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The management of blood pressure is a significant concern for surgeons and anesthesiologists performing adrenalectomy for pheochromocytoma. We evaluated clinical factors in pheochromocytoma patients to identify the predictors of postoperative hypotension. The medical records of patients who underwent adrenalectomy for pheochromocytoma between 2001 and 2017 were retrospectively reviewed and clinical and biochemical data were evaluated. Of 29 patients, 13 patients needed catecholamine support in the perisurgical period while 16 patients did not. There were significant differences in median age, tumor size, and blood pressure drop (maxmin) between the 2 groups (68 vs 53 years old, p=0.045; 50 vs 32 mm diameter, p=0.022; 110 vs 71 mmHg, p=0.015 respectively). In univariate logistic analysis, age > 65.5 years, tumor size > 34.5 mm, urine metanephrine > 0.205 mg/day and urine normetanephrine > 0.665 mg/day were significant predictors of prolonged hypotension requiring postoperative catecholamine support. Tumor size and urine metanephrine and urine normetanephrine levels were correlated with postoperative hypotension. These predictors may help in the safe perioperative management of pheochromocytoma patients treated with adrenalectomy., Competing Interests: No potential conflict of interest relevant to this article was reported.

Context: Adrenal venous sampling (AVS) is the current criterion standard lateralization technique in primary aldosteronism (PA). Japanese registry data found that 30% of patients with unilateral PA did not undergo adrenalectomy, but the reasons for this and whether the same pattern is seen internationally are unknown., Objective: To assess the rate of AVS-guided adrenalectomy across an international cohort and identify factors that resulted in adrenalectomy not being performed in otherwise eligible patients., Design, Setting, and Participants: Retrospective, multinational, multicenter questionnaire-based survey of management of PA patients from 16 centers between 2006 and 2018., Main Outcome Measures: Rates of AVS implementation, AVS success rate, diagnosis of unilateral PA, adrenalectomy rate, and reasons why adrenalectomy was not undertaken in patients with unilateral PA., Results: Rates of AVS implementation, successful AVS, and unilateral disease were 66.3%, 89.3% and 36.9% respectively in 4818 patients with PA. Unilateral PA and adrenalectomy rate in unilateral PA were lower in Japanese than in European centers (24.0% vs 47.6% and 78.2% vs 91.4% respectively). The clinical reasoning for not performing adrenalectomy in unilateral PA were more likely to be physician-derived in Japan and patient-derived in Europe. Physician-derived factors included non-AVS factors, such as good blood pressure control, normokalemia, and the absence of adrenal lesions on imaging, which were present before AVS., Conclusion: Considering the various unfavorable aspects of AVS, stricter implementation and consideration of surgical candidacy prior to AVS will increase its diagnostic efficiency and utility., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Left ventricular hypertrophy (LVH) is often seen in patients with primary aldosteronism (PA), and the prevalence of LVH is reportedly higher among patients with PA than patients with essential hypertension. However, the correlation between aldosterone levels and LVH is undefined, and how aldosterone affects LVH in patients with PA remains unclear. We, therefore, retrospectively assessed a large PA database established by the multicenter JPAS (Japan Primary Aldosteronism Study) to reveal the factors associated with LVH in patients with PA without suspected autonomous cortisol secretion. In the 1186 patients with PA studied, the basal plasma aldosterone concentration, plasma renin activity, and the aldosterone-to-renin ratio did not significantly correlate with left ventricular LV mass index (LVMI) in single or multiple regression analyses. However, the plasma aldosterone concentration after the captopril challenge test or saline-infusion test, which are associated with autonomous aldosterone secretion, correlated significantly with LVMI, even after adjusting for patients' backgrounds, including age and blood pressure. In addition, hypokalemia and the unilateral subtype also correlated with LVMI. Longitudinal subanalysis of medically or surgically treated patients with PA showed significant reductions in LVMI in both the surgery (63.0±18.1 to 55.3±19.5 g/m 2.7 , P <0.001) and drug treatment (56.8±14.1 to 52.1±13.5 g/m 2.7 , P <0.001) groups. Our results suggest the autonomous aldosterone secretion level, not the basal aldosterone level itself, is relevant to LVH in patients with PA. In addition, the elevated LVMI seen in patients with PA is at least partially reversible with surgical or medical treatment.

