Whether adrenal mass more than 5 cm can pose problem in laparoscopic adrenalectomy? An evaluation of 22 patients
Ashok K. Hemal · Ashutosh Singh · Narmada P. Gupta
Received: 23 October 2007 / Accepted: 13 April 2008 / Published online: 7 June 2008 @ Springer-Verlag 2008
Abstract
Objectives To evaluate technical feasibility and analyze outcome of laparoscopic adrenalectomy (LA) for large adrenal masses more than 5 cm.
Methods The data of 22 patients (8 men, 14 women), who underwent LA for adrenal masses >5 cm between January 1995 and July 2007 were analyzed for this study.
Results Twenty-two patients with a mean age of 42.5 years underwent LA for large adrenal masses (>5 cm) between January 1995 and July 2007. Transperitoneal and retroperitoneal laparoscopic adrenalectomy (TPLA and RPLA) was performed in 15 and 7 patients, respectively. The mean-operative time, blood loss, tumor size and hospi- tal stay were 149.33 and 132.1 min, 132.33 and 94.28 ml, 7.85 and 5.85 cm and 3.5 and 3.28 days, respectively. His- topathological examination of the specimen confirmed adrenal carcinoma in 5, pheochromocytoma in 14, myeloli- poma in 2 and adenoma in 1 patient. Two patients of pheo- chromocytoma had required open conversion, one from each group (TPLA and RPLA). Three patients had postop- erative complications (wound infection 1, pneumonitis with fever 1 and retroperitoneal collection 1).
A. K. Hemal · A. Singh · N. P. Gupta Department of Urology, All India Institute of Medical Sciences, New Delhi 110029, India
A. K. Hemal Robotics / Minimally Invasive Surgery, Department of Urology, Wake Forest University School of Medicine, Wake Forest University Health Sciences, Medical Center Boulevard, Winston-Salem, NC 27157-1094, USA e-mail: ahemal@wfubmc.edu; akhaiims@gmail.com
Conclusions The size of an adrenal mass on preoperative imaging studies alone should not be the primary factor in determining whether LA should be performed. LA for adrenocortical cancers could be performed safely and effectively in the selected group. Transperitoneal approach is most suitable and recommended for large adrenal tumor and adrenal carcinoma to employ laparos- copy. One approach (TP or RP) over the other also does not lead to the substantial benefits either to the patients or to the surgeon.
Keywords Laparoscopy . Adrenal . Adrenalectomy . Adrenal mass · Robotic · Adrenal cancer
Introduction
First laparoscopic adrenalectomy (LA) was performed by Gagner et al. [1] in 1992, in a case of Cushing’s syndrome due to adrenocortical adenoma. It was done by anterior transperitoneal route. Subsequently, various modified approaches like lateral transperitoneal and retroperitoneal were reported [2]. Currently, LA is considered as a best approach for the treatment for adrenal tumors [3] and sev- eral studies have documented its superiority over conven- tional open adrenalectomy in terms of postoperative recovery, hospital stay and overall cost [1, 4-6].
Despite wide acceptance of LA for smaller tumor, its role in removal of larger tumor (>5 cm) is still ques- tioned due to concerns of malignancy, complexity of procedure and greater potential for intraoperative or postoperative complications [7]. There is also a worry that mishandling of large tumors can cause capsular rup- ture leading to tumor spillage and recurrence of local disease in adrenal bed [8].
Therefore, principal concerns regarding the laparoscopic approach to large adrenal tumors are the hypothetical risk of an inadequate resection, rupture of the tumor, tumor spillage and the potential for port site or peritoneal recur- rences, which would adversely affect the clinical outcome [9,10].
The aim of this study is to assess the technical feasibility of LA in handling cortical tumor ≥5 cm in diameter in size and to analyze the outcome of these cases.
Materials and methods
We analyzed the data of the patients, who had undergone LA for adrenal mass ≥5 cm in diameter during the period of January 1995-July 2007. A total of 22 patients satisfied the inclusion criteria for this study. Preopera- tive assessment included the detailed medical history with physical examination, laboratory investigations including haemorgram, complete blood counts, renal function tests, serum electrolytes, blood sugar, baseline serum cortisol, urine analysis and 24-h urine catecholamines.
Imaging studies included the transabdominal ultrasonog- raphy, computerized tomography (CT) scan and magnetic resonance imaging (MRI) study according to requirement. LA was performed by transperitoneal route in 15 and by retroperitoneal route in 7 patients. All intraoperative and postoperative parameters were recorded and specimens were sent for histopathological examination in all patients.
