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461 Laparoscopic adrenalectomy in urologic centres – the experience of the German Laparoscopic Working Group
461
Laparoscopic adrenalectomy in urologic centres – the experience of the German Laparoscopic Working Group Eur Urol Suppl 2013;12;e461
Springer C.1, Rassweiler J.2, Fahlenkamp D.3, Kutta N.4, Nesius D.4, Thüroff J.5, Krause A.6, Strohmaier W.7, Bachmann A.8, Hertle L.9, Popken G.10, Deger S.11, Jocham D.12, Doehn C.12, Loch T.13, Lahme S.14, Janitzky V.15, Gilfrich C.16, Klotz T.17, Kopper B.18, Rebmann U.19, Kälbe T.20, Wetterauer U.21, Leitenberger A.22, Raßler J.23, Fornara P.1, Greco F.1 1
UKH Universitätsklinikum Halle (Saale), Dept. of Urology, Halle Saale, Austria, 2SLK Kliniken Heilbronn, Dept. of
Urology, Heilbronn, Germany, 3Zeisigwaldkliniken Bethanien, Dept. of Urology, Chemnitz, Germany, 4Krankenhaus Der Barmherzigen Brüder, Dept. of Urology, Trier, Germany, 5University of Mainz, Dept. of Urology, Mainz, Germany, 6Kreiskrankenhaus
Freiberg, Dept. of Urology, Freiberg, Germany, 7Klinikum Coburg, Dept. of Urology, Coburg,
Germany, 8University of Basel, Dept. of Urology, Basel, Switzerland, 9University of Münster, Dept. of Urology, Münster, Germany, 10Helios Klinik Berlin-Buch, Dept. of Urology, Berlin, Germany, 11University of Berlin, Campus Charite´ Mitte, Dept. of Urology, Berlin, Germany, 12University of Lübeck, Dept. of Urology, Lübeck, Germany, 13Diakonie Krankenhaus, Dept. of Urology, Flensburg, Germany, 14Krankenhaus St. Trudpert, Dept. of Urology, Pforzheim, Germany, 15Klinikum Pirna, Dept. of Urology, Pirna, Germany, 16Klinikum St. Elisabeth, Dept. of Urology, Straubing, Germany, 17Klinikum Weiden, Dept. of Urology, Weiden, Germany, 18Westpfalz-Klinikum, Dept. of Urology, Kaiserslautern, Germany, 19Diakonie Krankenhaus, Dept. of Urology, Dessau, Germany, 20Klinikum Fulda, Dept. of Urology, Fulda, Germany, 21University of Freiburg, Dept. of Urology, Freiburg, Germany, 22Klinikum Wolfsburg,, Dept. of Urology, Wolfsburg, Germany, 23Elisabethenkrankenhaus,, Dept. of Urology, Leipzig, Germany INTRODUCTION & OBJECTIVES: Laparoscopic adrenalectomy (LA) has become the gold-standard approach for benign surgical adrenal disorders; however for solitary metastasis or primary adrenal cancer its precise role is uncertain. To evaluate the safety and feasibility of LA performed in several German centres with different laparoscopic experience. MATERIAL & METHODS: On behalf of the laparoscopic working group of the German Urological Association (DGU), we sent a questionnaire focusing on operative data after LA for benign and malignant conditions of the adrenal gland to 41 German urologic centres with laparoscopic experience. Twenty-three urological departments participated on this multi-centre study, prospectively collecting the data after LA. From 2003 to 2009 363 patients underwent a laparoscopic transperitoneal or retroperitoneal adrenalectomy at the participating urologic centres. All centres were stratified into 3 groups according to their experience: group A (< 10 adrenalectomies/year), group B (10-20 adrenalectomies/year) and group C (> 20 adrenalectomies/year). Group A included 13 centres; group B included 4 centres; and group C included 6 centres. Demographic data, perioperative and postoperative parameters, including operating time, surgical approach, tumour size, estimated blood loss, complications, length of hospital stay and histological tumour staging, were collected and analyzed.