Background: Because of the small numbers of cases in single centers, the indications for and survival benefits of adrenalectomy for adrenal metastasis remain unclear. We evaluated the outcomes of laparoscopic adrenalectomy for patients with adrenal metastasis., Methods: We retrospectively analyzed the records of 67 patients who underwent laparoscopic adrenalectomy for metastatic disease from 2003 to 2017 at 11 hospitals. Associations of clinical, surgical, and pathologic features with overall survival (OS) and positive surgical margins were evaluated using univariate and multivariate Cox regression analyses and univariate logistic regression analysis., Results: Lung cancer (30%) and renal cell carcinoma (30%) were the most common primary tumor types. Intraoperative complications were observed in seven patients (10%) and postoperative complications in seven (10%). The surgical margin was positive in 10 patients (15%). The median OS was 3.8 years. Univariate analysis showed that the tumor size, episodes of extra-adrenal metastasis before adrenalectomy, extra-adrenal metastasis at the time of adrenalectomy, and positive surgical margins were significantly associated with shorter OS (p = 0.022, p = 0.005, p < 0.001, and p = 0.022, respectively). Multivariate analysis showed that extra-adrenal metastasis at the time of adrenalectomy and positive surgical margins remained statistically significant (p = 0.022 and p = 0.049, respectively). In the univariate analysis, the tumor size was significantly associated with positive surgical margins (p = 0.039)., Conclusions: Laparoscopic adrenalectomy for adrenal metastasis can be safely performed in selected patients, and patients with isolated adrenal metastasis and negative surgical margins seem to have more favorable outcomes.

Primary aldosteronism causes renal structural damage after glomerular hyperfiltration, and primary aldosteronism-specific treatment leads to an acute fall in estimated glomerular filtration rate (eGFR). We investigated whether this change affected the long-term eGFR slope in a retrospective cohort from the multicenter Japan Primary Aldosteronism Study. We allocated patients with primary aldosteronism to the adrenalectomy (n=202) and MR (mineralocorticoid receptor) antagonist (n=303) groups based on their treatment history and analyzed the association between the initial eGFR fall and long-term eGFR slope. The increased age, low serum potassium levels, high eGFR, and high plasma aldosterone levels were independent predictors for a large initial eGFR fall in both groups. Our analysis of tertiles based on the initial eGFR fall revealed that in the MR antagonist group, patients with a small initial eGFR fall had a significantly steeper long-term eGFR slope than those with a large initial fall (tertile 1 versus 2, P=0.025; tertile 1 versus 3, P=0.017). These associations were not identified in the adrenalectomy group. Thus, the smaller the acute fall in eGFR by initiation of MR antagonists, the greater was the rate of long-term eGFR decline. While the acute fall in eGFR induced by primary aldosteronism-specific treatment is occasionally a clinical concern, our findings highlight the favorable implications of the acute fall with respect to long-term renal outcomes.

Primary aldosteronism (PA) is the most frequent cause of secondary hypertension. Adrenal vein sampling (AVS) is an established method for finding patients with the unilateral subtype of PA, for which adrenalectomy is an applicable treatment. In this study, we analyzed a large database of patients with PA who underwent adrenal vein sampling, to investigate the sex differences in the impact of age at diagnosis on the subtype and cause of PA. In 2122 patients, women with the unilateral subtype were younger than men with the same subtype and women with the bilateral subtype. Younger age and older age were associated with unilateral PA in women and men, respectively. After stratification by tertiles of age, there was a trend of decreased and increased incidence of unilateral PA with aging in women and men, respectively. Male sex was a predictor of unilateral PA in middle-aged and older patients but not in younger patients. We also found that obesity, a known factor associated with idiopathic hyperaldosteronism, was positively associated with bilateral PA in younger patients but not in older patients. These findings suggest that the proportion of operable patients with unilateral PA differs depending on the combination of sex and age, and that other than obesity, the cause of PA is also associated with the bilateral subtype in older patients.

