BJUI BJU International
International Consultation on Urological Diseases and European Association of Urology International Consultation on Minimally Invasive Surgery in Urology: laparoscopic and robotic adrenalectomy
Mark W. Ball*, Ashok K. Hemalt and Mohamad E. Allaf*
*James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, and +Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC, USA
The aim of this study was to provide an evidence-based systematic review of the use of laparoscopic and robotic adrenalectomy in the treatment of adrenal disease as part of the International Consultation on Urological Diseases and European Association of Urology consultation on Minimally Invasive Surgery in Urology. A systematic literature search (January 2004 to January 2014) was conducted to identify comparative studies assessing the safety and efficacy of minimally invasive adrenal surgery. Subtopics including the role of minimally invasive surgery for pheochromocytoma, adrenocortical carcinoma (ACC) and large adrenal tumours were examined. Additionally, the role of transperitoneal and retroperitoneal approaches, as well as laparoendoscopic single- site (LESS) and robotic adrenalectomy were reviewed. The major findings are presented in an evidence-based fashion. Large retrospective and prospective data were analysed and a set of recommendations provided by the committee was
produced. Laparoscopic surgery should be considered the first- line therapy for benign adrenal masses requiring surgical resection and for patients with pheochromocytoma. While a laparoscopic approach may be feasible for selected cases of ACC without adjacent organ involvement, an open surgical approach remains the ‘gold standard’. Large adrenal tumours without preoperative or intra-operative suspicion of ACC may be safely resected via a laparoscopic approach. Both transperitoneal and retroperitoneal approaches to laparoscopic adrenalectomy are safe. The approach should be chosen based on surgeon training and experience. LESS and robotic adrenalectomy should be considered as alternatives to laparoscopic adrenalectomy but require further study.
Keywords
guidelines, adrenalectomy, laparoscopy, robotics, #ProstateCancer, PCSM
Introduction
Adrenal tumours are common, with adrenal incidentalomas found in 3.4-7% of patients on imaging studies [1]. After appropriate imaging and endocrine investigation, the majority of functional adrenal masses, tumours >4 cm in size and tumours with concerning radiographic features are candidates for surgical resection. Recently published guidelines from the American Association of Clinical Endocrinologists and the American Association of Endocrine Surgeons [2] included recommendations for the diagnostic evaluation of adrenal lesions that are beyond the scope of the present review.
Laparoscopic adrenalectomy was initially described by Gagner et al. in 1992 [3]. Since its introduction, it has become the ‘gold standard’ for the surgical treatment of benign adrenal neoplasms and is increasingly used for malignant tumours [4-7]. Multiple retrospective and prospective series have reported less pain, lower estimated blood loss (EBL), faster convalescence, less ileus and shorter length of hospital stay
(LOS) [5,8-15]. Regardless of the underlying pathology, the best outcomes for adrenal resection have been associated with high-volume surgeons [16]. Although the majority of studies have focused on outcomes in adults, emerging literature also supports the safety and feasibility of a laparoscopic approach in children [17,18].
We sought to grade the evidence supporting the role of minimally invasive adrenalectomy in the treatment of adrenal pathology and to develop guidelines for its use as part of the International Consultation on Urological Diseases and European Association of Urology consultation on Minimally Invasive Surgery in Urology.
Methods Data Acquisition
This review was based on a systematic literature search from January 2004 to January 2014 of Medline and Embase. The
primary search terms used were (‘adrenal’ OR ‘adrenalectomy’) AND (‘laparoscopic’ or ‘robotic’ or ‘minimally invasive’). All fields including Medical Subject Heading (MeSH) terms were searched. The search was limited to human subjects and the English language. Additional searches were performed in the Web of Science and the Cochrane Library with a focus on systematic reviews, meta-analysis and randomized trials. Abstracts from major urological meetings were reviewed from the previous 3 years. Guideline statements from the Society of American Gastrointestinal and Endoscopic Surgeons [19], the American Association of Clinical Endocrinologists and the American Association of Endocrine Surgeons [2] were also reviewed. Studies were selected for inclusion if they were comparative studies including minimially invasive adrenalectomy (laparoscopic or robotic), compared with open adrenalectomy or a secondary minimally invasive technique. All results were intially screened by title. Selected studies were then screened by abstract, and all included studies were completely examined to assess their relevance to the review. Duplicate studies were excluded. Studies were assessed for level of evidence (1-4) as per previously described methodology [20]. Recommendations were graded (A-D) according to a modified verison of the Oxford system [20] as follows:
· A Grade A recommendation usually depends on consistent Level 1 evidence and often means that the recommendation is effectively mandatory and placed within a clinical care pathway; however, there will be occasions where excellent evidence (Level 1) does not lead to a Grade A recommendation; for example, if the therapy is prohibitively expensive, dangerous or unethical. A Grade A recommendation can follow from Level 2 evidence, but needs a greater body of evidence if based on anything except Level 1 evidence.
