@ 2022 EDIZIONI MINERVA MEDICA Minerva Urology and Nephrology 2023 February;75(1):73-84 Online version at https://www.minervamedica.it DOI: 10.23736/S2724-6051.22.05073-X ORIGINAL ARTICLE Management of the incidental adrenal mass, continued surveillance versus surgical excision: analysis of US claims data on contemporary socio- demographic predictors and perioperative outcomes Francesco DEL GIUDICE 1, 2 *, Wansuk KIM 3, Shufeng LI 2, 4, Ettore DE BERARDINIS 1, Alessandro SCIARRA 1, Stefano SALCICCIA 1, Matteo FERRO 5, Riccardo AUTORINO 6, Savio D. PANDOLFO 6,7, Felice CROCETTO 7, Antonio GALFANO 8, Paolo DELL’OGLIO 8, Giovanni E. CACCIAMANI 9, Benjamin PRADERE 10, Ekaterina LAUKHTINA 11, David D’ANDREA 11, Federico BELLADELLI 2, 12, Wojciech KRAJEWSKI 13, Andrea MARI 14, Andrea MINERVINI 14, Andrea GALLIOLI 15, Daniele AMPARORE 16, Enrico CHECCUCCI 16, Cristian FIORI 16, Francesco PORPIGLIA 16, Luca MORGANTINI 17, Simone CRIVELLARO 17, Benjamin I. CHUNG 2 1Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, Sapienza University, Rome, Italy; 2Department of Urology, Stanford University School of Medicine, Stanford, CA, USA; 3Department of Urology, Busan Paik Hospital, Inje University College of Medicine, Busan, South Korea; 4Department of Dermatology, Stanford University School of Medicine, Stanford, CA, USA; 5Department of Urology, European Institute of Oncology (IEO) IRCCS, Milan, Italy; 6Division of Urology, VCU Health, Richmond, VA, USA; 7Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Naples, Italy; 8Department of Urology, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy; 9USC Institute of Urology, University of Southern California, Los Angeles, CA, USA; 10Department of Urology, La Croix Du Sud Hospital, Quint Fonsegrives, France; 11Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; 12Division of Experimental Oncology, Unit of Urology, URI, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy; 13Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Medical University of Wroclaw, Wroclaw, Poland; 14Unit of Oncologic Minimally Invasive Urology and Andrology, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, Florence, Italy; 15Department of Urology, Puigvert Foundation, Barcelona, Spain; 16Department of Urology, San Luigi Hospital, University of Turin, Turin, Italy; 17University of Illinois Hospital & Health Sciences System, Chicago, IL, USA ABSTRACT BACKGROUND: Incidentally diagnosed adrenal masses represent an entity that can result in either long term follow- up, surgical excision, or both. Understanding when and which adrenal masses are ultimately excised surgically is not well understood. We sought to understand the ultimate fate of these incidentalomas using a large population-based dataset. METHODS: The primary outcome of the study was determining the trend in adoption of surveillance vs. surgical exci- sion according to socio-demographic, economic, and pathologic indices, and also provider specialty. Secondary outcomes were the assessment of perioperative complications, operative time, surgical approach, hospital stay, and provider spe- cialty (general surgery vs. urology) among the cohort that underwent excision. Vol. 75 - No. 1 MINERVA UROLOGY AND NEPHROLOGY cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher. or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically *Corresponding author: Francesco Del Giudice, Department of Maternal Infant and Urologic Sciences, Sapienza University of Rome, Policlinico Umberto I Hospital, viale del Policlinico 155, 00161 Rome, Italy. E-mail: francesco.delgiudice@uniromal.it 73

INCIDENTAL ADRENAL MASS MANAGEMENT IN THE US

RESULTS: Out of a total of N .= 91,560 adrenal masses, ultimately N .= 3375 (3.83%) of these underwent surgical exci- sion. In the surgical excision cohort, the incidence of aldosteronoma, functional adenoma/Cushing’s disease, and ad- renocortical carcinoma was higher than in the surveillance cohort. Those patients who were older, female, and with higher Charlson Comorbidity indexes (CCI) were less likely to undergo surgical resection. Factors that predicted for an increased probability of resection included obtaining more CT/MRI scans as well as general surgeons as primary physi- cian providers. Over the study period, the vast majority of surgeries were performed by surgeons other than urologists (12.9%) and open and laparoscopic approaches dominated, with the robotic-assisted approach accounting for a minority of the surgical cases (23.9%). The minimally invasive surgery (MIS) approach independently predicted for both lower rates of complications and shorter hospital stay.

CONCLUSIONS: In the US, adrenal incidentalomas are more likely to undergo surveillance rather than surgical resec- tion. In our study, surgery is mainly offered for functional or malignant disease and the receipt of surgery can vary by phy- sician specialty. A MIS approach independently predicted for both lower rates of complications and shorter hospital stay.

(Cite this article as: Del Giudice F, Kim W, Li S, De Berardinis E, Sciarra A, Salciccia S, et al. Management of the incidental adrenal mass, continued surveillance versus surgical excision: analysis of US claims data on contemporary socio-demographic predictors and perioperative outcomes. Minerva Urol Nephrol 2023;75:73-84. DOI: 10.23736/S2724- 6051.22.05073-X)

KEY WORDS: Watchful waiting; Epidemiology; Minimally invasive surgical procedures; General surgery; Urology.

A n incidental adrenal mass is defined by multiple professional societies as an as- ymptomatic mass in the adrenal gland detected on imaging not performed for suspected adrenal disease.1, 2 These incidentalomas represent an entity that is treated by a variety of medical and surgical specialties worldwide and often result in either long term follow-up, surgical excision, or both.3 Currently, understanding when and which adrenal masses are ultimately to be excised sur- gically is challenging and up to date society guidelines on surgical management are lack- ing. In the United States, for instance, both the American College of Surgeons and the American Urological Association do not have dedicated and accessible algorithms for both functional/ non-functional or benign/malignant adrenal le- sions (Available from: https://www.facs.org/ about-acs/guidelines and https://www.auanet. org/guidelines-x15197 respectively). Moreover, current recommendations rely on relatively low levels of evidence with limited sample size co- horts. Additionally, there is little recent data on perioperative outcomes to offer guidance about surgical decision making.1, 2, 4 Therefore, the objective of our study was to comprehensively examine the fate of these incidentalomas using a large population-based dataset and to analyze the factors that determined the ultimate decision to continue with a follow-up protocol versus sur- gical excision. We also sought to examine what factors predicted for more successful surgical outcomes with adrenalectomy.

