- Email: [email protected]
Posterior Retroperitoneoscopic Partial Adrenalectomy: Clinical Experience in 47 Procedures
European Urology
European Urology 43 (2003) 381–385
Posterior Retroperitoneoscopic Partial Adrenalectomy: Clinical Experience in 47 Procedures Isoji Sasagawa*, Yasuhiro Suzuki, Keiichi Itoh, Takuji Izumi, Michiharu Miura, Hitoshi Suzuki, Yoshihiko Tomita Department of Urology, Yamagata University School of Medicine, 2-2-2 Iidanishi, Yamagata-shi, Yamagata 990-9585, Japan Accepted 7 February 2003
Abstract Objectives: We evaluated posterior retroperitoneoscopic partial adrenalectomy with regard to operative complications, operation time, intraoperative blood loss. Patients and Methods: Between January 1997 and April 2002, we performed 47 posterior retroperitoneoscopic partial adrenalectomies. There were 18 males and 29 females with a mean age of 48 years (range 28–82 years). The average adrenal tumor size was 26 mm (range 10–50 mm). All procedures required three trocars. Results: There was no mortality and conversion rate to open surgery was 2.1%. Average operative time and average blood loss was 198.0 ml (range 71–420 ml) and 40.8 ml (range 0–1100 ml), respectively. There was a significant correlation of operative time with the number of procedures performed. However, no significant correlation was observed between intraoperative blood loss and the number of procedures. Tumor size did not correlate with intraoperative blood loss and operative time. No significant correlation was found between body mass index and operative time. The operative time in the initial 20 cases was significantly longer than that in the subsequent 26 cases. Conclusion: Posterior retroperitoneoscopic partial adrenalectomy is a safe and less invasive method for treatment of adrenal tumors. With improved operative technique, the time required for this procedure has been decreased. # 2003 Elsevier Science B.V. All rights reserved. Keywords: Partial adrenalectomy; Retroperitoneoscopy; Adrenal tumor; Complication
1. Introduction Since 1992, laparoscopic adrenalectomy has become a standard procedure for the treatment of adrenal tumors [1]. For primary tumors of the adrenal gland the excellent view with endoscopic operating procedures makes the surgeon possible to distinguish between adrenal neoplasia and normal adrenal gland parenchyma. Therefore, laparoscopic partial adrenalectomy has been mentioned for the first time by Janetschek et al. for aldosterone-producing adenoma [2] and pheochromocytoma [3]. In addition, Walz et al. [4] reported partial adrenalectomy for Cushing adenomas. Since 1997, we have applied posterior retroperitoneoscopic partial adrenalectomy to 47 patients with unilateral adrenal *
Corresponding author. Tel.: þ81-236-242837; Fax: þ81-236-242837. E-mail address: [email protected] (I. Sasagawa).
tumor. The aim of the present study was to analyze prospectively 47 posterior retroperitoneoscopic partial adrenalectomies with regard to intraoperative complications, morbidity, and length of operation time.
2. Patients and methods 2.1. Patients Between January 1997 and April 2002, 47 patients underwent posterior retroperitonoescopic partial adrenalectomy. There were 18 males and 29 females from 28 years to 82 years of age (mean 48 years). All patients had a typically solitary adenoma (right side in 27 and left side in 20). The tumor size ranged from 10 mm to 50 mm (mean 26). There were 13 cases of primary aldosteronism, 10 cases of Cushing’s syndrome (including 6 with pre-Cushing’s syndrome), 3 cases of pheochromocytoma, 2 cases of myelolipoma, 1 case of ganglioneuroma and 18 cases of nonfunctioning tumor. Since the diagnosis of myelolipoma could not be made preoperatively, two cases were included in this study. Nonfunctioning
0302-2838/03/$ – see front matter # 2003 Elsevier Science B.V. All rights reserved. doi:10.1016/S0302-2838(03)00087-3
382
I. Sasagawa et al. / European Urology 43 (2003) 381–385
tumors with diameter greater than 30 mm were also included in this study. 2.2. Surgical technique Patients were positioned in a low jackknife prone position with the trunk-thigh hinge of the table used as a flexion point to open the relevant posterior lumbar area between the 12th rib and iliac crest [5]. A 20 mm transverse incision just below the tip of the 12th rib was made for the first port. After preparation of the subcutaneous and muscle layers by sharp and blunt dissection, the retroperitoneal space was easily accessible by digital perforation of the dorsolumbar fascia. Subsequently, an artificial cavity was created using a distension balloon trocar (OMS-PDB 1000-S; Origin, San Francisco, CA, USA), which is inflated under endoscopic control to 60– 80 mm in diameter, ventral to Gerota’s fascia. After removing the distension trocar, the resulting cavity was palpated digitally, and two 10 mm standard trocars introduced with internal finger guide 20–30 mm laterally and medially to the first port. Then a blunt trocar with an inflatable balloon and adjustable sleeve (OMST10GS, Origin) was introduced