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© 2018 Urological Science | Published by Wolters Kluwer ‑ Medknow 293

introduction

Laparoscopic adrenalectomy has become a standard operative method replacing conventional open surgery in the past 20 years.[1,2] Due to the deeper site and smaller size of the adrenal gland, this minimally invasive surgery has many advantages including less postoperative pain, fewer complications, smaller wound length, and shorter hospital stay. However, minimally invasive adrenal surgery has also been able to reduce the number of ports from 3 or 4 to a single port and is described as

Address for correspondence: Dr. Ching‑Chia Li, No. 68, Jhonghua 3rd Rd, Cianjin District, Kaohsiung City 80145, Taiwan.

E‑mail: [email protected]

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DOI: 10.4103/UROS.UROS_9_18

Abstract

Original Article

Aims: Laparoendoscopic single-site (LESS) adrenalectomy has become a feasible choice for adrenal lesions and can substitute for conventional open adrenalectomy. This report shares our surgical experience and describes the characteristics of adrenal tumors after LESS retroperitoneal adrenalectomy. Subjects and Methods: Between January 2010 and August 2016, 123 patients underwent an LESS adrenalectomy by retroperitoneal approach in our hospital. We retrospectively reviewed the records of these patients and analyzed the characteristics of adrenal tumors. The incision is below the 12th rib in the posterior axillary line and is about 2.3–3.2 cm in length. A 5 mm 30° rigid laparoscope and other conventional laparoscopic instruments are manipulated through a commercial port. No postoperative drain is placed. Results: Among 123 patients, the mean operative time was 114.1 ± 31.1 min, and mean blood loss was 65.1 ± 68.7 ml. Mean hospital stay was 5.4 ± 1.2 days. The postoperative course was uneventful without complications. Among all adrenal tumors undergoing surgery, Conn’s disease is the most common (68.3% Conn’s disease, 19.5% nonfunctioning, 4.9% Cushing’s disease, 3.3% pheochromocytoma, and 0.8% malignancy). We found that left-side adrenal tumors (64.2%) were more common than right-side tumors (35.8%). Conclusions: Our experience shows that retroperitoneal LESS adrenalectomy is promising. Conn’s disease accounts for more than half of adrenal tumors undergoing surgery. In the future, further comparative study is warranted to define the role of LESS in adrenal surgery.

Keywords: Adrenal incidentaloma, adrenal tumor distribution, laparoendoscopic single-site adrenalectomy

A Single‑Institution Experience with Laparoendoscopic Single‑Site Retroperitoneal Adrenalectomy

Yu‑Chen Chen1,2, Hsiang‑Ying Lee1,2,3, Hao‑Wei Chen1,2, Hsin‑Chih Yeh1,3,4,5, Chia‑Chun Tsai1,3, Kuang‑Shun Chueh1,3, Yii‑Her Chou1,5, Chun‑Nung Huang1,5, Wen‑Jeng Wu1,3,5, Nien‑Ting Hou3, Yech‑Huei Lin3, Ching‑Chia Li1,4,5*

1Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, 2Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, 3Department of Urology, Kaohsiung Municipal Ta‑Tung Hospital, 4Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University,

5Department of Urology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

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For reprints contact: [email protected]

How to cite this article: Chen YC, Lee HY, Chen HW, Yeh HC, Tsai CC, Chueh KS, et al. A single-institution experience with laparoendoscopic single-site retroperitoneal adrenalectomy. Urol Sci 2018;29:293-7.

laparoendoscopic single-site (LESS) adrenalectomy.[3,4] LESS adrenalectomy results in improved patient satisfaction and cosmesis outcomes compared with conventional laparoscopic adrenalectomy.[5] Therefore, this procedure has been increasingly performed, with advances in surgical instruments.

