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Background: Indocyanine green imaging (ICG) is an expansion technology that can contribute to the development of demanding techniques such as cortical-sparing adrenalectomy (CSA). The aim of this study was to determine in which cases CSA should be performed and when total adrenalectomy should be performed instead based on ICG fluorescence. Here, we present our experience through a series of cases and videos. Methods: Prospective and descriptive study on patients with surgical adrenal lesions who were proposed for CSA using ICG with near-infrared fluorescence imaging in our center. A first bolus of 6,25 mg ICG was administered intravenously upon exposure of the retroperitoneal plane. Fluorescence was visualized using a Storz® NIR/ICG endoscopic system. Results: Seven patients were proposed for CSA. After the application of ICG, a change in attitude was carried out in 71.4% of the cases (five of seven). In the two patients in whom CSA could be performed, the adrenal remnants were functional, and the resection margins of the surgical specimens were free of disease. The reasons why partial adrenalectomy could not be completed, and a total adrenalectomy was decided instead were the presence of a tumor located very close to the adrenal vein that prevented a correct remnant volume (n = 4) and one case of isofluorescent tumor with the adrenal parenchyma. Conclusion: ICG fluorescence guidance could help in the decision making to select patients intraoperatively for successful cortical preservation. [ABSTRACT FROM AUTHOR]

Introduction We report a case of troubleshooting against bleeding from an inferior vena cava injury using a gelatin–thrombin matrix. Case presentation A 58‐year‐old man underwent robot‐assisted partial adrenalectomy for a right adrenal adenoma causing subclinical Cushing's syndrome. During the surgery, while dissecting between the adrenal gland and the inferior vena cava, bleeding occurred secondary to an inferior vena cava injury. Despite attempts at hemostasis, applying a human fibrinogen–thrombin patch and suturing were both difficult because of poor vision secondary to the bleeding. Hemostasis was ultimately achieved using a gelatin–thrombin matrix, which was accurately placed on the bleeding point using gauze. Open conversion was hence avoided, allowing the completion of the surgery as planned. Conclusion Gelatin–thrombin matrix may be effective for managing relatively small inferior vena cava injuries.

Background: Partial adrenalectomy (PA) is increasingly used to treat benign tumors to lower the probability of adrenal insufficiency and reduce need for lifetime hormone replacement therapy. Currently, two major concerns are increased bleeding and non-functioning adrenal remnants. This paper examines these concerns and compares surgical approaches with novel findings. Methods: Between 1993 and 2023, 72 patients underwent PA for primary adrenal disorders. Demographic, clinicopathologic and outcome data were analyzed for summary statistics, confidence intervals, and heteroscedastic t-test statistics. Results: The patients were 17–76 years-old and were 59.7 % female. The PA was on the left 54.2 % and bilaterally 4.2 %. The indications were adrenal adenoma, pheochromocytoma, cyst, hyperplasia, and other. The mean tumor diameter was 2.7 cm (range 0.7-10 cm). 23 were performed open, 43 laparoscopically, and 6 with an intended robotic approach. Median follow-up was 9.3 years.Robotic had the shortest length of stay (LOS) (p-value 0.01), then laparoscopic (p-value 0.00004), then open. The estimated blood loss (EBL) ranged from 5 to 500 mL (median 50 mL). The median LOS was two days.Intra-operative complication rate was 1.4 % and readmission within 30 days occurred in 2.8 %. Out of 72 patients, 6.8 % needed hormone replacement; of the 14 patients with contralateral adrenalectomy, 28.6 % needed replacement. Conclusion: PA appears to be safe with both laparoscopic and robotic-assisted techniques with superior perioperative outcomes. The functional results of PA prevent most patients from requiring ongoing steroid replacement treatment and recurrence rates were low. PA should be advised for more frequent use as the preferred treatment method of choice. Key message: Partial adrenalectomies' perioperative and long-term outcomes over a median 9.3 year follow-up emphasized its safety and efficacy with 95 % CI of (2.7 cm, 3.6 cm) for masses with adrenal sufficiency post-resection. Additionally, as healthcare institutions decide whether to invest in surgical robots, robotic approach's outperformance of laparoscopic and open on LOS may be counterbalanced by laparoscopic's strong performance in low EBL.

Objective: This study aimed to determine whether the Mayo adhesive probability (MAP) score could predict perioperative outcomes in transperitoneal laparoscopic total adrenalectomy (LTA) and laparoscopic partial adrenalectomy (LPA). Materials and Methods: The clinical data of 139 patients who underwent transperitoneal LTA (n = 116) or LPA (n = 23) between March 2013 and September 2022 were retrospectively analyzed. According to the images obtained from preoperative contrast-enhanced computed tomography or magnetic resonance imaging, the patients were divided into two groups: the low MAP score group (0–1 points) and the high MAP score group (2–5 points). General clinical features and perioperative outcomes were compared between the groups. Results: In patients with a high MAP score, the mean body mass index (BMI) (p: 0.005), tumor size (p: 0.005), operative time (p: 0.002), estimated blood loss (EBL) (p: 0.001), and complication rate (p: 0.013) were significantly higher compared with those with a low MAP score. The comparison of the patients between the LTA and LPA subgroups revealed that operative time and EBL were significantly higher in both subgroups among the patients with a high MAP score. Moreover, the complication rate in the LTA subgroup was significantly higher in the high MAP score group compared with the other group. The Multivariate analyses revealed that a high MAP score was a risk factor for prolonged operative time (Odds Ratio [OR]: 3.081, 95% Confidence Interval [CI]: 1.284–7.398, p: 0.012), increased EBL (OR: 2.495, 95% CI: 1.114–5.588, p: 0.026), and complications (OR: 6.085, 95% CI: 1.532–24.171, p: 0.01) Conclusions: Patients with a high MAP score had a prolonged operative time, increased EBL, and a higher complication rate compared with those with a low MAP score. In addition, we found that a high MAP score was an independent risk factor for perioperative parameters and complications in patients who underwent LTA and LPA. [ABSTRACT FROM AUTHOR]

