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Background: Limited information exists on postoperative hypocortisolism and hypothalamus-pituitary-adrenal axis recovery in patients with adrenal incidentaloma following unilateral adrenalectomy. We evaluated frequency of postoperative hypocortisolism and predictors for recovery in non-aldosterone-producing adrenocortical adenoma patients after unilateral adrenalectomy., Methods: A retrospective analysis of 32 adrenal incidentaloma patients originally included in the ITACA trial (NCT04127552) with confirmed non-aldosterone-producing adrenocortical adenoma undergoing unilateral adrenalectomy from September 2019 to April 2023 was conducted. Preoperative assessments included adrenal MRI, anthropometrics, evaluation of comorbidities, adrenal function assessed via ACTH, urinary free cortisol, and 1 mg dexamethasone suppression test. ACTH and serum cortisol or Short Synacthen test were performed within 6 days, 6 weeks, 6 months, and a year after surgery., Results: Six days postoperative, 18.8% of patients had normal adrenal function. Among those with postoperative hypocortisolism, 53.8% recovered by 6 weeks. Patients with earlier adrenal recovery (6 weeks) had lower preoperative 1 mg dexamethasone suppression test (median 1 mg dexamethasone suppression test 76.2 [61.8-111.0] nmol/L vs 260.0 [113.0-288.5] nmol/L, p < 0.001). Univariate analysis showed preoperative 1 mg dexamethasone suppression test negatively related with baseline ACTH levels (r = - 0.376; p = 0.041) and negatively associated with the 6-week baseline (r = - 0.395, p = 0.034) and 30-min cortisol levels during Short Synacthen test (r = - 0.534, p = 0.023). Logistic regression analysis demonstrated preoperative 1 mg dexamethasone suppression test as the only biochemical predictor for 6-week adrenal recovery: ROC curve identified a 1 mg dexamethasone suppression test threshold of 131 nmol/L predicting 6-week recovery with 89.5% sensitivity and 72.7% specificity (AUC 0.87; 95% CI 66.9-98.7, p < 0.001). Other preoperative assessments (tumor size, ACTH levels and anthropometrics) were not associated with postoperative hypothalamus-pituitary-adrenal axis function, but the presence of diabetes was associated with a lower probability of recovery (OR = 24.55, p = 0.036). ACTH levels increased postoperatively in all patients but did not predict hypothalamus-pituitary-adrenal axis recovery., Conclusions: The preoperative 1 mg dexamethasone suppression test cortisol value and presence of diabetes are the only relevant predictor of hypothalamus-pituitary-adrenal axis recovery in patients with non-aldosterone- producing adrenocortical adenoma undergoing surgery, regardless other clinical and biochemical variables. Notably, pre- and postoperative ACTH levels did not predict hypothalamus-pituitary-adrenal axis recovery. These findings point towards the potential for saving resources by optimizing their allocation during follow-up assessments for patients with non-aldosterone-producing adrenocortical adenoma undergoing unilateral adrenalectomy., (© 2024. The Author(s).)

Background: The management of primary aldosteronism is currently achieved by both medical and surgical treatment. Laparoscopy has in recent years unquestionably become the gold standard in adrenal surgery for benign lesions. This study aims to evaluate our clinical results among patients who underwent laparoscopic adrenalectomy (LA) for primary aldosteronism., Methods: From January 1994 to January 2006, amid LA series, 59 primary aldosteronism patients were treated in our institution. Patients were 33 males and 26 females with mean age 49.3 yr (19-78). The mean body mass index was 25.9 kg/m2 (20.5-33.3). The mean size of lesion was 2.9 cm (1-5.5). Clinical symptoms were as follows: hypertension and symptomatic/asymptomatic hypokalemia (54), hypokalemia (5)., Results: Thirty-five left and 24 right LA were performed. On the left side, 22 procedures were carried out by anterior approach, 9 by anterior submesocolic route, and 4 by means of flank approach. All right procedures were completed by the anterior supine approach. The mean operative time was 103.5 min for left and 92.8 min for right adrenalectomy. There was one major complication, a colonic post-operative fistula, regarding a left adrenalectomy case. The mean post-operative hospital stay was 3 days (1-9). The cure rate of hypertension and hypokalemia was similar to the current literature results., Conclusions: LA is a safe and effective option in the treatment of primary aldosteronism. Appropriate selection of patients, larger adrenal masses and duration of symptoms are determining factors in the success rate of hypertension management.