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Chen, et al.: Laparoendoscopic single-site retroperitoneal adrenalectomy

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Several approach methods have been developed for adrenal tumor surgery. Wang et al. compared transumbilical, transperitoneal subcostal, and retroperitoneal subcostal approaches and showed that each procedure has its strengths and weaknesses.[6] Lin et al. performed retroperitoneal adrenalectomy using a 2–3 cm skin incision just beneath the tip of the 12th rib.[7]

The aim of this study is to describe our experience with surgical techniques for retroperitoneal LESS adrenalectomy and to analyze the distribution of different types of adrenal tumors.

subjEcts and MEthods

We retrospectively reviewed the records of all patients with adrenal tumors undergoing LESS adrenalectomy at Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, and Kaohsiung Municipal Hsiao-Kang Hospital between January 2010 and August 2016. The study included 123 consecutive patients (58 men and 65 women). Informed consent was received from all patients before the procedure. This study was approved by the appropriate Institutional Review Board at Kaohsiung Medical University Hospital and performed according to the ethical standards laid down by the 1964 Declaration of Helsinki.

In principle, we can perform retroperitoneal LESS adrenalectomy for all kinds of adrenal tumors, regardless of size and characteristics; only adrenal tumors that lie near the renal hilum and may impede instrument approach are excluded. All patients underwent computed tomography or magnetic resonance imaging preoperatively. In this study, we examined intraoperative (estimated blood loss and operative time) and postoperative (time to resume oral intake, analgesic usage, and length of hospital stay) parameters. In addition, all parenterally administered analgesics were recorded including morphine, nalbuphine (1:1 equivalent to morphine), pethidine (10:1 equivalent to morphine), fentanyl (1:100 equivalent to morphine), and ketorolac (5:1 equivalent to morphine). The total number of ampoules/vials required by the patient was calculated during the hospital stay. Only one patient had a wound infection after discharge but recovered well after intensive wound care and oral antibiotics for about 1 week.

Operative techniqueThe patient was placed in flank position for the retroperitoneal approach with the lesion side up. We used a multiple instrument access single port (LagiPort; Lagis, Taiwan) for the LESS adrenalectomy [Figure 1]. The surgeon started the operation with a 2–3 cm skin incision just below the 12th rib in the posterior axillary line [Figure 2]. We accessed the retroperitoneal space through exposed thoracolumbar fascia and then created a space with balloon dilatation. After establishment of pneumoretroperitoneum under 15 mmHg insufflation pressure, a rigid 5 mm, 30° laparoscope, and two working instruments were inserted simultaneously through the LagiPort to prevent instrument conflict. We used standard laparoscopic instruments instead of curved instruments. We

then approached the upper pole of the kidney with dissection of fat to reveal the adrenal tumor. We performed blunt dissection around the adrenal tumor with a suction tube and grasping instrument and controlled vessels with a disposable harmonic scalpel (Ethicon Inc.). After resection of the adrenal tumor, we removed the specimen directly through laparoscopic grasper. No drainage tube was placed.

rEsults

Patient demographics are summarized in Table 1. Mean patient age was 50.9 ± 12.2 years. Among 123 patients with adrenal tumors with indications for LESS adrenalectomy, 84 (68.3%) had Conn’s disease, 6 (4.9%) had Cushing’s syndrome, 4 (3.3%) had a pheochromocytoma, 24 (19.5%) had nonfunctioning tumors, and 1 (0.8%) had a malignant tumor. Left-side adrenal tumors were more common than right-side tumors (79 [64.2%] vs. 44 [35.8%], respectively).

As shown in Table 2, mean operative time was 114.1 ± 31.1 min and mean blood loss was 65.1 ± 68.7 ml. No blood transfusions

Table 1: Patients’ demographics

LESS adrenalectomy (n=123)Age (years) 50.9±12.2Sex, n (%)

Male 58 (47.2)Female 65 (52.8)

BMI (kg/m2) 25.4±4.4Tumor site, n (%)

Left 79 (64.2)Right 44 (35.8)

Pathologic diagnosis, n (%)Conn’s syndrome 84 (68.3)Cushing’s syndrome 6 (4.9)Pheochromocytoma 4 (3.3)Nonfunctioning tumor 24 (19.5)Malignant 1 (0.8)

BMI: Body mass index, LESS: Laparoendoscopic single-site

Figure 1: A commercial single port device‑LagiPort (Lagis, Taiwan)



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were required. Mean tumor size was 4.3 ± 1.9 cm. No patients required additional ports. However, one patient with metastatic tumor from hepatocellular carcinoma required conversion to open adrenalectomy due to severe adhesion.