Primary aldosteronism (PA) is the most common cause of secondary hypertension and is associated with increased morbidity and mortality when compared with blood pressure–matched cases of primary hypertension. Current limitations in patient care stem from delayed recognition of the condition, limited access to key diagnostic procedures, and lack of a definitive therapy option for nonsurgical candidates. However, several recent advances have the potential to address these barriers to optimal care. From a diagnostic perspective, machine-learning algorithms have shown promise in the prediction of PA subtypes, while the development of noninvasive alternatives to adrenal vein sampling (including molecular positron emission tomography imaging) has made accurate localization of functioning adrenal nodules possible. In parallel, more selective approaches to targeting the causative aldosterone-producing adrenal adenoma/nodule (APA/APN) have emerged with the advent of partial adrenalectomy or precision ablation. Additionally, the development of novel pharmacological agents may help to mitigate off-target effects of aldosterone and improve clinical efficacy and outcomes. Here, we consider how each of these innovations might change our approach to the patient with PA, to allow more tailored investigation and treatment plans, with corresponding improvement in clinical outcomes and resource utilization, for this highly prevalent disorder. [ABSTRACT FROM AUTHOR]

Background: We analyze the long‐term outcome of surgery for Cushing's syndrome (CS) and the influence of the extent of surgical resection on the duration of postoperative cortisone substitution. Methods: One‐hundred forty‐one patients (129 female, 12 males; mean age: 45.7 ± 12.8 years) operated between January 2000 to June 2020 were included in the analysis. Patients suffered from manifest (124) or subclinical (17) CS due to benign unilateral adrenal neoplasia. All tumors were removed by the posterior retroperitoneoscopic approach. 105 patients had total (TA) and 36 partial (PA) adrenalectomies. All patients were discharged with ongoing corticosteroid supplementation therapy. Results: Follow‐up data could be obtained for 83 patients. Twenty‐four (1 male, 23 females; mean age 42.3 years) underwent PA and 59 TA (6 males, 53 females; mean age 44.6 years). Mean follow‐up time was 107 ± 68 months (range: 6–243 months). The median duration of postoperative corticosteroid therapy was 9.5 months after PA and 11 months after TA (p = 0.1). Significantly, more patients after total adrenalectomy required corticosteroid therapy for more than 24 months (25% vs. 4%; p = 0.03). Recurrent ipsilateral disease occurred in one case after partial adrenalectomy and was treated by completion adrenalectomy. A case of contralateral recurrence associated with subclinical Cushing's syndrome was observed after total adrenalectomy. Conclusions: The risk of local recurrence after partial adrenalectomy in CS is low. Cortical‐sparing surgery may shorten corticosteroid supplementation therapy after surgery. [ABSTRACT FROM AUTHOR]

Background: Partial adrenalectomy (PA) is an alternative option to total adrenalectomy for the treatment of hereditary pheochromocytoma (PHEO) to preserve cortical function and avoid life-long steroid replacement. The aim of this review is to summarize current evidence in terms of clinical outcome, recurrence, and corticosteroid therapy implementation after PA for MEN2-PHEOs. Material and Methods: From a total of 931 adrenalectomies (1997–2022), 16 of the 194 patients who underwent surgical treatment of PHEO had MEN2 syndrome. There were six patients scheduled for PA. MEDLINE®, EMBASE®, Web of Science, and Cochrane Library were searched for English studies from 1981 to 2022. Results: Among six patients who underwent PA for MEN2-related PHEO in our center, we reported two with bilateral synchronous disease and three with metachronous PHEOs. One recurrence was registered. Less than 20 mg/day Hydrocortison therapy was necessary in 50% of patients after bilateral procedures. Systematic review identified 83 PA for MEN2-PHEO. Bilateral synchronous PHEO, metachronous PHEO and disease recurrence were reported in 42%, 26%, and 4% of patients, respectively. Postoperative steroid implementation was necessary in 65% of patients who underwent bilateral procedures. Conclusions: PA seems to be a safe and valuable option for the treatment of MEN2-related PHEOs, balancing the risk of disease recurrence with the need for corticosteroid therapy. [ABSTRACT FROM AUTHOR]

Background: To evaluate the ability of therapeutic intensity score (TIS) in predicting the clinical outcomes of partial (PA) and total adrenalectomy (TA) for UPA. Methods: Between 2011 and 2022, a four-center adrenalectomy dataset was queried for "unilateral adrenal mass" and "UPA" (n = 90). Preoperative TIS of each antihypertensive medication were individually calculated and merged to create a single, cumulative variable. Probability of complete clinical, partial, and absent pooled success rates according to TIS were assessed for the overall cohort by Kaplan–Meier. Cox analyses were used to identify predictors of complete clinical and partial/absent success, respectively. For all analyses, a two-sided p < 0.05 was considered significant. Results: At a median follow-up of 42 months (IQR 27–54) complete partial, and absent clinical success were observed in 60%, 17.7%, and 22.3%, respectively. On Kaplan–Meier analysis, TIS < 1 predicted higher complete success rates (p < 0.001), while TIS ≥ 1 was predictor of either partial and absent clinical success (p = 0.008). On multivariable analysis, TIS < 1 (HR 0.25; 95% CI 0.11–0.57; p = 0.001) and adenoma size (HR 1.11; 95% CI 1–1.23; p = 0.0049) were independent predictors of complete clinical success, while TIS ≥ 1 (HR 2.84; 95% CI 1.32–6.1; p = 0.007) was the only independent predictor of absent clinical success. Conclusions: TIS score and adenoma size may help to identify patients who are likely to be at risk of persistent hypertension after surgery. [ABSTRACT FROM AUTHOR]

ObjectivesTo evaluate the feasibility, safety and efficacy of the newly developed KD-SR-01® robotic system for retroperitoneal partial adrenalectomy.Subjects and MethodsWe prospectively enrolled patients with benign adrenal mass undergoing KD-SR-01® robot-assisted partial adrenalectomy in our institution from November 2020 to May 2022. Surgeries were performed via a retroperitoneal approach using the KD-SR-01® robotic system. The baseline, perioperative and short-term follow-up data were prospectively collected. A descriptive statistical analysis was performed.ResultsA total of 23 patients were enrolled, including nine (39.1%) patients with hormone-active tumors. All patients received partial adrenalectomy via the retroperitoneal approach without conversions to other procedures. The median operative time was 86.5 min [interquartile range (IQR), 60.0–112.5] and the median estimated blood loss was 50 ml (range, 20–400). Three (13.0%) patients developed Clavien-Dindo grade I-II postoperative complications. The median postoperative stay was 4.0 days (IQR, 3.0–5.0). All surgical margins were negative. The short-term follow-up demonstrated complete or partial clinical and biochemical success as well as absence of imaging recurrence in all patients with hormone-active tumors.ConclusionsInitial results illustrate that the KD-SR-01® robotic system is safe, feasible and effective for the surgical management of benign adrenal tumors.

