- Email: [email protected]
Surgical experience and results in transperitoneal laparoscopic adrenalectomy
actas urol esp. 2010;34(5):412–416
Actas Urológicas Españolas www.elsevier.es/actasuro
Special article
Surgical experience and results in transperitoneal laparoscopic adrenalectomy M. Hevia Suáreza, J.M. Abascal Junqueraa,*, P. Boixb, M. Dieguezb, E. Delgadob, J.M. Abascal Garcíaa, and R. Abascal Garcíaa aDepartment bDepartment
of Surgery, Hospital Universitario Central de Asturias, Oviedo, Spain of Endocrinology, Hospital Universitario Central de Asturias, Oviedo, Spain
ARTICLE INFORMATION
A B S T R A C T
Article history:
Introduction: Laparoscopic adrenalectomy is currently the gold standard for surgical
Received 27 November, 2009
management of adrenal disease.
Accepted 8 March, 2010
Objectives: To analyze our results after 12 years of experience in this surgery and to compare them to those of the main published series.
Keywords:
Material and methods: A descriptive, retrospective study. An analysis was made of 100
Results
adrenalectomies performed from June 1997 to June 2009. Variables analyzed included
Adrenalectomy
age, size, side, preoperative diagnosis, operating time, blood loss, conversion to open
Laparoscopic
surgery, mean hospital stay, and pathological report. A Fisher’s exact test and a Chisquare test were used to compare categorical data. A Student’s t test was used to compare independent group means with a normal distribution. A value of p<0.05 was considered statistically significant. Results: Mean patient age was 53.1 years (±14.4). Mean lesion size was 3.7 cm (±2.2), and lesions occurred in the left side in 51% of cases. Mean follow-up time was 15 months (±11.9). Preoperative diagnoses were functional mass (44%), pheochromocytoma (17%), incidentaloma >4 cm (20%), metastasis (10%), and adrenal carcinoma (5%). Mean operating time was 145.1 min (±55.6). Mean hematocrit decrease was 6.26 points (±3.3). Conversion to open surgery was required in 9.6% of patients. Prolonged postoperative ileus occurred in two patients. Transfusion was required in two patients. One patient died from decompensated liver cirrhosis. Eighty percent of complications occurred in the right side. Mean hospital stay was 6 days (±5.6). In the last 30 procedures, significant differences in operating time (119.1 min vs 171.2 min) and mean hospital stay (4.1 vs 6.1 days) were found in the group of the last 30 procedures (p<0.05). Conclusions: Transperitoneal laparoscopic adrenalectomy is a feasible and safe surgical procedure in the hands of teams with prior laparoscopic experience. Our efficacy and morbidity results are similar to those reported by other series. © 2009 AEU. Published by Elsevier España, S.L. All rights reserved.
*Author for correspondence. E-mail: [email protected] (J.M. Abascal Junquera). 0210-4806/$ - see front matter © 2009 AEU. Published by Elsevier España, S.L. All rights reserved.
actas urol esp. 2010;34(5):412–416
413
Experiencia y resultados en la suprarrenalectomía laparoscópica transperitoneal R E S U M E N
Palabras clave:
Introducción: La suprarrenalectomía laparoscópica es actualmente el gold estándar en el
Resultados
manejo quirúrgico de la patología suprarrenal.
Suprarrenalectomía
Objetivos: Analizar nuestros resultados tras 12 años de experiencia en esta cirugía y
Laparoscopia
compararlos con las principales series publicadas. Material y métodos: Estudio descriptivo y retrospectivo. Análisis de 100 suprarrenalectomías realizadas entre junio de 1997 y junio de 2009. Se describen las siguientes variables: edad, tamaño, lateralidad, diagnóstico preoperatorio, tiempo quirúrgico, pérdida sanguínea, reconversión, complicaciones, estancia media y resultado anatomopatológico. Se utilizaron el test de Fisher y el test de chi cuadrado para comparar datos categóricos. Se utilizó el test t de Student para comparar medias de grupos independientes con distribución normal. Se consideró la significación estadística cuando p < 0,05. Resultados: La edad media fue de 53,1 años (± 14,4). El tamaño medio fue de 3,7 cm (± 2,2). En el 51% de los casos fue izquierda. La media de seguimiento fue de 15 meses (± 11,9). El diagnóstico preoperatorio fue masa funcionante (44%), feocromocitoma (17%), incidentaloma mayor de 4 cm (20%), metástasis (10%) y carcinoma suprarrenal (5%). El tiempo quirúrgico medio fue de 145,1 min (± 55,6). El descenso medio de hematocrito fue de 6,26 puntos (± 3,3). La tasa de reconversión fue del 9,6%. Hubo 2 casos de íleo postoperatorio prolongado. Dos pacientes requirieron transfusión. Uno murió en el postoperatorio por descompensación de cirrosis hepática asociada. El 80% de las complicaciones fueron en el lado derecho. La estancia media hospitalaria fue de 6 días (± 5,6). En el grupo de los 30 últimos procedimientos se obtuvieron diferencias significativas en cuanto al tiempo quirúrgico (119,1 vs. 171,2 min) y a la estancia media hospitalaria (4,1 vs. 6,1 días, p < 0,05). Conclusiones: La suprarrenalectomía laparoscópica transperitoneal es una cirugía factible y segura en grupos con experiencia laparoscópica previa. Nuestros resultados se asemejan a las series publicadas en cuanto a la eficacia y a la morbilidad de la técnica. © 2009 AEU. Publicado por Elsevier España, S.L. Todos los derechos reservados.