Objectives: To evaluate the current status of urological laparoendoscopic single-site and reduced port surgery in Japan., Methods: Of the 152 institutions to which councilors of the Japanese Society of Endourology belong, 42 (28%) have carried out laparoendoscopic single-site and reduced port surgery. A total of 32 of these institutions agreed to participate in this survey. Patients who had undergone surgery between January 2008 and March 2014 were included in the present study., Results: Overall, 1145 cases of laparoendoscopic single-site and reduced port surgery were recorded during the study period. The most frequent procedures were adrenalectomy and radical nephrectomy. Laparoendoscopic single-site and reduced port surgery represented 12% (872/7311) of all laparoscopic procedures carried out at participating institutions. The number of patients who underwent pyeloplasty, donor nephrectomy and simple nephrectomy tended to increase, whereas those who underwent adrenalectomy, radical nephrectomy and nephroureterectomy peaked in 2012, and then tended to decrease in 2013. The rates of conversion, perioperative and postoperative complications, were 2.7%, 2.2% and 4.5%, respectively., Conclusions: The number of laparoendoscopic single-site and reduced port urological surgeries in Japan has increased for benign indications, such as pyeloplasty, donor nephrectomy and simple nephrectomy. In contrast, procedures such as adrenalectomy and radical nephrectomy are trending down after reaching a peak in 2012. Overall, laparoendoscopic single-site and reduced port urological surgery in Japan is being safely carried out when compared with other reported series of laparoendoscopic single-site surgery and conventional laparoscopic surgery., (© 2017 The Japanese Urological Association.)

Background: Although the perioperative management of patients with pheochromocytoma has been improving recently, severe hypotensive episodes can occur that require postoperative catecholamine support and are challenging to manage. Our aim was to identify the clinical factors that predict prolonged postresection hypotension in patients after laparoscopic adrenalectomy for pheochromocytoma., Methods: The records of 73 Japanese patients who underwent unilateral laparoscopic adrenalectomy for pheochromocytoma were surveyed retrospectively. Patients were divided into 2 groups according to whether catecholamine support was needed after postoperatively. Clinical and biochemical data were evaluated at baseline and after operation., Results: Thirty-four of 73 patients (47%) required continuous infusion of catecholamine to maintain systolic blood pressure >90 mm Hg at the end of the operation. The median duration of postoperative catecholamine support was 17 hours (range, 3-130) in these 34 patients. On multivariate analysis, tumor size >60 mm, urinary epinephrine levels >200 μg/day, and urinary norepinephrine levels >600 μg/day were independent predictors of prolonged hypotension requiring postoperative catecholamine support. Tumor size and urinary norepinephrine levels were significantly correlated with the duration of postoperative catecholamine support., Conclusion: Larger tumor size and greater values of urinary epinephrine and norepinephrine levels were significant predictors of prolonged hypotension requiring postoperative catecholamine support. Moreover, tumor size and urinary norepinephrine levels were positively correlated with the duration of postoperative catecholamine support. Clinicians can identify and manage patients more effectively with a greater risk of prolonged hypotension after tumor resection using these preoperative clinical variables., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: The use of laparoendoscopic single-site (LESS) surgery has been increasing. The LESS procedure has been done for various urological diseases and studies have shown that it results in less pain, shorter hospi­tal stays and excellent cosmetic outcomes., Materials and Methods: We describe our initial experience with LESS adrenalectomy without the use of the transumbilical approach. The participants were 16 consecutive patients who underwent LESS adrenalectomy using a SILS port™ (Covidien, Mansfield, MA, USA) at Hiroshima University Hospital. Various parameters including the insufflation time, estimated blood loss, resumption of oral intake and complications were ana­lyzed., Results: The adrenalectomy was completed successfully with no major intraoperative complications in 15 of the patients. One LESS adrenalectomy was converted to a conventional laparoscopic adrenalectomy by placement of two additional 12 mm trocars; this patient was therefore excluded from the study. The mean (range) patient age was 53.8 (35-69) years, body mass index (BMI) was 23.5 (20.7-27.2) kg/m2, tumor size was 19.8 (9-45) mm, insufflation time was 188.0 (95-340) min and estimated blood loss was 36.3 (10-80) mL. In all cases articulating instruments were used for satisfactory dissection and triangulation. One bowel injury (serosal) occurred and was repaired in the open laparotomy before SILS port™ insertion. All patients at the follow-up visit were satisfied and pleased with their scars., Conclusion: We found LESS adrenalectomy to be apparently safe, effective and minimally invasive for ad­renal diseases. In our opinion, LESS adrenalectomy without using the transumbilical approach is feasible and easy to introduce.

