 1993 and 1998 at the University of California-San Francisco were reviewed by a single unblinded researcher (W.T.S.). MAIN OUTCOME MEASURES: Severity of hypertension and hypokalemia at diagnosis, their improvement after adrenalectomy, and operative complications. RESULTS: Thirty-eight patients underwent open adrenalectomy and 42 patients underwent laparoscopic adrenalectomy. The patients who underwent open adrenalectomy had documented hypertension for a median of 5 years before surgery; all had diastolic blood pressures greater than 100 mm Hg. Laparoscopically treated patients had documented hypertension for a median of 2.5 years preoperatively, and 20 (48%) had diastolic blood pressures greater than 100 mm Hg. The median preoperative serum potassium levels for the open and laparoscopic groups were 2.6 mmol/L and 3.3 mmol/L, respectively; the mean serum aldosterone levels were 1.47 nmol/L and 1.30 nmol/L. Thirty-two (84%) of the 38 patients who underwent open surgery and 41 (98%) of the 42 patients treated laparoscopically had adrenal adenomas. The sensitivity of preoperative computed tomographic scanning for adenomas was 83% for the patients treated with open adrenalectomy and 93% for those treated laparoscopically. There were 4 postoperative complications in the open surgery group and none in the laparoscopic group. Postoperatively, 30(81%) of 37 patients (excluding 1 patient who died of adrenocortical carcinoma) in the open surgery group and 37 (88%) of 42 patients treated laparoscopically were normotensive. Post-operative values were 3.6 to 5.0 of serum potassium per liter and 3.5 to 4.9 of serum potassium per liter in the open and laparoscopic groups, respectively. CONCLUSIONS: Patients who are treated with laparoscopic adrenalectomy for primary hyperaldosteronism are being referred with less severe hypertension and hypokalemia than patients formerly treated with open adrenalectomy. Patients treated laparoscopically had fewer postoperative complications and were equally likely to improve in blood pressure and hypokalemia. Laparoscopic adrenalectomy has become the treatment of choice for patients with primary hyperaldosteronism because of lower morbidity.

Adrenalectomy↗
PubMed1995

A comparison of laparoscopic and open adrenalectomies.

OBJECTIVE: To compare the relative merits of conventional transabdominal and posterior methods with a laparoscopic approach for adrenalectomy. DESIGN: A retrospective cohort study of consecutive series of patients having unilateral adrenalectomy for lesions less than 10 cm in diameter. SETTING: University hospital. PATIENTS: Ten patients who underwent laparoscopic adrenalectomy: 11, transabdominal adrenalectomy; and 13, posterior adrenalectomy. MAIN OUTCOME MEASURES: Operative time, estimated blood loss, length of hospital stay, and postoperative parenteral analgesic need. RESULTS: There was no significant difference in the operative time for laparoscopic and anterior adrenalectomy (mean +/- SD, 212 +/- 77 minutes vs 174 +/- 41 minutes), but the time for posterior adrenalectomy was significantly shorter (139 +/- 36 minutes) (P < .01). The mean (+/- SD) hospital stay after laparoscopic removal (2.1 +/- 0.9 days) was significantly shorter than the stay after anterior (6.4 +/- 1.5 days) and posterior (5.5 +/- 2.9 days) adrenalectomy. The postoperative need for parenteral pain medication as measured by the number of doses and the total milligrams of meperidine hydrochloride administered was significantly less with laparoscopic adrenalectomy compared with either open procedure (P < .0001). CONCLUSIONS: Laparoscopic adrenalectomy may take longer to perform than conventional open approaches but it has clear-cut advantages in shortening postoperative hospital stay and lessening postoperative analgesic requirements. It may be the preferred method for most patients requiring adrenalectomy.

Adrenalectomy↗
PubMed1997

Regulation of pituitary corticotropin releasing hormone (CRH) receptor mRNA and CRH binding during adrenalectomy: role of glucocorticoids and hypothalamic factors.