Introduction Since Gagner et al1 reported in 1992 their first experience in transperitoneal laparoscopic adrenalectomy on three patients with benign adrenal masses, several authors have demonstrated the feasibility and efficacy of laparoscopic adrenalectomy through different approaches. The transperitoneal approach was initially favored, until the retroperitoneal laparoscopic approach was described. Variations of these two approaches depending on patient position and surgical procedure have also been reported. At the end of the 90s, laparoscopic adrenalectomy became the standard surgery for management of most benign adrenal masses, mainly because of both its efficacy and the already reported general advantages of minimally invasive surgery. Several authors have reported the laparoscopic approach to be superior to open surgery for functional benign lesions or incidentalomas. Bilateral adrenalectomy through this approach has also been reported. More recently, oncological safety of the laparoscopic route in cases with tumor masses and for conservative surgery with partial adrenalectomy in selected patients has been shown2.
The purpose of this article was to report our experience in transperitoneal laparoscopic adrenalectomy after 12 years of use of the procedure, and to compare our results to those of the main published series.
Materials and methods Type of study. This was a descriptive, retrospective study on the 100 patients undergoing adrenalectomy from June 1997 to June 2009. Seventeen patients in whom surgical procedures other than transperitoneal laparoscopic adrenalectomy were performed were excluded from data analysis. Variables. The following variables were recorded: sex, age (years), adrenal lesion size (centimeters), side of lesion, suspected preoperative diagnosis, operating time (minutes), blood loss (hematocrit percentage), percent conversion to open surgery, complications, mean hospital stay (days), and pathological report. Statistical analysis. All data are reported as the mean, median, standard deviation, and range. SPSS 15 statistical software (SPSS Inc., Chicago, IL) was used for analysis. A
414
actas urol esp. 2010;34(5):412–416
Fisher’s exact test and a Chi-square test were used to compare categorical data. A Student’s t test was used to compare independent group means with a normal distribution. A value of p<0.05 was considered statistically significant. Preoperative management. The characteristics of adrenal masses of all patients had previously been assessed at the department of endocrinology. The diagnostic procedure of choice was computed tomography (CT), which was used to assess mass size and relationship to adjacent organs. If pheochromocytoma was suspected, CT was supplemented with a metaiodobenzylguanidine scan to define potential extraadrenal sites. All patients with suspected pheochromocytoma, except for one, were treated for at least two weeks before surgery with an a-blocker (Dybeniline® [20-40 mg/day]) to control blood pressure and catecholamine release during intraoperative management of the mass. These patients were also administered a b-blocker (propranolol [20 mg/8 h]) if tachycardia occurred or persisted, but never before the a-blocker. Only one patient in this group was administered a single preoperative nicardipine dose. Patients with Cushing syndrome were administered a single intraoperative dose of hydrocortisone 100 mg, which was tapered after surgery. In Conn’s disease, patients were given spironolactone (200 mg/ day) for 2 weeks before surgery. All patients received antiulcer (oral omeprazole [20 mg]) and antithrombotic (Fraxiparina® [0.4 mL] subcutaneously) prophylaxis the day before surgery. The latter was continued for 15 days at the same daily dose, and antibiotic prophylaxis (intravenous cefazolin [2 g]) was administered on anesthesia induction. No bowel preparation was administered to any patient. Surgical procedure. From June 1997 to June 2009, 100 adrenalectomies were performed: 16 by open surgery, 1 by retroperitoneoscopy, and 83 by the transperitoneal laparoscopic approach. The main reason for selecting an open approach in some patients at the start of the learning curve of transperitoneal laparoscopy was mass size, which was 5.5 cm on average in this subgroup. In the patient subject to retroperitoneoscopy, this approach was selected due to a history of multiple prior abdominal procedures. More than 95% of procedures were performed by the same surgeon, the first author of this article. Other staff members, also signing this review, are currently performing this surgical procedure. The standard procedure reported in prior publications was used for the transperitoneal laparoscopic approach3. For bilateral adrenalectomy, the same optical trocar was used in both sides. New lateral trocars were only used after repositioning the patient in contralateral decubitus.