Introduction. Several predictive scores to evaluate outcomes of adrenal surgery for unilateral primary aldosteronism (UPA), have been conceived. We compared a novel trifecta that summarizes outcomes of adrenal surgery for UPA with the clinical cure proposed by Vorselaars. Material and methods. Between March 2011 and January 2022, a multi-institutional dataset was queried for UPA. Baseline, perioperative and functional data were collected. Clinical and biochemical complete and partial success rates according to Primary Aldosteronism Surgical Outcome (PASO) criteria were assessed for the overall cohort. Clinical cure was defined either as normotension without antihypertensive medications or normotension with lower or equal use of antihypertensive medications. Trifecta was defined as the coexistence of =50% antihypertensive therapeutic intensity score (TIS) reduction (ΔTIS), no electrolyte impairment at 3-months and no Clavien-Dindo (2-5) complications. Cox regression analyses were used to identify predictors of long-term clinical and biochemical success. For all analyses, a two-sided p <0.05 was considered significant. Results Baseline, perioperative and functional outcomes were analyzed. Out of 90 patients, at a median follow-up of 42 months (IQR 27-54) a complete and partial clinical success was observed in 60% and 17.7% of cases while a complete and partial biochemical success was achieved in 83.3% and 12.3% of cases, respectively. Overall trifecta and clinical cure rates were 21.1% and 58.9%, respectively. On multivariable Cox regression analysis, trifecta achievement (HR 2.87; 95% CI 1.45-5.58; p = 0.02) was the only independent predictor of complete clinical success at long-term follow-up. Conclusions Despite its complex estimation and more restrictive criteria, trifecta but not clinical cure allows to independently predict composite PASO endpoints on the long run. [ABSTRACT FROM AUTHOR]

Background: Partial adrenalectomy (PA), as an alternative to total adrenalectomy in selected cases, allows for the preservation of adrenocortical function, especially in hereditary and/or bilateral diseases. In this study, we analyze our experience in posterior retroperitoneoscopic PA (PRPA) and its impact on adrenocortical function., Patients and Methods: From January 2010 to December 2023, 709 PRPAs were performed on 766 adrenal glands in a total of 697 patients (421F; 276M; and mean age 49.3 ± 15.3). Patients suffered from all types of adrenal tumors (239 pheochromocytoma, 225 Conn's syndrome, 102 Cushing's syndrome (CS), 66 nonfunctioning adenomas, 38 adrenal metastases, and 27 others). Mean tumor size was 2.7 ± 1.5 cm. Bilateral disease occurred in 135 patients (60 pheochromocytoma, 19 Conn's syndrome, 32 CS, 2 nonfunctioning adenomas, 17 adrenal metastases, and 5 combined diseases)., Results: Mean operating time for unilateral operation was 39.2 ± 17.2 min. Minor postoperative complications were observed in 1.5% and major complications in 0.1%. The median hospital stay was 2 days. In bilateral cases, 18 of 33 (54%) Cushing patients and nine of 102 (9%) non-Cushing patients received corticosteroid replacement therapy (CRT) early postoperatively. Long-term follow-up data were collected for 242 patients (35%). After unilateral surgery, only patients with CS required CRT (8/24). Eleven (24.4%) out of 45 patients with bilateral non-Cushing disease needed CRT. Eight patients (3%) developed ipsilateral recurrent disease., Conclusion: PRPA is a safe procedure with a low complication and recurrence rate. This makes it the preferred operation in cases of bilateral disease and for selected patients with benign pathologies., (© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

We aim to address incomplete procedures of adrenalectomy for pheochromocytoma (PHEO) on a bases of a mini-review. Dopamine, adrenaline and noradrenaline – secretor tumors are rare in general population, representing a neuroendocrine neoplasia with a strong genetic driving force and uncertain profile concerning a malignant behavior which may be less or more predicted based on initial post-operative report. There is no linear correlation with the post-operative recurrence in terms of clinical presentation, timing and prognostic. The first laparoscopic – based PHEO removal was done in 1992; and since then, the open procedure was replaced in majority of cases by the new gold standard – laparoscopic adrenalectomy; a current conversion rate is of 5%; alpha and beta - blockade is mandatory for preoperative management since an adrenergic crisis might be triggered by higher intraabdominal pressure during laparoscopy; bilateral PHEO may be addressed through one time procedure; minimally invasive technique is done trans-peritoneal or retroperitoneal; robotic – assisted laparoscopic procedure is the next logical step from traditional laparoscopy; in children, minimally invasive procedure is less likely to be used as in adults. Partial adrenalectomy (in terms of cortical - sparing technique) should be rarely performed for unilateral PHEO; its potential utility is for cases with non-feasible total removal due to tumor anatomy (like advanced local disease) or bilateral adrenal involvement in hereditary syndromes (like MEN 2A, VHL), especially in children and young adults to overcome the need of life long glucocorticoid replacement due to chronic adrenal insufficiency. A meta-analysis focusing on recurrence after total adrenalectomy revealed a 3% ratio after 2 years in PHEO. The percent for partial procedure is more than 10% depending on study. In conclusion, a particular aspect in PHEO management is the recurrence after an adrenalectomy, typically after a partial procedure. Unless bilateral involvement or a clear diagnostic of a hereditary syndrome involving bilateral PHEO, partial adrenalectomy should be limited.