Complications were defined according to the Clavien classification. RESULTS: The transperitoneal approach was used in 281 cases (77.4%) and the retroperitoneal approach was used in 82 patients (22.6%). The mean operative time was 127.22 ± 55.56 min and 130.16 ± 49.88 min after transperitoneal and retroperitoneal LA, respectively. The mean complication rates were 5% and 10.9%, respectively. Two hundred sixty-three of 363 lesions (72.5%) were benign and 100/363 lesions (27.5%) were malignant. Of the 37 primary
malignant
diseases,
34
were
represented
by
adrenocortical
carcinoma
and
3
by
malignant
pheochromocytoma. ACC tumours included 20 tumours represented by stage I and 14 tumours represented by stage II, according to the McFarlane-Sullivan classification. Three patients (3%) developed a postoperative port-site metastasis after laparoscopic retroperitoneal adrenalectomy. At multivariate analysis, there was a strong correlation between tumor size and operation time (r= 0.264, r2=0.069, p<0.0001) as well as the duration of hospital stay (r= 0.187, r2=0.35, p=0.001) (Fig.1, 3). Further, there was a moderate correlation between tumor size and the amount of estimated blood loss (Fig.1, 4). Furthermore, an inverse relationship was found between the tumor entity (benigne/maligne) and the duration of hospital stay (r=-0.103, r2=0.107, p=0.07), as well as operation time (r=-0.057, r2=0.003, p=ns). CONCLUSIONS: Transperitoneal and retroperitoneal LA performed by urologists with high laparoscopic experience is safe for the removal of benign and malignant adrenal masses. According to our study, laparoscopic surgery for malignant adrenal tumours should be performed only in high volume centers with at least > 10 adrenalectomies per year. At the same time surgeons with low laparoscopic experience should avoid to perform at the beginning of their learning curve LA for malignant disease because of the high risk to induce port-site metastasis.
Laparoscopic adrenalectomy in urologic centres – the experience of the German Laparoscopic Working Group Eur Urol Suppl 2013;12;e461
Springer C.1, Rassweiler J.2, Fahlenkamp D.3, Kutta N.4, Nesius D.4, Thüroff J.5, Krause A.6, Strohmaier W.7, Bachmann A.8, Hertle L.9, Popken G.10, Deger S.11, Jocham D.12, Doehn C.12, Loch T.13, Lahme S.14, Janitzky V.15, Gilfrich C.16, Klotz T.17, Kopper B.18, Rebmann U.19, Kälbe T.20, Wetterauer U.21, Leitenberger A.22, Raßler J.23, Fornara P.1, Greco F.1 1
UKH Universitätsklinikum Halle (Saale), Dept. of Urology, Halle Saale, Austria, 2SLK Kliniken Heilbronn, Dept. of
Urology, Heilbronn, Germany, 3Zeisigwaldkliniken Bethanien, Dept. of Urology, Chemnitz, Germany, 4Krankenhaus Der Barmherzigen Brüder, Dept. of Urology, Trier, Germany, 5University of Mainz, Dept. of Urology, Mainz, Germany, 6Kreiskrankenhaus
Freiberg, Dept. of Urology, Freiberg, Germany, 7Klinikum Coburg, Dept. of Urology, Coburg,
Germany, 8University of Basel, Dept. of Urology, Basel, Switzerland, 9University of Münster, Dept. of Urology, Münster, Germany, 10Helios Klinik Berlin-Buch, Dept. of Urology, Berlin, Germany, 11University of Berlin, Campus Charite´ Mitte, Dept. of Urology, Berlin, Germany, 12University of Lübeck, Dept. of Urology, Lübeck, Germany, 13Diakonie Krankenhaus, Dept. of Urology, Flensburg, Germany, 14Krankenhaus St. Trudpert, Dept. of Urology, Pforzheim, Germany, 15Klinikum Pirna, Dept. of Urology, Pirna, Germany, 16Klinikum St. Elisabeth, Dept. of Urology, Straubing, Germany, 17Klinikum Weiden, Dept. of Urology, Weiden, Germany, 18Westpfalz-Klinikum, Dept. of Urology, Kaiserslautern, Germany, 19Diakonie Krankenhaus, Dept. of