Materials and methods

Data source

We performed a retrospective cohort analysis using administrative insurance claims data from the Optum Clinformatics Data Mart® (CDM) de- identified database. Optum is a national database from adjudicated and paid insurance claims of privately insured individuals and Medicare cov- erage which includes 87 million enrollees in the United States. Individuals in the database repre- sent a geographically and ethnically diverse pop- ulation from a variety of age groups. The data in- cludes patient medical claims including inpatient and outpatient services, facility claims, pharma- cy claims, enrollment data, and socio-economic status. International Classification of Disease Ninth and Tenth Revisions, Clinical Modifica- tion (ICD-9-CM, ICD-10-CM) codes, current procedural terminology (CPT) codes were used to identify the study cohort, treatments, and co- morbidities. This method has been used in other studies5-11 and given de-identified information, this study was deemed exempt from informed consent requirements by the Stanford Univer- sity Medical Center Institutional Review Board. Data for this project were accessed using the Stanford Center for Population Health Sciences Data Core. The PHS Data Core is supported by a National Institutes of Health National Center for Advancing Translational Science Clinical and Translational Science Award (UL1TR003142) and from Internal Stanford funding.

to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,

or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access

INCIDENTAL ADRENAL MASS MANAGEMENT IN THE US

DEL GIUDICE

Patients

Patients consecutively identified by ICD-9/10- CM and CPT codes with a diagnosis for adrenal incidentaloma between 2003 and 2020 were re- viewed in order to create the cohort of interest. Patients were enrolled in the database for at least 3 months before and after their first computed tomography (CT) scan for the adrenal mass, considering this scan date as the index date for further evaluation. Patients were also further considered eligible if they had at least two CTs, with 3 months or more from the 1 st to the last CT. Affiliated codes were identified and reviewed to ensure that partial/total adrenalectomy rather than no-surgery (surveillance) was the primary procedure performed based on the diagnosis or concern for adrenal mass which included as fi- nal ICD-9/10-CM diagnosis code the following histological subtypes: adenoma/pheochromocy- toma, functional adrenal mass (causing Cush- ing syndrome and/or Aldosteronism), adenocar- cinoma, adrenal metastasis, as well as adrenal lymphomas and sarcomas. The study population was then divided according to “non-operation” vs. “operation” sub-groups. For each patient, age at first CT scan (index date), gender, race, level of education, income, region, provider type at diagnosis and eventually year of operation and surgical provider specialist along with type of operative approach were considered. Baseline Charlson Comorbidity Index (CCI) was calcu- lated according to Charlson et al.12 and adapted according to Deyo and colleagues.13 Patient in- surance status was grouped as commercial or Medicare. CPT codes for imaging procedures including both CT and MRI scans during the en- rollment period were also recorded for the two groups. Patients age <18 years as well as those with less than 3-month enrollment time before or after the index date were removed from the analyses. Additionally, further exclusion criteria included previously diagnosed hormonal adrenal disease, previous adrenalectomy, any previously diagnosed malignancy, patients undergoing con- current nephrectomy, either with a renal mass or with a history of kidney cancer. A comprehensive list of ICD-9/10 and CPT codes and a flow chart diagram summarizing the analytical steps for the data analysis and inclusion/exclusion criteria

are presented in Supplementary Digital Material 1, Supplementary Figure 1 and Supplementary Digital Material 2, Supplementary Table I, re- spectively.

Outcome ascertainment

The primary outcome of the study was to ascer- tain trends in the fate of the incidental adrenal mass in the United States and specifically to investigate the epidemiological factors and/or predictors which may influence the physician decision on which masses are ultimately excised surgically. The secondary aim of the study was to assess among the sole “operation” group, the contemporary trends in perioperative outcomes, resource use and surgical provider specialists’ performances with particular focus on urologist vs. general surgeon preferences. In particular, regarding our primary aim, the dates of subse- quent CT/MRI imaging scans after the index date were assessed to describe temporal trends in the follow-up adoption for conservative vs. surgical management balancing the influence of the particular adrenal subtype histologic diagno- sis on the aim of interest. Additionally, patients who received adrenalectomy according to differ- ent surgical approaches (minimally invasive vs. open) and surgeon provider (urology vs. general surgery vs. other) were identified and specific ICD-9/10 codes for intraoperative and 90-days postoperative complications as well as length of hospital stay were recorded.

Statistical analysis

Patient demographics, socio-economic, and clinical characteristics for those who received surgery vs. surveillance were compared by chi- square test for categorical variables, Student’s t-test for age, and Wilcoxon Rank-Sum Test for other continuous variables. Temporal trends with descriptive statistics in the adoption of im- aging modalities were presented to assess the number of surgeries performed by year on both per-scan and per-patient level and to depict time from imaging to surgery according to both CT and MRI scans. As per the primary outcome, a logistic regression model was applied to explore the multivariable adjusted influence of any epi- demiological and/or clinic-demographic vari-

INCIDENTAL ADRENAL MASS MANAGEMENT IN THE US

able on the probability for being addressed to surgical excision. All regressions were adjusted for gender, race, education, income and CCI. Furthermore, to eliminate possible confound- ing effects between the two groups, we per- formed propensity score matching to match one patient with surgery up to 10 patients without surgery on age and follow-up time, and subse- quently applied conditional logistic regression to the matched cohort as a sensitivity analysis. Prediction probability plots were generated by logistic regressions in order to explore the rela- tive influence of increasing number of CT scans to the likelihood to receive surgery. As per the secondary aims, to estimate the relative influ- ence of different confounders, multivariable logistic regression was applied for intraopera- tive events and longer median hospital stay, and Cox proportional hazard regression model was performed for 90-days postoperative complica- tions respectively. All analyses were two-sided with P<0.05 was considered significant, and per- formed using statistical software SAS, version 9.4 (SAS Institute Inc., Cary, NC, USA.)

Results

Study cohort

A cohort of N .= 91,560 patients who were di- agnosed with an incidental adrenal mass after undergoing a CT scan between 2003 and 2020 were retrospectively reviewed. For the entire co- hort, the majority of the patients were Caucasian (69.2%), female (62.3%), with a mean age of 61.8 years (std 13.8). The vast majority of pa- tients (N .= 88,185; 96.3%) did not undergo sur- gical resection with a median follow-up of 3.42 (IQR 1.61-6.60) years. The smaller group of pa- tients who underwent adrenalectomy (N .= 3375; 3.7%) had a similar median follow-up of 4.07 (IQR 1.80-7.97) years.