Background: Since its first description in 1992, laparoscopic adrenalectomy has become the gold standard for the surgical treatment of most adrenal conditions. We demonstrated the safety and feasibility of the laparoscopic technique in patients with primary hyperaldosteronism caused by solitary aldosteronoma treated by laparoscopic partial adrenalectomy. Aim: To demonstrate safety and feasibility of laparoscopic partial adrenalectomy in aldosterone-producing adenomas. Materials and methods: From 1992. to the present time, 13 patients presented with hyperaldosteronism and a single adrenal adenoma (Conn’s syndrome) and were treated with laparoscopic partial adrenalectomy. The mean age was 65 years, and the average tumor size was 1.35 cm in diameter. The mean follow-up of our patients for hypertension and local reccurence was 36 months (range 6 – 72 months). A transperitoneal approach was used in all patients, tumors were resected with safety margins by ultrasonic device. Results: All procedures were finished laparoscopically, and no conversion was necessary. The mean duration of the operations was 65 minutes, with a mean bleeding rate of 40 ml. No major intraoperative or postoperative complication was observed. Postoperative mean hospital stay was 4 days. In all the cases, hypertension improved totally or partially, and no local recurrence was observed. Conclusion: Laparoscopic partial adrenalectomy for aldosterone-producing adenomas is a minimally invasive procedure with a low complication rate. This procedure can be performed with good results for patients with small aldosteronomas of the adrenal gland, even with a healthy contralateral adrenal gland.

The interest on partial adrenalectomy has steadily increased over the past twenty years. Adrenal pathologies are mostly benign, making an organ-preserving procedure attractive for many patients. The introduction of minimally invasive techniques played probably an important role in this process because they transformed a complex surgical procedure, related to the difficult access to the retroperitoneal space, into a simple operation improving the accessibility to this organ. In this review we summarize the role of partial retroperitoneoscopic adrenalectomy over the years and the current indications and technique. [ABSTRACT FROM AUTHOR]

Von Hippel-Lindau disease (VHL) is a rare cause of hereditary bilateral Pheochromocytomas (PHEO). Traditionally, treatment has been total adrenalectomy due to a lifetime risk of developing new tumors. Limited data exists on the surgical management of bilateral PHEO in children with VHL. We reviewed our experience with laparoscopic partial adrenalectomy for bilateral PHEO. A retrospective review was performed of patients undergoing adrenalectomy for PHEO in children with VHL from 2004 to 2019. Eight children with VHL diagnosed with bilateral PHEO underwent 16 adrenalectomies (10 synchronous, 5 metachronous, 1 for recurrence). Median age at diagnosis was 13 [range 8–17] years with a median tumor size of 2.3 [range 0.5–7.7] cm. Of 16 adrenalectomies, all were performed laparoscopically, 14 were partial adrenalectomies; 2 patients required a contralateral total adrenalectomy due to size and diffuse multinodularity. There were no postoperative complications. No patients required corticosteroid replacement at the end of the study period. Two patients had new ipsilateral tumors identified after a median follow up of 5 [range 4–6] years with one undergoing repeat partial adrenalectomy. There were no mortalities in the study period. Partial adrenalectomy for bilateral PHEO in patients with VHL is safe and does not compromise outcomes. When technically feasible, laparoscopic partial adrenalectomy should be considered as a primary surgical approach for children with VHL. Level IV - Case series with no comparison group [ABSTRACT FROM AUTHOR]

The interest on partial adrenalectomy has steadily increased over the past twenty years. Adrenal pathologies are mostly benign, making an organ-preserving procedure attractive for many patients. The introduction of minimally invasive techniques played probably an important role in this process because they transformed a complex surgical procedure, related to the difficult access to the retroperitoneal space, into a simple operation improving the accessibility to this organ. In this review we summarize the role of partial retroperitoneoscopic adrenalectomy over the years and the current indications and technique.

Background: Partial adrenalectomy (PA) is an alternative option to total adrenalectomy for the treatment of hereditary pheochromocytoma (PHEO) to preserve cortical function and avoid life-long steroid replacement. The aim of this review is to summarize current evidence in terms of clinical outcome, recurrence, and corticosteroid therapy implementation after PA for MEN2-PHEOs. Material and Methods: From a total of 931 adrenalectomies (1997–2022), 16 of the 194 patients who underwent surgical treatment of PHEO had MEN2 syndrome. There were six patients scheduled for PA. MEDLINE®, EMBASE®, Web of Science, and Cochrane Library were searched for English studies from 1981 to 2022. Results: Among six patients who underwent PA for MEN2-related PHEO in our center, we reported two with bilateral synchronous disease and three with metachronous PHEOs. One recurrence was registered. Less than 20 mg/day Hydrocortison therapy was necessary in 50% of patients after bilateral procedures. Systematic review identified 83 PA for MEN2-PHEO. Bilateral synchronous PHEO, metachronous PHEO and disease recurrence were reported in 42%, 26%, and 4% of patients, respectively. Postoperative steroid implementation was necessary in 65% of patients who underwent bilateral procedures. Conclusions: PA seems to be a safe and valuable option for the treatment of MEN2-related PHEOs, balancing the risk of disease recurrence with the need for corticosteroid therapy.

Introduction: We report a case of troubleshooting against bleeding from an inferior vena cava injury using a gelatin-thrombin matrix., Case Presentation: A 58-year-old man underwent robot-assisted partial adrenalectomy for a right adrenal adenoma causing subclinical Cushing's syndrome. During the surgery, while dissecting between the adrenal gland and the inferior vena cava, bleeding occurred secondary to an inferior vena cava injury. Despite attempts at hemostasis, applying a human fibrinogen-thrombin patch and suturing were both difficult because of poor vision secondary to the bleeding. Hemostasis was ultimately achieved using a gelatin-thrombin matrix, which was accurately placed on the bleeding point using gauze. Open conversion was hence avoided, allowing the completion of the surgery as planned., Conclusion: Gelatin-thrombin matrix may be effective for managing relatively small inferior vena cava injuries., Competing Interests: The authors declare no conflict of interest., (© 2024 The Author(s). IJU Case Reports published by John Wiley & Sons Australia, Ltd on behalf of Japanese Urological Association.)

