19

LAPAROSCOPIC ADRENAL SURGERY FOR RECURRENT, HEREDITARY PHAEOCHROMOCYTOMA

Nambirajan T., Jeschke S., Leeb K., Janetschek G.

Elisabethinen Hospital, Department of Urology, Linz, Austria

INTRODUCTION & OBJECTIVES: Patients with hereditary form of phaeochromocytoma develop multiple tumours at young age and are prone for recurrences. Laparoscopic partial adrenalectomy removes the tumour, preserving the adrenal cortical function and avoiding hormonal replacement therapy. It is feasible to perform second adrenal sparing surgery laparoscopically for recurrences, which is illustrated with these 5 cases.

MATERIAL & METHODS:

RESULTS: Laparoscopic partial adrenalectomy was feasible in all but one patient despite previous surgery. There was no need for conversion to open surgery. There were no intra or postoperative complications. Histology confirmed phaeochromocytoma in all patients and there were no malignancies. At follow-up, blood pressure and urine catecholamines were within normal levels in all patients except one (no 5), who has asymptomatic elevation with a recurrent tumour on the contra lateral side. He is under surveillance. The patient 3 was pregnant at 20 weeks of gestation and she completed pregnancy with a full term baby. None of the patients required steroid replacement.

CONCLUSIONS: Laparoscopic partial adrenalectomy is feasible after previous explorations and is technically easier if the previous approach had been laparoscopic as well. Laparoscopy is the ideal approach in patients prone for recurrent tumours.

20

TRANSPERITONEAL LAPAROSCOPIC ADRENALECTOMY: LESSON LEARNED FROM MORE THAN 200 CONSECUTIVE CASES

Cestari A., Guazzoni G., Centemero A., Riva M., Zanoni M., Naspro R., Bellinzoni P., Rigatti P.

Vita-Salute, San Raffaele Hospital - Ville Turro, Urology, Milan, Italy

INTRODUCTION & OBJECTIVES: Laparoscopic adrenalectomy is considered the treatment of choice for the surgical ablation of most benign adrenal lesions. Several approaches and several surgical techniques have been described. We present our 12-year experience in laparoscopic transperitoneal adrenal surgery.

MATERIAL & METHODS: Between October 1992 and September 2003, 231 laparoscopic approaches to the adrenal gland have been performed, namely 185 unilateral adrenalectomy (79 right, 106 left, 65 Conn's disease, 42 Cushing's disease, 37 Phaeochromocytoma, 32 non functioning adenomas and 9 malignancy), 19 bilateral adrenalectomy and 8 cases of conservative surgery. The patients were placed in a 60- degree flank position with the bed flexed to increase the surgical field; the first step of the intervention was the early ligation of the adrenal vein, as a land mark to correctly dissect the adrenal gland.

RESULTS: The laparoscopic procedure was successfully completed in all but 5 cases which were converted into open surgery (1 for duodenal injury during pneumoperitoneum induction with open access and 2 during procedures for malignancy). Mean operative time was 152 min. in the unilateral group, 235 min in the bilateral group and 84 min in the conservative group. Delayed complications included 3 cases of hem peritoneum which were drained surgically, 3 cases of severe blood loss which were treated with blood transfusions, 2 cases of wound infection. Patients were able to ambulate on the morning of the first postoperative day and were discharged respectively 2.7, 5 and 1.5 days after surgery in the unilateral, bilateral and conservative group.

CONCLUSIONS: Laparoscopic transperitoneal adrenalectomy is a safe and effective, minimally invasive approach for patients with benign functioning or non functioning adrenal masses. This technique has low morbidity, minimal postoperative analgesic requirements, short hospital stay.

21

LAPAROSCOPIC ADRENALECTOMY FOR LARGE TUMOURS (5-10CM)

Droupy S.¹, Hammoudi Y.¹, Eschwège P.¹, Young J.², Giuliano F.², Benoit G.¹

¹CHU de Bicêtre, Department of Urology, Le Kremlin Bicêtre, France, ²CHU de Bicêtre, Department of Endocrinology, Le Kremlin Bicêtre, France

INTRODUCTION & OBJECTIVES: Laparoscopic adrenalectomy has become the standard technique for the surgical removal of the adrenal gland. The limits of laparoscopy have not been defined and evolve with surgeons experience. We reviewed our experience with laparoscopic treatment of adrenal tumours from 5 to 10 cm diameter in order to determine feasibility and carcinological safety.

