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4Adrenalectomy is a curative treatment option for renal cell cancer patients with solitary intraadrenal metastatic spread
2 IS L A P A R O S C O P I C A D R E N A L E C T O M Y E F F E C T I V E AND SAFE F O R A D R E N O C O R T I C A L C A R C I N O M A AND METASTASIS?
TRANSPERITONEAL LAPAROSCOPIC " P L A T I N U M STANDARD"?
ADRENALECTOMY:
THE
PoIpiglia E ~, Fiori C. 2, Tarabuzzi R. 1, Giraudo G?, Garrone C. 3, Morino M. 3, Fontana D. 2, Scarpa R.M.
Cestari A., Guazzoni G., Centemero A., Riva M., Losa A., Naspro R., Bellinzoni R, Rigatti R
1San Luigi Hospital, Dept. of Urology, Orbassano, Italy, 2San Giovanni Battista Hospital, Dept. of Urology, Torino, Italy, 3San Giovanni Battista Hospital, Dept. of Surgery, Torino, Italy
Universitfi Vitae Salute, San Raffaele Hospital - Tun'o, Urology, Milan, Italy
I N T R O D U C T I O N & O B J E C T I V E S : We reviewed our experience with laparoscopic adrenalectomy in order to evaluate effectiveness and safety of this procedure in the case of adrenal cancer or adrenal metastasis.
I N T R O D U C T I O N & O B J E C T I V E S : Laparoscopic adrenalectomy is considered the treatment of choice for the surgical ablation of most benign adrenal lesions. Several approaches and several surgical techniques have been described. We present our 13-year experience in laparoscopic transperitoneal adrenal surgery.
M A T E R I A L & METHODS: We included patients who underwent laparoscopic adrenalectomy from 1995 to June 2004, with histologically identified adrenocortical cancer (ACC) or metastasis. Indications for the laparoscopic treatment were adrenal masses without radiological evidence of involvement of the surrounding structures or solitary metastasis with well controlled primary cancer. The following parameters were evaluatedz size of the lesion, operative time, intra-operative complications, local, port-site, intra-abdominal recurrence, distant metastasis, and survival time. Statistical analyses were performed using commercially available PC software.
MATERIAL & METHODS: Between October 1992 and September 2004, 225 laparoscopic approaches to the adrenal gland have been performed, namely 196 unilateral adrenalectomy (73 89right, 107 left - 64 Conn's disease, 45 Cushing's Disease, 39 Pheocrhomocytoma, 37 non functioning adenomas and 11 malignancy), 21 bilateral adrenalectomy and 8 cases of conservative surgery. The patients were placed in a 60-degree flank position with the bed flexed to increase the surgical field; the first step of the intervention was the early ligation of the adrenal vein, as a land mark to correctly dissect the adrenal gland.
RESULTS: Seventeen malignant adrenal lesions were proven with histological diagnoses that showed a primary ACC in 6 cases and a metastasis in another 10 cases (in one case bilateral metastasis was found). Mean patient age was 62.5 years. Mean lesion size of malignant lesions was 5.2 ± 2.7 cm. Unilateral procedures (15 cases) requited a mean operative time of 155 ± 47 minutes, the bilateral procedure lasted 215 minutes. We recorded two conversions to open surgery due to local infiltration whereas no intra-operative complications were recorded. The mean follow-up was 35 months. During follow-up 3 patients died: one, who had primary cortical cancer, died of a stroke and one, who had metastatic breast cancer, died of recurrent disease (thoracic invasion). The last patient, who bad non-small cell lung carcinoma (NSCLC) adrenal metastasis, died after 9 months of follow up for an endoperitoneal and trocar port site inseeding that occurred 5 months after the adrenalectomy.
RESULTS: The laparoscopic procedure was successfully completed in all but 5 cases which were converted into open surgery (1 for duodenal injury during pneumoperitoneum induction with open access and 2 during procedures for malignancy). Mean operative time was 152 rain. in the unilateral group, 235 min in the bilateral group and 84 rain in the conservative group. Delayed complications included 3 cases of hemoperitoneum which were drained surgically, 3 cases of severe blood loss which were treated with blood transfusions, 2 cases of wound infection. Patients were able to ambulate on the morning of the first postoperative day and were discharged respectively 2.7, 5 and 1.5 days after surgery in the unilateral, bilateral and conservative group.