Over the study period, the vast majority of adrenalectomies were not performed by Urolo- gists (12.9%) and robotic surgery was less fre- quently utilized for surgical approach (23.9%) when compared to open (36%) and laparoscopic (40.1%). Table I shows baseline patient demo- graphic, clinical and hospital characteristics of our final cohort for both the “non-operation” vs.

“operation” (Table I) and Urology vs. General surgery comparison (Table II).

The incidence of adenoma/pheochromocyto- ma, functional adrenal masses (causing Cushing syndrome and/or hyperaldosteronism), and ad- enocarcinoma as final pathologic diagnosis was higher in the “operation” group rather than in the surveillance group (Supplementary Digital Ma- terial 3: Supplementary Table II). Whereas ad- renocortical carcinoma was more often resected after just one CT or MRI scan had been com- pleted, the other histologic subtypes that under- went adrenalectomy did so more frequently after 2 or more follow up CT/MRI scans had been completed (Supplementary Digital Material 4: Supplementary Table III).

The yearly trend for patients receiving sur- gery by the number of CT and/or MRI scans prescribed was represented in Figure 1A and de- picted an inversely proportional relationship in the number of imaging studies and the receipt of surgical resection. Also, there was an increased median time from first CT or MRI scan to sur- gery when compared with those who were on a surveillance protocol (0.8 years, IQR 0.2-1.4 vs. 0.2, IQR 0.1-0.4 years; P<0.001). Additionally, Figure 1B illustrates, for the “operation” cohort, the numbers of adrenalectomies performed by Urologists and General surgeons stratified by surgical approach. Interestingly, for both of the surgical specialties, while the trend in the adop- tion of the robotic surgical platform in the early 2000s was steep, this subsequent trajectory di- minished between 2013-2015, simultaneously coupled with a steep increase in the utilization of the laparoscopic approach.

Outcomes

The propensity matched results serving as sen- sitivity analysis are displayed in Supplementary Digital Material 5, Supplementary Table IV. Our multivariable logistic regression for the whole population has been presented in Table III and demonstrates that older age, female gender, and higher CCI scores were all independently associ- ated with a lower probability to undergo surgery. Also, those who underwent an increasing num- ber of both CT and MRI scans over the follow- up period was correlated with an almost two-fold

INCIDENTAL ADRENAL MASS MANAGEMENT IN THE US

TABLE I .- Baseline patient demographic, clinical and hospital characteristics of the final cohort of the study, ac- cording to treatment modality (non-operation vs. operation).
Variable	Total cohort	Non-operation	Operation	P value
N of patients	91560	88185	3375
Age, mean (std), years	61.8 (13.8)	62.0 (13.7)	55.7 (13.7)	<0.0001
1 st quartile	22922 (25.03)	21546 (24.43)	1376 (40.77)	<0.0001
2nd quartile	22474 (24.55)	21549 (24.44)	925 (27.41)
3rd quartile	22290 (24.34)	21647 (24.55)	643 (19.05)
4th quartile	23874 (26.07)	23443 (26.58)	431 (12.77)
Sex, N. (%)				0.0255
Female	57044 (62.30)	55003 (62.37)	2041 (60.47)
Male	34516 (37.70)	33182 (37.63)	1334 (39.53)
Time from 1 st CT, median (IQR), year	3.44 (1.62-6.66)	3.42 (1.61-6.60)	4.07 (1.80-7.97)	<0.0001
Race/ethnicity, N. (%)				0.0028
Asian	1992 (2.18)	1921 (2.18)	71 (2.1)
Black	11390 (12.44)	10978 (12.45)	412 (12.21)
Hispanic	8911 (9.73)	8647 (9.81)	264 (7.82)
Unknown	5909 (6.45)	5695 (6.46)	214 (6.34)
White	63358 (69.2)	60944 (69.11)	2414 (71.53)
Education, N. (%)				0.0007
Less than 12th grade	460 (0.5)	443 (0.5)	17 (0.5)
High school diploma	27270 (29.78)	26339 (29.87)	931 (27.59)
Less than bachelor's degree	47729 (52.13)	45968 (52.13)	1761 (52.18)
Bachelor's degree plus	11993 (13.1)	11475 (13.01)	518 (15.35)
Unknown	4108 (4.49)	3960 (4.49)	148 (4.39)
Income, N. (%)				<0.0001
Unknown	57923 (63.26)	55963 (63.46)	1960 (58.07)
<$49K	14246 (15.56)	13747 (15.59)	499 (14.79)
$50K-$99K	11481 (12.54)	10983 (12.45)	498 (14.76)
≥$100K	7910 (8.64)	7492 (8.5)	418 (12.39)
Division, N. (%)				<0.0001
East north central	13596 (14.85)	12990 (14.73)	606 (17.96)
East south central	4402 (4.81)	4241 (4.81)	161 (4.77)
Middle Atlantic	6197 (6.77)	5981 (6.78)	216 (6.4)
Mountain	8372 (9.14)	8074 (9.16)	298 (8.83)
New England	3854 (4.21)	3730 (4.23)	124 (3.67)
Pacific	8248 (9.01)	8017 (9.09)	231 (6.84)
South Atlantic	24123 (26.35)	23231 (26.34)	892 (26.43)
West north central	9199 (10.05)	8812 (9.99)	387 (11.47)
West south central	13504 (14.75)	13046 (14.79)	458 (13.57)
Insurance status, N. (%)				<0.0001
Commercial	40685 (44.44)	38512 (43.67)	2173 (64.39)
Medicare	50875 (55.56)	49673 (56.33)	1202 (35.61)
CCI, median (IQR)	1 (0-3)	1 (0-3)	1 (0-2)	<0.0001
0	32109 (35.07)	30583 (34.68)	1526 (45.21)	<0.0001
1	22090 (24.13)	21259 (24.11)	831 (24.62)
2	11942 (13.04)	11549 (13.1)	393 (11.64)
≥3	25419 (27.76)	24794 (28.12)	625 (18.52)
CT scan, median (IQR)	2 (1-4)	2 (1-4)	3 (2-5)	<0.0001
1	33260 (36.33)	32515 (36.87)	745 (22.07)
2-3	32701 (35.72)	31484 (35.7)	1217 (36.06)
≥4	25599 (27.96)	24186 (27.43)	1413 (41.87)
MRI after 1 st CT, median (IQR)	0 (0-0)	0 (0-0)	0 (0-1)	<0.0001
0	72005 (78.64)	69920 (79.29)	2085 (61.78)
1	14620 (15.97)	13696 (15.53)	924 (27.38)
2-3	4161 (4.54)	3857 (4.37)	304 (9.01)
≥4	774 (0.85)	712 (0.81)	62 (1.84)
Surgical provider, N. (%)
Other			1562 (46.28)
Urology			434 (12.86)
General Surgery			1379 (40.86)
Surgical approach, N. (%)
Laparoscopic			1354 (40.12)
Open			1215 (36)
Robotic			806 (23.88)
IQR: interquartile range; CCI: Charlson Comorbidity Index; CT: computed tomography; MRI: magnetic resonance imaging.