Results Fifty-two percent of patients were female. Mean patient age was 53.1 years (± 14.4). Left and right adrenalectomy was performed in 51% and 48% of cases respectively, and bilateral adrenalectomy was required in one patient. Mean mass size was 3.7 cm (±2.2). Mean patient follow-up was 15 months (±11.9). Before surgery, a functional mass was diagnosed in 34 patients (43.9%), pheochromocytoma was suspected in 17 patients (17%), and an incidentaloma was found in 20 patients
(20%). Malignant disease was suspected in 15 patients, 10 with metastases and five with adrenal carcinoma. Results in the group undergoing transperitoneal laparoscopic adrenalectomy are reported below. Mean operating time in the total series (table 1) was 145.1 min (±55.6). A mean 6.26% (±3.3) decrease was seen in hematocrit, which was associated to a mean hemoglobin decrease by 1.5 - 2 g. Surgery was completed laparoscopically in all but 8 procedures (conversion to open surgery was required in 9.6% of patients). Emergency conversion to open surgery was required in a single patient due to avulsion of a lumbar arising from vena cava during difficult dissection of a mass on the right side. In all other cases, conversion to open surgery was due to technical or anesthetic problems including morbid obesity (two patients), giant hepatomegaly (three patients), hemodynamic instability (two patients) during pheochromocytoma handling, and a giant hepatic hemangioma previously diagnosed as an adrenal mass (one patient). One of the patients with intraoperative hemodynamic instability had been treated with a calcium channel blocker (nicardipine) before surgery. The other patient experienced several hypertensive attacks during mass dissection and right adrenal vein could not be controlled, which determined conversion to open surgery. The complication rate was 7%. Intraoperative complications included two patients with hepatic laceration and one patient with splenic laceration, which were successfully controlled with hemostatic materials. Two patients (2.5%) experienced intestinal ileus after surgery, one because of an intestinal hernia through the trocar opening which required exploratory laparotomy. Another patient with an underlying liver cirrhosis experienced decompensated ascites in the early postoperative period. Peri- and postoperative complications occurred in the left and right sides in two and nine patients respectively. Transfusion was required in two patients. One of these was an elderly patient with low hemoglobin levels before surgery, and the other was a patient with morbid obesity who received a transfusion due to self-limited postoperative bleeding from the opening of one of the trocars (abdominal wall hematoma). One patient died early following surgery due to a decompensated cirrhosis of the liver that caused multiorgan failure. Mean hospital stay was six days (±5.6), including the day before surgery at the time of patient admission. Mean follow-up was 15 months (±11.9). Patients with endocrine hypertension before surgery required no additional antihypertensive medication after
Table 1 – Results in the group of patients undergoing transperitoneal laparoscopic adrenalectomy Variables Conversion Vascular complication Visceral complication Postoperative ileus Transfusion
Patients, n (%)
Right/left side
8 (9.6) 1 (1.5) 5 (6.3) 2 (2.5) 2 (2.5)
1/7 0/1 1/4 1/1 1/1
415
*Last 30 procedures. **Continuous variables are given as mean and standard deviation.
5.8 5.4 2.8 3 2.8 4.8 (±6) 6.1 (±5.6) 4.1 (±1.2)** 132 − 7 8.7 − 129 − 5 7.5 − 160 − 2.5 5.1 − 151 − 1.9 3 − 125 60 6.9 6.9 7.4 135 (±32) 250 (±100) 5 9.6 − 145.1 (±55.6) 119.1 (±22.1)* 150 (±50) 9.6 7 7 Mancini et al8 172 Henry et al9 169 Guazzoni et al2 161 Guazzoni et al6 264 El- Kappany et al10 43 Zacharias et al 52 Hevia et al (2009) 83
Hospital stay, days Vascular or visceral lesion, % Complications, % Conversion, % Blood loss, mL Operating time, min Surgeries, n
In our view, there is no question about the advantages of a laparoscopic approach to the adrenal gland over open surgery in terms of operating time, blood loss, postoperative convalescence, cosmetic results, and recovery. Current medical literature has shown no clear advantages of either a transperitoneal or retroperitoneal laparoscopic approach. Use of one or the other probably depends more on the habits and preferences of the surgical team. We performed the standard transperitoneal procedure previously described by other groups4-7. This article has reviewed the experience at our department during the last 12 years. This is the time elapsed since the laparoscopic surgery program was started at our department to replace the conventional open surgery approach we had been using since 1990 in close collaboration with the endocrinology department, which referred us all patients with surgical adrenal conditions based on the good results achieved. This is why we have accumulated a significant experience in adrenal surgery, which should in our view be managed by urological departments because of its location and relationships. Like other authors, we