Aim: The aim of this study was to evaluate the feasibility of our minimum incision endoscopic surgeries (MIES), adrenalectomy, radical nephrectomy and radical prostatectomy, which are operated via a single minimum incision which narrowly permits extraction of the specimen, using an endoscope, without gas insufflation, without any trocar ports and without injury to the peritoneum. These operations have been developed in our department in the late 1990 s and have since been performed in more than 1000 patients and certified as advanced surgery by the Japanese government in 2006., Methods: Adrenalectomy, radical nephrectomy and radical prostatectomy were carried out via a single minimum incision under the conditions of gasless, portless (without trocar ports), intact peritoneum and at low cost with reusable devices. The anatomic plane was separated through the incision and a wide working space was made extraperitoneally. New devices were made especially for this operation in our department, which are now commercially available. The results of the most recent consecutive cases (2005-2007) are evaluated. The results of adrenalectomy and radical nephrectomy performed by 12 operators including inexperienced doctors were compared with the initial results performed by 2 operators, mostly by one operator., Results: In the recent 60 cases of adrenalectomy, the average length of incision, operative time, estimated blood loss were 5.7 cm (5.6 cm in the initial 30 cases), 156 min (147 min) and 174 ml (139 ml), respectively. A complication was observed in one case, injury to the renal artery. Blood transfusion was not performed. Average days to oral feeding, to long walking (more than 100 m) and to possible minimal hospital stay were 1.3 days (2 days), 1.1 days (1.1 days) and 1.9 days (4.6 days), respectively. In the recent 80 cases of radical nephrectomy, the average length of incision, operative time, estimated blood loss were 6.6 cm (6.6 cm in the initial 80 cases), 192 min (186 min) and 315 ml (324 ml), respectively. Complications were not observed in any of the cases (2) and blood transfusion was performed in 1 case (3). Average days to oral feeding, to long walking (more than 100 m) and to possible minimal hospital stay were 1.1 days (1.4 days), 1.2 days (1.4 days) and 1.9 days (4.8 days), respectively. In the recent 50 cases of radical prostatectomy, the average length of incision and operative time were 5.9 cm and 261 min, respectively. Two complications (small rectal injuries) were observed and one blood transfusion was performed. Average days to oral feeding, to long walking (more than 100 m) and possible minimal hospital stay were 1.0 days, 1.0 days and 2.4 days, respectively. Wound pain was minimal and analgesics were generally not required on the second postoperative day in the above 3 operations. Although prophylactic antibiotics were not used in the recent cases of adrenalectomy and radical nephrectomy, surgical site infection was not observed., Conclusion: Minimum incision endoscopic surgery (MIES) in Japanese urology is a safe, reproducible, cost-effective and minimally invasive treatment option for adrenal tumor, renal cell carcinoma and prostate carcinoma.

Objective: We examined the clinical outcomes and the learning curve for a laparoscopic adrenalectomy (LA) in 103 consecutive cases performed by three surgeons at our institute, according to the type of adrenal disorder., Patients and Methods: One hundred and three patients with adrenal tumors, including 38 cases of primary aldosteronism, 33 cases of Cushing syndrome (including preclinical Cushing syndrome), 15 cases of pheochromocytoma, and nine cases of non-functioning adenoma were evaluated, while focusing on the approaches, intraoperative and postoperative data, and the learning curve of LA, according the type of adrenal disorder., Results: There was no significant difference in the operation time, estimated blood loss, incidence of conversion to open surgery and blood transfusion, or postoperative recovery among the patients treated by LA for aldosteronoma, Cushing adenoma, pheochromocytoma, and non-functioning adenoma. In the cases of aldosteronoma and Cushing adenoma, the learning curve for the operation time and blood loss in each operator tended to decrease as the number of operations increased. On the other hand, in the cases treated by LA for pheochromocytoma, no trends in either the operation time or blood loss were observed. However, there has been neither any conversion to open surgery nor blood transfusion in cases treated by LA since 1998 (our 42nd case), even after the changes in the operators., Conclusions: Our results clearly indicate that LA is becoming safer than before, probably due to improvements in the technique, education, and training of surgeons, in addition to the increased number of cases now treated by LA.

