Robotic treatment of giant adrenal myelolipoma: A case report and review of the literature

Abstract

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.

Macroscopic Appearance of Giant Adrenal Myelolipoma During Laparoscopy: An Adjunct in Differential Diagnosis

“…AMLs are usually asymptomatic and incidentally identified during imaging studies presented for other reasons, as they are usually small, located retroperitoneally and hormonally inactive [1,2]. Larger tumors may be palpable or may cause symptoms related to compression of surrounding tissues, which were not confirmed in our case [6,7].…”

“…AMLs are rare, benign tumors composed of mature adipose tissue and bone marrow represented by all three lineages of hematopoietic elements [1,2]. Their incidence is 0.08%-0.4% at autopsy, and they represent 10%-15% of adrenal incidentalomas [1,3]. Their size varies and is usually less than 4 cm.…”

“…Their size varies and is usually less than 4 cm. They usually occur between fifth to seventh decades of life, with no gender or site predilection [1,2]. They are usually encountered unilaterally, although they can occur bilaterally or outside adrenal gland [4].…”

“…The origin and pathogenesis of AMLs are unclear [1,3]. The risk factors include infection, inflammation, necrosis, stressful lifestyle, obesity, hypertension, diabetes and unbalanced diet [1]. They may coexist with hormone-secreting adrenal masses, but AMLs are always hormonally inactive [2].…”

“…The diagnosis of AML is indicated by clinical presentation, although it is usually asymptomatic, and by imaging studies and is confirmed by pathological examination. The treatment of choice of giant AML is open surgical removal, but there are numerous reports of giant AMLs which were successfully removed by using minimal invasive approaches (pure laparoscopy, robotic-assisted laparoscopy) during the last years [1].…”