think it is important to have prior experience in laparoscopic surgery before this procedure is undertaken4. Our results were compared to those reported in the main series published and were found to be similar (table 2). Conversion rates to open surgery ranged from 2.5%-7% in the main series (as compared to 9.6% in our series). The complication rate reported in medical literature ranged from 5.1%-9.6%, as compared to 7% in our series. An analysis comparing the last 30 procedures to the first 50 procedures found statistically significant differences in operating time (171.2 vs 119.1 min) and mean hospital stay (6.1 vs 4.1 days). This is consistent with the operating times ranging from 125-160 min and hospital stays ranging from 12.6-5.8 days reported in the published series. It should be noted that the histopathological report on the specimen may not agree with preoperative diagnosis in some cases. This review only confirmed 14 of the 17 initially suspected pheochromocytomas. In this regard, the importance of adequate preoperative diagnostic work-up and close
Table 2 – A comparison of the different series of transperitoneal laparoscopic adrenalectomy published in medical literature
Discussion
Mortality, %
surgery. In patients in whom pheochromocytoma was histologically documented, blood and urine catecholamine levels normalized after surgery. Results of the final pathological report of the complete series showed adenoma in 50 patients (53.2%), pheochromocytoma in 14 patients (14.9%), cortical nodular hyperplasia in eight (8.5%), adrenal metastases from lung adenocarcinoma in seven (7%), adrenal metastases from clear cell renal carcinoma in three (3%), adrenal carcinoma in five (5.3%), and cysts in four (4.3%). An analysis of the last 30 laparoscopic procedures showed statistically significant differences as compared to all other procedures in operating time (119.1 vs 171.2 min) and mean hospital stay (4.1 vs 6.1 days).
4.2 0 0 0 0 − 1.2
actas urol esp. 2010;34(5):412–416
416
actas urol esp. 2010;34(5):412–416
cooperation with the endocrinologist should be emphasized. In patients with pheochromocytoma, mass behavior during surgery may already suggest its actual nature. A single patient with suspected pheochromocytoma received calcium channel blockers before surgery. This patient showed a great hemodynamic instability during the procedure which mandated conversion to open surgery. While there is a group which has reported good management of these patients with nicardipine, we still use conventional treatment with a-blockers and b-blockers if required3. Partial adrenalectomy in patients with bilateral (pheochromocytoma or adenomas) or single adrenal disease may preserve endocrine function of the gland without the need for replacement therapy. Use of intraoperative endoscopic ultrasound is advised in these cases. In some of our patients, conservative surgery could have been considered based on the resected specimen3.
Conclusions Transperitoneal laparoscopic adrenalectomy is a feasible and safe procedure in the hands of urological teams with prior experience in laparoscopic surgery. Our results are similar to those reported in the main series published and support the efficacy, safety, and reproducibility of the procedure.
Conflicts of interest The authors state that they have no conflicts of interest.
R E F E R E N C E S
1. Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl J Med. 1992;327:1033. 2. Guazzoni G, Cestari A, Montorsi F, Lanzi R, Rigatti P, Kaouk JH, et al. Current role of laparoscopic adrenalectomy. Eur Urol. 2001;40:8-16. 3. Hevia M, Abascal Junquera JM, Abascal García JM, Estébanez C, Boix P, Abascal García R. Adrenalectomía laparoscópica transperitoneal: resultados tras 70 procedimientos. Arch Esp Urol. 2008;61:611-20. 4. Zacharias M, Haese A, Jurczok A, Stolzenburg JU, Fornara P. Transperitoneal laparoscopic adrenalectomy: Outline of the preoperative management, surgical approach and outcome. Eur Urol. 2006;49:448-59. 5. Castillo O, Vitagliano G, Kerkebe M, Parma P, Pinto I, Díaz M. Laparoscopic adrenalectomy for suspected metastasis of adrenal glands: Our experience. Urology. 2007;69:637-41. 6. Guazzoni G, Cestari A, Montorsi F, Lanzi R, Nava L, Centemero A, et al. Eight-year experience with transperitoneal laparoscopic adrenal surgery. J Urol. 2001;166:820-4. 7. Pascual JI, Cuesta JA, Grasa V, Labairu L, Napal S, Ipiens AP. Laparoscopy adrenalectomy. Considerations on 24 different procedures. Actas Urol Esp. 2007;31:98-105. 8. Mancini F, Mutter D, Peix JL, Chapuis Y, Henry JF, Proye C, et al. Experiences with adrenalectomy in 1997. Apropos of 247 cases. A multicenter prospective study of the French-speaking Association of Endocrine Surgery. Chirurgie. 1999;124:368-74. 9. Henry JF, Defechereux T, Raffaelli M, Lubrano D, Gramatica L. Complications of laparoscopic adrenalectomy: Results of 169 consecutive procedures. World J Surg. 2000;24:1342-6. 10. El-Kappany H, Shoma A, El-Tabey N, El-Nahas AR, Eraky II. Laparoscopic adrenalectomy: A single-center experience of 43 cases. J Endourol. 2005;19:1170-3.
