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Laparoscopic bilateral partial adrenalectomy for pheochromocytoma
SURGICAL TECHNIQUES IN UROLOGY
LAPAROSCOPIC BILATERAL PARTIAL ADRENALECTOMY FOR PHEOCHROMOCYTOMA JIHAD H. KAOUK, SURENA MATIN, EMMANUEL L. BRAVO,
AND
INDERBIR S. GILL
ABSTRACT Introduction. To describe the technique of transperitoneal laparoscopic bilateral synchronous partial adrenalectomy in a patient with bilateral adrenal pheochromocytoma. Technical considerations. An 81-year-old woman with bilateral adrenal pheochromocytoma underwent bilateral laparoscopic partial adrenalectomy. A three-port transperitoneal approach was used for each side, with an additional port for liver retraction during right partial adrenalectomy. Laparoscopic flexible ultrasonography was invaluable for localizing the adrenal tumor and for precise planning of the line of excision. The right main adrenal vein was preserved. Dissection and enucleation of the adrenal tumor and parenchymal hemostasis was achieved effectively using a harmonic scalpel. The total operative time was 2 and 2.5 hours for the left and right adrenal gland, respectively. No major intraoperative hemodynamic instability was noted. The total blood loss was 150 mL, and the hospital stay was 4 days. Pathologic examination confirmed bilateral adrenal pheochromocytoma. Conclusions. Laparoscopic partial adrenalectomy for pheochromocytoma is safe and technically feasible. Intraoperative ultrasonography is helpful to accurately plan resection of the tumor. If tumor location permits, the main adrenal vein should be preserved to ensure adequate vascularity for the adrenal remnant. UROLOGY 60: 1100–1103, 2002. © 2002, Elsevier Science Inc.
P
artial adrenalectomy for pheochromocytoma is mainly indicated for patients with bilateral adrenal disease often associated with multiple endocrine neoplasia (MEN 2) and von Hippel-Lindau disease. Laparoscopy is now widely regarded as the preferred technique for performing adrenalectomy in the vast majority of patients with benign adrenal disease. To our knowledge, only 2 cases of bilateral synchronous laparoscopic partial adrenalectomy for pheochromocytoma have been reported.1,2 The goal of partial adrenalectomy is to excise the adrenal tumor completely with meticulous preservation of a functional remnant of adrenal tissue to obviate the need for medical adrenal replacement and avoid the side effects of lifelong steroid therapy. We describe a laparoscopic partial adrenalectomy technique, in which bilateral adrenal pheoFrom the Section of Laparoscopic and Minimally Invasive Surgery, Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio Reprint requests: Inderbir S. Gill, M.D., M.Ch., Section of Laparoscopic and Minimally Invasive Urology, Urological Institute, A100, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195 Submitted: May 14, 2002, accepted (with revisions): August 15, 2002
1100
© 2002, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
chromocytoma were completely excised, preserving a viable adrenal remnant bilaterally. MATERIAL AND METHODS An 81-year-old woman, American Society of Anesthesiologists class 3, presented with bilateral adrenal masses incidentally discovered during a routine medical checkup that included body magnetic resonance imaging. The adrenal tumor measured 2.5 ⫻ 1.8 cm and 4.0 ⫻ 2.8 cm for the right and left adrenal gland, respectively. Both adrenal glands showed increased signal intensity on T2-weighted magnetic resonance imaging, suggesting pheochromocytoma (Fig. 1). Biochemical evaluation did not reveal increased catecholamine level in the serum or urine. Before being referred to our center, the left adrenal mass was biopsied under computed tomography guidance and pathologically read as pheochromocytoma. Metaiodobenzylguanidine scan revealed increased isotope uptake of the left adrenal gland only. Her past surgical history included abdominal hysterectomy through a Pfannensteil incision. Although follow-up may be considered for a small nonfunctioning adrenal mass, our decision to operate was based on the biopsy-proved pheochromocytoma. During intraoperative manipulation of the adrenal glands, a significant increase in serum catecholamine was noted. Preoperative patient preparation included calcium channel blocker administration 1 week before surgery. The patient was admitted the day before surgery for intravenous hydration. Two bottles of magnesium citrate laxative were given the 0090-4295/02/$22.00 PII S0090-4295(02)02013-7