The role of glucocorticoids and hypothalamic factors on CRH receptor expression in the pituitary were studied by analysis of the effects of adrenalectomy and suppression of CRH and VP secretion by hypothalamic lesions in the rat. Consistent with previous in situ hybridization studies, Northern blots showed that pituitary CRH receptor mRNA decreased only transiently after adrenalectomy, falling to 51% of the control levels after 18 h, and returning to control values after 6 days (112%). The early decrease was prevented by dexamethasone injection, 100 micrograms, s.c. The role of increased levels of CRH and VP in the pituitary portal circulation on the transient decrease in CRH receptor mRNA levels after adrenalectomy were studied by in situ hybridization in rats subjected in PVN lesions or median eminence deafferentation by hypothalamic anterolateral cuts (ALC). PVN lesion (12 days) or ALC (8 days) resulted in undetectable irCRH and VP in the external zone of the median eminence and had no effect on basal levels of pituitary POMC mRNA, CRH binding and CRH receptor mRNA. In sham lesioned rats, adrenalectomy for 18 h or 4 days caused the expected increases in pituitary POMC hnRNA and mRNA, and decreases in CRH binding. CRH-R mRNA levels decreased by about 50% after 18 h adrenalectomy but returned to basal by 4 days. PVN lesion or ALC fully prevented the fall in CRH binding after 18 h or 4 days adrenalectomy and the increase in POMC mRNA after 4 days adrenalectomy, whereas only attenuated the decrease in CRH receptor mRNA and increase in POMC mRNA levels after 18 h adrenalectomy. Administration of a CRH antagonist did not affect CRH receptor mRNA and POMC hnRNA and mRNA indicating that residual CRH in the median eminence after hypothalamic surgery is not responsible for the effect of adrenalectomy. These studies confirm previous in situ hybridization studies showing that adrenalectomy causes transient decreases in pituitary CRH receptor mRNA levels. The data indicate that while increases in hypothalamic CRH secretion following glucocorticoid withdrawal mediate pituitary CRH receptor binding loss and the increase in POMC expression after long-term adrenalectomy, CRH only partially accounts for the early changes in CRH receptor mRNA and POMC mRNA.

Adrenal Glands↗
PubMed2003

One hundred laparoscopic adrenalectomies: a single surgeon's experience.

BACKGROUND: Since the first laparoscopic adrenalectomy was performed in 1992, it has quickly gained acceptance as the standard of care for the treatment of benign adrenal neoplasms. We report a single surgeon's experience with 100 consecutive laparoscopic adrenalectomies. METHODS: The records of all patients having adrenalectomy at the Johns Hopkins Hospital from 1993 until 2000 were reviewed. We examined the length of stay, time to diet resumption, perioperative morbidity, operative cost, and total cost of 100 consecutive laparoscopic adrenalectomies. These data are compared with those of 20 patients within our institution having open adrenalectomy and with 428 patients statewide having all forms of adrenalectomy during the same time period. RESULTS: A total of 93 patients had unilateral laparoscopic adrenalectomy and 7 had bilateral procedures. The mean age was 49 years (11 to 70). Indications were aldosteronoma (n = 40), pheochromocytoma (n = 22), glucocorticoid-producing adenoma (n = 14), nonfunctioning adenoma (n = 12) Cushing's disease (n = 5), and others (n = 7). The median length of stay for this series was 1.0 day. Average length of stay and time to resumption of diet were 1.8 and 1.0 days, respectively. Patients having open procedures during this same time period had an average length of stay of 6.5 days. CONCLUSIONS: Laparoscopic adrenalectomy provides clear advantages over open adrenalectomy. Patients having laparoscopic adrenalectomy have decreased length of stay, shorter time to resumption of diet, and lower total hospital charges when compared with those having open adrenalectomy.

Adolescent↗
PubMed1999

Laparoscopic adrenalectomy: new gold standard.