This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access

INCIDENTAL ADRENAL MASS MANAGEMENT IN THE US

TABLE II .- Baseline patient demographic, clinical and hospital characteristics of the final cohort of the study, ac- cording to surgical provider (urology vs. general surgery).
Variable	Total cohort	Urology	General Surgery	P value
N. of patients
Age, mean (std), years	54.3 (13.6)	56.2 (13.3)	53.7 (13.7)	0.0009
1 st quartile	442 (24.38)	90 (20.74)	352 (25.53)	0.0031
2nd quartile	444 (24.49)	101 (23.27)	343 (24.87)
3rd quartile	481 (26.53)	108 (24.88)	373 (27.05)
4th quartile	446 (24.6)	135 (31.11)	311 (22.55)
Sex, N. (%)				0.0008
Female	1061 (58.52)	224 (51.61)	837 (60.7)
Male	752 (41.48)	210 (48.39)	542 (39.3)
Time from 1 st CT, median (IQR), year	3.56 (1.59-7.15)	3.36 (1.43-6.66)	3.60 (1.61-7.34)	0.0904
Race/ethnicity, N. (%)				0.2932
Asian	36 (1.99)	13 (3)	23 (1.67)
Black	247 (13.62)	53 (12.21)	194 (14.07)
Hispanic	125 (6.89)	35 (8.06)	90 (6.53)
Unknown	119 (6.56)	28 (6.45)	91 (6.6)
White	1286 (70.93)	305 (70.28)	981 (71.14)
Education, N. (%)				0.9388
Less than 12th grade	<11	<11	<11
High school diploma	497 (27.41)	116 (26.73)	381 (27.63)
Less than bachelor's degree	922 (50.85)	223 (51.38)	699 (50.69)
Bachelor's degree plus	304 (16.77)	71 (16.36)	233 (16.9)
Unknown	≥70	≥11	≥50
CCI, median (IQR)	1 (0-2)	1 (0-2)	1 (0-2)	0.7421
0	824 (45.45)	193 (44.47)	631 (45.76)	0.9533
1	434 (23.94)	108 (24.88)	326 (23.64)
2	226 (12.47)	54 (12.44)	172 (12.47)
≥3	329 (18.15)	79 (18.2)	250 (18.13)
CT scan, median (IQR)	2 (1-4)	2 (1-5)	2 (1-4)	0.2024
1	527 (29.07)	117 (26.96)	410 (29.73)	0.3316
2,3	708 (39.05)	167 (38.48)	541 (39.23)
≥4	578 (31.88)	150 (34.56)	428 (31.04)
MRI after 1 st CT, median (IQR)	0 (0-1)	1 (0-1)	0 (0-1)	<0.0001
0	1034 (57.03)	207 (47.7)	827 (59.97)	<0.0001
1	575 (31.72)	165 (38.02)	410 (29.73)
2-3	168 (9.27)	51 (11.75)	117 (8.48)
≥4	36 (1.99)	11 (2.53)	25 (1.81)
Surgical approach, N. (%)				<0.0001
Laparoscopic	497 (27.41)	160 (36.87)	337 (24.44)
Open	887 (48.92)	184 (42.4)	703 (50.98)
Robotic	429 (23.66)	90 (20.74)	339 (24.58)

increased probability for undergoing surgery. This was further presented in Figure 2 testing the increasing number of scans on the predict- ed probability to undergo surgery. Although, no additional racial, income, or educational fac- tors influenced the receipt of adrenalectomy, the primary provider specialty at diagnosis was independently associated with the patient’s de- cision to undergo adrenalectomy at a later time. In particular, those patients assigned to general surgeons, had significantly higher rates of adre- nalectomy when compared with both Urologists

(OR, 9.1 95%CI 7.69-10) and other medical spe- cialties (OR, 4.55 95%CI 3.70-5.56).

In our secondary outcome, we explored the univariable and multivariable adjusted effect of confounders on complications. Table IV displays detailed risk estimates for specific and cumula- tive perioperative events. The univariate effect of patient gender, education, income, CCI, pro- vider specialty, and surgical approach on any complications up to postoperative day 90 has been presented in Figure 3. Of note, the lowest patient income bracket (i.e.,<$49K/year) along

INCIDENTAL ADRENAL MASS MANAGEMENT IN THE US


Year	Surgery	CT	MRI
2003	7.64	20.96	25.82
2004	5.72	27.65	25.39
2005	6.51	24.72	26.03
2006	6.22	31.46	24.31
2007	4.72	32.58	24.72
2008	4.87	35.94	23.43
2009	4.29	39.98	21.70
2010	4.60	40.69	20.96
2011	4.33	40.23	22.43
2012	3.57	39.24	21.26
2013	3.91	37.18	21.83
2014	3.67	38.78	21.15
2015	2.72	38.58	21.39
2016	2.06	44.45	19.76
2017	2.36	48.13	20.41
2018	2.11	45.26	19.21
2019	2.31	41.38	18.16
2020	2.25	22.95	16.05

Percent of surgery/MRI %

Number of CT Scan/1,000-person

2003

2007

2011

2015

2019

Year

Surgery

MRI

CT scan

	Year	General surgery			Urology
	Laparoscopic		Open	Robotic	Laparoscopic Open Robotic
	2003	9.26	75.93	14.81	0.00	92.31	7.69
	2004	18.97	70.69	10.34	30.77	61.54	7.69	2
	2005	8.89	71.11	20.00	22.22	50.00	27.78
	2006	11.34	63.92	24.74	6.90	79.31	13.79	2
	2007	12.24	67.35	20.41	18.18	54.55	27.27	@ 60 00
	2008	11.93	64.22	23.85	14.29	47.62	38.10	5
	2009	16.44	63.01	20.55	20.00	60.00	20.00	i
	2010	18.68	58.24	23.08	5.26	68.42	26.32	4 0
	2011	12.33	67.12	20.55	19.23	61.54	19.23	=
	2012	12.50	60.94	26.56	23.08	46.15	30.77	U
	2013	13.70	58.90	27.40	13.79	58.62	27.59	U
	2014	21.05	48.68	30.26	33.33	33.33	33.33	@ 20 a
	2015	43.08	30.77	26.15	51.85	33.33	14.81
	2016	46.48	16.90	36.62	66.67	17.95	15.38
	2017	55.68	20.45	23.86	66.67	18.18	15.15
	2018	47.44	17.95	34.62	39.70	21.21	9.09
	2019	45.12	23.17	31.71	65.52	17.24	17.24
	2020	53.85	23.08	23.08	66.67	5.56	27.78
B