FIGURE 1. Preoperative magnetic resonance image revealing bilateral adrenal masses (arrows). evening before surgery for bowel preparation, and prophylactic antibiotics (intravenous Ancef, 1 g) was given at time of anesthesia induction. With the patient in the 45° modified left flank position, a three-port transperitoneal approach was used (Fig. 2), with the primary port placed in the umbilicus and used for the right and left adrenalectomies. The descending colon was mobilized medially, and the left renal vein was traced to the main left adrenal vein. Intraoperative ultrasonography was performed using a laparoscopic ultrasound probe, and the line of tumor excision was planned to preserve a normal-appearing cortical remnant. During left partial adrenalectomy, the main adrenal vein was heading directly into the adrenal mass, necessitating clip-ligation and transection. Using a harmonic scalpel (U.S. Surgical, Norwalk, Conn), the adrenal tumor was excised precisely with good parenchymal hemostasis (Fig. 3). The specimen was extracted intact within an Endocatch bag (Video). All ports were sutured, except for the umbilical port site, which was covered with a sterile dressing. The patient was repositioned in the 45° right flank position, and the same procedure was repeated for the right adrenal gland with some variation. An additional 5-mm port was inserted at the subxiphoid area to help in liver retraction cephalad (Fig. 2). The peritoneal reflection over the vena cava and parallel to the liver was incised, and the adrenal gland was exposed. Laparoscopic ultrasonography localized the adrenal tumor, which was away from the main adrenal vein. Using the harmonic scalpel, the tumor was completely excised, and the main right adrenal vein was preserved.
FIGURE 2. Patient placed in 45° modified flank position. (A) For laparoscopic left partial adrenalectomy, a three-port transperitoneal approach was used. (B) During right partial adrenalectomy, a four-port transperitoneal approach was used, with an additional 5-mm port placed at the subxyphoid area for liver retraction. Note that the 12-mm port placed at the umbilicus was used for both sides. Reprinted with the permission of the Cleveland Clinic Foundation.
RESULTS The total operative time was 5 hours (2 hours for the left and 2.5 hours for the right adrenal gland, and 30 minutes for repositioning). The estimated blood loss was 150 mL. Hemodynamically, no major fluctuations were noted. The blood pressure ranged between 180/90 and 80/50 mm Hg. The pulse rate ranged between 50 and 110 beats per minute without arrhythmias. No vasodilator medication was necessary intraoperatively. The blood catecholamine levels were measured at induction, directly after adrenal vein clamping, and in the recovery area 1 hour after surgery (Table I). During tumor manipulation, serum catecholamine evaluation revealed a significant increase in epinephrine and norepinephrine from a UROLOGY 60 (6), 2002
FIGURE 3. Intraoperative laparoscopic view demonstrating partial left adrenalectomy using a harmonic scalpel. Note the preserved adrenal remnant (arrows). 1101
TABLE I. Serum adrenal function tests at different operative intervals
Cortisol Aldosterone Dopamine Epinephrine Norepinephrine
Adrenal Dissection
Before Surgery
Induction
NA NA 48 70 179
NA 7.1 45 1371 597
Left
Right
After Surgery*
Normal Value†
Unit
NA 5.7 79 3243 930
NA NA ⬍20 584 421
13.8 ⬍2.5 ⬍20 18 547
3.4–26.9 4.5–35.4 0–20 10–200 80–520
g/hr ng/dL pg/mL pg/mL pg/mL
KEY: NA ⫽ not assessed. *Forty-eight hours after surgery. † Normal values at the Cleveland Clinic Laboratory.