Nearly 600 cases of laparoscopic adrenalectomy have been described in the world literature, documenting the safety and effectiveness of the procedure. Comparative studies have demonstrated the advantages of the laparoscopic approach when compared to traditional open approaches to adrenalectomy, documenting a more rapid and comfortable recovery, shorter hospitalization, and fewer complications. Several techniques of laparoscopic adrenalectomy have been described. We prefer the transabdominal approach in the lateral decubitus position. Herein we report our experience with 28 adrenalectomies using this approach. Indications for adrenalectomy have been hyperaldosteronism (9), hypercortisolism (4), pheochromocytoma (3), incidentaloma (6), metastasis (3), lymphoma (1), angiomyolipoma (1), other (1). Average tumor size was 3.3 cm (1. 4-8.3 cm). Average operative time was 152 minutes (110-210 minutes), with left adrenalectomy taking slightly longer to perform than on the right (156 vs. 145 minutes). There were no intraoperative complications and one conversion to open adrenalectomy for a large metastatic lung cancer found to be invading the liver. One patient experienced left rib pain from a cannula site immediately at the costal margin. There were no other complications. Average length of hospitalization was 2.3 days (1-6 days). With this and others' experience, laparoscopic adrenalectomy has become the gold standard for adrenalectomy. This manuscript reviews the literature on laparoscopic adrenalectomy and describes the transabdominal lateral approach.

Adrenal Gland Diseases↗
PubMed2005

Thirty robotic adrenalectomies: a single institution's experience.

BACKGROUND: Robotic adrenalectomy is a minimally invasive alternative to traditional laparoscopic adrenalectomy. To date, only case reports and small series of robotic adrenalectomies have been reported. This study presents a single institution's series of 30 robotic adrenalectomies, and evaluates the procedure's safety, efficacy, and cost. METHODS: Thirty patients underwent robotic adrenalectomy at the Johns Hopkins Hospital between April 2001 and January 2004. Patient morbidity, hospital length of stay, operative time, and conversion rate to traditional laparoscopic or open surgery are presented. Improvement in operative time with surgeon experience is evaluated. Hospital charges are compared to charges for traditional laparoscopic and open adrenalectomies performed during the same time period. RESULTS: Median operative time was 185 min. Patient morbidity was 7%. There were no conversions to traditional laparoscopic or open surgery. The median hospital stay was 2 days. Operative time improved significantly by 3 min with each operation. Hospital charges for robotic adrenalectomy (12,977 dollars) were not significantly different than charges for traditional laparoscopic (11,599 dollars) or open adrenalectomy (14,600 dollars). CONCLUSIONS: Robotic adrenalectomy is a safe and effective alternative to traditional laparoscopic adrenalectomy.

Adrenalectomy↗
PubMed1995

The effect of adrenalectomy on 5-hydroxytryptamine and corticosteroid receptor subtype messenger RNA expression in rat hippocampus.

Both central serotonergic dysfunction and glucocorticoid hypersecretion have been separately implicated in the aetiology of affective disorders. The hippocampus highly expresses receptors for 5-hydroxytryptamine and glucocorticoids, and adrenalectomy alters the responsivity of hippocampal neurons to 5-hydroxytryptamine. The hippocampus thus represents a prime locus for interactions between the two systems. In this study we examined the effects of glucocorticoid manipulations on neuronal expression of messenger RNA encoding corticosteroid receptor and 5-hydroxytryptamine receptor subtypes in the hippocampus and 5-hydroxytryptamine1A messenger RNA expression in the dorsal raphe, in the rat. Interestingly, there was no effect of adrenalectomy on 5-hydroxytryptamine1A or 5-hydroxytryptamine2A receptor messenger RNA expression in the dorsal or ventral hippocampus at any time point measured. Furthermore, no changes in 5-hydroxytryptamine1A receptor gene expression were seen in the dorsal raphe (encoding autoreceptors) after adrenalectomy. However, 5-hydroxytryptamine2C (5-hydroxytryptamine1C) receptor messenger RNA expression was increased specifically in posterior CA1 and CA3 neurons following adrenalectomy, an effect that was reversed by glucocorticoid replacement. Following adrenalectomy, glucocorticoid and mineralocorticoid receptor messenger RNA expression increased in the dentate gyrus, CA1 and CA3 subfields of the hippocampus. These increases were apparent 6 h after adrenalectomy, were maintained at two days, but 14 days after adrenalectomy hippocampal glucocorticoid receptor and mineralocorticoid receptor gene expression had returned to control levels. These effects of adrenalectomy were abolished by dexamethasone, but not aldosterone administration, suggesting mediation by autoregulatory glucocorticoid receptors. Our results show that adrenalectomy only transiently increases corticosteroid receptor gene expression in the hippocampus, and selectively increases hippocampal 5-hydroxytryptamine2C receptor messenger RNA expression. The resulting change in 5-hydroxytryptamine2C receptor-mediated responses may produce the alterations in hippocampal neuronal activity in response to 5-hydroxytryptamine observed after adrenalectomy.