Urology, Dessau, Germany, 20Klinikum Fulda, Dept. of Urology, Fulda, Germany, 21University of Freiburg, Dept. of Urology, Freiburg, Germany, 22Klinikum Wolfsburg,, Dept. of Urology, Wolfsburg, Germany, 23Elisabethenkrankenhaus,, Dept. of Urology, Leipzig, Germany INTRODUCTION & OBJECTIVES: Laparoscopic adrenalectomy (LA) has become the gold-standard approach for benign surgical adrenal disorders; however for solitary metastasis or primary adrenal cancer its precise role is uncertain. To evaluate the safety and feasibility of LA performed in several German centres with different laparoscopic experience. MATERIAL & METHODS: On behalf of the laparoscopic working group of the German Urological Association (DGU), we sent a questionnaire focusing on operative data after LA for benign and malignant conditions of the adrenal gland to 41 German urologic centres with laparoscopic experience. Twenty-three urological departments participated on this multi-centre study, prospectively collecting the data after LA. From 2003 to 2009 363 patients underwent a laparoscopic transperitoneal or retroperitoneal adrenalectomy at the participating urologic centres. All centres were stratified into 3 groups according to their experience: group A (< 10 adrenalectomies/year), group B (10-20 adrenalectomies/year) and group C (> 20 adrenalectomies/year). Group A included 13 centres; group B included 4 centres; and group C included 6 centres. Demographic data, perioperative and postoperative parameters, including operating time, surgical approach, tumour size, estimated blood loss, complications, length of hospital stay and histological tumour staging, were collected and analyzed.
Complications were defined according to the Clavien classification. RESULTS: The transperitoneal approach was used in 281 cases (77.4%) and the retroperitoneal approach was used in 82 patients (22.6%). The mean operative time was 127.22 ± 55.56 min and 130.16 ± 49.88 min after transperitoneal and retroperitoneal LA, respectively. The mean complication rates were 5% and 10.9%, respectively. Two hundred sixty-three of 363 lesions (72.5%) were benign and 100/363 lesions (27.5%) were malignant. Of the 37 primary
malignant
diseases,
34
were
represented
by
adrenocortical
carcinoma
and
3
by
malignant
pheochromocytoma. ACC tumours included 20 tumours represented by stage I and 14 tumours represented by stage II, according to the McFarlane-Sullivan classification. Three patients (3%) developed a postoperative port-site metastasis after laparoscopic retroperitoneal adrenalectomy. At multivariate analysis, there was a strong correlation between tumor size and operation time (r= 0.264, r2=0.069, p<0.0001) as well as the duration of hospital stay (r= 0.187, r2=0.35, p=0.001) (Fig.1, 3). Further, there was a moderate correlation between tumor size and the amount of estimated blood loss (Fig.1, 4). Furthermore, an inverse relationship was found between the tumor entity (benigne/maligne) and the duration of hospital stay (r=-0.103, r2=0.107, p=0.07), as well as operation time (r=-0.057, r2=0.003, p=ns). CONCLUSIONS: Transperitoneal and retroperitoneal LA performed by urologists with high laparoscopic experience is safe for the removal of benign and malignant adrenal masses. According to our study, laparoscopic surgery for malignant adrenal tumours should be performed only in high volume centers with at least > 10 adrenalectomies per year. At the same time surgeons with low laparoscopic experience should avoid to perform at the beginning of their learning curve LA for malignant disease because of the high risk to induce port-site metastasis.