Background: Partial adrenalectomy (PA) is increasingly used to treat benign tumors to lower the probability of adrenal insufficiency and reduce need for lifetime hormone replacement therapy. Currently, two major concerns are increased bleeding and non-functioning adrenal remnants. This paper examines these concerns and compares surgical approaches with novel findings., Methods: Between 1993 and 2023, 72 patients underwent PA for primary adrenal disorders. Demographic, clinicopathologic and outcome data were analyzed for summary statistics, confidence intervals, and heteroscedastic t -test statistics., Results: The patients were 17-76 years-old and were 59.7 % female. The PA was on the left 54.2 % and bilaterally 4.2 %. The indications were adrenal adenoma, pheochromocytoma, cyst, hyperplasia, and other. The mean tumor diameter was 2.7 cm (range 0.7-10 cm). 23 were performed open, 43 laparoscopically, and 6 with an intended robotic approach. Median follow-up was 9.3 years.Robotic had the shortest length of stay (LOS) ( p -value 0.01), then laparoscopic (p-value 0.00004), then open. The estimated blood loss (EBL) ranged from 5 to 500 mL (median 50 mL). The median LOS was two days.Intra-operative complication rate was 1.4 % and readmission within 30 days occurred in 2.8 %. Out of 72 patients, 6.8 % needed hormone replacement; of the 14 patients with contralateral adrenalectomy, 28.6 % needed replacement., Conclusion: PA appears to be safe with both laparoscopic and robotic-assisted techniques with superior perioperative outcomes. The functional results of PA prevent most patients from requiring ongoing steroid replacement treatment and recurrence rates were low. PA should be advised for more frequent use as the preferred treatment method of choice., Key Message: Partial adrenalectomies' perioperative and long-term outcomes over a median 9.3 year follow-up emphasized its safety and efficacy with 95 % CI of (2.7 cm, 3.6 cm) for masses with adrenal sufficiency post-resection. Additionally, as healthcare institutions decide whether to invest in surgical robots, robotic approach's outperformance of laparoscopic and open on LOS may be counterbalanced by laparoscopic's strong performance in low EBL., Competing Interests: None., (© 2024 The Authors.)

Adrenalectomy is the first line of treatment in unilateral aldosterone-producing adenoma. Whether adrenalectomy should be performed using a cortex-sparing technique (partial adrenalectomy) or total adrenalectomy remains debatable. Therefore, this meta-analysis aims to evaluate the safety and effectiveness of partial adrenalectomy (PA) to total adrenalectomy (TA) by comparing perioperative and functional outcomes. A systematic search was performed across Pubmed, Embase, Web of Science, Cochrane Library database for RCTs and non-RCTs comparing PA and TA on unilateral aldosterone-producing adenoma. The main outcomes analyzed were the perioperative and postoperative effectiveness. In addition, weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals of continuous and dichotomous variables are presented. Two RCTs and 5 non-RCTs trials, including 834 patients were identified and included in the meta-analysis. PA was associated with statistically significant shorter hospital stay (WMD − 0.51 days, 95% CI − 0.87, − 0.14; p = 0.007), shorter operative time (WMD − 15.54 min, 95% CI − 25.12, − 5.97; p = 0.001) and lower overall complications (OR 0.52, 95% CI 0.32, 0.85; p = 0.009) compared to TA. There was no statistical significance in postoperative effectiveness, including postoperative blood pressure, potassium, hypokalemia, ARR and renin between TA and PA. PA seems to have advantages over TA. The surgical outcomes were comparable in TA and PA. The hospital stay, operative time and overall complications may be reduced. When technically feasible, PA might be considered as a better treatment for unilateral aldosterone-producing adenoma. [ABSTRACT FROM AUTHOR]

We aim to address incomplete procedures of adrenalectomy for pheochromocytoma (PHEO) on a bases of a mini-review. Dopamine, adrenaline and noradrenaline – secretor tumors are rare in general population, representing a neuroendocrine neoplasia with a strong genetic driving force and uncertain profile concerning a malignant behavior which may be less or more predicted based on initial post-operative report. There is no linear correlation with the post-operative recurrence in terms of clinical presentation, timing and prognostic. The first laparoscopic – based PHEO removal was done in 1992; and since then, the open procedure was replaced in majority of cases by the new gold standard – laparoscopic adrenalectomy; a current conversion rate is of 5%; alpha and beta - blockade is mandatory for preoperative management since an adrenergic crisis might be triggered by higher intraabdominal pressure during laparoscopy; bilateral PHEO may be addressed through one time procedure; minimally invasive technique is done trans-peritoneal or retroperitoneal; robotic – assisted laparoscopic procedure is the next logical step from traditional laparoscopy; in children, minimally invasive procedure is less likely to be used as in adults. Partial adrenalectomy (in terms of cortical - sparing technique) should be rarely performed for unilateral PHEO; its potential utility is for cases with non-feasible total removal due to tumor anatomy (like advanced local disease) or bilateral adrenal involvement in hereditary syndromes (like MEN 2A, VHL), especially in children and young adults to overcome the need of life long glucocorticoid replacement due to chronic adrenal insufficiency. A meta-analysis focusing on recurrence after total adrenalectomy revealed a 3% ratio after 2 years in PHEO. The percent for partial procedure is more than 10% depending on study. In conclusion, a particular aspect in PHEO management is the recurrence after an adrenalectomy, typically after a partial procedure. Unless bilateral involvement or a clear diagnostic of a hereditary syndrome involving bilateral PHEO, partial adrenalectomy should be limited. [ABSTRACT FROM AUTHOR]

Although safe and feasible, partial adrenalectomy is not a widespread procedure. Endorsement of robotic technologies and fluorescence techniques in adrenal surgery might help develop partial adrenalectomy and could avoid unnecessary total adrenalectomies. When performed in selected cases, partial adrenalectomy is associated with good postoperative outcomes comparable with those reported after total adrenalectomy. It has been hypothesized that one of the advantages of the robotic approach in adrenal-sparing surgery is to reduce manipulation of the gland allowing preservation of the vascularization of the residual adrenal, overcoming some limits when performing a laparoscopic conventional approach. A major drawback of the robotic surgery is its cost, but the overcost due to the use of the robotic system could be balanced by the execution of a high number of partial adrenalectomies leading to fewer life-long replacement steroid treatment. Partial adrenalectomy could become the recommended management for small benign and hormonal active adrenal tumors. Indocyanine green fluorescence (IGF) also seems to be a useful technique to help surgeons identify the adrenal gland and to locate small tumors from the normal adrenal tissue in difficult patients. It is likely that the use of a robotic approach associated with IGF may extend indications of partial adrenalectomy in the years to come. [ABSTRACT FROM AUTHOR]