Adrenal Glands↗
PubMed2000

Laparoscopic adrenalectomy for benign adrenal tumors.

Laparoscopic adrenalectomy has been rapidly accepted for treatment of benign adrenal tumors. To evaluate the advantages of laparoscopic adrenalectomy, we examined 55 patients who underwent laparoscopic adrenalectomy. In all patients, adrenal tumors were successfully removed. The mean operating time was 143 minutes, and the estimated mean blood loss was 49 mL in all patients. The postoperative course was uneventful in all cases. The mean frequency of administration of analgesics was only 2.9 times, and the time elapsed to first walking after surgery was 17 hours. The peak white blood cell count and C-reactive protein values after surgery were 8,266 +/- 1,963/mm3 and 2.5 +/- 1.2 mg/dL, respectively. Of the 55 patients, 44 underwent total adrenalectomy and another 11 underwent partial adrenalectomy, which was introduced in the expectation of preserving normal adrenal cortex; it is therefore indicated in solitary and peripherally located benign tumors. The mean operating time was 154 minutes for the total adrenalectomy, which was longer than that of partial adrenalectomy (92 minutes). The estimated blood loss was 50 mL for the total and 46 mL for the partial adrenalectomy. The postoperative course was uneventful and surgical outcome was excellent in each group. In conclusion, our results are encouraging enough to suggest that laparoscopic adrenalectomy should be a preferential therapeutic option for benign adrenal tumors; also, partial adrenalectomy could be a safe, effective, and less invasive procedure in selected cases.

Adrenal Gland Neoplasms↗
PubMed2003

Laparoscopic adrenalectomy for incidentaloma and bilateral adrenal disease.

Adrenalectomy is ideally suited to minimally invasive surgery based on the characteristics of adrenal tumours, which are usually small and benign. The aim of this study was to verify that laparoscopic adrenalectomy is minimally invasive and to assess the indication of laparoscopic adrenalectomy for incidentaloma. From October 1995 through August 2002, 133 patients underwent adrenal surgery at the Department of Surgery II, Nagoya University School of Medicine. Of these, 111 underwent laparoscopic adrenalectomy. All laparoscopic adrenalectomies were performed using the transabdominal lateral approach. In 50 of 133 patients, the adrenal tumours were incidentally discovered. There were 27 non-functioning adrenal tumours and six of seven preclinical Cushing's test syndrome cases incidentally discovered. Six of 27 non-functioning adrenal tumour patients underwent open adrenalectomy because of large tumour size or malignancy. Based on the present criteria for laparoscopic adrenalectomy, 15 of 133 patients were retrospectively considered to have required open adrenalectomy. The average size of a non-functioning adrenal tumour was 5.8 cm in diameter, which was equal to the average size of a phaeochromocytoma. A simultaneous bilateral laparoscopic adrenalectomy was performed in a patient in poor condition with advanced Cushing's syndrome due to adrenocorticotrophic hormone-independent macronodular adrenocortical hyperplasia (AIMAH). The adrenal glands were successfully removed without fragmentation in this patient, and the postoperative course was uneventful, thanks to the minimally invasive surgery. The laparoscopic technique assures less morbidity and faster recovery, and appears to be equally effective in eradicating functioning and non-functioning adrenal masses. The benefits of the laparoscopic approach to adrenalectomy should not result in a more aggressive attitude toward the excision of clinically silent, benign-appearing adrenal incidentalomas.