into the first port and blocked. Thereafter, CO2 retropneumoperitoneum was created by maintaining a CO2 pressure of 10–12 mmHg. Retroperitoneoscopy was carried out with a 5 mm 08 endoscope introduced via the first port. Preparation began by the incision of the Gerota’s fascia from just below the diaphragm. Dissection of the adrenal gland was begun using an ultrasonic aspirator system (Olympus Ltd., Tokyo, Japan). During this procedure, the dissection plane remains close to the renal surface to avoid injury to the adjacent organs. In addition, endoscopic blunt-tip and Cherry dissectors (Ethicon, Cincinnati, OH, USA) were used. Partial adrenalectomy was carried out without clipping the adrenal vein, which emerged from the hilus of the gland, emptying into the inferior caval vein on the right side and renal vein on the left side. At partial adrenalectomy, the line of the adrenal resection does not always correspond with the avascular or hypervascular region, as the gland is supplied by superior, middle and inferior arteries. To identify the margin of the adenoma, the surrounding fatty tissue was removed. After clear identification, the adrenal tumor was resected using an endoscopic stapling device (ETS-Flex Endoscopic Linear Cutter; Ethicon) or an ultrasonically activated scalpel at level 3 (Harmonic Scalpel LCS 15, Ethicon) [6,7], and the tumor and its attached uninvolved adrenal tissue removed. The adrenal tissue was extracted through the middle port with a retrieval bag system (Endopouch; Olympus). Depending on the tumor size, the incision site occasionally needed to be enlarged. All ports were closed with fascial and subcuticular sutures after optional drain insertion. 2.3. Statistical analysis All data were entered into a computer database and results are expressed as the mean S:D: Statistical analysis of the learning curve effect, and the influence of tumor size and body mass index (BMI) on results was done using Pearson’s correlation coefficients and Student’s t test. Comparative analysis of two groups was performed using Student’s t test. Significance was defined as p < 0:05.
Table 1 Comparison of initial 20 cases and subsequent 26 cases in operative time and blood loss Variables
Initial 20 cases
Subsequent 26 cases
Operative time (minutes) Blood loss (ml)
269.9 65.4 77.1 242.1
198.0 86.2** 12.8 26.7
Each value represents mean S:D: ** p < 0:01: compared to the initial 20 cases.
retroperitoneoscopic partial adrenalectomy, there were three (6.4%) adrenal bleedings, two (4.3%) pneumothraxes, one (2.1%) massive hemorrhage (more than 1000 ml) and one (2.1%) injury of the renal vein. Adrenal bleeding was successfully controlled using a hemostatic agent [8]. Pneumothorax was detected after posterior retroperitoneoscopic adrenalectomy, and pleural drainage was required. Massive hemorrhage was caused by a superior adrenal vein injury and blood transfusion of 600 ml was required. One operation was converted to open surgery. These complication occurred only until the initial 20 cases. After excluding one patient with conversion to open surgery, average operative time and average blood loss were 198.0 minutes (71–420 minutes) and 40.8 ml (0–1100 ml), respectively. There was a significant correlation of operative time with the number of procedures (r ¼ 0:721, p < 0:001). However, no significant correlation was found between intraoperative blood loss and the number of procedures (r ¼ 0:219). As shown in Table 1, the operative time in our initial 20 cases was significantly longer than that in the subsequent 26 cases. However, intraoperative blood loss was not different between the initial 20 cases and subsequent 26 cases. Tumor size did not significantly correlate with intraoperative blood loss and operative time (Fig. 1). No significant correlation was found between body mass index and operative time (Fig. 2). All patients with functional cortical adenoma and pheochromocytoma showed normal adrenal function after the operation. In patients with nonfunctioning tumor, no endocrinological changes were found after the partial adrenalectomy. Postoperative adrenal scintigraphy with the use of 131 I-idiomethyl norcholestenol showed that the adrenal remnant was actually functional. Cortisol supplementation was not required for any of the patients.
3. Results 4. Discussion Posterior retroperitoneoscopic partial adrenalectomy was successfully performed in 46 of 47 patients (97.9%). As intraoperative complications of posterior
During the course of the rapid development in endoscopic surgery, endoscopic preparation to the
I. Sasagawa et al. / European Urology 43 (2003) 381–385
Fig. 1. (A) Tumor size vs. operative time, r ¼ 0:198, p > 0:05. (B) Tumor size vs. intraoperative blood loss, r ¼ 0:196, p > 0:05.
adrenal glands has become the standard procedure. Compared with the transperitoneal laparoscopic approach, retroperitoneoscopic approach seems to have specific advantages. Since the peritoneal cavity
Fig. 2. No significant correlation between body mass index (BMI) and operative time. r ¼ 0:116, p > 0:05.