Figure 1 .- Trend for patients receiving adrenalectomy by the number of CT and/or MRI scans over time (A). Trend in surgi- cal approach (open vs. laparoscopic vs. robotic) for adrenalectomies performed by urologists and general surgeons (B). CT: computer-tomography; MRI: magnetic resonance imaging.

2003

2007

2011

2015

2019

2003

2007

2011

2015

2019

Year

Laparoscopic

Open

Robotic

with the open technique for adrenalectomy were associated with higher probability of adverse events, denoting the possible presence of both socio-economic and specific procedure related factors on postoperative outcomes. This was also consistently true on our multivariable regression models. Notably, the open approach was found associated with worse surgical postoperative complications when compared with the laparo- scopic and robotic approach (HR, 0.63 95%CI 0.49-0.82; HR, 0.63 95%CI 0.47-0.85). Also, the open approach predicted for higher rates of intra- operative complications (OR, 0.51 95%CI 0.39- 0.66; OR, 0.36 95%CI 0.26-0.50), postoperative transfusion rates (HR, 0.36 95%CI 0.21-0.62; HR, 0.33 95%CI 0.17-0.66) and longer hospi- tal stay (OR, 0.44 95%CI 0.37-0.54; OR, 0.27 95%CI 0.21-0.35; Supplementary Digital Mate- rial 6, Supplementary Table V).

We found that an increased number of scans performed preoperatively was an independent predictor for later, more severe intra and postop- erative complications, denoting the possibility for more frequent cross-sectional imaging acting as a surrogate of more advanced and complex disease at the time of resection (Table IV). At this time, however, the specialty of the surgeon perform- ing adrenalectomy was not correlated with any specific perioperative adverse events (Table IV).

Discussion

The incidence of adrenal incidentaloma in autop- sy series approaches 9%.14 Similarly, in clinical practice, these lesions not only are more likely to detected incidentally by the ubiquity of cross- sectional imaging studies ordered, but also are increasingly more likely to be functional because

INCIDENTAL ADRENAL MASS MANAGEMENT IN THE US

DEL GIUDICE TABLE III .- Multivariable logistic regression analysis of the unmatched cohort on the probability for under- going surgery. 80 to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher. or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically OR: odds ratio; CI: confidential interval; Q: quartile; CCI: Charlson Comorbidity Index; CT: computed tomography; MRI: magnetic resonance imaging.

Variable	OR (95%CI)	P value
Age, Q1	Ref.
Q2	0.67 (0.62-0.74)	<0.0001
Q3	0.49 (0.45-0.55)	<0.0001
Q4	0.33 (0.30-0.38)	<0.0001
Gender, male	Ref.
Female	0.92 (0.86-0.99)	0.0323
Race, white	Ref.
Asian	0.93 (0.72-1.18)	0.5400
Black	1.00 (0.90-1.12)	0.9508
Hispanic	0.77 (0.67-0.88)	<0.0001
Unknown	1.05 (0.90-1.21)	0.5549
Income, <$49K	Ref.
≥$100K	1.14 (0.99-1.31)	0.0600
$50K-$99K	1.02 (0.90-1.17)	0.7370
Unknown	0.89 (0.80-0.98)	0.0200
CCI, 0	Ref.
1	0.88 (0.81-0.97)	0.0059
2	0.85 (0.75-0.95)	0.0060
3	0.73 (0.66-0.81)	<0.0001
CT scan(s), 1	Ref.
2-3	1.76 (1.60-1.93)	<0.0001
≥4	2.55 (2.32-2.80)	<0.0001
MRI scan(s), 0	Ref.
1	2.03 (1.87-2.21)	<0.0001
2-3	2.20 (1.93-2.50)	<0.0001
≥4	2.21 (1.69-2.89)	<0.0001
Surgical provider, general surgeon	Ref.
Other	0.11 (0.10-0.13)	<0.0001
Urologist	0.22 (0.18-0.27)	<0.0001

of increasingly common evaluations for sub- clinical adrenal syndromes.15 As a consequence, incidentally discovered adrenal lesions can be considered as a surrogate for “modern medical approach and evolving technology” as nicely de- fined by Bada et al.16 As most of these conditions are usually diagnosed, followed, and eventually treated by a variety of medical and surgical spe- cialists, there is a need for standardized guide- lines. Despite this, up to date and clear guidelines are lacking, with the AACE/AAES work-up on incidental adrenal mass last updated in 2009.1 The more recently updated ESE/ENSAT con- sensus is from 2016,2 which states the important key message is to avoid both ‘over-diagnosis’ and ‘over- treatment’ without missing relevant diseases, but also admitting uncertainties that

make it difficult to provide clear evidence-based recommendations. In our series, we found that both general surgeons and urologic surgeons were involved in the care of these patients. In the urologic literature, we also found that there were no AUA or European Association of Urol- ogy (EAU) Guidelines (Available from: https:// uroweb.org/guidelines) for surgical recommen- dations on adrenal tumors available.