· A Grade B recommendation usually depends on consistent Level 2 and/or 3 studies, or ‘majority evidence’ from randomized controlled trials.
· A Grade C recommendation usually depends on Level 4 studies or ‘majority evidence’ from Level 2/3 studies or Delphi-processed expert opinion.
· A Grade D ‘No recommendation possible’ would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi.
Results
A total of 1 545 abstracts were screened. Ultimately 52 comparative studies met the inclusion criteria. Of these, 11 studies compared laparoscopic with open adrenalectomy for benign renal masses, eight studies compared laparoscopic with open adrenalectomy for adrenocortical carcinoma (ACC), eight studies compared
laparoscopic with open adrenalectomy for pheochromocytoma, six studies compared laparoscopic with open adrenalectomy for large adrenal masses not suspicious for malignancy, nine studies compared conventional laparoscopy and laparoendoscopic single-site (LESS) surgery and 10 studies compared conventional laparoscopy and robotic adrenalectomy.
Laparoscopic Adrenalectomy for Benign Renal Masses
Several studies have analysed the role of laparoscopy for specific adrenal tumours. In patients with symptomatic primary hyperaldosteronism, laparoscopic adrenalectomy was associated with fewer postoperative complications, shorter LOS and equivalent improvement of hypertension and hypokalaemia compared with patients treated with an open approach [8,21]. Table 1 lists comparative series of laparoscopic vs open adrenalectomy for benign adrenal tumours.
Recommendation 1: Laparoscopic surgery should be considered the first-line therapy for benign renal masses requiring surgical resection (Grade B).
Pheochromocytoma
The resection of pheochromocytomas, thought to be more difficult because of both catecholamine release during manipulation and greater vascularity, is aided by a laparoscopic approach. Compared with open surgery, laparoscopy was associated with lower EBL [22-25] and shorter LOS [12,22,23,26-28]. Additionally, episodes of intra- operative hypertension or hypotension were either fewer [23,28] or similar in number during laparoscopic procedures. Table 2 lists comparative series of laparoscopic vs open adrenalectomy for pheochromocytoma.
Recommendation 2: Laparoscopic surgery should be considered the first-line therapy for patients with pheochromocytoma (Grade B).
Known or Suspected Adrenocortical Carcinoma
The use of laparoscopy for ACC is debated. While no prospective, comparative series have been reported, retrospective series have reported increased recurrence, peritoneal carcinomatosis, positive margins and local recurrence rates for laparoscopic cases compared with open [29-33]. Conversely, in a matched comparison of laparoscopic and open adrenalectomy for ACCs <10 cm, no difference in cancer-specific survival, tumour capsule violation or carcinomatosis was noted [34]. Taken together, while a laparoscopic approach may be feasible for select cases of ACC without adjacent organ invasion, an open surgical approach
| First author (year) | Surgical approach: | Critical findings | Level of evidence |
|---|---|---|---|
| laparoscopic vs open, n | |||
| Thompson et al. [63] | 50 vs 50 | Laparoscopic surgery has shorter LOS and lower morbidity time, but longer operating time than open surgery | 3 |
| Brunt et al. [64] | 24 vs 42 | Laparoscopic surgery has less EBL, shorter LOS but longer operating time than open surgery. | 3 |
| Lee et al. [65] | 358 vs 311 | Laparoscopic surgery has less EBL, shorter LOS and shorter operating time than open surgery | 3 |
| Barreca et al. [66] | 79 vs 93 | Laparoscopic surgery has shorter LOS but similar EBL and operating time compared with open surgery. | 3 |
| Kwan et al. [67] | 353 vs 133 | Laparoscopic surgery has less EBL, shorter LOS and similar operating time compared with open surgery | 3 |
| Chotirosnramit et al. [68] | 41 vs 39 | Laparoscopic surgery has less EBL, shorter LOS and longer operating time compared with open surgery | 3 |
| Wu et al. [69] | 37 vs 30 | Laparoscopic surgery has less EBL, shorter LOS and similar operating time compared with open surgery | 3 |
| Hallfeldt et al. [9] | 40 vs 30 | Laparoscopic surgery has less EBL, shorter LOS and longer operating time compared with open surgery | 3 |
| Tanaka et al. [70] | 54 vs 7 | Laparoscopic surgery has shorter LOS and similar EBL and operating time compared with open surgery | 3 |
| Imai et al. [71] | 40 vs 40 | Laparoscopic surgery has less EBL, shorter LOS and similar operating time compared with open surgery | 3 |
| Shen et al. [8] | 42 vs 38 | Laparoscopic surgery has less morbidity compared with open surgery | 3 |
EBL, estimated blood loss; LOS, length of hospital stay.