383
is avoided completely, manipulation and mobilization of bowel is virtually nonexistent. The retroperitoneoscopy is superior in patients with intraperitoneal adhesions secondary to prior abdominal surgery. In addition, retroperitoneoscopic approach is preferred in markedly or morbidly obese patients, because it gives a shorter and more direct access to the adrenal gland. There are two retroperitoneoscopic approaches to the adrenal gland: retroperitoneal lateral [9–11] and retroperitoneal posterior [5,12]. The lateral retroperitoneal approach is performed with the patient in the standard flank position, while the posterior retroperitoneal approach is performed with the patient in the prone position. Since the parietal peritoneum is bluntly dissected down to the line of the midclavicular line in lateral approach, the space created by lateral approach is usually larger than that made by posterior approach. With lateral approach, the anatomic landmarks are the upper pole of the ipsilateral kidney, the parietal peritoneum and psoas muscle. Therefore, the difficulty in the identification of the adrenal gland, which looks like the same yellow fragile tissue as perirenal fat, may misdirect the cleavage line even to the pancreas tail by left adrenalectomy. According to Baba et al. [12], the operation time with posterior retroperitoneoscopic adrenalectomy is shorter than that with lateral retroperitoneoscopic adrenalectomy by almost 50 minutes. Furthermore, posterior approach usually requires three trocar sites, while lateral approach needs four to five trocar sites. These findings indicate that posterior retroperitoneoscopic adrenalectomy is the most minimally invasive operation. Partial adrenalectomy has been usually recommended for bilateral hereditary pheochromocytomas to maintain cortical function of the adrenal gland [13–15]. Recently, partial adrenalectomy has been reported in patients with alodosterone-producing adenoma [2,7,16]. With regard to therapeutic outcome, ambulation and furosemide administration under lowsodium diet stimuli remarkably enhanced plasma renin activity and aldosterone in the partial adrenalectomy group, so that the findings were similar to those of normal subjects, but increment magnitudes were decreased in the adrenalectomy group five years after operation [17]. Postoperatively, the responses of plasma aldosterone to angiotensin II infusion and of plasma cortisol to ACTH administration were more sensitive in the partial adrenalectomy group than those in the adrenalectomy group [17]. However, there was no recurrence of hyperaldosteronism in either group. These facts indicate that partial adrenalectomy for aldosteroneproducing adenoma is preferable to adrenalectomy. Endoscopic operating procedures give an excellent view
384
I. Sasagawa et al. / European Urology 43 (2003) 381–385
of the adrenal gland and its surroundings, allowing clear differentiation of tumor and normal tissue, thereby making precise dissection possible. In patients with Cushing adenoma and sporadic pheochromocytoma, tumors less than 30 mm in diameter should be regarded as benign and subsequently do not require radical resection to preserve remnant adrenal function. Total adrenalectomy is necessary for patients with suspected malignancy. Although malignant adrenal tumors are usually greater than 50 mm in diameter [18], adrenal tumors with diameter greater than 30 mm are not excluded from malignancy [19]. In our series, therefore, partial adrenalectomy was indicated for nonfunctioning tumors with diameter greater than 30 mm. Since leaving as much normal adrenal tissue as possible is more physiologic and provides patients with more hormone reserve, partial adrenalectomy not only with bilateral tumors but also with unilateral tumors seems generally rationale. Therefore, partial adrenalectomy may be indicated for Cushing adenoma, sporadic pheochromocytoma and nonfunctioning adenoma under certain preconditions. According to Suzuki et al. [20], there are significant correlations of tumor size with intraoperative blood loss, body mass index and operative time for laparoscopic adrenalectomy. In our series, however, tumor size did not correlate with intraoperative blood loss. In
addition, no significant correlation was found between body mass index and operative time. Partial adrenalectomy was usually carried out without clipping the adrenal vein, which emerged from hilus of the gland, emptying into the inferior caval vein on the right side and the renal vein on the left side. When a normal limb of an adrenal gland reaches deep into the renal hilum or adheres to the liver, making complete resection risky, partial adrenalectomy is safer than total adrenalectomy. Therefore, this procedure can reduce intraoperative blood loss and operation time even in cases with large tumor size, and can shorten operative time with high body mass index. In our series, 1 (2.1%) of 47 patients was converted to open surgery. This conversion rate is similar to that of other reported series, such as about 5%, ranged from 0% to 17% [5,11,20–22]. Seven (14.9%) complications were observed in our series. There were two (4.2%) major and five (10.7%) minor complications. This complication rate is also similar to that of already reported series [5,11,20–22]. However, these complications did not occur from the 21st case. In conclusion, posterior retroperitoneoscopic partial adrenalectomy constitutes a safe and less invasive method for treatment of adrenal tumors. With improved operative technique, the time required for this procedure has been decreased.