A 46-year-old woman was presented with mineralocorticoid excess syndrome and a large mass originating from the right adrenal gland. Clinical examination before right adrenalectomy revealed elevated serum concentrations of 18-hydroxy-11-deoxycorticosterone (18-OH-DOC) both systemically and in the adrenal veins bilaterally. Histopathological and immunohistochemical analyses of the surgical specimen demonstrated adrenal hyperplasia of outer fasciculata cells, and the presence of cystic mass. The adrenalectomy ameliorated her blood pressure (BP) from 156/96 mmHg to 148/87 mmHg with a concomitant increase of serum potassium concentration from 3.1 mEq/l to 3.5 mEq/l. These results suggest that uni-adrenalectomy is, at least in part, effective in ameliorating not only BP but also potassium concentration in a patient of adrenal hyperplasia with excessive bilateral 18-OH-DOC production.

A decade has elapsed since laparoscopic adrenalectomy was first performed in 1992. Accumulated experiences of laparoscopic adrenalectomy have shown superior results to treat small functional benign tumors and make the indication expand to large tumors, pheochromocytomas and localized malignant tumors. Following the initially established transperitoneal approach, which includes anterior and lateral approaches, the retroperitoneal lateral flank and posterior lumber approaches have been performed. Each approach has advantages and disadvantages. The transperitoneal approach supplies a large operative field, many anatomical landmarks and easy handling. But it causes post-operative irritability and it is very difficult to perform after previous upper abdominal surgery. The retroperitoneal approach can be performed even after previous abdominal surgery and patients may be more comfortable after the operation. However, the narrow working space and the lack of anatomical landmarks may increase the rate of intra-operative complications and the rate of conversion to open surgery. Although there is no clear preference between transperitoneal and retroperitoneal approaches, the transperitoneal approach is commonly employed and the transperitoneal anterior approach seems to be the easiest one for right adrenal tumors and the transperitoneal lateral approach for left adrenal tumors. The shorter convalescence with laparoscopic adrenalectomy as compared with open adrenalectomy has been accepted and lower morbidity from laparoscopic adrenalectomy has been achieved. The operative time has been shortened to the level of open adrenalectomy. Less blood loss, less pain and better cosmesis are absolute advantages for the patients. Laparoscopic adrenalectomy is now the gold standard for the treatment of adrenal tumors.

We report our experience with transperitoneal laparoscopic adrenalectomy in 26 cases (mean age 45 years). We experienced primary aldosteronism in 19 cases, Cushing syndrome in 6 cases and non-functioning tumor in one case. There was no significant difference in the operation time between right and left, men and women, primary aldosteronism and Cushing syndrome. The blood loss decreased with training. There were no severe complications during and after the operation. The weight of the resected adrenal glands increased. The blood loss decreased significantly compared with the open surgery. Transperitoneal laparoscopic adrenalectomy is becoming the safe and standard surgery for the adrenal gland tumor, and the number of suitable cases for this procedure is expected to increase in the future.

Objective: We analyzed the complications of endoscopic adrenalectomy., Methods: We retrospectively reviewed the operative and postoperative complications among 75 patients with adrenal tumors who underwent endoscopic adrenalectomy by the same surgeon., Results: Five patients (6.7%) were converted to open surgery. Of these, there were 2 with metastatic adrenal carcinoma, and 1 with adrenal tuberculosis. A total of 21 patients (28%) had 24 complications (32%). There was no mortality. As for access and pneumoperitoneum-related complications, 5 cases of subcutaneous emphysema and 3 of radiating shoulder pain occurred. Intraoperative complications included 2 cases of vascular injury, 2 of organ injury, and 4 of massive bleeding (>500 ml). Postoperative complications included 2 cases of mild paralytic ileus, 2 asthma, and 1 each of angina, wound infection, retroperitoneal hematoma, and contralateral atelectasis. Except for the patients with adrenal malignancy and adrenal tuberculosis, 71% of the complications occurred among the initial 25 patients with laparoscopic adrenalectomy and 80% occurred in the initial 10 retroperitoneoscopic patients., Conclusion: Although endoscopic adrenalectomy is a valuable alternative to open surgery, it should be done by a skilled laparoscopist in patients with adrenal inflammatory lesions or malignancy. Careful patient selection and correct choice of surgical approach according to the tumor size and the patient's condition are the most important points for avoiding the complications of laparoscopic adrenalectomy.