baseline of 70 pg/mL and 179 pg/mL to greater than 2000 pg/mL and 930 pg/mL, respectively. The patient resumed oral fluids and ambulation on postoperative day 1, and the hospital stay was 4 days. The total amount of analgesia comprised 32.4 mg of morphine sulfate equivalent. No intraoperative complications were noted. Postoperatively, however, the patient had episodes of mild orthostatic hypotension; thus, steroid therapy (dexamethasone) was started temporarily, awaiting the results of adrenocorticotropic adrenal stimulation test. She resumed normal activity within 3 weeks after surgery. The pathologic examination documented bilateral, completely excised, pheochromocytomas. The patient was asymptomatic with no signs of pheochromocytoma recurrence after 3 months of follow-up (Fig. 4). COMMENT Traditionally, treatment of bilateral adrenal pheochromocytoma includes bilateral total adrenalectomy. However, this approach requires lifelong steroid replacement, resulting in numerous related side effects. Preservation of normal adrenocortical tissue is important in patients with a solitary adrenal gland or bilateral adrenal disease, obviating the need for medical adrenal replacement therapy. More than 49 cases of laparoscopic partial adrenalectomy have been reported3– 6; however only 2 cases were synchronous laparoscopic bilateral partial adrenalectomy (Table II). Recurrence of pheochromocytoma is a concern during partial adrenalectomy, especially for hereditary forms of pheochromocytoma. In patients with MEN 2 and von Hippel-Lindau disease, recurrence occurred in 0% to 33% and 15% of cases after 54 to 88 months and 18 months, respectively.2 Preservation of only the adrenal tail during partial adrenalectomy may decrease recurrence because of the lack of medullary tissue in that portion of the gland. Recurrence was not reported for any of the reviewed 49 laparoscopic cases; however, since this is a new technique, only 1 report had a 3-year follow-up after a laparoscopic partial adrenalec1102
tomy for hereditary pheochromocytoma with no recurrence.7 The risk of a hypertensive crisis during surgery cannot be ignored; however, it can be reduced by adequate preoperative calcium channel blockade and gentle intraoperative manipulation of the adrenal mass. Preservation of the main adrenal vein is recommended if possible because of the theoretical risk of adrenal congestion with increased risks of adrenal parenchymal hemorrhage or venous thrombosis and adrenal remnant necrosis after surgery. However, the rich blood supply of the adrenal gland facilitates segmental resection of it. Ligation of the main adrenal vein diverts blood drainage into small venae comitantes or emissary veins that accompany the arterial blood supply.7 In our case, we ligated the main left adrenal vein, because it was adjacent to the adrenal mass; however, no increased bleeding was noted compared with the right adrenal gland, whose main adrenal vein was preserved. In an effort to achieve secure hemostasis during partial adrenalectomy, several techniques have been described. The harmonic scalpel provides adequate hemostasis during adrenal parenchymal dissection; however, it may not control major adrenal blood vessels, necessitating additional bipolar
FIGURE 4. Two month postoperative photograph of the patient’s abdomen demonstrating healed port site incisions (arrows). UROLOGY 60 (6), 2002
None Right, 0.5 ⫾ 0.3 Left, 0.5
Right, 2 Left, 3.2
100
150 Right, 150 Left, 120
CONCLUSIONS
Transperitoneal
Right preserved, left clipped
Laparoscopic adrenal cortex-sparing surgery for select patients with bilateral adrenal pheochromocytoma is safe and effective. Synchronous, bilateral laparoscopic partial adrenalectomy is well tolerated with relatively low morbidity. Laparoscopic intraoperative ultrasonography is helpful for accurate localization and excision planning of the tumor. The harmonic scalpel helps reduce parenchymal bleeding in such procedures.
KEY: EBL ⫽ estimated blood loss; NA ⫽ not assessed.
1 Current case
6
1 Walther et al.,2 2000
6
Transperitoneal
Clipped
Right, 205 Left, 200
Right, 90 Left, 160 5 Radmayr et al., 2000
Investigator
1
1
Transperitoneal
Preserved
Electrocautery and ultrasonic scalpel and fibrin glue Suture ligature and ultrasonic scalpel Ultrasonic scalpel
None
None NA NA
Complications Specimen Size (cm) EBL (mL) Operative Time (min) Cutting Device Main Adrenal Vein Approach Total Ports (n) Patients (n)
TABLE II. Laparoscopic bilateral synchronous partial adrenalectomy for pheochromocytoma
UROLOGY 60 (6), 2002
coagulation, clipping, or suturing of major bleeders. EndoGIA stapler (U.S. Surgical) has also been used for tumor excision during partial adrenalectomy.3,4 Even though hemostasis may be achieved, the stapler may not allow excision of the tumor with high precision. Fibrin glue or Surgicel may be a good adjunct for additional hemostasis.1 Laparoscopic adrenalectomy has been performed using the transperitoneal and the retroperitoneal approach.8 To our knowledge, no prospective studies have yet been published proving the advantage of the retroperitoneal versus the transperitoneal approach. We used the transperitoneal approach for this particular case for the advantage of using the umbilical port as a primary port during both procedures.