Background: This article reports an alternative laparoscopic access to left adrenal gland., Methods: From January 1994 to August 2004, 209 laparoscopic adrenalectomies were performed in our Department. Indications were Conn adenoma (55 cases), incidentaloma (64), Cushing adenoma (45), pheochromocytoma (32), adreno-genital syndrome (two), mielolipoma (two), and metastatic mass(nine). Of 209, in 12 cases the left adrenalectomy was performed through a submesocolic access (seven pheochromocytoma, two incidentaloma, two Cushing adenoma, one Conn adenoma,). The identification and closure of the adrenal vein with minimal gland manipulation resulted the main benefit of this approach. Moreover, the adrenalectomy was performed with minimal anatomical dissection., Results: No mortality or major complications occurred. During the operation, the blood pressure and cardiac rhythm were significantly more stable, in the group of patients who underwent a left adrenalectomy by the submesocolic approach compared to the anterior or flank lateral transperitoneal group., Conclusions: Left adrenal lesions, as selected cases of pheochromocytoma, can be safely treated by laparoscopic submesocolic access.

Background: Three approaches are currently used for endoscopic adrenalectomy-the lateral (transperitoneal), the posterior (retroperitoneal), and the anterior (transperitoneal). Both the lateral and posterior approaches are performed with the patient placed in the flank decubitus position; in the anterior approach the patient is supine. This study was designed to compare these three types of access in a relatively large series of patients undergoing adrenalectomy at three different institutions., Methods: Laparoscopic adrenalectomy was performed in 216 patients with a variety of adrenal disorders, including 66 patients with Conn's syndrome, 55 with incidentaloma, 58 with Cushing's syndrome, 33 with pheochromocytoma, two with virilizing adrenogenital syndrome, and two with other lesions. Seventy-two adrenalectomies were performed using the lateral access, 67 via the posterior approach, and 77 via the transperitoneal anterior approach. There were 111 right and 105 left lesions., Results: One patient in the lateral access group and three patients in the posterior group required conversion to open surgery. No conversions were needed in the anterior group. The learning curve was statistically significant only in the anterior access group. In both of the transperitoneal approaches (lateral and anterior), a statistically significant correlation was found between the operative time and the patient's body mass index (BMI). The postoperative hospital stay and time needed to return to normal activities were similar for the three groups. One patient who underwent retroperitoneal adrenalectomy for Cushing' disease died in the postoperative period of Candida sepsis and peritonitis., Conclusions: The anterior access route requires that the surgeon be skilled in advanced laparoscopic surgery. Both of the transperitoneal approaches (anterior and lateral) are suitable to remove larger adrenal masses. The posterior access may represent a better option in obese patients or in cases with small lesions.

Background: The feasibility, safety, and results of 108 laparoscopic anterior transperitoneal adrenalectomies (six bilateral) were evaluated in a series of 105 patients. Three patients with a preoperative diagnosis of primary adrenal carcinoma were excluded from the study., Methods: A total of 102 patients were included in the study based on exhaustive endocrinological and imaging assessment. Twenty-nine patients with nonsecreting adenoma, 34 with aldosterone-producing adenoma, 27 with cortisol-producing adenoma (five bilateral), 13 with pheochromocytoma (one bilateral), two with androgen-secreting adenoma, and three with metastases were considered eligible for adrenalectomy. Lesion size ranged from 3.5 to 12 cm. Concurrent surgical procedures were performed in 10 patients (9.8%)., Results: One (0.9%) intraoperative complication, a colon tear in a bilateral adrenalectomy, required conversion. There were two (1.9%) postoperative complications: one patient with thrombocytopenia developed hemoperitoneum and required a second laparoscopic procedure, and an intraabdominal abscess was treated medically. Mean postoperative hospital stay was 2.5 days (range, 1-7 days). Postoperative mortality was 0.9%; the patient with the colon tear died of sepsis 60 days after the operation. At a mean follow-up of 30 months (range, 1-62), normalization or improvement in hormone levels was observed in all patients with secreting adenomas, and significant improvement or cure was achieved in all patients with hypertension., Conclusion: Patients with secreting and nonsecreting adrenal lesions can be treated safety and effectively by laparoscopy with the anterior transperitoneal approach.