| First author (year) | Surgical approach: laparoscopic vs open, n | Critical findings | Level of evidence |
|---|---|---|---|
| Gonzalez et al. [29] | 6 vs 154 | All patients undergoing laparoscopic surgery experienced recurrence, and 5/6 experienced carcinomatosis | 3 |
| Leboulleux et al. [30] | 6 vs 58 | Carcinomatosis occurred in 67% of laparoscopic vs 27% of open cases | 3 |
| Miller et al. [72] | 17 vs 71 | 3 | |
| Porpiglia et al. [33] | 18 vs 25 | No difference in recurrence-free survival | 3 |
| Brix et al. [34] | 35 vs 17 | No difference in disease-free survival, but over 1/3 of laparoscopic surgeries were converted to open | 3 |
| Lombardi et al. [73] | 30 vs 126 | No difference in recurrence, metastasis, disease-free survival or overall survival | 3 |
| Miller et al. [32] | 46 vs 110 | Higher positive margin rate in laparoscopic (30% vs 18%), shorter time to recurrence in laparoscopic | 3 |
| Mir et al. [15] | 18 vs 26 | No difference in recurrence or overall survival | 3 |
remains the gold standard. Table 3 lists comparative series of laparoscopic vs open adrenalectomy for ACC.
Recommendation 3: While a laparoscopic approach may be feasible for select cases of ACC without adjacent organ involvement, an open surgical approach remains the gold standard (Grade C).
Large Adrenal Masses not Suspicious for Malignancy
Laparoscopic resection of ‘large’ adrenal masses is not well studied, due to both inconsistency of what size constitutes a large mass and a dearth of studies addressing this question. It is well established, however, that size is correlated with the risk of ACC. Using a size threshold of 4 cm, the sensitivity
for ACC is 93%, although the specificity is only 42% [35]. As previously described, tumours with preoperative concern for ACC are most safely resected by an open approach. For benign tumours, however, most series describe similar outcomes across size ranges, with similar morbidity [27,36,37], but resection of adrenal masses >8 cm is associated with longer operating times, more EBL and longer LOS [37]. Moreover, larger tumours may be associated with a higher risk of open conversion [38]. For larger tumours found to be locally invasive or otherwise suspicious for ACC during laparoscopy, most authors recommend an open conversion [39,40].
Recommendation 4: Large adrenal tumours without preoperative or intra-operative suspicion for ACC may be safely resected via a laparoscopic approach (Grade C).