Actas Urológicas Españolas www.elsevier.es/actasuro
Special article
Surgical experience and results in transperitoneal laparoscopic adrenalectomy M. Hevia Suáreza, J.M. Abascal Junqueraa,*, P. Boixb, M. Dieguezb, E. Delgadob, J.M. Abascal Garcíaa, and R. Abascal Garcíaa aDepartment bDepartment
of Surgery, Hospital Universitario Central de Asturias, Oviedo, Spain of Endocrinology, Hospital Universitario Central de Asturias, Oviedo, Spain
ARTICLE INFORMATION
A B S T R A C T
Article history:
Introduction: Laparoscopic adrenalectomy is currently the gold standard for surgical
Received 27 November, 2009
management of adrenal disease.
Accepted 8 March, 2010
Objectives: To analyze our results after 12 years of experience in this surgery and to compare them to those of the main published series.
Keywords:
Material and methods: A descriptive, retrospective study. An analysis was made of 100
Results
adrenalectomies performed from June 1997 to June 2009. Variables analyzed included
Adrenalectomy
age, size, side, preoperative diagnosis, operating time, blood loss, conversion to open
Laparoscopic
surgery, mean hospital stay, and pathological report. A Fisher’s exact test and a Chisquare test were used to compare categorical data. A Student’s t test was used to compare independent group means with a normal distribution. A value of p<0.05 was considered statistically significant. Results: Mean patient age was 53.1 years (±14.4). Mean lesion size was 3.7 cm (±2.2), and lesions occurred in the left side in 51% of cases. Mean follow-up time was 15 months (±11.9). Preoperative diagnoses were functional mass (44%), pheochromocytoma (17%), incidentaloma >4 cm (20%), metastasis (10%), and adrenal carcinoma (5%). Mean operating time was 145.1 min (±55.6). Mean hematocrit decrease was 6.26 points (±3.3). Conversion to open surgery was required in 9.6% of patients. Prolonged postoperative ileus occurred in two patients. Transfusion was required in two patients. One patient died from decompensated liver cirrhosis. Eighty percent of complications occurred in the right side. Mean hospital stay was 6 days (±5.6). In the last 30 procedures, significant differences in operating time (119.1 min vs 171.2 min) and mean hospital stay (4.1 vs 6.1 days) were found in the group of the last 30 procedures (p<0.05). Conclusions: Transperitoneal laparoscopic adrenalectomy is a feasible and safe surgical procedure in the hands of teams with prior laparoscopic experience. Our efficacy and morbidity results are similar to those reported by other series. © 2009 AEU. Published by Elsevier España, S.L. All rights reserved.
*Author for correspondence. E-mail: [email protected] (J.M. Abascal Junquera). 0210-4806/$ - see front matter © 2009 AEU. Published by Elsevier España, S.L. All rights reserved.
actas urol esp. 2010;34(5):412–416
413
Experiencia y resultados en la suprarrenalectomía laparoscópica transperitoneal R E S U M E N
Palabras clave:
Introducción: La suprarrenalectomía laparoscópica es actualmente el gold estándar en el
Resultados
manejo quirúrgico de la patología suprarrenal.
Suprarrenalectomía
Objetivos: Analizar nuestros resultados tras 12 años de experiencia en esta cirugía y
Laparoscopia
compararlos con las principales series publicadas. Material y métodos: Estudio descriptivo y retrospectivo. Análisis de 100 suprarrenalectomías realizadas entre junio de 1997 y junio de 2009. Se describen las siguientes variables: edad, tamaño, lateralidad, diagnóstico preoperatorio, tiempo quirúrgico, pérdida sanguínea, reconversión, complicaciones, estancia media y resultado anatomopatológico. Se utilizaron el test de Fisher y el test de chi cuadrado para comparar datos categóricos. Se utilizó el test t de Student para comparar medias de grupos independientes con distribución normal. Se consideró la significación estadística cuando p < 0,05. Resultados: La edad media fue de 53,1 años (± 14,4). El tamaño medio fue de 3,7 cm (± 2,2). En el 51% de los casos fue izquierda. La media de seguimiento fue de 15 meses (± 11,9). El diagnóstico preoperatorio fue masa funcionante (44%), feocromocitoma (17%), incidentaloma mayor de 4 cm (20%), metástasis (10%) y carcinoma suprarrenal (5%). El tiempo quirúrgico medio fue de 145,1 min (± 55,6). El descenso medio de hematocrito fue de 6,26 puntos (± 3,3). La tasa de reconversión fue del 9,6%. Hubo 2 casos de íleo postoperatorio prolongado. Dos pacientes requirieron transfusión. Uno murió en el postoperatorio por descompensación de cirrosis hepática asociada. El 80% de las complicaciones fueron en el lado derecho. La estancia media hospitalaria fue de 6 días (± 5,6). En el grupo de los 30 últimos procedimientos se obtuvieron diferencias significativas en cuanto al tiempo quirúrgico (119,1 vs. 171,2 min) y a la estancia media hospitalaria (4,1 vs. 6,1 días, p < 0,05). Conclusiones: La suprarrenalectomía laparoscópica transperitoneal es una cirugía factible y segura en grupos con experiencia laparoscópica previa. Nuestros resultados se asemejan a las series publicadas en cuanto a la eficacia y a la morbilidad de la técnica. © 2009 AEU. Publicado por Elsevier España, S.L. Todos los derechos reservados.