CONCLUSIONS: On the basis of our experience, we can conclude that when the malignancy is only confined to adrenal gland, laparoscopic adrenalectomy seems to be a feasible option, if the principles of oncologic surgery are respected. Nevertheless further investigations are required to evaluate the appropriateness of this operation.
CONCLUSIONS: Laparoscopic transperitoneal adrenalectomy is a safe and effective, minimally invasive approach for the removal of the adrenal gland both in cases of benign lesions and organ confined malignant diseases. Conservative surgery is feasible. The laparoscopic technique has low morbidity, minimal postoperative analgesic requirements, short hospital stay and should be considered the gold standard for the surgical treatment of adrenal pathologies.
3
4
THE I M P O R T A N C E OF L A P A R O S C O P I C F O R A D R E N A L METASTASIS A B O U T O U R R E T R O S P E C T I V E STUDY OF 2 0 CASES
A D R E N A L E C T O M Y IS A CURATIVE T R E A T M E N T O P T I O N F O R R E N A L C E L L C A N C E R PATIENTS W I T H SOLITARY I N T R A A D R E N A L METASTATIC SPREAD
Emerian D., Vallee V., Ferroud V., Ballanger P.
Zimmermann R.1, Merseburger A. 1 Stenzl A.1, Wegener G. 2, Jonas U.3, Kuczyk M.1
Du Pr Ballanger, Service Urologic, Bordeaux, France INTRODUCTION & OBJECTIVES: The surgical treatment of adrenal metastasis is a current and controversial issue. In order to evaluate the risks, the limits and the indications of the laparoscopic treatment for adrenal metastasis, we did a retrospective study in which 20 cases were operated between October 1999 and April 2004. MATERIAL & METHODS: 16 patients presented solitary adrenal metastasis, 2 presented bilateral adrenal metastasis from small cell lung carcinoma (NSCLC) or not, or kidney tumours, or melanoma. 7 indications were curative, 7 were diagnostic and 6 were palliative. RESULTS: 8 patients ASA I/II. 10 patients ASA III. Mean age 57 years old. Mean size lesion 68 mm [20-120].9 on the left side, 11 on the fight side. Mean surgery time for unilateral adrenalectomy 87 rain [45-150] with mean blood loss 255 ml. Mean surgery time for bilateral adrenalectomy 160 rain [140-180]. 6 patients were transfused. Adrenalectomy for palliative indications allowed to decrease at least half of the morphinic analgesy before surgery. Resumption of transit 2 days later [1-4]. Mean hospital stay 4.3 days[3-7]. Tumour free margins were obtained in every case for curative indication. 3 patients required open conversion (2 fixed lesions, 1 important blood loss). 2 complications during surgery time (disruption of the adrenal capsule, diaphragmatic injury), 2 post operative complications (haematoma, retroperituneal extravasation) and tardive complication (local recurrence has been observed 10 months later) The mean follow-up was 13.5 months[2-48]. No radiological predictive argument on the possibility of dissection on the friable character of the injury could be found, expect if the lesion was superior to 100 ram. Observations during surgery time are crucial and the decision of open conversion must be easy. Adrenalectomy for metastasis is associated to a morbidity rate more important than benign adrenal tumour. 4 patients are still alive without recurrence 18, 28, 44 and 48 months after their adrenalectomy. Diagnostic laparoscopy may be useful, and in some cases, may establish a diagnosis. Laparoscopic adrenalectomy has to be cautiously performed, with the goals of achieving complete mmour resection. A laparoscopic approach with patients with suspected adrenal metastasis can be both diagnostic and therapeutic. It represents a means of diagnosis at least better than fine needle aspiration biopsy. CONCLUSIONS: Because of its simplicity and its acceptable morbidity rate, adrenal laparoscopic transperitoneal approach presents a diagnostic, prognostic and therapeutic interest for synchronous or metachronous metastasis of primitive tumours. The results are encouraging enough to justify further investigation of this aggressive treatment strategy.