Adenoma↗
PubMed1981

Brain serotonin turnover correlates inversely with plasma adrenocorticotropin during the triphasic response to adrenalectomy in rats.

After bilateral adrenalectomy in adult male rats a triphasic change occurs in the plasma concentration of radioimmunoassayable ACTH. Plasma ACTH is markedly elevated at 2 h, returns almost to normal at 20 h, and is again markedly elevated 92 h after adrenalectomy. We have examined brain serotonin (5HT) turnover during this period using two nonsteady state methods: accumulation of 5HT after monoamine oxidase inhibition with pargyline and decline of 5-hydroxyindoleacetic acid (5HIAA) after pargyline. Both endpoints demonstrated decreases in hypothalamic and brain stem 5HT turnover 2 and 92 h after adrenalectomy, but normal 5HT turnover 20 h after adrenalectomy. Thus, we demonstrated inverse relationships between 5HT turnover in both the hypothalamus and brain stem and the plasma ACTH concentration throughout the period of triphasic change after adrenalectomy. The adrenalectomy-induced increases in plasma ACTH and decreases in brain 5HT turnover both 2 and 92 h after adrenalectomy are inhibited by treatment with small doses of corticosterone. The data strongly suggest that the activity of some brain 5HT neurons changes after adrenalectomy in a triphasic pattern and, further, that these changes are related in part to glucocorticoid withdrawal. 5HT receptor antagonists blunted corticosterone inhibition of the adrenalectomy-induced decreases in brain 5HT turnover, providing further evidence for an interaction between glucocorticoids and brain 5HT neurons. The data are consistent with a role of brain 5HT neurons in the adrenalectomy-induced triphasic changes in ACTH secretion.

Adrenalectomy↗
PubMed1975

Bilateral adrenalectomy for advanced breast cancer: a 21 year experience.

Of 680 patients who had bilateral adrenalectomies for metastatic breast cancer, 583 were evaluable. Two hundred and nine patients (36 percent) responded (180 objective, 29 subjective responders) for at least 6 months. Age, menstrual status, prior response to oophorectomy, disease-free interval, involved organ systems, and incidental splenectomy were correlated with adrenalectomy response. Patients aged 21 to 35 years did poorly (23 percent response rate), whereas 41 percent of patients aged 51 to 65 responded. Menstrual status appeared to have no effect upon whether or not a patient responded to adrenalectomy. Oophorectomy responders benefited from adrenalectomy 40 percent of the time and oophorectomy failures responded in 27 percent of the cases. Patients with a disease-free interval of zero to 2.5 years responded to adrenalectomy at a rate of 31 percent whereas patients with a free interval greater than 2.5 years responded at a rate of 50 percent. When a single visceral organ or any combination of bone and soft tissue was involved, the average response rate was 39 percent. However, when multiple visceral organs or a single visceral organ with any combination of bone or soft tissue was involved, the response rate dropped to 26 percent. Sixty-six patients had splenectomies at the time of adrenalectomy with a 44 percent response rate, whereas nonsplenectomized patients had a 35 percent response rate. The median survival rate of 209 adrenalectomy responders was 26 months; it was 10 months for 374 nonresponders. The 5 and 10 year survival rates for adrenalectomy responders were 18 and 7 percent, respectively, and zero percent for adrenalectomy nonresponders. The patients who received greatest benefit from adrenalectomy in this series were aged 51 to 65 years, had a disease-free interval greater than 2.5 years and had metastases limited to a single visceral organ or any combination of bone and soft tissues.

Adolescent↗
PubMed1994

Adrenalectomy increases local cerebral blood flow in the rat hippocampus.

The present study examined the effect of glucocorticoid manipulations on local cerebral blood flow in the hippocampus. We measured local cerebral blood flow in the hippocampus at 1-h intervals over a 1-day period in freely moving rats, by means of the H2 clearance method, before and after sham adrenalectomy, adrenalectomy or adrenalectomy with corticosterone replacement. We also measured local cerebral blood flow in the prefrontal cortex before and after adrenalectomy. Four weeks after the adrenalectomy, hippocampal blood flow at each time of day was an average of 47% greater than before the operation, showing diurnal variation as before. After the sham adrenalectomy or adrenalectomy with corticosterone replacement, hippocampal blood flow did not change significantly with respect to either its level or its diurnal variation. Local cerebral blood flow in the prefrontal cortex increased by only 19% after adrenalectomy. The present study demonstrates that adrenalectomy causes a remarkable increase in hippocampal blood flow, probably due to a lack of corticosterone.