MATERIAL & METHODS: From 1997 to 2002, 56 laparoscopic adrenalectomy were performed by one surgeon. 6 bilateral, 34 for adrenal tumour less than 5 cm and 10 for tumours from 5 to 10 cm. The first 21 were performed using the retroperitoneal laparoscopic approach and the 35 last using a transperitoneal laparoscopic approach. Causes of discover were ultrasonography for abdominal pain (4), Cushing disease (2), a CT scan for breast cancer (2), flank pains (1) and hypertension (1). Patients were 7 women and 3 men, from 28 to 82 years of age.

RESULTS: All the tumours were removed by laparoscopy: the first one using the retroperitoneal approach and 9 using the transperitoneal approach as handling of the tumour was difficult in the confined retroperitoneal space.

Mean operative time was 155 min. (90-215). No preoperative complication occurred. Postoperative complications were one pleural effusion and one haematoma on a trocar site needing two days more of hospital stay. Mean hospital stay was 4.1 days (3-6). Pathological examination showed 3 adrenocortical carcinomas, 2 adenomas (Weiss 1), 2 cavernous lymphangiomas, one leiomyosarcoma, one myolipoma and one adenomatoide tumour. Mean follow-up was 29 months (7 to 60). One patient with a metastatic adrenocortical carcinoma at the time of surgery progressed under OP’DDD. Two patients with adrenocortical carcinomas are free of disease after 60 and 48 months.

CONCLUSIONS: Laparoscopic removal of adrenal tumours more than 5 cm is feasible and carcinologically safe. Tumours are carcinomas or rare tumours for which radical adrenalectomy is required. The transperitoneal laparoscopic approach seems to be more appropriate for large tumours.

26

ADRENAL METASTASES OF UNKNOWN PRIMARY MALIGNANCY - WHAT IS THE DIAGNOSTIC WAY?

Wunderlich H.¹, Reichelt O.¹, Hindermann W.², Kosmehl H.³, Schubert J.¹

¹Friedrich-Schiller-University, Department of Urology, Jena, Germany, ²Friedrich- Schiller-University, Department of Pathology, Jena, Germany, ³Helios-Clinic, Department of Pathology, Erfurt, Germany

INTRODUCTION & OBJECTIVES: The approach to incidental adrenal masses depends on whether the patient is known to have a primary malignancy. Adrenal glands are frequently involved in metastatic disease. The extent of diagnostic imaging in metastatic findings has been reconsidered, in view of the detection of the primary tumour.

MATERIAL & METHODS: In a series of 14.793 autopsies from 1985 till 1995 323 adrenal metastases were revealed. More than half (68,2%) of all adrenal tumours were metastases, of which more than 40% were bilateral.

RESULTS: Most of the metastatic tumours were carcinoma (306/323 metastases), sarcoma (8/323 metastases), malignant melanoma (5/323 metastases) and malignant lymphomas (4/323 metastases). Metastatic disease from lung carcinoma was seen in 195 out of 323 adrenal metastases. Adenocarcinoma and small cell carcinoma were the most common subtype. The second and third most common sites were breast cancer and colorectal cancer in female patients and renal cell carcinoma and colorectal as well as pancreas carcinoma in male patients. Urological carcinomas have shown a low frequency of adrenal metastases, except of renal cell carcinoma. Adrenal metastases in prostate cancer were seen in 5 out of 229 cases, in transitional cell carcinoma of the urinary bladder in 3 out of 125 patients and in transitional cell carcinoma of the renal pelvic in 2 out of 17 cases. In malignant tumours of the testes (n=36) and the penis (n=4) no adrenal metastases were found.

CONCLUSIONS: As soon as adrenal metastasis is suspected without knowing the primary tumour diagnostic work-up needs to be focused on kidney, liver, spleen, GIsystem, breast and especially on lung. Adrenal exploration has to be considered as long as no primary tumour is diagnosed.

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