| Series | Surgical approach: LESS vs laparoscopic, n | Critical findings | Level of evidence |
|---|---|---|---|
| Kim et al. [10] | 15 vs 9 | Laparoscopic surgery had shorter time to oral intake, shorter LOS, less analgesic requirement | 3 |
| Humphrey et al. [12] | 30 vs 14 | No difference in operating time, haemodynamic instability, or rate of recurrence | 3 |
| Tiberio et al. [22] | 13 vs 9 | Laparoscopic surgery had less EBL, shorter operating time and shorter LOS. No difference in haemodynamic stability | 3 |
| Lang et al. [23] | 56 vs 50 | Laparoscopic surgery had less EBL, shorter LOS and shorter operating time than open surgery | 3 |
| Ichikawa et al. [24] | 40 vs 40 | Laparoscopic surgery had less EBL, less haemodyamic instability, fewer blood transfusions, systemic inflammatory response syndrome, and no difference in recurrence | 3 |
| Hemal et al. [25] | 12 vs 7 | Laparoscopic had favourable EBL, LOS and analgesic requirement | 3 |
| Davies et al. [26] | 12 vs 12 | Laparoscopic had favourable operating time and LOS. No difference in complications or haemodynmainc instability | 3 |
| Edwin et al. [28] | 7 vs 9 | Laparoscopic had favourable LOS, analgesia requirement, haemodynamic instability, need for vasoactive drugs | 3 |
EBL, estimated blood loss; LOS, length of hospital stay.
Laparoscopic Surgical Approaches
Multiple surgical approaches have been described to access the adrenal gland, but the two most common approaches are lateral transabdominal adrenalectomy (LTA) and posterior retroperitoneoscopic adrenalectomy (PRA). Less common approaches include anterior transabdominal adrenalectomy and lateral retroperitoneoscopic adrenalectomy.
The LTA approach is the most common transperitoneal one. This allows greater working space than the retroperitoneal approach, which can be beneficial for larger tumours and in obese patients [41]. The patient is placed in the flank position with the side of the tumour facing up, allowing gravity to retract the abdominal contents medially. Ports are placed to allow triangulation to the side of interest. Left-sided tumours often require three ports, while right-sided tumours require an additional port for liver retraction.
The PRA approach is the most common retroperitoneal one [42]. This approach allows avoidance of entering the peritoneal cavity, which may be beneficial in patients who have previously undergone abdominal surgery; however, there is often less working room and anatomical landmarks may be unfamiliar compared with the transperitoneal view. Access to the retroperitoneum is gained inferolaterally to the tip of the 12-rib by perforating the dorsal lumbar fascia, placing a balloon trocar and inflating the retroperitoneal space.
In a systematic review and meta-analysis comparing LTA and PRA, no difference was found in operating time, EBL, time to ambulation and oral intake or complication rate between these techniques, with similar findings regarding LOS and
convalescence time [43]. A more recent meta-analysis found no difference in any peri-operative outcome, including operating time, EBL, LOS, time to oral intake, overall and major morbidity and mortality [44].
Recommendation 5: Both transperitoneal and retroperitoneal approaches to laparoscopic adrenalectomy are safe. The approach should be chosen based on surgeon training and experience (Grade A).
Laparoendoscopic Single-Site Surgery
Laparoendoscopic single-site (LESS) surgery, or alternatively, single-incision laparoscopic surgery or single-port laparoscopic surgery, is a laparoscopic procedure performed through a single multi-channel port rather than separate ports. Compared with traditional laparoscopy, LESS surgery may be more challenging to perform because of loss of instrument triangulation [45]. Multiple case-control studies have shown similar outcomes for LESS and traditional laparoscopic series when performed by experienced surgeons [46]. A systematic review and meta-analysis of LESS vs conventional adrenalectomy, comprising entirely retrospective studies, showed no difference in EBL, time to oral intake resumption or LOS [47]. Interestingly, there were no differences in the perceived advantages of LESS surgery, including cosmesis, recovery time or port-related complications. Table 4 lists comparative series of LESS vs laparoscopic adrenalectomy.
Recommendation 6: LESS adrenalectomy may be considered an alternative to laparoscopic adrenalectomy but requires further study (Grade C).
| First author (year) | Surgical approach: LESS VS laparoscopic, n | Critical findings | Level of evidence |
|---|---|---|---|
| Jeong et al. [74] | 9 vs 17 | LESS had favourable analgesia requirement. No difference in EBL, time to oral intake, LOS | 3 |
| Walz et al. [75] | 47 vs 47 | LESS had favourable analgesia requirements and LOS and unfavourable operating time | 3 |
| Ishida et al. [76] | 10 vs 10 | No difference in operating room tine EBL, time to oral intake | 3 |
| Shi et al. [77] | 19 vs 38 | LESS had favourable analgesia requirement, but longer operating time. No difference in EBL, LOS or complications | 3 |
| Kwak et al. [78] | 10 vs 12 | No difference in operating time, time to oral intake or LOS | 3 |
| Vidal et al. [79] | 20 vs 20 | No difference in operating time, complications, time to oral intake or LOS | 3 |
| Wang et al. [47] | 13 vs 26 | LESS had longer operating time, but favourable analgesia, time to oral intake and cosmetic satisfaction | 3 |
| Tunca et al. [80] | 22 vs 74 | No difference in operating time, EBL, favourable pain scores or LOS | 3 |
| Lin et al. [81] | 21 vs 28 | LESS had favorable time to oral intake, LOS and analgesia requirement | 3 |
EBL, estimated blood loss; LOS, length of hospital stay.