Purpose This prospective study presents the results of a new approach in the treatment of primary macronodular adrenal hyperplasia (PMAH), with simultaneous total adrenalectomy of the larger adrenal gland and partial adrenalectomy of the contralateral adrenal gland (adrenal-sparing surgery). Materials and Methods We performed a prospective study including 17 patients with PMAH treated surgically with adrenal-sparing surgery in a tertiary referral hospital, with a median follow-up of 41 months. Clinical, hormonal, and genetic parameters were evaluated before surgery and during follow-up. All patients had at least 1 radiological examination before and after the procedure. Results Among the 17 patients, all but 1 patient had complete hypercortisolism control, and 12 recovered normal adrenal function after surgery. Significant improvement in clinical parameters was observed: weight loss (P =.004); reduction of both systolic (P =.001) and diastolic (P =.001) blood pressure; and reduction in the number of antihypertensive drugs (P <.001). Intra-, peri-, and postoperative complications were not observed. Conclusion Adrenal-sparing surgery is a safe and feasible procedure to treat patients with PMAH, providing a substantial chance of hypercortisolism control without the disadvantages of lifetime corticosteroid replacement. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the recurrence and functional outcomes in a primarily hereditary cohort of patients undergoing partial adrenalectomy for pheochromocytoma.Methods: A retrospective review from a prospectively managed database of patients undergoing partial adrenalectomy from 1995 to 2018 at the National Cancer Institute was performed. Local recurrence was defined as imaging evidence of a recurrent or de novo lesion on the operative side. Steroid dependency was defined as requiring daily steroid replacement at time of last follow-up.Results: One hundred and twenty-four partial adrenalectomies, removing 162 tumors, were performed in 107 patients. Most patients had a known hereditary predisposition to develop bilateral, multifocal, and recurrent pheochromocytoma. Median tumor size was 2 cm (interquartile range (IQR) 1.5-2.8). Median follow-up was 60 months (IQR 13-131). Local recurrence occurred in 17 patients (15.8%) and were managed with active surveillance or surgery. A single patient (1/106, 0.9%) developed metastatic spread of pheochromocytoma approximately 14 years after his first of 2 partial adrenalectomies and remains alive under active surveillance. Median time to recurrence was 71 months (IQR 26-127) with 10 patients (9.3%) requiring daily steroid replacement at time of last follow-up.Conclusion: Partial adrenalectomy offers excellent oncologic and functional outcomes, sparing most patients from lifelong steroid replacement therapy. Recurrences can be easily managed with repeat surgery or active surveillance via functional work-up and imaging. Partial adrenalectomy remains the recommended surgical management for patients pre-disposed to development of bilateral, multifocal and recurrent pheochromocytoma. [ABSTRACT FROM AUTHOR]

Background: Indocyanine green (ICG) fluorescence imaging represents an emerging technology that facilitates the assessment of tissue vascularity, tissue distinction, and tumor localization during surgery. The aim of this study was to investigate the potential role of ICG imaging during laparoscopic partial adrenalectomy.Methods: Indocyanine fluorescence imaging was carried out during laparoscopic partial adrenalectomy for bilateral pheochromocytoma and bilateral Cushing's syndrome. A first bolus of 5 mg ICG was applied intravenously upon exposure of the retroperitoneal plane to identify the adrenal borders. The fluorescence was visualized using a Storz® NIR/ICG endoscopic system. As the camera of this system detects NIR light as a blue signal, the well-vascularized adrenal tissue was expected to show a strong fluorescence in the blue color channel in contrast to the surrounding adipose tissue. Following partial adrenalectomy, a second bolus of 5 mg ICG was applied intravenously to evaluate the vascularity of the remaining adrenal tissue.Results: We investigated six adrenal glands from three patients undergoing bilateral partial adrenalectomy. The indication for surgery was pheochromocytoma in two patients and Cushing's syndrome with bilateral adenomas in one patient. Regarding left adrenalectomies, ICG imaging was helpful in visualizing the adrenal borders and the adrenal vein. Further, it facilitated the identification of the hypofluorescent pheochromocytoma and to resect the entire tumor. On the right side, due to the more apparent anatomy, ICG imaging did not contribute to the conduct of the operation. Four adrenal remnants showed a strong vascularization and two remnants were only reasonably vascularized.Conclusion: ICG fluorescence may be helpful in guiding partial adrenalectomy and assessing the vascularity of remaining adrenal tissue. [ABSTRACT FROM AUTHOR]

Pheochromocytoma are the functional adrenal lesions originating from the chromaffin cells. For the cases of pheochromocytoma observed in multiple endocrine neoplasia Type 2 and Von Hippel syndrome, the bilateral adrenal glands are involved. In classical approach, total adrenalectomy is applicable on such masses while adrenal failure is almost inevitable. Lifelong cortisol and fludrocortisones replacement are necessary for the patients with adrenal failure while the rate of morbidity and mortality has significantly increased. With the introduction of the minimal invasive surgical approach, cortex sparing adrenalectomy has been brought forward for the adrenal tumors. The primary objective of the cortex sparing surgery is to prevent the lifelong replacement and the permanent adrenal failure after adrenalectomy. Therefore, it is particularly preferred in the case of genetic pheochromocytoma with bilateral adrenal involvement. However, in the case of the selected cases, it can also be applicable for adenoma producing aldostrerone and Cushing syndrome. The adrenal tumor will be completely removed and if sufficient tissue is reserved in the manner to preserve the cortex function, no long-term recurrence and adrenal failure is to be developed. Therefore, cortex-sparing surgery may be a good alternative to total adrenalectomy for the patients with small benign functional adrenal tumors or bilateral genetic pheochromocytoma. [ABSTRACT FROM AUTHOR]