REFERENCES 1. Radmayr C, Neumann H, Bartsch G, et al: Laparoscopic partial adrenalectomy for bilateral pheochromocytoma in a boy with von Hipple-Landau disease. Eur Urol 38: 344 –348, 2000. 2. Walther MM, Herring J, Choyke PL, et al: Laparoscopic partial adrenalectomy in patients with hereditary forms of pheochromocytoma. J Urol 164: 14 –17, 2000. 3. Sasagawa I, Suzuki H, Tateno T, et al: Retroperitoneoscopic partial adrenalectomy using an endoscopic stapling device in patients with adrenal tumor. Urol Int 61: 101–103, 1998. 4. Imai T, Tanaka Y, Kikumori T, et al: Laparoscopic partial adrenalectomy. Surg Endosc 13: 343–345, 1999. 5. Ishikawa T, Inaba M, Nishiguchi Y, et al: Laparoscopic adrenalectomy for benign adrenal tumors. Biomed Pharmacother 54: 183–186, 2000. 6. Sasagawa I, Suzuki H, Izumi T, et al: Posterior retroperitoneoscopic partial adrenalectomy using ultrasonic scalpel for aldosterone-producing adenoma. J Endourol 14: 573–576, 2000. 7. Walther M, Keiser HR, Choyke PL, et al: Management of hereditary pheochromocytoma in von Hippel-Landau kindreds with partial adrenalectomy. J Urol 161: 395–398, 1999. 8. Hsu THS, and Gill IS: Bilateral laparoscopic adrenalectomy: retroperitoneal and transperitoneal approaches. Urology 59: 184 –189, 2002.
A video clip of this procedure can be viewed on the Internet at: http://www.goldjournal. net.
1103
LAPAROSCOPIC BILATERAL PARTIAL ADRENALECTOMY FOR PHEOCHROMOCYTOMA JIHAD H. KAOUK, SURENA MATIN, EMMANUEL L. BRAVO,
AND
INDERBIR S. GILL
ABSTRACT Introduction. To describe the technique of transperitoneal laparoscopic bilateral synchronous partial adrenalectomy in a patient with bilateral adrenal pheochromocytoma. Technical considerations. An 81-year-old woman with bilateral adrenal pheochromocytoma underwent bilateral laparoscopic partial adrenalectomy. A three-port transperitoneal approach was used for each side, with an additional port for liver retraction during right partial adrenalectomy. Laparoscopic flexible ultrasonography was invaluable for localizing the adrenal tumor and for precise planning of the line of excision. The right main adrenal vein was preserved. Dissection and enucleation of the adrenal tumor and parenchymal hemostasis was achieved effectively using a harmonic scalpel. The total operative time was 2 and 2.5 hours for the left and right adrenal gland, respectively. No major intraoperative hemodynamic instability was noted. The total blood loss was 150 mL, and the hospital stay was 4 days. Pathologic examination confirmed bilateral adrenal pheochromocytoma. Conclusions. Laparoscopic partial adrenalectomy for pheochromocytoma is safe and technically feasible. Intraoperative ultrasonography is helpful to accurately plan resection of the tumor. If tumor location permits, the main adrenal vein should be preserved to ensure adequate vascularity for the adrenal remnant. UROLOGY 60: 1100–1103, 2002. © 2002, Elsevier Science Inc.