References [1] Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl J Med 1992; 327:1033. [2] Janetschek G, Lhotta K, Gasser R, Finkenstedt G, Jaschke W, Bartsch G. Adrenal-sparing laparoscopic surgery for aldosteroneproducing adenoma. J Endourol 1997;11:145–8. [3] Janetschek G, Finkenstedt G, Gasser R, Waibel UG, Peschel R, Bartsch G, et al. Laparoscopic surgery for pheochromocytoma: adrenalectomy, partial resection, excision of paragangliomas. J Urol 1998;160:330–4. [4] Walz MK, Peitgen K, Saller B, Giebler RM, Lederbogen S, Nimtz K, et al. Subtotal adrenalectomy by the posterior retroperitoneoscopic approach. World J Surg 1998;22:621–7. [5] Walz MK, Peitgen K, Hoermann R, Giebler RM, Mann K, Eiger FW. Posterior retroperitoneoscopy as a new minimally invasive approach for adrenalectomy: Results of 30 adrenalectomies in 27 patients. World J Surg 1996;20:769–74. [6] Sasagawa I, Suzuki H, Tateno T, Izumi T, Shoji N, Nakada T. Retroperitoneoscopic partial adrenalectomy using an endoscopic stapling device in patients with adrenal tumor. Urol Int 1998;61: 101–3. [7] Sasagawa I, Suzuki H, Izumi T, Suzuki Y, Tateno T, Nakada T. Posterior retroperitoneoscopic partial adrenalectomy using ultrasonic scalpel for aldosterone-producing adenoma. J Endourol 2000;14: 573–6. [8] Suzuki Y, Itoh K, Tsukigi M, Miura M, Sasagawa I. The use of a new haemostatic agent for controlling adrenal bleeding during posterior retroperitoneoscopic partial adrenalectomy. BJU Int 2002;90:351.
[9] Gill IS, Clayman RV, Albala DM, Aso Y, Chiu AW, Das S, et al. Retroperitoneal and pelvic extraperitoneal laparoscopy: An international perspective. Urology 1998;52:566–71. [10] Rassweiler JJ, Seemann O, Frede T, Henkel TO, Alken P. Retroperitoneoscopy: Experience with 200 cases. J Urol 1998;160: 1265–9. [11] Salomon L, Soulie M, Mouly P, Saint F, Cicco A, Olsson E, et al. Experience with retroperitoneal laparoscopic adrenalectomy in 115 procedures. J Urol 2001;166:38–41. [12] Baba S, Miyajima A, Uchida A, Asanuma H, Miyakawa A, Murai M. A posterior lumbar approach for retroperitoneoscopic adrenalectomy. Assessment of surgical efficacy. Urology 1997;50:19–24. [13] van Heerden JA, Sizemore GW, Carney JA, Brennan MD, Sheps SG. Bilateral subtotal adrenal resection for bilateral pheochromocytomas in multiple endocrine neoplasia, type IIa: A case report. Surgery 1985;98:363–6. [14] Neumann HPH, Reincke M, Bender BU, Elsner R, Janetschek G. Preserved adrenocortical function after laparoscopic bilateral adrenal sparing surgery for hereditary pheochromocytoma. J Clin Endocrinol Metab 1999;84:2608–10. [15] Radmayr C, Neumann H, Bartsch G, Elsner R, Janetschek G. Laparoscopic partial adrenalectomy for bilateral pheochromocytomas in a boy with von Hippel-Lindau disease. Eur Urol 2000;38: 344–8. [16] Al-sobhi S, Peschel R, Bartsch G, Gasser R, Finkenstedt G, Janetschek G. Partial laparoscopic adrenalectomy for aldosteroneproducing adenoma: Short- and long-term results. J Endourol 2000; 14:497–9.
I. Sasagawa et al. / European Urology 43 (2003) 381–385 [17] Nakada T, Kubota Y, Sasagawa I, Yagisawa T, Watanabe M, Ishigooka M. Therapeutic outcome of primary aldosteronism: Adrenalectomy versus enucleation of aldostreone-producing adenoma. J Urol 1995;153:1775–80. [18] Aso Y, Homma Y. A survey on incidental adrenal tumors in Japan. J Urol 1992;147:1479–81. [19] Icard P, Chapuis Y, Andreaasian B, Bernard A, Proye C. Adrenocortical carcinoma in surgically treated patients: A retrospective study on 156 cases by the French Association of Endocrine Surgery. Surgery 1992;112:972–9.
385
[20] Suzuki K, Kageyama S, Hirano Y, Ushiyama T, Rajamahanty S, Fujita K. Comparison of 3 surgical approaches to laparoscopic adrenalectomy. A nonrandomized, background matched analysis. J Urol 2001;166:437–43. [21] Vargas HI, Kavoussi LR, Bartlett DL, Wagner JR, Venzon DJ, Fraker DL, et al. Laparoscopic adrenalectomy. A new standard of care. Urology 1997;49:673–8. [22] Rutherford JC, Stowasser M, Tunny TJ, Klemm SA, Gordon RD. Laparoscopic adrenalectomy. World J Surg 1996;20:758–60.