Our primary aim was focused on answering the question on what factors led to resection ver- sus monitoring these adrenal masses. The gener- al consensus from systematic reviews is in favor of an immediate adrenalectomy for a hyperfunc- tioning mass of any size and for nonfunctioning masses >4 cm.17, 18 As expected, in our study, we confirmed that functional lesions were more fre- quently excised after significantly less imaging studies than those patients on surveillance. In ad- dition, important patient related characteristics that predicted for adrenalectomy were younger age, female gender, Caucasian ethnicity, few co- morbidities, and high-income class which depicts adrenalectomy as an elective procedure, whereas those who are not good surgical candidates will otherwise continue on surveillance and monitor- ing. We also discovered, however, that a higher number of scans over the follow-up period was also a surrogate for a significantly higher prob- ability of undergoing surgery. This could be ex- plained by the fact that in lieu of clinical doubts and therefore strict monitoring, the choice of resection is preferred by both surgeons and pa- tients. Also, it could be that the higher number of scans reflects a situation of some complex- ity, which ultimately requires additional scans to untangle and ultimately requires adrenalectomy to resolve. Although the reliance on a variable such as CT scan number could be subject to con- founding bias, it has to be acknowledged that number of CT and MRI scans has been continu- ously found as an associated variable with clear trends of the estimates according to the predicted aim of interest. This was true at the multivariable analysis as well was confirmed after propensity score matching and clearly there is an impact on the relation between the higher number of follow up scans and the decision to undergo surgical re- section. Finally, at each analytical step of our lo-

INCIDENTAL ADRENAL MASS MANAGEMENT IN THE US

Figure 2 .- Predicted probability plots for surgical excision generated by logistic regressions exploring the relative influence of number of CT scans (A), number of MRI (B), Charlson Comorbidity Index (C), and age at first CT scan (D).

Predicted probability of surgery %

0.80

1.00

0.75

0.95

0.70

0.90

0.65

0.85

0.60

0.80

0.75

0.55

0.70

0.50

0.65

0.45

‘edicted probabilit

0.60

0.40

0.55

0.50

0.35

0.45

0.30

0.40

0.25

0.35

0.20

0.30

0.25

0.15

0.20

0.10

0.15

0.05

0.10

0.00

0.05

0.00

: 10

11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Number of CT scan

Number of MRI

Predicted probability of surgery %

0.30

Predicted probability of surgery %

0.80

0.75

0.25

0.70

0.65

0.60

0.20

0.55

0.50

0.45

0.15

0.40

0.35

0.10

0.30

0.25

0.20

0.05

0.15

0.10

0.05

0.00

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Comorbidity index

Age at first CT scan

gistic regression models, general surgeons were consistently associated with a marked increased probability to resect adrenal masses. The exact reasons are not clear, but could be due to refer- ral patterns that refer those patients most likely to undergo surgery to these surgeons. Urologists may not have as high a likelihood for surgical resection as they may have fewer surgical refer- rals and a higher rate of detecting non-surgical incidentalomas due to frequent imaging of the retroperitoneum, for both benign and neoplastic urologic etiologies.

Regarding surgical approach, we found some interesting trends in our study, with no particu- lar domination by specific approach. We did find that robotic adrenalectomy underwent a rise and subsequent decline. This is dissimilar to trends in robotic urologic surgeries, such as robotic prosta- tectomy, robotic partial nephrectomy, or robotic radical nephrectomy,19 where after initial robotic

adoption, adoption continues to increase, with- out decline. Unlike these other examples, adre- nalectomy is not a procedure which only urolo- gists perform, which may explain the differences in robotic adoption. Also, adrenalectomy is not a case where the robotic platform offers significant advantages, such as intra corporeal suturing or articulated instrumentation. However, a hint may lie in a meta-analysis from Agrusa et al.20 which found no significant perioperative differences in laparoscopic vs. robotic adrenalectomies. This knowledge coupled with a higher prevalence of laparoscopy procedures when compared with ro- botic procedures in the general surgery may ex- plain our findings.

Our study also delineates that an MIS ap- proach predicted for improved intra, postopera- tive, and resource use outcomes. This was true for all the surgical providers involved in the analysis and all in all, is not surprising. Given