Adrenalectomy↗
PubMed2005

Endoscopic adrenalectomy for pheochromocytoma: difference between the transperitoneal and retroperitoneal approaches in terms of the operative course.

BACKGROUND: Due to the intraoperative catecholamine secretion with hemodynamic changes, a larger tumor size and marked neovascularization, as compared with other adrenal pathologies, endoscopic adrenalectomy for pheochromocytoma represents a particular challenge involving a more difficult and morbid procedure. The aim of this study was to identify the optimal surgical approach for endoscopic adrenalectomy in patients with pheochromocytoma. METHODS: Over a period of 10 years (February 1994 to June 2004), 38 consecutive patients underwent endoscopic adrenalectomy for pheochromocytoma. As three patients underwent a bilateral procedure, a total of 41 adrenalectomies were performed. The transperitoneal approach was carried out in 23 patients, whereas 18 patients underwent a retroperitoneal adrenalectomy by a single operative team. Perioperative parameters were prospectively followed. RESULTS: There was no conversion to the open procedure. Intraoperative hypertensive episodes occurred in 21 patients (55.3%) and were controlled by antihypertensive agents. In 11 patients (28.9%), blood pressure values rose to above 200 mmHg (> 1 min). A comparison between the retroperitoneal and transperitoneal procedures did not show a significant difference between the maximum intraoperative systolic (p = 0.730) and diastolic (p = 0.663) blood pressure values although intraoperative blood pressure peaks were seen more frequently during retroperitoneal adrenalectomy. The operative time was shorter for the patients who had transperitoneal adrenalectomy than compared to for those who had retroperitoneal adrenalectomy, although the difference was not significant. The intraoperative blood loss, perioperative morbidity, and length of postoperative hospital stay did not differ significantly between the surgical techniques (p > 0.05). CONCLUSION: After adequate preparation, endoscopic adrenalectomy may be performed in patients with pheochromocytoma via both the retroperitoneal and the transperitoneal approaches. The shorter operating time, less frequent intraoperative blood pressure peaks, and the better overview of the operating field recommend the transperitoneal approach with the patient placed in a lateral position as the preferred operative procedure.

Adrenal Gland Neoplasms↗
PubMed2003

Functional results after endoscopic subtotal cortical-sparing adrenalectomy.

PURPOSE: We examined the required amount of residual adrenal tissue and whether an intact adrenal vein are necessary to achieve sufficient function after endoscopic subtotal adrenalectomy. METHOD: Endoscopic subtotal adrenalectomy was performed in 14 patients. Two patients underwent unilateral subtotal and contralateral total adrenalectomy and another two patients underwent unilateral subtotal adrenalectomy after contralateral total adrenalectomy several years earlier. We analyzed the postoperative serum levels of cortisol and adrenocorticotropic hormone (ACTH). Patients with bilateral tumors underwent an ACTH test. RESULTS: We had to cut the main adrenal vein in ten patients, and less than one third of the adrenal gland was left in situ in four patients. Subtotal adrenalectomy was performed unilaterally in two patients with bilateral tumors. One third of the adrenal gland was preserved in these patients, and also in the two patients with unilateral subtotal adrenalectomy after previous contralateral total adrenalectomy. The postoperative ACTH test confirmed satisfactory adrenocortical function. During the follow-up period of about 24 months no recurrent tumors have been found. CONCLUSION: Subtotal cortical-sparing adrenalectomy can be successfully performed laparoscopically. The venous drainage of the main adrenal vein does not seem to be crucial for sufficient adrenocortical function. We estimate that leaving about one third of the entire adrenal gland as remnant adrenal tissue will result in sufficient function.