European Urology 43 (2003) 381–385
Posterior Retroperitoneoscopic Partial Adrenalectomy: Clinical Experience in 47 Procedures Isoji Sasagawa*, Yasuhiro Suzuki, Keiichi Itoh, Takuji Izumi, Michiharu Miura, Hitoshi Suzuki, Yoshihiko Tomita Department of Urology, Yamagata University School of Medicine, 2-2-2 Iidanishi, Yamagata-shi, Yamagata 990-9585, Japan Accepted 7 February 2003
Abstract Objectives: We evaluated posterior retroperitoneoscopic partial adrenalectomy with regard to operative complications, operation time, intraoperative blood loss. Patients and Methods: Between January 1997 and April 2002, we performed 47 posterior retroperitoneoscopic partial adrenalectomies. There were 18 males and 29 females with a mean age of 48 years (range 28–82 years). The average adrenal tumor size was 26 mm (range 10–50 mm). All procedures required three trocars. Results: There was no mortality and conversion rate to open surgery was 2.1%. Average operative time and average blood loss was 198.0 ml (range 71–420 ml) and 40.8 ml (range 0–1100 ml), respectively. There was a significant correlation of operative time with the number of procedures performed. However, no significant correlation was observed between intraoperative blood loss and the number of procedures. Tumor size did not correlate with intraoperative blood loss and operative time. No significant correlation was found between body mass index and operative time. The operative time in the initial 20 cases was significantly longer than that in the subsequent 26 cases. Conclusion: Posterior retroperitoneoscopic partial adrenalectomy is a safe and less invasive method for treatment of adrenal tumors. With improved operative technique, the time required for this procedure has been decreased. # 2003 Elsevier Science B.V. All rights reserved. Keywords: Partial adrenalectomy; Retroperitoneoscopy; Adrenal tumor; Complication
1. Introduction Since 1992, laparoscopic adrenalectomy has become a standard procedure for the treatment of adrenal tumors [1]. For primary tumors of the adrenal gland the excellent view with endoscopic operating procedures makes the surgeon possible to distinguish between adrenal neoplasia and normal adrenal gland parenchyma. Therefore, laparoscopic partial adrenalectomy has been mentioned for the first time by Janetschek et al. for aldosterone-producing adenoma [2] and pheochromocytoma [3]. In addition, Walz et al. [4] reported partial adrenalectomy for Cushing adenomas. Since 1997, we have applied posterior retroperitoneoscopic partial adrenalectomy to 47 patients with unilateral adrenal *
Corresponding author. Tel.: þ81-236-242837; Fax: þ81-236-242837. E-mail address: [email protected] (I. Sasagawa).
tumor. The aim of the present study was to analyze prospectively 47 posterior retroperitoneoscopic partial adrenalectomies with regard to intraoperative complications, morbidity, and length of operation time.
2. Patients and methods 2.1. Patients Between January 1997 and April 2002, 47 patients underwent posterior retroperitonoescopic partial adrenalectomy. There were 18 males and 29 females from 28 years to 82 years of age (mean 48 years). All patients had a typically solitary adenoma (right side in 27 and left side in 20). The tumor size ranged from 10 mm to 50 mm (mean 26). There were 13 cases of primary aldosteronism, 10 cases of Cushing’s syndrome (including 6 with pre-Cushing’s syndrome), 3 cases of pheochromocytoma, 2 cases of myelolipoma, 1 case of ganglioneuroma and 18 cases of nonfunctioning tumor. Since the diagnosis of myelolipoma could not be made preoperatively, two cases were included in this study. Nonfunctioning
0302-2838/03/$ – see front matter # 2003 Elsevier Science B.V. All rights reserved. doi:10.1016/S0302-2838(03)00087-3
382
I. Sasagawa et al. / European Urology 43 (2003) 381–385
tumors with diameter greater than 30 mm were also included in this study. 2.2. Surgical technique Patients were positioned in a low jackknife prone position with the trunk-thigh hinge of the table used as a flexion point to open the relevant posterior lumbar area between the 12th rib and iliac crest [5]. A 20 mm transverse incision just below the tip of the 12th rib was made for the first port. After preparation of the subcutaneous and muscle layers by sharp and blunt dissection, the retroperitoneal space was easily accessible by digital perforation of the dorsolumbar fascia. Subsequently, an artificial cavity was created using a distension balloon trocar (OMS-PDB 1000-S; Origin, San Francisco, CA, USA), which is inflated under endoscopic control to 60– 80 mm in diameter, ventral to Gerota’s fascia. After removing the distension trocar, the resulting cavity was palpated digitally, and two 10 mm standard trocars introduced with internal finger guide 20–30 mm laterally and medially to the first port. Then a blunt trocar with an inflatable balloon and adjustable sleeve (OMST10GS, Origin) was introduced into the first port and blocked. Thereafter, CO2 retropneumoperitoneum