P
artial adrenalectomy for pheochromocytoma is mainly indicated for patients with bilateral adrenal disease often associated with multiple endocrine neoplasia (MEN 2) and von Hippel-Lindau disease. Laparoscopy is now widely regarded as the preferred technique for performing adrenalectomy in the vast majority of patients with benign adrenal disease. To our knowledge, only 2 cases of bilateral synchronous laparoscopic partial adrenalectomy for pheochromocytoma have been reported.1,2 The goal of partial adrenalectomy is to excise the adrenal tumor completely with meticulous preservation of a functional remnant of adrenal tissue to obviate the need for medical adrenal replacement and avoid the side effects of lifelong steroid therapy. We describe a laparoscopic partial adrenalectomy technique, in which bilateral adrenal pheoFrom the Section of Laparoscopic and Minimally Invasive Surgery, Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio Reprint requests: Inderbir S. Gill, M.D., M.Ch., Section of Laparoscopic and Minimally Invasive Urology, Urological Institute, A100, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195 Submitted: May 14, 2002, accepted (with revisions): August 15, 2002
1100
© 2002, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
chromocytoma were completely excised, preserving a viable adrenal remnant bilaterally. MATERIAL AND METHODS An 81-year-old woman, American Society of Anesthesiologists class 3, presented with bilateral adrenal masses incidentally discovered during a routine medical checkup that included body magnetic resonance imaging. The adrenal tumor measured 2.5 ⫻ 1.8 cm and 4.0 ⫻ 2.8 cm for the right and left adrenal gland, respectively. Both adrenal glands showed increased signal intensity on T2-weighted magnetic resonance imaging, suggesting pheochromocytoma (Fig. 1). Biochemical evaluation did not reveal increased catecholamine level in the serum or urine. Before being referred to our center, the left adrenal mass was biopsied under computed tomography guidance and pathologically read as pheochromocytoma. Metaiodobenzylguanidine scan revealed increased isotope uptake of the left adrenal gland only. Her past surgical history included abdominal hysterectomy through a Pfannensteil incision. Although follow-up may be considered for a small nonfunctioning adrenal mass, our decision to operate was based on the biopsy-proved pheochromocytoma. During intraoperative manipulation of the adrenal glands, a significant increase in serum catecholamine was noted. Preoperative patient preparation included calcium channel blocker administration 1 week before surgery. The patient was admitted the day before surgery for intravenous hydration. Two bottles of magnesium citrate laxative were given the 0090-4295/02/$22.00 PII S0090-4295(02)02013-7
FIGURE 1. Preoperative magnetic resonance image revealing bilateral adrenal masses (arrows). evening before surgery for bowel preparation, and prophylactic antibiotics (intravenous Ancef, 1 g) was given at time of anesthesia induction. With the patient in the 45° modified left flank position, a three-port transperitoneal approach was used (Fig. 2), with the primary port placed in the umbilicus and used for the right and left adrenalectomies. The descending colon was mobilized medially, and the left renal vein was traced to the main left adrenal vein. Intraoperative ultrasonography was performed using a laparoscopic ultrasound probe, and the line of tumor excision was planned to preserve a normal-appearing cortical remnant. During left partial adrenalectomy, the main adrenal vein was heading directly into the adrenal mass, necessitating clip-ligation and transection. Using a harmonic scalpel (U.S. Surgical, Norwalk, Conn), the adrenal tumor was excised precisely with good parenchymal hemostasis (Fig. 3). The specimen was extracted intact within an Endocatch bag (Video). All ports were sutured, except for the umbilical port site, which was covered with a sterile dressing. The patient was repositioned in the 45° right flank position, and the same procedure was repeated for the right adrenal gland with some variation. An additional 5-mm port was inserted at the subxiphoid area to help in liver retraction cephalad (Fig. 2). The peritoneal reflection over the vena cava and parallel to the liver was incised, and the adrenal gland was exposed. Laparoscopic ultrasonography localized the adrenal tumor, which was away from the main adrenal vein. Using the harmonic scalpel, the tumor was completely excised, and the main right adrenal vein was preserved.
FIGURE 2. Patient placed in 45° modified flank position. (A) For laparoscopic left partial adrenalectomy, a three-port transperitoneal approach was used. (B) During right partial adrenalectomy, a four-port transperitoneal approach was used, with an additional 5-mm port placed at the subxyphoid area for liver retraction. Note that the 12-mm port placed at the umbilicus was used for both sides. Reprinted with the permission of the Cleveland Clinic Foundation.