Adrenal gland surgery has been practiced by the urologists ever increasingly in line with their interest in this particular field. Total adrenalectomy which is the classical approach for adrenal masses, is replaced by the organ-sparing surgery as soon as the significance of the organ sparing approach is understood as in the case of the renal masses. The partial adrenalectomy which has been in use through open surgery method since 1950's, was adapted to adrenal surgery by Gagner in 1991 and technical advancement was achieved since then with the introduction of the laparoscopic adrenalectomy by Janetschek six years later. Although it is increasingly being used, there still exist ambiguities concerning the technique and indications of the adrenal sparing surgery. In this review, the updated status of the adrenal sparing surgery is discussed with the current literature. [ABSTRACT FROM AUTHOR]

Objectives: Standard multi-port laparoscopic adrenalectomy (LA) is considered the gold standard for benign adrenal tumors. Single-site LA has been proposed as a feasible and safe alternative because of lower invasiveness, improved cosmetics, less pain and shorter hospital stay. The objective was to evaluate and compare results of single-site transumbilical laparoendoscopic adrenalectomy with standard LA for adrenal tumors. Materials and methods: One hundred consecutive adrenalectomies from 93 patients, performed between March 2009 and June 2017, were laparoscopically excised: 59 by standard multi-port LA (group 1) and 41 by transumbilical laparoendoscopic single-site adrenalectomy (group 2). Data gathered included demographics, comorbidities, preoperative imaging, tumor characteristics, perioperative data, surgical complications, pathology and follow-up. IBM SPSS Statistics 23 software was used and p value < 0.05 was considered significant. Results: Patients of group 2 were younger (48.7 ± 13.9 versus 59.7 ± 15.1 years; p < 0.001) and had fewer comorbidities (p < 0.05). Mean tumor diameter in group 2 was lower than those of group 1 (27.52 ± 14.3 versus 47.9 ± 30.6 mm; p < 0.001). Tumor laterality did not influence the choice of technique nor the surgical morbidity. All procedures were successfully completed, although one standard LA needed conversion to open surgery. Mean operative time, hemorrhagic losses, postoperative opioid analgesic requirement and hospital stay were not statistically different between groups. Most patients in group 2 (31 patients, 85.4%) did not require drainage, compared to 14 (25.4%) patients of group 1 (p < 0.001). Patients who underwent single-site LA resumed normal diet earlier (1.0 ± 0.2 versus 1.6 ± 0.7 days; p < 0.001). There were no reoperations and no perioperative mortality. Overall mean follow-up time was 94.9 ± 3.1 months, not statiscally different between groups (p = 0.7). Conclusions: Our results revealed that transumbilical approach for laparoendoscopic single-site adrenalectomy for adrenal tumors is a feasible and safe alternative to standard laparoscopic adrenalectomy.

Adrenal myelolipoma is a rare mesenchymal tumour with benign biological behaviour that is mainly composed of mature adipose and myeloid tissue. Both sexes are equally affected, most commonly between the fifth and seventh decades of life. The diagnosis of adrenal myelolipoma is mostly incidental. Although it may occasionally be associated with necrosis, rupture and haemorrhage, causing abdominal pain, this tumour is usually asymptomatic. Consequently, management is conservative, while surgical treatment is reserved for symptomatic cases, or for masses growing quickly or to a size >6 cm. Giant myelolipomas (sized >10 cm) are rare. Open radical adrenalectomy is the standard treatment for giant myelolipomas, while the minimally invasive approach has been used in only few cases. We herein report the case of a patient with a giant adrenal myelolipoma who underwent robotic partial adrenalectomy. To the best of our knowledge, this is the largest giant adrenal myelolipoma treated with robotic surgery reported in the literature to date. A 55-year-old male patient underwent an abdominal computed tomography scan during follow-up after radical prostatectomy for prostate cancer Gleason Score 6 (ISUP 1) due to biochemical recurrence. The examination revealed a right hypodense adrenal mass, sized 16×13 cm. Abdominal magnetic resonance imaging confirmed the presence of characteristics suggestive of a myelolipoma. The patient did not report any symptoms. Due to the benign characteristics of the mass, robotic partial adrenalectomy and enucleation of the mass were performed. The operative time and estimated blood loss were 205 min and 100 ml, respectively. No intra- or postoperative complications occurred. The patient was mobilized on the first postoperative day and the time to flatus was 36 h; the length of hospitalization was 4 days. Histological examination confirmed the diagnosis of adrenal myelolipoma, sized 18×11.5×6 cm. No tumour recurrence occurred over a follow-up period of 12 months. In conclusion, robotic surgery allows performing partial adrenalectomy with a lower risk of bleeding and with preservation of healthy adrenal tissue, which is of paramount importance for the patient as it reduces recovery time and the need for medical substitution therapy. [ABSTRACT FROM AUTHOR]

Abstract Background In the era of minimally invasive surgery, partial adrenalectomy has certainly been underused. We aimed to report surgical technique and perioperative, pathologic, and early functional outcomes of a two-center robot-assisted partial adrenalectomy (RAPA) series. Objective To detail surgical technique of RAPA for unilateral aldosterone-producing adenoma (UAPA), and to report perioperative and 1-yr functional outcomes. Design, setting, and participants Data of 10 consecutive patients who underwent RAPA for UAPA at two centers from June 2014 to April 2017 were prospectively collected and reported. Surgical procedure RAPA was performed using a standardized technique with the da Vinci Si in a three-arm configuration. Measurements Baseline and perioperative data were reported. One-year functional outcomes were assessed according to primary aldosteronism surgery outcome guidelines. A descriptive statistical analysis was performed. Results and limitations All cases were completed robotically. Median nodule size was 18 mm (interquartile range [IQR] 16–20). Intraoperative blood loss was negligible. A single (10%) postoperative Clavien grade 2 complication occurred. Median hospital stay was 3 d (IQR 2–3). Patients became normotensive immediately after surgery (median pre- and postoperative blood pressure: 150/90 and 120/70 mmHg, respectively). At both 3-mo and 1-yr functional evaluation, all patients achieved biochemical success (aldosterone level, plasmatic renin activity, and aldosterone-renin ratio within normal range). Complete clinical success was achieved in nine patients, but one required low-dose amlodipine at 6-mo evaluation. At a median follow-up of 30.5 mo (IQR 19–42), neither symptoms nor imaging recurrence was observed. Conclusions We demonstrated feasibility and safety of RAPA for UAPA; this technique had very low risk of complications and excellent functional results. Increased availability of robotic platform and increasing robotic skills among urologists make RAPA a treatment option with potential for widespread use in urologic community. Patient summary Robot-assisted partial adrenalectomy is a safe, feasible, and minimally invasive surgical approach. Promising perioperative and functional outcomes suggest an increasing adoption of this technique in the near future. Take Home Message Robot-assisted partial adrenalectomy is a feasible and safe surgical option for small, isolated unilateral aldosterone-producing adenoma. The role of partial adrenalectomy (PA) versus total adrenalectomy is still a matter of debate, and indications for PA should be discussed in a multidisciplinary setting. [ABSTRACT FROM AUTHOR]