was created by maintaining a CO2 pressure of 10–12 mmHg. Retroperitoneoscopy was carried out with a 5 mm 08 endoscope introduced via the first port. Preparation began by the incision of the Gerota’s fascia from just below the diaphragm. Dissection of the adrenal gland was begun using an ultrasonic aspirator system (Olympus Ltd., Tokyo, Japan). During this procedure, the dissection plane remains close to the renal surface to avoid injury to the adjacent organs. In addition, endoscopic blunt-tip and Cherry dissectors (Ethicon, Cincinnati, OH, USA) were used. Partial adrenalectomy was carried out without clipping the adrenal vein, which emerged from the hilus of the gland, emptying into the inferior caval vein on the right side and renal vein on the left side. At partial adrenalectomy, the line of the adrenal resection does not always correspond with the avascular or hypervascular region, as the gland is supplied by superior, middle and inferior arteries. To identify the margin of the adenoma, the surrounding fatty tissue was removed. After clear identification, the adrenal tumor was resected using an endoscopic stapling device (ETS-Flex Endoscopic Linear Cutter; Ethicon) or an ultrasonically activated scalpel at level 3 (Harmonic Scalpel LCS 15, Ethicon) [6,7], and the tumor and its attached uninvolved adrenal tissue removed. The adrenal tissue was extracted through the middle port with a retrieval bag system (Endopouch; Olympus). Depending on the tumor size, the incision site occasionally needed to be enlarged. All ports were closed with fascial and subcuticular sutures after optional drain insertion. 2.3. Statistical analysis All data were entered into a computer database and results are expressed as the mean S:D: Statistical analysis of the learning curve effect, and the influence of tumor size and body mass index (BMI) on results was done using Pearson’s correlation coefficients and Student’s t test. Comparative analysis of two groups was performed using Student’s t test. Significance was defined as p < 0:05.
Table 1 Comparison of initial 20 cases and subsequent 26 cases in operative time and blood loss Variables
Initial 20 cases
Subsequent 26 cases
Operative time (minutes) Blood loss (ml)
269.9 65.4 77.1 242.1
198.0 86.2** 12.8 26.7
Each value represents mean S:D: ** p < 0:01: compared to the initial 20 cases.
retroperitoneoscopic partial adrenalectomy, there were three (6.4%) adrenal bleedings, two (4.3%) pneumothraxes, one (2.1%) massive hemorrhage (more than 1000 ml) and one (2.1%) injury of the renal vein. Adrenal bleeding was successfully controlled using a hemostatic agent [8]. Pneumothorax was detected after posterior retroperitoneoscopic adrenalectomy, and pleural drainage was required. Massive hemorrhage was caused by a superior adrenal vein injury and blood transfusion of 600 ml was required. One operation was converted to open surgery. These complication occurred only until the initial 20 cases. After excluding one patient with conversion to open surgery, average operative time and average blood loss were 198.0 minutes (71–420 minutes) and 40.8 ml (0–1100 ml), respectively. There was a significant correlation of operative time with the number of procedures (r ¼ 0:721, p < 0:001). However, no significant correlation was found between intraoperative blood loss and the number of procedures (r ¼ 0:219). As shown in Table 1, the operative time in our initial 20 cases was significantly longer than that in the subsequent 26 cases. However, intraoperative blood loss was not different between the initial 20 cases and subsequent 26 cases. Tumor size did not significantly correlate with intraoperative blood loss and operative time (Fig. 1). No significant correlation was found between body mass index and operative time (Fig. 2). All patients with functional cortical adenoma and pheochromocytoma showed normal adrenal function after the operation. In patients with nonfunctioning tumor, no endocrinological changes were found after the partial adrenalectomy. Postoperative adrenal scintigraphy with the use of 131 I-idiomethyl norcholestenol showed that the adrenal remnant was actually functional. Cortisol supplementation was not required for any of the patients.
3. Results 4. Discussion Posterior retroperitoneoscopic partial adrenalectomy was successfully performed in 46 of 47 patients (97.9%). As intraoperative complications of posterior
During the course of the rapid development in endoscopic surgery, endoscopic preparation to the
I. Sasagawa et al. / European Urology 43 (2003) 381–385
Fig. 1. (A) Tumor size vs. operative time, r ¼ 0:198, p > 0:05. (B) Tumor size vs. intraoperative blood loss, r ¼ 0:196, p > 0:05.
adrenal glands has become the standard procedure. Compared with the transperitoneal laparoscopic approach, retroperitoneoscopic approach seems to have specific advantages. Since the peritoneal cavity
Fig. 2. No significant correlation between body mass index (BMI) and operative time. r ¼ 0:116, p > 0:05.