Background: A difficulty score for laparoscopic adrenalectomy (LA) is lacking in the literature. A retrospective cohort study was designed to develop a preoperative "difficulty score" for LA. Methods: A multicenter study was conducted involving four Italian tertiary centers for adrenal disease. The population was randomly divided into two subsets: training group and validation one. A multicenter study was undertaken, including 964 patients. Patient, adrenal lesion, surgeon's characteristics, and the type of procedure were studied as potential predictors of target events. The operative time (pOT), conversion rate (cLA), or both were used as indicators of the difficulty in three multivariate models. All models were developed in a training cohort (70% of the sample) and validated using 30% of patients. For all models, the ability to predict complicated postoperative course was reported describing the area under the curve (AUCs). Logistic regression, reporting odds ratio (OR) with p-value, was used. Results: In model A, gender (OR 2.04, p = 0.001), BMI (OR 1.07, p = 0.002), previous surgery (OR 1.29, p = 0.048), site (OR 21.8, p < 0.001) and size of the lesion (OR 1.16, p = 0.002), cumulative sum of procedures (OR 0.99, p < 0.001), extended (OR 26.72, p < 0.001) or associated procedures (OR 4.32, p = 0.015) increased the pOT. In model B, ASA (OR 2.86, p = 0.001), lesion size (OR 1.20, p = 0.005), and extended resection (OR 8.85, p = 0.007) increased the cLA risk. Model C had similar results to model A. All scores obtained predicted the target events in validation cohort (OR 1.99, p < 0.001; OR 1.37, p = 0.007; OR 1.70, p < 0.001, score A, B, and C, respectively). The AUCs in predicting complications were 0.740, 0.686, and 0.763 for model A, B, and C, respectively. Conclusion: A difficulty score based on both pOT and cLA (Model C) was developed using 70% of the sample. The score was validated using a second cohort. Finally, the score was tested, and its results are able to predict a complicated postoperative course. [ABSTRACT FROM AUTHOR]

Background: Some authors consider adrenal lesions size of less than 4 cm as a positive cut-off limit to set the indications for minimally invasive surgery due to a lower risk of malignancy. Aim of this study is to report the risk of cancer for adrenal lesions measuring 4 cm or more in diameter, assessed as benign at preoperative workup (primary outcome), and to evaluate the feasibility and safety of laparoscopic adrenalectomy (LA) in these cases (secondary outcome). Methods: From January 1994 to February 2019, 579 patients underwent adrenalectomy. Fifty patients with a preoperative diagnosis of primary adrenal cancer or metastases were excluded. The remaining 529 patients were included and divided in five subgroups based on adrenal lesion size at definitive histology: group A, 4–5.9 cm (137 patients); group B, 6–7.9 cm (64 patients); group C, 8–9.9 cm (13 patients); group D, ≥ 10 cm (11 patients); group E, < 4 cm (304 patients). Each group was further divided based on diagnosis of benign or malignant lesions at definitive histology. Results: Four (2.9%) malignant lesions were observed in group A, 5 (7.8%) in group B, 2 (15.4%) in Groups C and D (18.2%) and 13 (4.3%) in Group E. Comparing the cancer risk among the groups, no statistically significant differences were observed. Operative time increased with increasing lesion size. However, no statistically significant differences were observed between benign and malignant lesions in each group comparing operative time, conversion and complication rates, postoperative hospital stay and mortality rate. Conclusions: Adrenal lesions measuring 4 cm or more in diameter are not a contraindication for LA neither in terms of cancer risk nor of conversion and morbidity rates, even if the operative time increases with increasing adrenal lesion diameter. Further prospective studies with a larger number of patients are required to draw definitive conclusions. [ABSTRACT FROM AUTHOR]