INCIDENTAL ADRENAL MASS MANAGEMENT IN THE US

TABLE IV .- Multivariable logistic regression for intraoperative events and Cox proportional hazard regression for 90-days postoperative specific and cumulative complications of the cohort.
Variable	OR (95%CI)	HR (95%CI)
Variable	Intraoperative	Digestive	Respiratory	Hemorrhagic	Cardiac	Infectious	Wound	Transfusions	Any Com- plication
Age, Q1
Q2	0.97	1.43	1.52	1.16	0.41	1.31	1.46	0.87	1.19
	(0.69-1.36)	(0.73-2.80)	(0.55-4.22)	(0.59-2.27)	(0.10-1.69)	(0.69-2.47)	(0.67-3.19)	(0.47-1.60)	(0.87-1.64)
Q3	1.19	1.77	1.89	0.50	0.67	2.33	2.22	0.65	1.27
Q3	(0.85-1.65)	(0.91-3.42)	(0.69-5.18)	(0.22-1.17)	(0.19-2.32)	(1.29-4.19)	(1.06-4.64)	(0.34-1.26)	(0.93-1.75)
Q4	1.65	0.94	1.25	0.47	0.83	0.77	1.62	0.48	0.80
Q4	(1.20-2.28)	(0.45-1.99)	(0.42-3.68)	(0.20-1.12)	(0.24-2.85)	(0.37-1.57)	(0.75-3.49)	(0.24-0.96)	(0.56-1.13)
Gender, male
Female	0.91	0.80	1.40	1.17	0.96	0.97	0.87	0.75	0.91
	(0.73-1.14)	(0.51-1.27)	(0.70-2.79)	(0.66-2.05)	(0.39-2.41)	(0.64-1.47)	(0.54-1.40)	(0.48-1.17)	(0.73-1.14)
Race, white
Asian	1.25	0.64	N/A	0.84	N/A	2.15	0.65	1.32	1.00
	(0.60-2.61)	(0.09-4.63)		(0.11-6.15)		(0.78-5.95)	(0.09-4.76)	(0.32-5.53)	(0.47-2.14)
Black	1.29	1.33	0.58	1.16	0.43	0.65	0.88	1.63	1.03
Black	(0.94-1.77)	(0.70-2.52)	(0.17-1.93)	(0.51-2.67)	(0.06-3.30)	(0.31-1.38)	(0.41-1.87)	(0.90-2.95)	(0.74-1.44)
Hispanic	0.86	0.30	0.62	1.07	0.98	0.86	1.32	1.14	0.93
Hispanic	(0.56-1.33)	(0.07-1.24)	(0.15-2.63)	(0.41-2.78)	(0.22-4.30)	(0.39-1.88)	(0.62-2.80)	(0.53-2.42)	(0.62-1.39)
Unknown	1.08 (0.67-1.74)	1.55 (0.66-3.69)	1.87	2.81 (1.15-6.89)	N/A	1.79 (0.88-3.65)	1.11 (0.40-3.14)	1.31 (0.51-3.34)	1.61 (1.06-2.43)
Unknown	1.08 (0.67-1.74)	1.55 (0.66-3.69)	(0.63-5.57)	2.81 (1.15-6.89)	N/A	1.79 (0.88-3.65)	1.11 (0.40-3.14)	1.31 (0.51-3.34)	1.61 (1.06-2.43)
Income, <$49K
≥$100K	0.51	0.61	0.36	0.77	5.27	0.65	0.50	0.40	0.56
	(0.33-0.79)	(0.27-1.39)	(0.09-1.35)	(0.31-1.90)	(0.57-48.51)	(0.32-1.30)	(0.22-1.13)	(0.17-0.96)	(0.38-0.84)
$50K-$99K	0.64	0.72	0.40	0.84	7.27	0.50	0.41	0.25	0.57
$50K-$99K	(0.44-0.93)	(0.35-1.46)	(0.12-1.32)	(0.37-1.91)	(0.89-59.75)	(0.24-1.001)	(0.19-0.88)	(0.10-0.62)	(0.39-0.81)
Unknown	0.59 (0.44-0.78)	0.49 (0.28-0.88)	0.56 (0.25-1.26)	0.39 (0.19-0.79)	2.21	0.53 (0.32-0.88)	0.40 (0.24-0.69)	0.49 (0.29-0.83)	0.48 (0.37-0.64)
Unknown	0.59 (0.44-0.78)	0.49 (0.28-0.88)	0.56 (0.25-1.26)	0.39 (0.19-0.79)	(0.27-17.75)	0.53 (0.32-0.88)	0.40 (0.24-0.69)	0.49 (0.29-0.83)	0.48 (0.37-0.64)
CCI, 0
1	0.93	0.59	2.01	1.42	1.80	1.08	0.99	0.87	0.98
	(0.71-1.23)	(0.33-1.08)	(0.92-4.38)	(0.75-2.69)	(0.63-5.10)	(0.66-1.79)	(0.55-1.78)	(0.47-1.64)	(0.74-1.29)
2	0.66	0.52	1.87	0.86	1.08	1.02	0.66	1.01	0.85
2	(0.44-0.98)	(0.22-1.24)	(0.68-5.09)	(0.32-2.30)	(0.22-5.23)	(0.52-2.01)	(0.27-1.61)	(0.45-2.23)	(0.58-1.25)
3	0.95 (0.70-1.30)	0.82 (0.44-1.52)	0.90 (0.31-2.65)	1.20 (0.53-2.72)	1.04 (0.25-4.32)	1.13 (0.64-2.00)	1.16 (0.63-2.15)	2.16 (1.21-3.88)	1.20 (0.89-1.63)
CT scan(s), 1
2-3	1.29	1.71	0.40	5.36	0.99	2.45	1.63	1.51	1.60
	(0.91-1.83)	(0.72-4.06)	(0.14-1.12)	(1.23-23.41)	(0.23-4.22)	(1.07-5.63)	(0.64-4.10)	(0.67-3.43)	(1.08-2.37)
≥4	2.13	3.24	1.26	12.08	1.85	4.46	2.99	3.13	3.07
	(1.53-2.97)	(1.44-7.29)	(0.56-2.83)	(2.86-51.02)	(0.49-6.95)	(2.01-9.88)	(1.25-7.10)	(1.45-6.74)	(2.12-4.43)
MRI scan(s), 0
1	1.07	1.22	0.67	0.96	0.60	1.23	0.85	1.33	1.06
	(0.83-1.38)	(0.74-2.01)	(0.30-1.48)	(0.50-1.82)	(0.19-1.88)	(0.78-1.94)	(0.48-1.51)	(0.80-2.21)	(0.82-1.36)
2-3	0.79	0.52	0.23	1.38	0.44	0.95	0.80	1.24	0.86
2-3	(0.53-1.18)	(0.19-1.46)	(0.03-1.70)	(0.63-3.03)	(0.06-3.41)	(0.47-1.93)	(0.34-1.88)	(0.62-2.49)	(0.58-1.26)
≥4	0.83 (0.37-1.89)	0.63 (0.09-4.61)	N/A	0.95 (0.13-7.08)	1.81 (0.23-14.43)	0.56 (0.08-4.10)	0.66 (0.09-4.86)	1.60 (0.38-6.71)	0.43 (0.14-1.36)
Surgical provider, general surgeon
Other	1.93	2.44	2.19	1.09	6.8	1.54	2.8	1.86	1.84
	(1.49-2.51)	(1.34-4.46)	(1.02-4.70)	(0.57-2.07)	(1.45-31.84)	(0.94-2.53)	(1.46-5.36)	(1.08-3.18)	(1.41-2.41)
Urologist	0.96 (0.64-1.43)	1.56 (0.66-3.66)	0.65 (0.14-2.92)	1.58 (0.71-3.52)	7.76 (1.39-43.15)	1.12 (0.54-2.34)	0.92 (0.30-2.84)	1.66 (0.83-3.34)	1.33 (0.91-1.95)
Surgical approach, open
Laparoscopic	0.51	1.19	0.29	0.41	0.40	1.17	1.3	0.36	0.63
Laparoscopic	(0.39-0.66)	(0.69-2.05)	(0.12-0.69)	(0.21-0.84)	(0.13-1.23)	(0.71-1.93)	(0.72-2.35)	(0.21-0.62)	(0.49-0.82)
Robotic	0.36	0.64	0.75	0.89	0.83	0.91	0.83	0.33	0.63
Robotic	(0.26-0.50)	(0.31-1.30)	(0.34-1.66)	(0.46-1.74)	(0.28-2.49)	(0.51-1.64)	(0.40-1.70)	(0.17-0.66)	(0.47-0.85)

OR: odd ratio; HR: hazard ratio; Q: quartile; CCI: Charlson Comorbidity Index; CT: computed tomography; MRI: magnetic resonance imaging: N/A: not applicable.

INCIDENTAL ADRENAL MASS MANAGEMENT IN THE US

Figure 3 .- Kaplan Meier plots assessing any 90-days postoperative complications by any (A), gender (B), education (C), income (D), race (E) and surgical approach (F).