Technique of transperitoneal and retroperitoneal laparo- scopic adrenalectomy (TPLA and RPLA) were performed as described by us earlier and it consists of resecting the adrenal mass with the adrenal gland and peri-adrenal fat [19, 24].
Results
Between January 1995 and July 2007, 22 patients with adrenal masses more than 5 cm in size underwent LA. There were 8 male and 14 female patients with mean age of 42.5 years (range 20-69 years). Fifteen cases were done by transperitoneal (6 right and 9 left sided) route and 7 by ret- roperitoneal route (4 right and 3 left sided). Final histopa- thological diagnosis revealed pheochromocytoma in 14 cases, adrenal carcinoma in 5 cases, adenoma in 1 case and adrenal myelolipoma in 2 cases. We did not perform preop- erative fine needle aspiration biopsy in any of these patients. Mean tumor size was 7.85 cm (range 5.2-14) and 5.85 cm (range 5-7.2) in transperitoneal and retroperitoneal group, respectively. The transperitoneal route was chosen for relatively large tumors. The largest tumor size removed transperitoneally was 14 cm which on histological exami- nation proved to be adrenocortical carcinoma. Two patients of pheochromocytomas required open conversion, one from each group due to adherence with adjacent organ especially to pancreas. The mean operating time was 149.33 min (range 100-260) in transperitoneal and 132.1 min (70-200) in retroperitoneal group. Relatively longer operating time in transperitoneal group may be due to larger size of the tumor. The mean blood loss was 132.33 ml (range 70-250) in transperitoneal and 94.28 ml (range 50-230) in retroperi- toneal group and none of the patient required blood transfu- sion. There was no incidence of capsular rupture or peritoneal contamination by tumor intraoperatively or dur- ing extraction of the specimen. The mean hospital stay was 3.5 days (range 2-7) for transperitoneal and 3.28 days (range 2-5) for retroperitoneal group (Tables 1, 2).
Postoperatively one patient had wound infection, one patient had pneumonitis and one developed retroperitoneal collection. All three were managed conservatively. In a
| Transperitoneal | Retroperitoneal | |
|---|---|---|
| N | 15 (6 right and 9 left) | 7 (4 right and 3 left) |
| Mean age, SD (years) | 42.53, 13 (20-69) | 42.57, 11.87 (23-57) |
| Mean tumor size, SD (cm) | 7.85, 2.1 (5.2-14) | 5.85, 0.85 (5-7.2) |
| Mean-operative time, median (min) | 149.33, 150 (100-260) | 132.1, 130 (70-200) |
| Open conversion | 1 | 1 |
| Mean-blood loss, median (ml) | 132.33, 110 (70-250) | 94.28, 70 (50-230) |
| Mean hospital stay, SD (days) | 3.5, 1.12 (2-7) | 3.28, 1.11 (2-5) |
| Mean return to work, SD (days) | 18.73, 4.55 (12-30) | 16.5, 5.31 (12-28) |
| Histopathology | ||
| Pheochromocytoma | 10 | 4 |
| Carcinoma | 4 | 1 |
| Adenoma | 0 | 1 |
| Myelolipoma | 1 | 1 |
| Death | 4 | 0 |
| Outcome | No. of patients | Metastasis | Median follow up (months) |
|---|---|---|---|
| Disease free | 17 | – | 48 |
| Alive with disease | 0 | – | – |
| Disease specific death | 3 | 3 | 17 |
| Death from other causes | 1 | – | 42 |
| Lost to follow up | 1 | – | 14 |
long-term follow up, 3 patients died after 13, 17 and 25 months of surgery due to metastatic disease. No local or port-site recurrences were seen in any of these patients of malignancy. Two patients of malignancy are still alive without evidence of disease at follow-up of 48 and 60 months after LA. One patient of pheochromocytoma also died 42 months after the surgery due to nonspecific cause.
Discussion
After the first report of LA in 1992 [1], the technique has been modified and with the experience, the results of LA are improving drammatically [2]. As a result, the LA has become the procedure of choice for benign adrenal disease because it is associated with less blood loss [6], lower mor- bidity, shorter hospital stay [4], rapid return to work, fewer incisional hernias [5] and lower cost [11] than open sur- gery. Open adrenalectomy is therefore now reserved for malignant adrenal tumor with local invasion because this disease requires compartmental resection including lym- phadenectomy and possibly splenectomy, nephrectomy or distal pancreatectomy.