1Eberhard-Karls-University, Dept. of Urology, Tuebingen, Germany, 2Hannover University Medical School, Clinical Cancer Registry, Hannover, Germany, 3Hannover University Medical School, Dept. of Urology, Hannover, Germany INTRODUCTION & OBJECTIVES: Solitary adrenal metastases occur in about 1.2 - 10 % of renal cell cancer patients. Due to the observation that the vast majority of intraadrenal lesions can be detected preoperatively, we have recently recommended to renounce a routine adrenalectomy during the surgical treatment of renal cell cancer. However, the impact of adrenalectomy on the patients" clinical prognosis in case of a solitary metastatic lesion within the adrenal gland remains an issue of controversial discussion. Whereas some authors suggest adrenalectomy as a potentially curative treatment option in these cases, others compare its clinical value with that of a mere lymphadenectomy. MATERIAL & METHODS: Between 1981 and 2000, 652 patients (443 males and 209 females) underwent nephrectomy in combination with adrenalectomy in our clinic for the diagnosis of renal cell cancer. The median age at first diagnosis was 59 (33 - 84) and 60 (20 - 85) years for male and female patients, respectively. The median postoperative follow - up was 7.4 years (2 months - 18 years).According to the TNM - classification system tumour stages were classified as follows: T1,231 pat. (37%); T2, 70 pat. (11%); T3,287 pat. (46%); T4, 37 pat. (6%). In total, 339 patients revealed regional lymph node or distant metastases at the time of the surgical treatment. Solitary intraadrenal metastases without further systemic spread were observed in 13 cases. The correlation of several patients" and tumour characteristics (age, tumour stage and size, the presence of regional lymph node/distant metastases or a solitary intraadrenal metastasis) with patients" overall survival was determined by univariate and multivariate statistical analysis (logistic Cox regression analysis). RESULTS: For patients revealing regional lymph node or distant metastases, the long term survival was decreased to 21%/16% and 14%/12% at 5 and 10 years following the initial surgical treatment when compared with patients without any metastatic spread (median survival: 4.8 years). In contrast, the median survival was 12 years for patients with solitary intraadrenal metastases (survival rate at 5 and 10 years after surgery: 5i %). The long - term survival of patients without systemic spread was not statistically. CONCLUSIONS: In patients with a solitary intraadreal metastasis adrenalectomy is a potentially curative treatment option. The observation that the long - term survival of the latter patients is comparable to that of patients with organ - confined disease might suggest the establishment of a separate TNM - category for patients revealing a solitary metastasis within the adrenal gland and no hint at further systemic metastatic spread.
European Urology Supplements 4 (2005) No. 3, pp. 3
TRANSPERITONEAL LAPAROSCOPIC " P L A T I N U M STANDARD"?
ADRENALECTOMY:
THE
PoIpiglia E ~, Fiori C. 2, Tarabuzzi R. 1, Giraudo G?, Garrone C. 3, Morino M. 3, Fontana D. 2, Scarpa R.M.
Cestari A., Guazzoni G., Centemero A., Riva M., Losa A., Naspro R., Bellinzoni R, Rigatti R
1San Luigi Hospital, Dept. of Urology, Orbassano, Italy, 2San Giovanni Battista Hospital, Dept. of Urology, Torino, Italy, 3San Giovanni Battista Hospital, Dept. of Surgery, Torino, Italy
Universitfi Vitae Salute, San Raffaele Hospital - Tun'o, Urology, Milan, Italy
I N T R O D U C T I O N & O B J E C T I V E S : We reviewed our experience with laparoscopic adrenalectomy in order to evaluate effectiveness and safety of this procedure in the case of adrenal cancer or adrenal metastasis.
I N T R O D U C T I O N & O B J E C T I V E S : Laparoscopic adrenalectomy is considered the treatment of choice for the surgical ablation of most benign adrenal lesions. Several approaches and several surgical techniques have been described. We present our 13-year experience in laparoscopic transperitoneal adrenal surgery.
M A T E R I A L & METHODS: We included patients who underwent laparoscopic adrenalectomy from 1995 to June 2004, with histologically identified adrenocortical cancer (ACC) or metastasis. Indications for the laparoscopic treatment were adrenal masses without radiological evidence of involvement of the surrounding structures or solitary metastasis with well controlled primary cancer. The following parameters were evaluatedz size of the lesion, operative time, intra-operative complications, local, port-site, intra-abdominal recurrence, distant metastasis, and survival time. Statistical analyses were performed using commercially available PC software.