Any complication probability %

0.20

Any complication probability %

0.20

Logrank p=Q 3228

Any complication probability %

0.20

Logrank p=0 2899

0.15

0.10

0.05

0.00

518

502

488

486

出&店

482

430

476

479

478

477

$89

0.00

1653

G15

138

130

132

122

130

132

1.32

FEMALE

2041

1364

1916

1076

1871

1855

1460

1860

1454

1862

1845

1848

1648

0.00

MALE

1334

1273

1230

1225

1215

1200

1207

1206

1204

1201

1198

1107

1195

1194

7 14 21 28 35 42 49 56 63 70 77 84 91

At Risk

3375 3227

3155

3080

3058 3054

7 14 21 28 35 42 49 56 63 70 77 84 91

3001

3072

3057

3050

3045

3043 30 3042

7 14 21 28 35 42 49 56 63 70 77 84 91

Time from surgery (day)

1: Bachelor Degree Plus

Time from surgery (day)

FEMALE MALE

& Less than 12th Grade

2: High School Diploma

5: Unknown

4: Less than Bachelor Degree

Any complication probability %

0.20

Logrank p < 0001

Any complication probability %

0.20

Logrank pm0.7983

Any complication probability %

0.20

Logrank p=0 0032

0.15

0.10

0.05

0.00

$100K*

418

988

385

366

384

383

382 O

380

Asian

382

Hispanic

373

0.00

55DK-S99K

1354

1311

1277

$49K

1260

1243

#245

1241

1239

1237

1234

1229

1225

1224

1223

Unknown

499

1846

1813

1808

1806

1803

1802

1800

1798

1797

17g?

1796

Jnknown

White

214

2414

200

123

100

2 108

190

188

Open

1215

1136

1112

1000

1002

1080

1088

1087

1385

1960

1824

2309

2234

2218

2213

2207

2204

2200

2195

2190

2186

2184

2183

Robotic

806

780

756

755

751

7.45

743

742

1080

741

1080

741

239

14 21 28 35 42 49 56 63 70 77 84 91

7 14 21 28 35 42 49 56 63 70 77 84 91

Time from surgery (day)

$100K+

550K-SB9K

<549K

Unknown

Asian

Black

Hispanic

Unknown

White

Laparoscopic

Open

Robotic

the morbidity of an incision to access the ret- roperitoneum and high likelihood of adrenalec- tomies to be elective cases, we would therefore underline the importance of such a finding to reduce the morbidity and mortality related to the operation. Of course, as we cannot define complexity by means of tumor characteristics in this administrative dataset, it is possible that this decrease in morbidity with the MIS approach is reflective of less complex clinical situations as there are surgical situations where an MIS ap- proach is not always feasible.

Limitations of the study

Also, our article is not devoid of limitations. As the dataset is administrative in nature, which re- lies on accurate coding of diagnoses and proce- dures, there is a possibility of misclassification. Additionally, procedures done prior to access to insurance and entry into the database may not have been captured. In addition, in keeping with the administrative nature of the dataset, no stag- ing or information regarding tumor characteris- tics were available, which could limit our ability to assess the indication for surgical excision and related oncological outcomes.

Conclusions

In the US, most adrenal masses are placed in a surveillance protocol rather than surgical exci- sion, but this is based on both patient and histo- logic-related factors. General surgeons are more likely to perform adrenalectomy than urologic surgeons in this setting, with each surgical spe- cialty having different preferences, especially with regards to surgical approach, but with equivalent operative and resource use outcomes. Overall, the laparoscopic approach is the most common surgical approach to adrenalectomy. Due to the paucity of guidelines, professional so- cieties should continue to strive for standardiza- tion and reporting of practical recommendations or guidelines on adrenal tumors.

References

1. Zeiger MA, Thompson GB, Duh QY, Hamrahian AH, Angelos P, Elaraj D, et al .; American Association of Clinical Endocrinologists; American Association of Endocrine Sur- geons. American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal Incidentalo- mas: executive summary of recommendations. Endocr Pract 2009;15:450-3.

DEL GIUDICE

INCIDENTAL ADRENAL MASS MANAGEMENT IN THE US

2. Fassnacht M, Arlt W, Bancos I, Dralle H, Newell-Price J, Sahdev A, et al. Management of adrenal incidentalomas: Eu- ropean Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol 2016;175:G1-34.

3. Baltzer P, Clauser P, Klatte T, Walz J. Work-up of the Inci- dental Adrenal Mass. Eur Urol Focus 2016;1:217-22.

4. Cambos S, Tabarin A. Management of adrenal incidentalo- mas: working through uncertainty. Best Pract Res Clin Endo- crinol Metab 2020;34:101427.

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Conflicts of interest .- The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.

Authors’ contributions .- Francesco Del Giudice and Wansuk Kim have equally contributed. Francesco Del Giudice: conceptualiza- tion, data curation, formal analysis, methodology, drafting of the document, revision, supervision; Wansuk Kim: conceptualization, data curation, formal analysis, methodology; Shufeng Li: data curation, formal analysis, methodology, Ettore De Berardinis: draft- ing of the document, revision, supervision; Alessandro Sciarra: drafting of the document, revision, supervision; Stefano Salciccia1: drafting of the document, revision, supervision; Matteo Ferro5: drafting of the document, revision, supervision; Riccardo Autorino: drafting of the document, supervision; Savio D. Pandolfo: drafting of the document, revision; Felice Crocetto7: drafting of the document, revision, supervision; Antonio Galfano: methodology, revision, supervision, Paolo Dell’Oglio: methodology, revision, supervision; Giovanni E. Cacciamani: methodology, revision, supervision; Benjamin Pradere: methodology, revision, supervision, Ekaterina Laukhtina: methodology, revision, supervision; David D’Andrea: methodology, revision, supervision; Federico Belladelli: methodology, revision, supervision; Wojciech Krajewski: methodology, revision, supervision; Andrea Mari: methodology, revision, supervision; Andrea Minervini: methodology, revision; Andrea Gallioli: methodology, revision, Daniele Amparore: methodology, revision, supervision, Enrico Checcucci: methodology, revision, supervision; Cristian Fiori: methodology, revision, supervision, Francesco Porpiglia: methodology, revision, supervision, Luca Morgantini: methodology, revision; Simone Crivellaro: methodology, revision, supervision and Benjamin I. Chung: methodology, revision, supervision. All authors read and approved the final version of the manuscript.

History .- Article first published online: October 5, 2022- Manuscript accepted: September 14, 2022 .- Manuscript revised: September 5, 2022. - Manuscript received: July 5, 2022.

Supplementary data .- For supplementary materials, please see the HTML version of this article at www.minervamedica.it

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Materials and methods

Data source

Patients

Outcome ascertainment

Statistical analysis

Results

Study cohort

Outcomes

INCIDENTAL ADRENAL MASS MANAGEMENT IN THE US

Discussion

Limitations of the study

Conclusions

References

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Table of Contents

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