Because all patients underwent a retroperitoneal approach to avoid injury to the intestine, the number of days until return to oral intake was 0.24 ± 0.43. No patients had any gastrointestinal symptoms. The minor complications were pain and ecchymosis. Mean postoperative intravenous or intramuscular analgesics on-demand doses were 0.35 ± 0.59. Most patients tolerated the wound pain and could ambulate freely. Mean length of postoperative hospital stay was 5.4 ± 1.2 days and the course was uneventful after discharge.

discussion

With advances in diagnostic imaging such as computed tomography, adrenalectomy rates have increased along with the increased prevalence of incidental adrenal masses.[8] In our institution, the average number of laparoscopic adrenalectomy cases performed was over 15 (123 cases/7 years) per year which is more than Hirano et al. reported.[9] When laparoscopic adrenalectomy became standard treatment, we started to accumulate experience with technique. Since 2008, researchers have reported LESS adrenalectomy surgical techniques and have decreased the number of ports with minimally invasive procedures and have improved cosmesis and postoperative outcomes.[10,11] Because of well-prepared and skillful laparoscopic surgical experience, LESS adrenalectomy was initiated in our institution in 2010.

Many surgical strategies have been proposed for adrenal tumors. Previous studies suggested that transumbilical access has cosmetic benefits. However, due to the limited access for manipulation, angle of approach, and difficult organ retraction, the transumbilical access is challenging.[6,12] For cosmetic benefit and an easier operative procedure, we have used retroperitoneal access in all patients. There are many advantages of a retroperitoneal approach including

direct access to the adrenal tumor near the upper pole of the kidney, lack of need for mobilization of the intestine and liver or spleen retraction, and decreased intraperitoneal contamination.[13] In addition, the risk of fatal complications from internal bleeding can be reduced. The retroperitoneal space can provide limited compression to contain bleeding with the formation of hematoma. In our experience, all patients can resume oral intake within 24 h after surgery due to the avoidance of intestinal retraction. In addition, the average analgesic usage is significantly less than reported in another study.[6] This also avoids bowel dysfunction caused by opioids and nonsteroidal anti-inflammatory drugs.[14] Because most Taiwanese have National Health Insurance coverage, hospitalization is inexpensive. However, patients who recover more quickly can receive complete care in another setting. Our approach results in an average postoperative stay of 5 days, oral feeding can resume within 24 h, and pain is minimal. In our experience, an incision at the posterior axillary line offers the advantages of (1) safe and direct access to the retroperitoneal space and (2) superior cosmesis compared to the subcostal approach.

Obesity does not exclude retroperitoneal LESS adrenalectomy. Among all our patients, the highest body mass index was 34 kg/m2. Shi et al.[15] also suggested that retroperitoneal LESS adrenalectomy is a good choice for morbidly obese patients. Hasegawa et al.[16] calculated visceral fat volume using abdominal computed tomography at the level of the umbilicus and stated that this could increase surgical difficulty with the use of transumbilical access. Thus, the retroperitoneal posterior axillary approach is less influenced by obesity.

Previous studies suggested that LESS adrenalectomy required a longer operative time than conventional laparoscopic adrenalectomy due to greater technical difficulty.[7,9] Our results showed an average operative time of 114.1 ± 31.1 min, compared to 145 min reported by Lin et al.[7] and 205 ± 57 min reported by Hirano et al.[9] The operative time is dependent on surgical experience and skill and has a learning curve. Hirasawa et al.[3] indicated that a surgeon familiar with conventional laparoscopic surgery would have a less steep learning curve with less likelihood of conversion from a single-site approach. Our institution has long experience with laparoscopic urologic surgery. Therefore, the outcomes of retroperitoneal LESS adrenalectomy are good, there are few complications, and the procedure is smooth and safe.

