2. UroToday Home
  3. Recent Abstracts
  4. Endourology & Urolithiasis
  5. Minimally Invasive Procedures

NARUS 2019: Robotic Adrenalectomy

Las Vegas, Nevada (UroToday.com) Dr. Craig Rogers presented on performing adrenal surgery with the robotic system.  He began his talk describing the indication for adrenalectomy in general. These include:

  1. A functioning adrenal tumor (secreting aldosterone, catecholamines, or cortisol)
  2. If an adrenal mass is suspected to harbor cancer:
  • Attenuation and washout not consistent with benign lesions
  • Size >4 cm, and enlarging with time
  • Atypical imaging, irregular borders, enhancement of mass, heterogeneity, calcification, and necrosis
A missed pheochromocytoma tumor, which secrets catecholamines, can be fatal and can result in stroke, arrhythmia, myocardial infarction, cardiomyopathy, and heart failure. Approximately 1-10% of all adrenal incidentalomas are pheochromocytomas (with 50% of the patients being normotensive). These tumors are highly vascularized with marked enhancement and demonstrate the high signal intensity of T2 MRI imaging. If an adrenal tumor is suspected of being a pheochromocytoma, the patient needs to undergo biochemical testing. These include:

  • Plasma-free metanephrines, which harbor a sensitivity of 97-100%, and a specificity of 85-89%.
  • 24-hour urinary metanephrines
The goals of preoperative management of a patient with pheochromocytoma entail expanding of the plasma volume, normalization of the blood pressure, and prevention of arrhythmia. There are several steps that comprise the critical preoperative preparation of these patients. These include:

  1. Adequate hydration and salt intake
  2. Preoperative blockade with alpha-adrenergic blockade (for several weeks before surgery until the patient’s blood pressure has normalized). For this purpose, either phenoxybenzamine or doxazosin can be used.
  3. Administration of a beta blocker, which must be given after alpha blockade. For this purpose, either metoprolol, propranolol, or atenolol can be used.
  4. Alpha methyltyrosine (metyrosine), which is a tyrosine kinase inhibitor, can be given to the patients in an attempt to inhibit catecholamine production
Dr. Rogers continued and provided some important surgical tips that can be used during the robotic procedure. Dr. Rogers believes that all adrenal tumors should be treated like they are a potential pheochromocytoma and it is best to avoid touching them during the procedure. The patient should be “dissected” away from the tumor, rather than excising the mass out of the patient. This helps develop good and safe habits. It is critical to making sure that patients are well-hydrated and are under alpha and beta blockade, after being seen by the endocrinologist. Preoperative coordination with anesthesia is key to the success of the surgery. During the surgery, the surgeon needs to make sure the margins are wide and that the spleen or liver are mobilized enough for adrenal exposure. The surgeon should use a top-down approach with the release of the kidney attachments last. Lastly, early identification and ligation of the adrenal vein is the most important step.

Dr. Rogers concluded his talk and discussed the rare procedure of partial adrenalectomy. Its indications include:
  1. Bilateral disease
  2. Solitary adrenal gland
  3. Familial syndromes (VHL, MEN2, SDH, NF1)
Relative indications include refractory hypertension and equivocal functional workup, or patient symptoms. Potential benefits include avoidance of adrenal insufficiency and steroid dependence, good tumor control, and preservation of quality of life.

During partial adrenalectomy, it is important to mobilize the adrenal limb with the tumor and use intraoperative ultrasound to delineate the exact location of the tumor. Clips should be used along the resection line to reduce bleeding, and it is preferable to avoid excessive thermal injury to the spared adrenal limb.

 
Presented by: Craig Rogers, MD, Henry Ford Health System, Detroit, Michigan

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at  2019 3rd Annual North American Robotic Urology Symposium (NARUS), February 8-9, 2018 - Las Vegas, Nevada, United States