RESULTS The total operative time was 5 hours (2 hours for the left and 2.5 hours for the right adrenal gland, and 30 minutes for repositioning). The estimated blood loss was 150 mL. Hemodynamically, no major fluctuations were noted. The blood pressure ranged between 180/90 and 80/50 mm Hg. The pulse rate ranged between 50 and 110 beats per minute without arrhythmias. No vasodilator medication was necessary intraoperatively. The blood catecholamine levels were measured at induction, directly after adrenal vein clamping, and in the recovery area 1 hour after surgery (Table I). During tumor manipulation, serum catecholamine evaluation revealed a significant increase in epinephrine and norepinephrine from a UROLOGY 60 (6), 2002
FIGURE 3. Intraoperative laparoscopic view demonstrating partial left adrenalectomy using a harmonic scalpel. Note the preserved adrenal remnant (arrows). 1101
TABLE I. Serum adrenal function tests at different operative intervals
Cortisol Aldosterone Dopamine Epinephrine Norepinephrine
Adrenal Dissection
Before Surgery
Induction
NA NA 48 70 179
NA 7.1 45 1371 597
Left
Right
After Surgery*
Normal Value†
Unit
NA 5.7 79 3243 930
NA NA ⬍20 584 421
13.8 ⬍2.5 ⬍20 18 547
3.4–26.9 4.5–35.4 0–20 10–200 80–520
g/hr ng/dL pg/mL pg/mL pg/mL
KEY: NA ⫽ not assessed. *Forty-eight hours after surgery. † Normal values at the Cleveland Clinic Laboratory.
baseline of 70 pg/mL and 179 pg/mL to greater than 2000 pg/mL and 930 pg/mL, respectively. The patient resumed oral fluids and ambulation on postoperative day 1, and the hospital stay was 4 days. The total amount of analgesia comprised 32.4 mg of morphine sulfate equivalent. No intraoperative complications were noted. Postoperatively, however, the patient had episodes of mild orthostatic hypotension; thus, steroid therapy (dexamethasone) was started temporarily, awaiting the results of adrenocorticotropic adrenal stimulation test. She resumed normal activity within 3 weeks after surgery. The pathologic examination documented bilateral, completely excised, pheochromocytomas. The patient was asymptomatic with no signs of pheochromocytoma recurrence after 3 months of follow-up (Fig. 4). COMMENT Traditionally, treatment of bilateral adrenal pheochromocytoma includes bilateral total adrenalectomy. However, this approach requires lifelong steroid replacement, resulting in numerous related side effects. Preservation of normal adrenocortical tissue is important in patients with a solitary adrenal gland or bilateral adrenal disease, obviating the need for medical adrenal replacement therapy. More than 49 cases of laparoscopic partial adrenalectomy have been reported3– 6; however only 2 cases were synchronous laparoscopic bilateral partial adrenalectomy (Table II). Recurrence of pheochromocytoma is a concern during partial adrenalectomy, especially for hereditary forms of pheochromocytoma. In patients with MEN 2 and von Hippel-Lindau disease, recurrence occurred in 0% to 33% and 15% of cases after 54 to 88 months and 18 months, respectively.2 Preservation of only the adrenal tail during partial adrenalectomy may decrease recurrence because of the lack of medullary tissue in that portion of the gland. Recurrence was not reported for any of the reviewed 49 laparoscopic cases; however, since this is a new technique, only 1 report had a 3-year follow-up after a laparoscopic partial adrenalec1102
tomy for hereditary pheochromocytoma with no recurrence.7 The risk of a hypertensive crisis during surgery cannot be ignored; however, it can be reduced by adequate preoperative calcium channel blockade and gentle intraoperative manipulation of the adrenal mass. Preservation of the main adrenal vein is recommended if possible because of the theoretical risk of adrenal congestion with increased risks of adrenal parenchymal hemorrhage or venous thrombosis and adrenal remnant necrosis after surgery. However, the rich blood supply of the adrenal gland facilitates segmental resection of it. Ligation of the main adrenal vein diverts blood drainage into small venae comitantes or emissary veins that accompany the arterial blood supply.7 In our case, we ligated the main left adrenal vein, because it was adjacent to the adrenal mass; however, no increased bleeding was noted compared with the right adrenal gland, whose main adrenal vein was preserved. In an effort to achieve secure hemostasis during partial adrenalectomy, several techniques have been described. The harmonic scalpel provides adequate hemostasis during adrenal parenchymal dissection; however, it may not control major adrenal blood vessels, necessitating additional bipolar
FIGURE 4. Two month postoperative photograph of the patient’s abdomen demonstrating healed port site incisions (arrows). UROLOGY 60 (6), 2002
None Right, 0.5 ⫾ 0.3 Left, 0.5
Right, 2 Left, 3.2
100
150 Right, 150 Left, 120
CONCLUSIONS
Transperitoneal
Right preserved, left clipped
Laparoscopic adrenal cortex-sparing surgery for select patients with bilateral adrenal pheochromocytoma is safe and effective. Synchronous, bilateral laparoscopic partial adrenalectomy is well tolerated with relatively low morbidity. Laparoscopic intraoperative ultrasonography is helpful for accurate localization and excision planning of the tumor. The harmonic scalpel helps reduce parenchymal bleeding in such procedures.