Introduction Since Gagner et al1 reported in 1992 their first experience in transperitoneal laparoscopic adrenalectomy on three patients with benign adrenal masses, several authors have demonstrated the feasibility and efficacy of laparoscopic adrenalectomy through different approaches. The transperitoneal approach was initially favored, until the retroperitoneal laparoscopic approach was described. Variations of these two approaches depending on patient position and surgical procedure have also been reported. At the end of the 90s, laparoscopic adrenalectomy became the standard surgery for management of most benign adrenal masses, mainly because of both its efficacy and the already reported general advantages of minimally invasive surgery. Several authors have reported the laparoscopic approach to be superior to open surgery for functional benign lesions or incidentalomas. Bilateral adrenalectomy through this approach has also been reported. More recently, oncological safety of the laparoscopic route in cases with tumor masses and for conservative surgery with partial adrenalectomy in selected patients has been shown2.
The purpose of this article was to report our experience in transperitoneal laparoscopic adrenalectomy after 12 years of use of the procedure, and to compare our results to those of the main published series.
Materials and methods Type of study. This was a descriptive, retrospective study on the 100 patients undergoing adrenalectomy from June 1997 to June 2009. Seventeen patients in whom surgical procedures other than transperitoneal laparoscopic adrenalectomy were performed were excluded from data analysis. Variables. The following variables were recorded: sex, age (years), adrenal lesion size (centimeters), side of lesion, suspected preoperative diagnosis, operating time (minutes), blood loss (hematocrit percentage), percent conversion to open surgery, complications, mean hospital stay (days), and pathological report. Statistical analysis. All data are reported as the mean, median, standard deviation, and range. SPSS 15 statistical software (SPSS Inc., Chicago, IL) was used for analysis. A
414
actas urol esp. 2010;34(5):412–416
Fisher’s exact test and a Chi-square test were used to compare categorical data. A Student’s t test was used to compare independent group means with a normal distribution. A value of p<0.05 was considered statistically significant. Preoperative management. The characteristics of adrenal masses of all patients had previously been assessed at the department of endocrinology. The diagnostic procedure of choice was computed tomography (CT), which was used to assess mass size and relationship to adjacent organs. If pheochromocytoma was suspected, CT was supplemented with a metaiodobenzylguanidine scan to define potential extraadrenal sites. All patients with suspected pheochromocytoma, except for one, were treated for at least two weeks before surgery with an a-blocker (Dybeniline® [20-40 mg/day]) to control blood pressure and catecholamine release during intraoperative management of the mass. These patients were also administered a b-blocker (propranolol [20 mg/8 h]) if tachycardia occurred or persisted, but never before the a-blocker. Only one patient in this group was administered a single preoperative nicardipine dose. Patients with Cushing syndrome were administered a single intraoperative dose of hydrocortisone 100 mg, which was tapered after surgery. In Conn’s disease, patients were given spironolactone (200 mg/ day) for 2 weeks before surgery. All patients received antiulcer (oral omeprazole [20 mg]) and antithrombotic (Fraxiparina® [0.4 mL] subcutaneously) prophylaxis the day before surgery. The latter was continued for 15 days at the same daily dose, and antibiotic prophylaxis (intravenous cefazolin [2 g]) was administered on anesthesia induction. No bowel preparation was administered to any patient. Surgical procedure. From June 1997 to June 2009, 100 adrenalectomies were performed: 16 by open surgery, 1 by retroperitoneoscopy, and 83 by the transperitoneal laparoscopic approach. The main reason for selecting an open approach in some patients at the start of the learning curve of transperitoneal laparoscopy was mass size, which was 5.5 cm on average in this subgroup. In the patient subject to retroperitoneoscopy, this approach was selected due to a history of multiple prior abdominal procedures. More than 95% of procedures were performed by the same surgeon, the first author of this article. Other staff members, also signing this review, are currently performing this surgical procedure. The standard procedure reported in prior publications was used for the transperitoneal laparoscopic approach3. For bilateral adrenalectomy, the same optical trocar was used in both sides. New lateral trocars were only used after repositioning the patient in contralateral decubitus.
