Tailored Approach in Adrenal Surgery: Retroperitoneoscopic Partial Adrenalectomy

Abstract

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.

Outcome of Partial Adrenalectomy in MEN2 Syndrome: Personal Experience and Systematic Review of Literature

“…Less blood loss and shorter operative times during adrenal partial procedures have been reported when compared with whole-organ removal [ 40 , 42 ]. Alesina et al [ 13 ] suggested that PA should always be contemplated in case of PHEO, especially when considering that familial diseases account, nowadays, for almost 40% of all cases. Kawasaki et al [ 43 ] applied PA surgery for MEN2A PHEOs, whereas for MEN2B, bilateral TA was performed based on their experience of stronger association with multicentricity and aggressive behavior in such cases.…”

“…In order to avoid, or at least reduce, the need for life-long corticosteroid therapy, partial adrenalectomy (PA) has been proposed as a valuable alternative to TA. This approach is based on three assumptions: infrequency of malignant PHEO in some inherited syndromes, acceptable risk of recurrence (7% over 3 years and 10–15% over 10 years) and high likelihood of corticosteroid independence [ 8 , 13 ]. Risk of recurrence in such cases seems to be of lesser significance when compared to the morbidity and mortality of adrenal insufficiency, consequent lifelong hormone replacement and its deleterious effect on puberty and quality of life [ 9 ].…”

“…Therefore, the selection of patients who will benefit the most from PA, as a component of bilateral surgical treatment, is critical for ensuring good outcomes [ 15 ]. In MEN2-related PHEOs, the specific type of RET mutation is relevant for the planning of surgical strategy: in families with a low incidence of malignancy PA surgery may represent a safe and feasible option to avoid steroid dependency [ 7 , 9 , 10 , 13 , 16 ]. In these patients the importance of preserving normal adrenal tissue is underscored by the risk of decreased quality of life associated with chronic exogenous steroid replacement [ 17 ].…”

“…Given the above considerations, PA strategies have been more recently accepted as a valuable alternative for the treatment of bilateral disease and in patients with PHEOs related to genetic syndromes, including MEN2 [ 7 , 9 , 10 , 13 ]. However, PA should still be considered as a technically demanding surgical procedure, which may expose the patients to the risk of recurrence [ 18 ].…”

Disorders of the adrenal cortex: Genetic and molecular aspects

“…Recently, two new drugs were approved by the FDA, levoketoconazole and osilodrostat, which are both inhibitors of steroidogenic enzyme activity. Non-functioning adrenal tumors are evaluated to verify eligibility for partial adrenalectomy based on size and potential to malignancy ( 229 ). In general, surgery should be considered in lesions >4cm in size or those that are hormonally indeterminate, even if imaging characteristics resemble those of a benign lesion ( 50 ).…”