KEY: EBL ⫽ estimated blood loss; NA ⫽ not assessed.
1 Current case
6
1 Walther et al.,2 2000
6
Transperitoneal
Clipped
Right, 205 Left, 200
Right, 90 Left, 160 5 Radmayr et al., 2000
Investigator
1
1
Transperitoneal
Preserved
Electrocautery and ultrasonic scalpel and fibrin glue Suture ligature and ultrasonic scalpel Ultrasonic scalpel
None
None NA NA
Complications Specimen Size (cm) EBL (mL) Operative Time (min) Cutting Device Main Adrenal Vein Approach Total Ports (n) Patients (n)
TABLE II. Laparoscopic bilateral synchronous partial adrenalectomy for pheochromocytoma
UROLOGY 60 (6), 2002
coagulation, clipping, or suturing of major bleeders. EndoGIA stapler (U.S. Surgical) has also been used for tumor excision during partial adrenalectomy.3,4 Even though hemostasis may be achieved, the stapler may not allow excision of the tumor with high precision. Fibrin glue or Surgicel may be a good adjunct for additional hemostasis.1 Laparoscopic adrenalectomy has been performed using the transperitoneal and the retroperitoneal approach.8 To our knowledge, no prospective studies have yet been published proving the advantage of the retroperitoneal versus the transperitoneal approach. We used the transperitoneal approach for this particular case for the advantage of using the umbilical port as a primary port during both procedures.
REFERENCES 1. Radmayr C, Neumann H, Bartsch G, et al: Laparoscopic partial adrenalectomy for bilateral pheochromocytoma in a boy with von Hipple-Landau disease. Eur Urol 38: 344 –348, 2000. 2. Walther MM, Herring J, Choyke PL, et al: Laparoscopic partial adrenalectomy in patients with hereditary forms of pheochromocytoma. J Urol 164: 14 –17, 2000. 3. Sasagawa I, Suzuki H, Tateno T, et al: Retroperitoneoscopic partial adrenalectomy using an endoscopic stapling device in patients with adrenal tumor. Urol Int 61: 101–103, 1998. 4. Imai T, Tanaka Y, Kikumori T, et al: Laparoscopic partial adrenalectomy. Surg Endosc 13: 343–345, 1999. 5. Ishikawa T, Inaba M, Nishiguchi Y, et al: Laparoscopic adrenalectomy for benign adrenal tumors. Biomed Pharmacother 54: 183–186, 2000. 6. Sasagawa I, Suzuki H, Izumi T, et al: Posterior retroperitoneoscopic partial adrenalectomy using ultrasonic scalpel for aldosterone-producing adenoma. J Endourol 14: 573–576, 2000. 7. Walther M, Keiser HR, Choyke PL, et al: Management of hereditary pheochromocytoma in von Hippel-Landau kindreds with partial adrenalectomy. J Urol 161: 395–398, 1999. 8. Hsu THS, and Gill IS: Bilateral laparoscopic adrenalectomy: retroperitoneal and transperitoneal approaches. Urology 59: 184 –189, 2002.
A video clip of this procedure can be viewed on the Internet at: http://www.goldjournal. net.
1103