Results Fifty-two percent of patients were female. Mean patient age was 53.1 years (± 14.4). Left and right adrenalectomy was performed in 51% and 48% of cases respectively, and bilateral adrenalectomy was required in one patient. Mean mass size was 3.7 cm (±2.2). Mean patient follow-up was 15 months (±11.9). Before surgery, a functional mass was diagnosed in 34 patients (43.9%), pheochromocytoma was suspected in 17 patients (17%), and an incidentaloma was found in 20 patients
(20%). Malignant disease was suspected in 15 patients, 10 with metastases and five with adrenal carcinoma. Results in the group undergoing transperitoneal laparoscopic adrenalectomy are reported below. Mean operating time in the total series (table 1) was 145.1 min (±55.6). A mean 6.26% (±3.3) decrease was seen in hematocrit, which was associated to a mean hemoglobin decrease by 1.5 - 2 g. Surgery was completed laparoscopically in all but 8 procedures (conversion to open surgery was required in 9.6% of patients). Emergency conversion to open surgery was required in a single patient due to avulsion of a lumbar arising from vena cava during difficult dissection of a mass on the right side. In all other cases, conversion to open surgery was due to technical or anesthetic problems including morbid obesity (two patients), giant hepatomegaly (three patients), hemodynamic instability (two patients) during pheochromocytoma handling, and a giant hepatic hemangioma previously diagnosed as an adrenal mass (one patient). One of the patients with intraoperative hemodynamic instability had been treated with a calcium channel blocker (nicardipine) before surgery. The other patient experienced several hypertensive attacks during mass dissection and right adrenal vein could not be controlled, which determined conversion to open surgery. The complication rate was 7%. Intraoperative complications included two patients with hepatic laceration and one patient with splenic laceration, which were successfully controlled with hemostatic materials. Two patients (2.5%) experienced intestinal ileus after surgery, one because of an intestinal hernia through the trocar opening which required exploratory laparotomy. Another patient with an underlying liver cirrhosis experienced decompensated ascites in the early postoperative period. Peri- and postoperative complications occurred in the left and right sides in two and nine patients respectively. Transfusion was required in two patients. One of these was an elderly patient with low hemoglobin levels before surgery, and the other was a patient with morbid obesity who received a transfusion due to self-limited postoperative bleeding from the opening of one of the trocars (abdominal wall hematoma). One patient died early following surgery due to a decompensated cirrhosis of the liver that caused multiorgan failure. Mean hospital stay was six days (±5.6), including the day before surgery at the time of patient admission. Mean follow-up was 15 months (±11.9). Patients with endocrine hypertension before surgery required no additional antihypertensive medication after
Table 1 – Results in the group of patients undergoing transperitoneal laparoscopic adrenalectomy Variables Conversion Vascular complication Visceral complication Postoperative ileus Transfusion
Patients, n (%)
Right/left side
8 (9.6) 1 (1.5) 5 (6.3) 2 (2.5) 2 (2.5)
1/7 0/1 1/4 1/1 1/1
415
*Last 30 procedures. **Continuous variables are given as mean and standard deviation.
5.8 5.4 2.8 3 2.8 4.8 (±6) 6.1 (±5.6) 4.1 (±1.2)** 132 − 7 8.7 − 129 − 5 7.5 − 160 − 2.5 5.1 − 151 − 1.9 3 − 125 60 6.9 6.9 7.4 135 (±32) 250 (±100) 5 9.6 − 145.1 (±55.6) 119.1 (±22.1)* 150 (±50) 9.6 7 7 Mancini et al8 172 Henry et al9 169 Guazzoni et al2 161 Guazzoni et al6 264 El- Kappany et al10 43 Zacharias et al 52 Hevia et al (2009) 83
Hospital stay, days Vascular or visceral lesion, % Complications, % Conversion, % Blood loss, mL Operating time, min Surgeries, n
In our view, there is no question about the advantages of a laparoscopic approach to the adrenal gland over open surgery in terms of operating time, blood loss, postoperative convalescence, cosmetic results, and recovery. Current medical literature has shown no clear advantages of either a transperitoneal or retroperitoneal laparoscopic approach. Use of one or the other probably depends more on the habits and preferences of the surgical team. We performed the standard transperitoneal procedure previously described by other groups4-7. This article has reviewed the experience at our department during the last 12 years. This is the time elapsed since the laparoscopic surgery program was started at our department to replace the conventional open surgery approach we had been using since 1990 in close collaboration with the endocrinology department, which referred us all patients with surgical adrenal conditions based on the good results achieved. This is why we have accumulated a significant experience in adrenal surgery, which should in our view be managed by urological departments because of its location and relationships. Like other authors, we