Adrenal Cortex↗
PubMed2000

Laparoscopic adrenalectomy for large-volume (> or = 5 cm) adrenal masses.

BACKGROUND AND PURPOSE: Laparoscopic adrenalectomy has emerged as the standard of care at many centers for small surgical adrenal masses. However, the role of laparoscopic adrenalectomy in the treatment of large adrenal masses has not been specifically addressed. Our aim was to evaluate the outcome of laparoscopic v open adrenalectomy for large-volume (> or =5 cm) adrenal masses and to compare laparoscopic adrenalectomy for large- and small-volume (<5 cm) masses. PATIENTS AND METHODS: Data from 14 patients with large adrenal masses undergoing laparoscopic adrenalectomy between February 1998 and March 1999 (Group I) were retrospectively compared with 14 contemporary large-volume open adrenalectomies between December 1992 and May 1998 (Group II) and 45 small-volume laparoscopic adrenalectomies between July 1997 and November 1998 (Group III). RESULTS: In Group I and Group II, the mean surgical time (205 min v 216 min) and blood loss (400 mL v 584 mL) were similar. Although the mean adrenal size was also comparable (8 cm v 7.8 cm), the specimen weight of the en bloc adrenal gland and periadrenal fat was greater in Group I (168 g v 106 g). The hospital stay was shorter in Group I (2.4 days v 7.7 days). Minor complications occurred in 21.4% of Group I and 50% of Group II patients. On comparing Group I and Group III (laparoscopic <5 cm), Group I had larger specimen weight (168 g v 51.4 g), longer surgical time (205 min v 158 min), greater blood loss (400 mL v 113 mL), longer hospital stay (2.4 days v 1.5 days), a higher complication rate (21.4% v 8.9%), and a higher incidence of open surgical conversion (14.3% v 2.2%). Over a mean follow-up of 9.9 months, no local or port-site recurrences have been noted in Group I. CONCLUSIONS: Laparoscopic adrenalectomy for large-volume adrenal masses is technically feasible and seems to replicate open surgical oncologic principles of achieving a wide-margin, en bloc excision of the adrenal gland and periadrenal fat. Successful laparoscopic resection is not impacted by the large size of the adrenal mass per se but rather by the presence of local invasion and poorly defined tissue planes that may be encountered in adrenal malignancy. As such, laparoscopic adrenalectomy for large masses should be attempted only by experienced laparoscopic surgeons and then with a low threshold for open conversion.

Adrenal Gland Neoplasms↗
PubMed2001

Current role of laparoscopic adrenalectomy.

OBJECTIVE: Laparoscopic adrenalectomy is now a standard procedure for the vast majority of patients with surgical adrenal disease. Herein, we evaluate various techniques employed during laparoscopic adrenalectomy, and assess the current role of laparoscopic adrenalectomy, and possible future developments. MATERIALS AND METHODS: We reviewed large series of reports presenting the results of laparoscopic transperitoneal and retroperitoneal adrenalectomy and we compared the data of different series and authors, adding our experience. RESULTS: Laparoscopic adrenalectomy is a safe, reproducible and effective procedure with low complication rates. With increasing worldwide experience, the indications for laparoscopic adrenalectomy are expanding. When retrospectively compared to open surgery, laparoscopic adrenalectomy is superior in terms of postoperative pain, hospital stay, return to normal activity and complications. CONCLUSIONS: Laparoscopic adrenalectomy is a safe and effective option for most surgical adrenal pathologies. Moreover, laparoscopic adrenalectomy is associated with a superior patient tolerance profile. It is safe to say that today, laparoscopy must be considered the first choice procedure for excision of benign surgical adrenal lesions.

Adrenalectomy↗
PubMed1989

Role of adenosine 3',5'-monophosphate and the Ri-receptor Gi-coupled adenylate cyclase inhibitory pathway in the mechanism whereby adrenalectomy increases the adenosine antilipolytic effect in rat fat cells.