383
is avoided completely, manipulation and mobilization of bowel is virtually nonexistent. The retroperitoneoscopy is superior in patients with intraperitoneal adhesions secondary to prior abdominal surgery. In addition, retroperitoneoscopic approach is preferred in markedly or morbidly obese patients, because it gives a shorter and more direct access to the adrenal gland. There are two retroperitoneoscopic approaches to the adrenal gland: retroperitoneal lateral [9–11] and retroperitoneal posterior [5,12]. The lateral retroperitoneal approach is performed with the patient in the standard flank position, while the posterior retroperitoneal approach is performed with the patient in the prone position. Since the parietal peritoneum is bluntly dissected down to the line of the midclavicular line in lateral approach, the space created by lateral approach is usually larger than that made by posterior approach. With lateral approach, the anatomic landmarks are the upper pole of the ipsilateral kidney, the parietal peritoneum and psoas muscle. Therefore, the difficulty in the identification of the adrenal gland, which looks like the same yellow fragile tissue as perirenal fat, may misdirect the cleavage line even to the pancreas tail by left adrenalectomy. According to Baba et al. [12], the operation time with posterior retroperitoneoscopic adrenalectomy is shorter than that with lateral retroperitoneoscopic adrenalectomy by almost 50 minutes. Furthermore, posterior approach usually requires three trocar sites, while lateral approach needs four to five trocar sites. These findings indicate that posterior retroperitoneoscopic adrenalectomy is the most minimally invasive operation. Partial adrenalectomy has been usually recommended for bilateral hereditary pheochromocytomas to maintain cortical function of the adrenal gland [13–15]. Recently, partial adrenalectomy has been reported in patients with alodosterone-producing adenoma [2,7,16]. With regard to therapeutic outcome, ambulation and furosemide administration under lowsodium diet stimuli remarkably enhanced plasma renin activity and aldosterone in the partial adrenalectomy group, so that the findings were similar to those of normal subjects, but increment magnitudes were decreased in the adrenalectomy group five years after operation [17]. Postoperatively, the responses of plasma aldosterone to angiotensin II infusion and of plasma cortisol to ACTH administration were more sensitive in the partial adrenalectomy group than those in the adrenalectomy group [17]. However, there was no recurrence of hyperaldosteronism in either group. These facts indicate that partial adrenalectomy for aldosteroneproducing adenoma is preferable to adrenalectomy. Endoscopic operating procedures give an excellent view
384
I. Sasagawa et al. / European Urology 43 (2003) 381–385
of the adrenal gland and its surroundings, allowing clear differentiation of tumor and normal tissue, thereby making precise dissection possible. In patients with Cushing adenoma and sporadic pheochromocytoma, tumors less than 30 mm in diameter should be regarded as benign and subsequently do not require radical resection to preserve remnant adrenal function. Total adrenalectomy is necessary for patients with suspected malignancy. Although malignant adrenal tumors are usually greater than 50 mm in diameter [18], adrenal tumors with diameter greater than 30 mm are not excluded from malignancy [19]. In our series, therefore, partial adrenalectomy was indicated for nonfunctioning tumors with diameter greater than 30 mm. Since leaving as much normal adrenal tissue as possible is more physiologic and provides patients with more hormone reserve, partial adrenalectomy not only with bilateral tumors but also with unilateral tumors seems generally rationale. Therefore, partial adrenalectomy may be indicated for Cushing adenoma, sporadic pheochromocytoma and nonfunctioning adenoma under certain preconditions. According to Suzuki et al. [20], there are significant correlations of tumor size with intraoperative blood loss, body mass index and operative time for laparoscopic adrenalectomy. In our series, however, tumor size did not correlate with intraoperative blood loss. In
addition, no significant correlation was found between body mass index and operative time. Partial adrenalectomy was usually carried out without clipping the adrenal vein, which emerged from hilus of the gland, emptying into the inferior caval vein on the right side and the renal vein on the left side. When a normal limb of an adrenal gland reaches deep into the renal hilum or adheres to the liver, making complete resection risky, partial adrenalectomy is safer than total adrenalectomy. Therefore, this procedure can reduce intraoperative blood loss and operation time even in cases with large tumor size, and can shorten operative time with high body mass index. In our series, 1 (2.1%) of 47 patients was converted to open surgery. This conversion rate is similar to that of other reported series, such as about 5%, ranged from 0% to 17% [5,11,20–22]. Seven (14.9%) complications were observed in our series. There were two (4.2%) major and five (10.7%) minor complications. This complication rate is also similar to that of already reported series [5,11,20–22]. However, these complications did not occur from the 21st case. In conclusion, posterior retroperitoneoscopic partial adrenalectomy constitutes a safe and less invasive method for treatment of adrenal tumors. With improved operative technique, the time required for this procedure has been decreased.