think it is important to have prior experience in laparoscopic surgery before this procedure is undertaken4. Our results were compared to those reported in the main series published and were found to be similar (table 2). Conversion rates to open surgery ranged from 2.5%-7% in the main series (as compared to 9.6% in our series). The complication rate reported in medical literature ranged from 5.1%-9.6%, as compared to 7% in our series. An analysis comparing the last 30 procedures to the first 50 procedures found statistically significant differences in operating time (171.2 vs 119.1 min) and mean hospital stay (6.1 vs 4.1 days). This is consistent with the operating times ranging from 125-160 min and hospital stays ranging from 12.6-5.8 days reported in the published series. It should be noted that the histopathological report on the specimen may not agree with preoperative diagnosis in some cases. This review only confirmed 14 of the 17 initially suspected pheochromocytomas. In this regard, the importance of adequate preoperative diagnostic work-up and close
Table 2 – A comparison of the different series of transperitoneal laparoscopic adrenalectomy published in medical literature
Discussion
Mortality, %
surgery. In patients in whom pheochromocytoma was histologically documented, blood and urine catecholamine levels normalized after surgery. Results of the final pathological report of the complete series showed adenoma in 50 patients (53.2%), pheochromocytoma in 14 patients (14.9%), cortical nodular hyperplasia in eight (8.5%), adrenal metastases from lung adenocarcinoma in seven (7%), adrenal metastases from clear cell renal carcinoma in three (3%), adrenal carcinoma in five (5.3%), and cysts in four (4.3%). An analysis of the last 30 laparoscopic procedures showed statistically significant differences as compared to all other procedures in operating time (119.1 vs 171.2 min) and mean hospital stay (4.1 vs 6.1 days).
4.2 0 0 0 0 − 1.2
actas urol esp. 2010;34(5):412–416
416
actas urol esp. 2010;34(5):412–416
cooperation with the endocrinologist should be emphasized. In patients with pheochromocytoma, mass behavior during surgery may already suggest its actual nature. A single patient with suspected pheochromocytoma received calcium channel blockers before surgery. This patient showed a great hemodynamic instability during the procedure which mandated conversion to open surgery. While there is a group which has reported good management of these patients with nicardipine, we still use conventional treatment with a-blockers and b-blockers if required3. Partial adrenalectomy in patients with bilateral (pheochromocytoma or adenomas) or single adrenal disease may preserve endocrine function of the gland without the need for replacement therapy. Use of intraoperative endoscopic ultrasound is advised in these cases. In some of our patients, conservative surgery could have been considered based on the resected specimen3.
Conclusions Transperitoneal laparoscopic adrenalectomy is a feasible and safe procedure in the hands of urological teams with prior experience in laparoscopic surgery. Our results are similar to those reported in the main series published and support the efficacy, safety, and reproducibility of the procedure.
Conflicts of interest The authors state that they have no conflicts of interest.
R E F E R E N C E S
1. Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl J Med. 1992;327:1033. 2. Guazzoni G, Cestari A, Montorsi F, Lanzi R, Rigatti P, Kaouk JH, et al. Current role of laparoscopic adrenalectomy. Eur Urol. 2001;40:8-16. 3. Hevia M, Abascal Junquera JM, Abascal García JM, Estébanez C, Boix P, Abascal García R. Adrenalectomía laparoscópica transperitoneal: resultados tras 70 procedimientos. Arch Esp Urol. 2008;61:611-20. 4. Zacharias M, Haese A, Jurczok A, Stolzenburg JU, Fornara P. Transperitoneal laparoscopic adrenalectomy: Outline of the preoperative management, surgical approach and outcome. Eur Urol. 2006;49:448-59. 5. Castillo O, Vitagliano G, Kerkebe M, Parma P, Pinto I, Díaz M. Laparoscopic adrenalectomy for suspected metastasis of adrenal glands: Our experience. Urology. 2007;69:637-41. 6. Guazzoni G, Cestari A, Montorsi F, Lanzi R, Nava L, Centemero A, et al. Eight-year experience with transperitoneal laparoscopic adrenal surgery. J Urol. 2001;166:820-4. 7. Pascual JI, Cuesta JA, Grasa V, Labairu L, Napal S, Ipiens AP. Laparoscopy adrenalectomy. Considerations on 24 different procedures. Actas Urol Esp. 2007;31:98-105. 8. Mancini F, Mutter D, Peix JL, Chapuis Y, Henry JF, Proye C, et al. Experiences with adrenalectomy in 1997. Apropos of 247 cases. A multicenter prospective study of the French-speaking Association of Endocrine Surgery. Chirurgie. 1999;124:368-74. 9. Henry JF, Defechereux T, Raffaelli M, Lubrano D, Gramatica L. Complications of laparoscopic adrenalectomy: Results of 169 consecutive procedures. World J Surg. 2000;24:1342-6. 10. El-Kappany H, Shoma A, El-Tabey N, El-Nahas AR, Eraky II. Laparoscopic adrenalectomy: A single-center experience of 43 cases. J Endourol. 2005;19:1170-3.