Robotic Adrenalectomy
Robotic surgery is increasingly performed as an alternative to laparoscopic surgery [48]. The perceived advantage of robotics over traditional laparoscopy includes stereoscopic vision, improved magnification and greater range of motion [49]. Both transperitoneal and retroperitoneal robotic approaches have been described, but no comparative series of these two approaches has been reported.
Several non-comparative initial studies have shown the safety and feasibility of robotic adrenalectomy [50-56]. The first study, by Winter et al. in 2006 [53], reported outcomes of 30 robotic adrenalectomies using an LTA approach. In this initial series, they reported an operating room time of 185 min, no conversions, a 7% complication rate and a median LOS of 2 days. Subsequent studies reported shorter operating times, with otherwise similar outcomes.
Multiple comparative series have evaluated the outcomes of robotic and laparoscopic adrenalectomy. Morino et al. [57] compared outcomes of 10 robotic and 10 laparoscopic cases. In this early series, the authors found that the laparoscopic approach had a shorter operating time (115 vs 169 min), more conversions (4 vs 0) and longer LOS (5.7 vs 5.4 days). Brunaud et al. [58] evaluated a larger cohort of 50 robotic and 59 laparoscopic adrenalectomies. While the operating time was again longer in the robotic cohort (189 vs 159 min), EBL was less (49 vs 71 mL) and LOS was shorter in the robotic surgery cohort (6.3 vs 6.9 days), while the number of conversions was similar (4 vs 4). Agcaoglu et al. [59]
compared outcomes in patients with large adrenal tumours. The authors evaluated 24 patients in the robotic cohort and 38 in the laparoscopic group with a mean tumour size of >6 cm. The authors found that favourable outcomes in the robotic arm in all domains evaluated: shorter operating time (159.4 vs 187.2 min); lower EBL (836.6 vs 166.6 mL); fewer conversions (1 vs 4); and shorter LOS (1.4 vs 1.9 days). The same group also evaluated robotic vs laparoscopic PRA [56]. Again, a robotic approach was associated with a shorter operating time (163.2 vs 165.7 min), less EBL (25.3 vs 35.6 mL) and similar LOS (1 vs 1 day).
Comparative robotic and laparoscopic series have also been reported for specific patient cohorts. Aksoy et al. [60] compared outcomes in obese patients. Evaluating 42 patients who underwent robotic and 57 who underwent laparoscopic surgery, the authors found similar operating times (186.1 vs 187.3 min), less EBL (50.3 vs 76.6 mL) and shorter LOS (1.2 vs 1.7 days). Aliyev et al. [61] reported outcomes for 25 patients undergoing robotic and 40 undergoing laparoscopic adrenalectomy for pheochromocytoma. They found that patients undergoing robotic surgery had shorter operating times (149 vs 178 min), less EBL (36 vs 43 mL), fewer conversions (1 vs 3), and shorter LOS (1.2 vs 1.7 days).