References [1] Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl J Med 1992; 327:1033. [2] Janetschek G, Lhotta K, Gasser R, Finkenstedt G, Jaschke W, Bartsch G. Adrenal-sparing laparoscopic surgery for aldosteroneproducing adenoma. J Endourol 1997;11:145–8. [3] Janetschek G, Finkenstedt G, Gasser R, Waibel UG, Peschel R, Bartsch G, et al. Laparoscopic surgery for pheochromocytoma: adrenalectomy, partial resection, excision of paragangliomas. J Urol 1998;160:330–4. [4] Walz MK, Peitgen K, Saller B, Giebler RM, Lederbogen S, Nimtz K, et al. Subtotal adrenalectomy by the posterior retroperitoneoscopic approach. World J Surg 1998;22:621–7. [5] Walz MK, Peitgen K, Hoermann R, Giebler RM, Mann K, Eiger FW. Posterior retroperitoneoscopy as a new minimally invasive approach for adrenalectomy: Results of 30 adrenalectomies in 27 patients. World J Surg 1996;20:769–74. [6] Sasagawa I, Suzuki H, Tateno T, Izumi T, Shoji N, Nakada T. Retroperitoneoscopic partial adrenalectomy using an endoscopic stapling device in patients with adrenal tumor. Urol Int 1998;61: 101–3. [7] Sasagawa I, Suzuki H, Izumi T, Suzuki Y, Tateno T, Nakada T. Posterior retroperitoneoscopic partial adrenalectomy using ultrasonic scalpel for aldosterone-producing adenoma. J Endourol 2000;14: 573–6. [8] Suzuki Y, Itoh K, Tsukigi M, Miura M, Sasagawa I. The use of a new haemostatic agent for controlling adrenal bleeding during posterior retroperitoneoscopic partial adrenalectomy. BJU Int 2002;90:351.
[9] Gill IS, Clayman RV, Albala DM, Aso Y, Chiu AW, Das S, et al. Retroperitoneal and pelvic extraperitoneal laparoscopy: An international perspective. Urology 1998;52:566–71. [10] Rassweiler JJ, Seemann O, Frede T, Henkel TO, Alken P. Retroperitoneoscopy: Experience with 200 cases. J Urol 1998;160: 1265–9. [11] Salomon L, Soulie M, Mouly P, Saint F, Cicco A, Olsson E, et al. Experience with retroperitoneal laparoscopic adrenalectomy in 115 procedures. J Urol 2001;166:38–41. [12] Baba S, Miyajima A, Uchida A, Asanuma H, Miyakawa A, Murai M. A posterior lumbar approach for retroperitoneoscopic adrenalectomy. Assessment of surgical efficacy. Urology 1997;50:19–24. [13] van Heerden JA, Sizemore GW, Carney JA, Brennan MD, Sheps SG. Bilateral subtotal adrenal resection for bilateral pheochromocytomas in multiple endocrine neoplasia, type IIa: A case report. Surgery 1985;98:363–6. [14] Neumann HPH, Reincke M, Bender BU, Elsner R, Janetschek G. Preserved adrenocortical function after laparoscopic bilateral adrenal sparing surgery for hereditary pheochromocytoma. J Clin Endocrinol Metab 1999;84:2608–10. [15] Radmayr C, Neumann H, Bartsch G, Elsner R, Janetschek G. Laparoscopic partial adrenalectomy for bilateral pheochromocytomas in a boy with von Hippel-Lindau disease. Eur Urol 2000;38: 344–8. [16] Al-sobhi S, Peschel R, Bartsch G, Gasser R, Finkenstedt G, Janetschek G. Partial laparoscopic adrenalectomy for aldosteroneproducing adenoma: Short- and long-term results. J Endourol 2000; 14:497–9.
I. Sasagawa et al. / European Urology 43 (2003) 381–385 [17] Nakada T, Kubota Y, Sasagawa I, Yagisawa T, Watanabe M, Ishigooka M. Therapeutic outcome of primary aldosteronism: Adrenalectomy versus enucleation of aldostreone-producing adenoma. J Urol 1995;153:1775–80. [18] Aso Y, Homma Y. A survey on incidental adrenal tumors in Japan. J Urol 1992;147:1479–81. [19] Icard P, Chapuis Y, Andreaasian B, Bernard A, Proye C. Adrenocortical carcinoma in surgically treated patients: A retrospective study on 156 cases by the French Association of Endocrine Surgery. Surgery 1992;112:972–9.
385
[20] Suzuki K, Kageyama S, Hirano Y, Ushiyama T, Rajamahanty S, Fujita K. Comparison of 3 surgical approaches to laparoscopic adrenalectomy. A nonrandomized, background matched analysis. J Urol 2001;166:437–43. [21] Vargas HI, Kavoussi LR, Bartlett DL, Wagner JR, Venzon DJ, Fraker DL, et al. Laparoscopic adrenalectomy. A new standard of care. Urology 1997;49:673–8. [22] Rutherford JC, Stowasser M, Tunny TJ, Klemm SA, Gordon RD. Laparoscopic adrenalectomy. World J Surg 1996;20:758–60.