Purpose: Organ-sparing surgery (OSS) for the kidney and adrenals has emerged as the need for preservation of function is paramount in patients with poor functional reserve. As reports increasingly showed that oncological outcomes were equivalent to radical excision, elective OSS became a viable alternative in patients with otherwise normal reserve. In this review, we summarize the current knowledge of OSS for adrenal and renal tumors.Materials and methods: PubMed, Web of Science and Cochrane Library Central Search were searched for recently published articles up to December 2017. The following keywords were used; "partial adrenalectomy", "adrenal sparing", "partial nephrectomy", "nephron sparing", "kidney/renal cancer".Results: Partial adrenalectomy became an attractive alternative to total adrenalectomy avoiding adrenal insufficiency. Both minimally invasive surgery and ablative techniques were increasingly reported for adrenal OSS with adequate residual adrenal function and excellent oncological outcome. Radical nephrectomy remained for many years as the gold standard of treatment for organ-confined renal cell carcinoma. As the need to reduce the impact on renal function, more conservative approaches were utilized. Soon, the non-inferiority of nephron-sparing surgery to that of radical excision became evident and elective partial nephrectomy was gaining ground as the standard of care for small renal masses in patients with normal contralateral kidneys.Conclusions: Herein, we present a comprehensive review of the current status of OSS in renal and adrenal tumors. [ABSTRACT FROM AUTHOR]

Objectives: Standard multi-port laparoscopic adrenalectomy (LA) is considered the gold standard for benign adrenal tumors. Single-site LA has been proposed as a feasible and safe alternative because of lower invasiveness, improved cosmetics, less pain and shorter hospital stay. The objective was to evaluate and compare results of single-site transumbilical laparoendoscopic adrenalectomy with standard LA for adrenal tumors. Materials and methods: One hundred consecutive adrenalectomies from 93 patients, performed between March 2009 and June 2017, were laparoscopically excised: 59 by standard multi-port LA (group 1) and 41 by transumbilical laparoendoscopic single-site adrenalectomy (group 2). Data gathered included demographics, comorbidities, preoperative imaging, tumor characteristics, perioperative data, surgical complications, pathology and follow-up. IBM SPSS Statistics 23 software was used and p value < 0.05 was considered significant. Results: Patients of group 2 were younger (48.7 ± 13.9 versus 59.7 ± 15.1 years; p < 0.001) and had fewer comorbidities (p < 0.05). Mean tumor diameter in group 2 was lower than those of group 1 (27.52 ± 14.3 versus 47.9 ± 30.6 mm; p < 0.001). Tumor laterality did not influence the choice of technique nor the surgical morbidity. All procedures were successfully completed, although one standard LA needed conversion to open surgery. Mean operative time, hemorrhagic losses, postoperative opioid analgesic requirement and hospital stay were not statistically different between groups. Most patients in group 2 (31 patients, 85.4%) did not require drainage, compared to 14 (25.4%) patients of group 1 (p < 0.001). Patients who underwent single-site LA resumed normal diet earlier (1.0 ± 0.2 versus 1.6 ± 0.7 days; p < 0.001). There were no reoperations and no perioperative mortality. Overall mean follow-up time was 94.9 ± 3.1 months, not statiscally different between groups (p = 0.7). Conclusions: Our results revealed that transumbilical approach for laparoendoscopic single-site adrenalectomy for adrenal tumors is a feasible and safe alternative to standard laparoscopic adrenalectomy. [ABSTRACT FROM AUTHOR]

Background: We previously reported our initial experience with laparoendoscopic single-site (LESS) retroperitoneal partial adrenalectomy using a custom-made single-port device and conventional straight laparoscopic instruments. Methods: Between December 2010 and February 2012, LESS retroperitoneal partial adrenalectomies were performed in 11 patients. Six patients had aldosterone-producing adenomas (APAs) and five patients had nonfunctioning tumors. A single-port access was created with an Alexis wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA) through an incision of 2–3 cm beneath the tip of the 12th rib. All procedures were performed with straight laparoscopic instruments. Results: All LESS procedures were successfully completed without conversion to traditional laparoscopic conversion. The tumors ranged from 1 cm to 4.7 cm (mean, 2.3 cm). The operative time was 71–257 minutes (mean, 121 minutes). Most patients (n = 8) had minimal blood loss; the other three patients had a blood loss of 150 mL, 100 mL, and 100 mL. The mean hospital stay was 3 days (range, 1–6 days). There were no perioperative or postoperative complications. Pathological examinations revealed negative surgical margins in all specimens. All patients with Conn's syndrome had an improvement in blood pressure and normalization of plasma renin activity and serum aldosterone levels; all patients were free of potassium supplementation. Conclusion: Our results clearly demonstrate that LESS retroperitoneal partial adrenalectomy can be performed safely and effectively using a custom-made single-access platform and standard laparoscopic instruments.

Long-term results have been estimated for laparoscopic adrenalectomy and laparoscopic partial adrenalectomy in the treatment of adrenal tumors. If preoperative data and intra-operating evaluation show no sign of malignancy, it is possible to perform organ-sparing surgery.