A recent systematic review and meta-analysis, including one randomized clinical trial and eight observational studies of robotic vs laparoscopic adrenalectomy, was performed by Brandao et al. [62]. Their meta-analysis of nine studies included 600 patients (277 in the robotic group and 323 in
| First author (year) | Surgical approach: robotic vs laparoscopic, n | Critical findings | Level of evidence |
|---|---|---|---|
| Morino et al. [57] | 10 vs 10 | No difference in EBL, time to oral intake, LOS | 2 |
| Brunaud et al. [58] | 50 vs 59 | Robotic surgery had longer operating time, but no difference in operating time after 20 cases, and favourable EBL | 3 |
| Agcaoglu et al. [59] | 24 vs 38 | Tumours >5 cm: robotic had favourable operating time and LOS, and similar EBL | 3 |
| Agcaoglu et al. [56] | 31 vs 31 | Similar operating time, but after 20 cases robotic surgery had favourable operating time. Lower pain scores | 3 |
| Karabulut et al. [52] | 50 vs 50 | Robotic surgery had less morbidity and shorter LOS. Similar operating times | 3 |
| Pineda-Solis et al. [82] | 30 vs 30 | Robotic surgery had longer operating time. Similar EBL, morbidity and LOS | 3 |
| Aksoy et al. [60] | 42 vs 57 | Obese patients: no difference in peri-operative outcomes | 3 |
| You et al. [83] | 15 vs 8 | Robotic has increased operating time | 3 |
| Aliyev et al. [61] | 25 vs 40 | Pheochromocytoma: Robotics has favorable morbidity, pain scores and LOS | 3 |
| Lin et al. [81] | 21 vs 28 | Robotic associated with less operating time, LOS, EBL | 3 |
EBL, estimated blood loss; LOS, length of hospital stay.
the laparoscopic group). The authors found no difference in conversion rates, operating time or postoperative complications; however, LOS was shorter and there was less EBL in the robotic group. Table 5 lists comparative series of robotic vs laparoscopic adrenalectomy.
Recommendation 7: Robotic adrenalectomy may be considered an alternative to laparoscopic adrenalectomy but requires further study (Grade B).
Discussion
The routine use of minimally invasive adrenalectomy is well supported for the majority of adrenal masses requiring surgical resection; however, the best minimally invasive approach to employ is less clear. Both laparoscopic transperitoneal and retroperitoneal approaches seem to offer equivalent outcomes. LESS adrenalectomy and robotic adrenalectomy are alternatives to conventional laparoscopy, but high-quality comparative data to demonstrate the superiority or inferiority of either approach compared with conventional laparoscopy are currently lacking. Ideally, prospective randomized studies comparing approaches should be carried out.
The majority of adrenal surgery research focuses on the feasibility of new technologies, but the literature would benefit from studies that focus on patient selection, the objective benefits of new technologies over conventional techniques, and the cost-effectiveness of new technologies. This is particularly true for both LESS and robotic adrenalectomy. The role of minimally invasive technologies for partial adrenalectomy and for metastatectomy were outside the scope of the present review, but the paucity of
data for these techniques shows the need for more studies to evaluate the role of these emerging techniques [48].
In conclusion, comparative studies show the superiority of laparoscopic adrenalectomy over open adrenalectomy for the majority of indications. While open surgery remains the gold standard for ACC, select cases may be amenable to a minimally invasive approach. More work is needed to define the role of robotic and LESS adrenalectomy.
Summary of Recommendations
1 Laparoscopic surgery should be considered the first-line therapy for benign adrenal masses requiring surgical resection (Grade B).
2 Laparoscopic surgery should be considered the first-line therapy for patients with pheochromocytoma (Grade B).
3 While a laparoscopic approach may be feasible for select cases of ACC without adjacent organ involvement, an open surgical approach remains the gold standard (Grade C).
4 Large adrenal tumours without preoperative or intra- operative suspicion of ACC may be safely resected via a laparoscopic approach (Grade C).
5 Both transperitoneal and retroperitoneal approaches to laparoscopic adrenalectomy are safe. The approach should be chosen based on surgeon training and experience (Grade A).
6 LESS adrenalectomy should be considered an an alternative to laparoscopic adrenalectomy but requires further study (Grade C).
7 Robotic adrenalectomy may be considered an alternative to laparoscopic adrenalectomy but requires further study (Grade B).
ICUD-EAU Minimally Invasive Adrenalectomy
Conflict of Interest None declared.
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@ 2016 The Authors 20 BJU International @ 2016 BJU International
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Correspondence: Mark W. Ball, James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street/ Marburg 134, Baltimore, Maryland 21287, USA.
e-mail: mark.ball@jhmi.edu
Abbreviations: ACC, adrenocortical carcinoma; EBL, estimated blood loss; LESS, laparoendoscopic single-site; LOS, length of hospital stay; LTA, lateral transabdominal adrenalectomy; PRA, posterior retroperitoneoscopic adrenalectomy.