MATERIAL & METHODS: Between October 1992 and September 2004, 225 laparoscopic approaches to the adrenal gland have been performed, namely 196 unilateral adrenalectomy (73 89right, 107 left - 64 Conn's disease, 45 Cushing's Disease, 39 Pheocrhomocytoma, 37 non functioning adenomas and 11 malignancy), 21 bilateral adrenalectomy and 8 cases of conservative surgery. The patients were placed in a 60-degree flank position with the bed flexed to increase the surgical field; the first step of the intervention was the early ligation of the adrenal vein, as a land mark to correctly dissect the adrenal gland.
RESULTS: Seventeen malignant adrenal lesions were proven with histological diagnoses that showed a primary ACC in 6 cases and a metastasis in another 10 cases (in one case bilateral metastasis was found). Mean patient age was 62.5 years. Mean lesion size of malignant lesions was 5.2 ± 2.7 cm. Unilateral procedures (15 cases) requited a mean operative time of 155 ± 47 minutes, the bilateral procedure lasted 215 minutes. We recorded two conversions to open surgery due to local infiltration whereas no intra-operative complications were recorded. The mean follow-up was 35 months. During follow-up 3 patients died: one, who had primary cortical cancer, died of a stroke and one, who had metastatic breast cancer, died of recurrent disease (thoracic invasion). The last patient, who bad non-small cell lung carcinoma (NSCLC) adrenal metastasis, died after 9 months of follow up for an endoperitoneal and trocar port site inseeding that occurred 5 months after the adrenalectomy.
RESULTS: The laparoscopic procedure was successfully completed in all but 5 cases which were converted into open surgery (1 for duodenal injury during pneumoperitoneum induction with open access and 2 during procedures for malignancy). Mean operative time was 152 rain. in the unilateral group, 235 min in the bilateral group and 84 rain in the conservative group. Delayed complications included 3 cases of hemoperitoneum which were drained surgically, 3 cases of severe blood loss which were treated with blood transfusions, 2 cases of wound infection. Patients were able to ambulate on the morning of the first postoperative day and were discharged respectively 2.7, 5 and 1.5 days after surgery in the unilateral, bilateral and conservative group.
CONCLUSIONS: On the basis of our experience, we can conclude that when the malignancy is only confined to adrenal gland, laparoscopic adrenalectomy seems to be a feasible option, if the principles of oncologic surgery are respected. Nevertheless further investigations are required to evaluate the appropriateness of this operation.
CONCLUSIONS: Laparoscopic transperitoneal adrenalectomy is a safe and effective, minimally invasive approach for the removal of the adrenal gland both in cases of benign lesions and organ confined malignant diseases. Conservative surgery is feasible. The laparoscopic technique has low morbidity, minimal postoperative analgesic requirements, short hospital stay and should be considered the gold standard for the surgical treatment of adrenal pathologies.
3
4
THE I M P O R T A N C E OF L A P A R O S C O P I C F O R A D R E N A L METASTASIS A B O U T O U R R E T R O S P E C T I V E STUDY OF 2 0 CASES
A D R E N A L E C T O M Y IS A CURATIVE T R E A T M E N T O P T I O N F O R R E N A L C E L L C A N C E R PATIENTS W I T H SOLITARY I N T R A A D R E N A L METASTATIC SPREAD
Emerian D., Vallee V., Ferroud V., Ballanger P.