The aim of this study was to establish the mechanism by which adrenalectomy promotes the antilipolytic effect of the adenosine analog (-)-N6-(R-phenyl-isopropyl)adenosine (R-PIA) in rat fat cells. This action of adrenalectomy was not specific for R-PIA, since it was also observed with nicotinic acid and was prevented by phosphodiesterase inhibitors. In contrast, the inhibitory effect of R-PIA and nicotinic acid toward isoproterenol-stimulated cAMP accumulation was unaltered by adrenalectomy regardless of whether phosphodiesterase inhibitors were present. Whatever the conditions used, however, the cAMP levels in adrenalectomized rat adipocytes were one quarter to one third of those in sham-operated rats and remained below the limit over which variations in cAMP had no more influence in lipolysis. Both total and particulate low Km cAMP phosphodiesterase activities per adipocyte were decreased in adrenalectomized rats, but the stimulatory responses of the particulate enzyme to R-PIA remained unchanged. Pertussis toxin-catalyzed ADP ribosylation studies revealed a marked decrease in the total amount of the alpha-subunits of Go and the adenylate cyclase inhibitory regulatory protein Gi after adrenalectomy. However, the inhibitory dose-response curves of adenylate cyclase to R-PIA, nicotinic acid, GTP, guanylylimidodiphosphate, and guanosine 5'-O-(3-thiotriphosphate) were unaltered by adrenalectomy, indicating that the inhibitory function of Gi is unimpaired by adrenalectomy. Lastly, adrenalectomy resulted in a 60% reduction of the Mn2+-stimulated adenylate cyclase activity/adipocyte, which indicates that adrenalectomy causes a defect in adenylate cyclase catalytic activity. Thus, enhanced antilipolytic effects of R-PIA induced by adrenalectomy do not involve increased function of the adenosine receptor Gi-coupled adenylate cyclase inhibitory pathway, but are related to abnormally low intracellular cAMP levels due to defective adenylate cyclase catalytic activity.

1-Methyl-3-isobutylxanthine↗
PubMed1982

How effective is surgical adrenalectomy in lowering steroid hormone concentrations?

Surgical adrenalectomy produces objective tumour regression in 50-60% of estrogen receptor-positive women with metastatic breast carcinoma. Additional responses to antiestrogens or further suppression of estrogens with aminoglutethimide after adrenalectomy suggest the possibility of continued adrenal steroid secretion even after surgical ablation. The use of sensitive and specific RIAs allows precise determination of the degree of hormone suppression after adrenalectomy and could provide documentation of nonsuppression or escape from suppression in individual patients. To evaluate the possibility of continued hormone secretion, we measured 14 hormones in 26 postmenopausal women with breast carcinoma before and after adrenalectomy. While the mean levels of androgens were markedly suppressed [dehydroepiandrosterone sulfate (DHEA-S), 99%, androstenedione, 94%; testosterone, 77%; dihydrotestosterone, 73%] after adrenalectomy, estrogen concentrations fell to a much lesser extent (plasma estrone, 73%; urinary estrone, 86%; plasma estradiol, 53%; urinary estradiol, 67%). Examination of data in individual patients revealed incomplete suppression in several women (less than 50% suppression of plasma estradiol in 14 of 25 patients, of urinary estradiol in 4 of 22, and of urinary estrone in 1 of 22). Androgen concentrations also fell incompletely after adrenalectomy in a few patients. Androstenedione concentrations were greater than 2 SD above the group mean in 2 of 23 patients, and in 2 of 25 patients, DHEA-S concentrations were also greater that 2 SD above the group mean. Serial measurements of hormones over a 1- to 3-yr period following surgery revealed escape from suppression over time (i.e. greater than 2-fold increase in hormone levels) in 7 of 26 women. The practical significance of the lack of suppression or of escape from inhibition was assessed by comparing estrogen levels in responders vs. nonresponders to surgical adrenalectomy. Of all steroids measured, greater suppression of only 1 hormone (urinary estrone) was observed in responders vs. nonresponders. These data indicate that adrenalectomy does not uniformly suppress circulating androgen and estrogen levels in postmenopausal patients. Women who initially suppress after adrenalectomy may show recovery of either androgen or estrogen levels with time.

Adrenalectomy↗