Background: The aim of this case–control study is to compare the surgical outcomes of laparoscopic adrenalectomy (LA) for lesions measuring ≥6 cm versus ≤5.9 cm in diameter. Methods: Eighty-one patients with adrenal gland lesions ≥6 cm in diameter (intervention group) were identified. Patients were matched to 81 patients with adrenal gland ≤5.9 cm in diameter (control group) based on disease (Conn–Cushing syndrome, pheochromocytoma, primary or secondary adrenal cancer or other disease), lesion side (right, left), surgical technique (anterior transperitoneal approach for right and left LA or anterior transperitoneal submesocolic for left LA) and body mass index class (18–24.9, 25–29.9, 30–34.9, 35–39.9, ≥40 kg/m2). Surgical outcomes were compared between the intervention and control groups. Results: Mean operative time was statistically significantly longer in the interventional arm (101.4 ± 52.4 vs. and 85 ± 31.6 min, p = 0.0174). Eight conversions were observed in the intervention group (9.8%) compared to four in the control group (4.9%) (p = 0.3690). Five (6.1%) and three (3.7%) postoperative complications were observed in the intervention and control groups, respectively (p = 0.7196). Mean postoperative hospital stay was 4.6 ± 2.4 and 4.1 ± 2.3 days in the intervention and control groups, respectively (p = 0.1957). Conclusions: Operative time was statistically significantly longer in adrenal gland lesions ≥6 cm in diameter (vs. ≤5.9 cm). Conversion and complication rates were also higher, but the difference was not statistically significant. Based on the present data, adrenal gland lesions ≥6 cm in diameter are not an absolute contraindication to the laparoscopic approach. [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to evaluate the feasibility, safety, advantages and surgical outcomes of laparoscopic bilateral adrenalectomy (LBA) by an anterior transperitoneal approach.Methods: From 1994 to 2018, 552 patients underwent laparoscopic adrenalectomy, unilateral in 531 and bilateral in 21 patients (9 females and 12 males). All patients who underwent LBA were approached via a transperitoneal anterior route and form our study population. Indications included: Cushing's disease (n = 11), pheochromocytoma (n = 6), Conn's disease (n = 3) and adrenal cysts (n = 1).Results: Mean operative time was 195 ± 86.2 min (range 55-360 min). Conversion was necessary in one case for bleeding. Three patients underwent concurrent laparoscopic cholecystectomy with laparoscopic common bile duct exploration and ductal stone extraction in one. Three postoperative complications occurred in one patient each: subhepatic fluid collection, intestinal ileus and pleural effusion. Mean hospital stay was 6.1 ± 4.7 days (range 2-18 days).Conclusions: In our experience, transperitoneal anterior LBA was feasible and safe. Based on our results, we believe that this approach leads to prompt recognition of anatomical landmarks with early division of the main adrenal vein prior to any gland manipulation, with a low risk of bleeding and without the need to change patient position. Unlike the lateral approach, there is no need to mobilize the spleno-pancreatic complex on the left or the liver on the right. The ability to perform associated intraperitoneal procedures, if required, is an added benefit. [ABSTRACT FROM AUTHOR]

Background: The aim of the present study is to report and to compare the results of three different laparoscopic transperitoneal surgical approaches [lateral transperitoneal (LT), anterior transperitoneal (AT) and anterior transperitoneal submesocolic (ATS)] for the treatment of Conn's and Cushing's syndrome from left adrenal disease.Methods: This study is a retrospective analysis of prospectively collected data. From 1994 to 2017, 535 laparoscopic adrenalectomies (LA) were performed. One hundred and sixty-four patients with Conn's or Cushing's syndrome underwent left LA. Patients were divided in three groups based on the approach: LT (Group A), AT (Group B) and ATS (Group C).Results: The diagnosis was Conn's and Cushing's syndrome in 99 and 65 patients, respectively. LT was used in 13 cases, AT in 55 and ATS in 96. No significant differences in patient's gender, age and BMI were observed. Mean operative time was 117.6 ± 33.7, 107.6 ± 40.3 and 96.2 ± 47.5 min for Groups A, B and C, respectively. Conversion to open surgery was observed in 4 Group C patients (4.1%). Morbidity occurred in 2 Group B (2%) and in 5 Group C patients (5.2%).Conclusions: In case of Conn's or Cushing's syndrome, left LA with ATS approach is equally safe and effective as compared to the LT and AT approaches. Early control of the adrenal vein with minimal gland manipulation and limited surgical dissection are the major advantages of the submesocolic approach. Even if statistically significant differences are not observed, postoperative results are the same as those reported in the literature with other approaches. [ABSTRACT FROM AUTHOR]

Author's Reply: Are Adrenal Lesions of 6 cm or more in Diameter a Contraindication to Laparoscopic Adrenalectomy? In this sense, hand-assisted laparoscopy allows to perform an atraumatic exposure of the structures using finger dissection and to restore the surgeon's tactile sense, which can be very useful during surgery, especially in case of suspected or confirmed primary adrenal cancer or metastasis [[4]]. Author contributions Dr. AB, Dr. LP, Dr. FM, Dr. DC, Dr. MO, Dr. PU, Prof. MG, Dr. SQ and Prof. [Extracted from the article]