Zimmermann R.1, Merseburger A. 1 Stenzl A.1, Wegener G. 2, Jonas U.3, Kuczyk M.1
Du Pr Ballanger, Service Urologic, Bordeaux, France INTRODUCTION & OBJECTIVES: The surgical treatment of adrenal metastasis is a current and controversial issue. In order to evaluate the risks, the limits and the indications of the laparoscopic treatment for adrenal metastasis, we did a retrospective study in which 20 cases were operated between October 1999 and April 2004. MATERIAL & METHODS: 16 patients presented solitary adrenal metastasis, 2 presented bilateral adrenal metastasis from small cell lung carcinoma (NSCLC) or not, or kidney tumours, or melanoma. 7 indications were curative, 7 were diagnostic and 6 were palliative. RESULTS: 8 patients ASA I/II. 10 patients ASA III. Mean age 57 years old. Mean size lesion 68 mm [20-120].9 on the left side, 11 on the fight side. Mean surgery time for unilateral adrenalectomy 87 rain [45-150] with mean blood loss 255 ml. Mean surgery time for bilateral adrenalectomy 160 rain [140-180]. 6 patients were transfused. Adrenalectomy for palliative indications allowed to decrease at least half of the morphinic analgesy before surgery. Resumption of transit 2 days later [1-4]. Mean hospital stay 4.3 days[3-7]. Tumour free margins were obtained in every case for curative indication. 3 patients required open conversion (2 fixed lesions, 1 important blood loss). 2 complications during surgery time (disruption of the adrenal capsule, diaphragmatic injury), 2 post operative complications (haematoma, retroperituneal extravasation) and tardive complication (local recurrence has been observed 10 months later) The mean follow-up was 13.5 months[2-48]. No radiological predictive argument on the possibility of dissection on the friable character of the injury could be found, expect if the lesion was superior to 100 ram. Observations during surgery time are crucial and the decision of open conversion must be easy. Adrenalectomy for metastasis is associated to a morbidity rate more important than benign adrenal tumour. 4 patients are still alive without recurrence 18, 28, 44 and 48 months after their adrenalectomy. Diagnostic laparoscopy may be useful, and in some cases, may establish a diagnosis. Laparoscopic adrenalectomy has to be cautiously performed, with the goals of achieving complete mmour resection. A laparoscopic approach with patients with suspected adrenal metastasis can be both diagnostic and therapeutic. It represents a means of diagnosis at least better than fine needle aspiration biopsy. CONCLUSIONS: Because of its simplicity and its acceptable morbidity rate, adrenal laparoscopic transperitoneal approach presents a diagnostic, prognostic and therapeutic interest for synchronous or metachronous metastasis of primitive tumours. The results are encouraging enough to justify further investigation of this aggressive treatment strategy.
1Eberhard-Karls-University, Dept. of Urology, Tuebingen, Germany, 2Hannover University Medical School, Clinical Cancer Registry, Hannover, Germany, 3Hannover University Medical School, Dept. of Urology, Hannover, Germany INTRODUCTION & OBJECTIVES: Solitary adrenal metastases occur in about 1.2 - 10 % of renal cell cancer patients. Due to the observation that the vast majority of intraadrenal lesions can be detected preoperatively, we have recently recommended to renounce a routine adrenalectomy during the surgical treatment of renal cell cancer. However, the impact of adrenalectomy on the patients" clinical prognosis in case of a solitary metastatic lesion within the adrenal gland remains an issue of controversial discussion. Whereas some authors suggest adrenalectomy as a potentially curative treatment option in these cases, others compare its clinical value with that of a mere lymphadenectomy. MATERIAL & METHODS: Between 1981 and 2000, 652 patients (443 males and 209 females) underwent nephrectomy in combination with adrenalectomy in our clinic for the diagnosis of renal cell cancer. The median age at first diagnosis was 59 (33 - 84) and 60 (20 - 85) years for male and female patients, respectively. The median postoperative follow - up was 7.4 years (2 months - 18 years).According to the TNM - classification system tumour stages were classified as follows: T1,231 pat. (37%); T2, 70 pat. (11%); T3,287 pat. (46%); T4, 37 pat. (6%). In total, 339 patients revealed regional lymph node or distant metastases at the time of the surgical treatment. Solitary intraadrenal metastases without further systemic spread were observed in 13 cases. The correlation of several patients" and tumour characteristics (age, tumour stage and size, the presence of regional lymph node/distant metastases or a solitary intraadrenal metastasis) with patients" overall survival was determined by univariate and multivariate statistical analysis (logistic Cox regression analysis). RESULTS: For patients revealing regional lymph node or distant metastases, the long term survival was decreased to 21%/16% and 14%/12% at 5 and 10 years following the initial surgical treatment when compared with patients without any metastatic spread (median survival: 4.8 years). In contrast, the median survival was 12 years for patients with solitary intraadrenal metastases (survival rate at 5 and 10 years after surgery: 5i %). The long - term survival of patients without systemic spread was not statistically. CONCLUSIONS: In patients with a solitary intraadreal metastasis adrenalectomy is a potentially curative treatment option. The observation that the long - term survival of the latter patients is comparable to that of patients with organ - confined disease might suggest the establishment of a separate TNM - category for patients revealing a solitary metastasis within the adrenal gland and no hint at further systemic metastatic spread.
European Urology Supplements 4 (2005) No. 3, pp. 3