In the absence of local tumor invasion or metastasis, there is no clinical, biochemical or radiologic test that enables preoperative identification of malignant adrenal tumors. Clinical presentation such as virilization, mixed hormonal secretion and elevated dihydroxy epiandroster- one sulfate (DHEA-S) levels were suggestive but rarely allow absolute prediction of malignancy [12]. Equally low attenuation on computed tomography and MRI scans, which demonstrates rapid enhancement after gadolinium contrast followed by rapid wash out, cannot unequivocally exclude malignancy. Positron emission tomography scan- ning, which is increasingly adopted in the investigation of large adrenal tumors, is useful for identifying metastasis to adrenal gland but is less reliable for primary adrenal disease [13]. The risk of adrenal malignancy increases with the size of tumor [14], and the intraoperative features suggesting malignant nature of an adrenal tumor are local fixity, inva- sion of the pancreas, spleen or superior pole of the kidney, venous thrombosis and lymphadenopathy.
In presence of the above mentioned findings on preoper- ative imaging or during the surgery, it is prudent to convert such cases into open surgery or if LA is being pursued then should have low threshold for the conversion. Although the size of the adrenal tumor may be correlated with risk of malignancy, but most of large adrenal tumors are benign histologically and behaviorally [15]. The small diameter is no guarantee of benign behavior because as many as 13.5% of resected adreno-cortical carcinomas are less than 5 cm in diameter at diagnosis [16].
Suzuki et al. [2] were the first group to report the differ- ent approaches for LA by transperitoneal and retroperito- neal route. The safety and advantages of laparoscopic surgery over open surgery is reported in various other stud- ies [17, 18]. The transperitoneal route is often preferred by many surgeons because of its wide working space and familiar anatomy. Although retroperitoneal LA has gained in popularity because it provides a direct access to the adre- nal gland and avoids bowel handling and the potential for injury to the intraabdominal viscera but both the trans and retroperitoneal approaches are equally efficacious and safe [20]. Authors have published the comparative study of ret- roperitoneoscopic versus open adrenalectomy and conclude that retroperitoneoscopic adrenalectomy is safe efficacious and associated with minimal morbidity even for pheochro- mocytoma [19]. They also subsequently reported the cost reductive retroperitoneoscopic techniques with reusuable instruments to tackle a variety of adrenal pathologies [24].
LA for large adrenal tumor requires advanced surgical experience, because of the risk of capsular rupture, location of the tumor close to vital structures and technically more difficult dissection. Much of this debate has taken place over the appropriateness of LA for any large adrenal lesions over 4-5 cm size of the tumor. Various authors including us concluded that laparoscopy can be performed for large adrenal tumor [21-23], safely with complete resection but can extrapolate into increase intraoperative blood loss and operative time with increasing tumor size, and in addition a trend toward a higher rate of malignancy has also been sug- gested [7, 8].
In the absence of unequivocally preoperative or intraop- erative malignant features, the appropriate procedure is simple adrenalectomy with removal of gland and its sur- rounding fat. As the size of adrenal gland increases, there is a small but not insignificant risk that an occult adreno-corti- cal cancer may be removed.
Our series suggests that capsular disruption is unlikely to be frequent with laparoscopic surgery in experienced hands. In our series, two-third of patients operated by trans- peritoneal route (15 patients) because of more preference for transperitoneal route for larger tumor, as it provides more room for manipulation and applying retractor, when dissecting in close vicinity of vital visceral structures. The
mean size of the tumor (7.85 cm) was larger in transperito- neal access than retroperitoneal (5.85 cm), which also translated into longer mean operating time (149.33 vs 132.1 min) and mean blood loss (132.33 vs 94.20 ml). Of 22 patients, 5 turned out to be adrenocortical carcinoma on final histopathology and none of these patients developed port site or local recurrence.
In a long-term follow up, three patients of adrenal malig- nancy died after 13, 17 and 25 months of surgery due to metastatic disease and one patient of pheochromocytoma died 42 months after the surgery due to nonspecific cause.
Conclusion
This study suggests that LA can safely be employed for tumor size more than 5 cm without increasing the incidence of open conversion, tumor rupture or capsular breach and intraoperative complications. Patients with adrenocortical cancers can be removed with all advantage of minimal access surgery, however, it may not be suitable in all such cases and preoperative selection is important. The choice of laparoscopic access transperitoneal versus retroperitoneal does not supersede by significant benefits either to the patients or to the surgeon; hence, one may select it taking into consideration of various factors such as, the size of tumor, body habitus of the patient and personal experience, expertise with familiarity for a particular technique of sur- geon.
Conflict of interest statement There is no conflict of interest.
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