Table 2: Surgical outcomes

LESS adrenalectomy (n=123)Operation time (min) 114.1±31.1Blood loss (ml) 65.1±68.7Resumption and oral intake (days) 0.24±0.43Analgesics after surgery (n) 0.35±0.59Length of hospital stay (days) 5.4±1.2Tumor size (cm) 4.3±1.9LESS: Laparoendoscopic single-site

Figure 2: A 2–3 cm skin incision just below the 12th rib in the posterior axillary line



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Earlier studies showed a high incidence of nonfunctioning adrenal tumors among incidental adrenal masses after hormone evaluation, with rates ranging from 70% to 80%.[17-19] Functional adrenal tumor distribution varied among studies. Al-Thani et al.[20] showed that Conn’s disease was present in 3.7% of cases, while 2.9% had a pheochromocytoma. Comlekci et al.[17] reported a 4%–5% prevalence for pheochromocytoma, 5.3% for Cushing’s disease, and 1%–3% for Conn’s disease. However, in our surgical series, the most common adrenal tumor was Conn’s disease, at 68.3%, far exceeding the rate of pheochromocytoma. Nonfunctioning adrenal tumor was not the most common lesion in our study because all of our cases had indications for surgery. To determine whether a mass is a functioning adrenal tumor, we perform a hormone evaluation before surgery. Another indication is the high likelihood of malignancy according to tumor size. A mass >4 cm has been found to be an independent predictor of malignancy.[21] Another indication for surgery can be a request by the patient or family, to alleviate the psychological stress caused by an enlarging mass during follow-up. Based on these criteria, we monitor nonfunctioning adrenal tumors with mass size <4 cm. Therefore, the frequency of nonfunctioning tumors in our study does not represent the prevalence in the general population. Left-sided adrenal tumors (64.2%) were more common than right-side tumors (35.8%) in our study, consistent with a report by Cho et al.[22] On the other hand, Wang et al. reported no trend of laterality for adrenal tumor distribution.[23]

The disadvantage of a small working space will limit the instruments used for dissection and increase the difficulty of controlling the adrenal vein through a retroperitoneal approach. This difficulty may prevent physicians from performing retroperitoneal LESS adrenalectomy due to the risk of hemodynamic instability associated with pheochromocytomas. We prescribe an α-blocker for at least 2 weeks before surgery to prevent a hypertensive crisis. During our early experience, we performed balloon dilatation through the surgical wound to create a larger operative space. In addition, it is important to perform adequate blunt dissection around the adrenal gland with two working instruments. Therefore, we are able to perform retroperitoneal LESS adrenalectomy for pheochromocytomas without complications. Retroperitoneal LESS adrenalectomy should be promoted because there is no need to suture during the operation and retraction of the liver and spleen is not necessary.[24] Thus, we propose that the retroperitoneal approach is a more rational way of performing LESS adrenalectomy for tumors.

The limitations of our study are (1) its retrospective, nonrandomized design based on data derived from the medical records of enrolled patients and procedure notes and (2) its descriptive design rather than comparative study design. However, our results for retroperitoneal LESS adrenalectomy seem promising. Physicians experienced in laparoscopic surgery can easily perform this procedure despite the steep learning curve. In addition, the technique can be performed for various adrenal tumors and even in obese patients. No additional ports are required for retraction.

conclusion

Our experience shows that retroperitoneal LESS adrenalectomy is promising. In the future, further comparative study is warranted to define the role of LESS in adrenal surgery.

Financial support and sponsorshipNil.

Conflicts of interestThere are no conflicts of interest.

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16. Hasegawa M, Miyajima A, Jinzaki M, Maeda T, Takeda T, Kikuchi E, et al. Visceral fat is correlated with prolonged operative time in laparoendoscopic single-site adrenalectomy and laparoscopic adrenalectomy. Urology 2013;82:1312-8.

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