Original Paper
Urologia Internationalis
Received: September 30, 2013 Accepted after revision: November 6, 2013 Published online: January 23, 2015
Urol Int 2015;94:144–148 DOI: 10.1159/000357627
Comparison of Retroperitoneoscopic and Transperitoneal Laparoscopic Adrenalectomy for Right-Sided Benign Tumors: A Single-Institute Experience Po Hui Chiang Cheng Jen Yu Wei Ching Lee Hung Jen Wang Wu Chi Hsu Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
Key Words Transperitoneal · Retroperitoneal · Laparoscopic · Adrenalectomy
safely and effectively via either RLA or TLA. Surgeons can adopt either approach with confidence depending on their preference if they are familiar with that approach. © 2015 S. Karger AG, Basel
© 2015 S. Karger AG, Basel 0042–1138/15/0942–0144$39.50/0 E-Mail [email protected] www.karger.com/uin
Introduction
Since the first report of laparoscopic adrenalectomy in 1992 [1], several advantages of this procedure over open adrenalectomy for benign adrenal disease have been proven [2–5]. Several studies have compared transperitoneal laparoscopic adrenalectomy (TLA) versus retroperitoneal laparoscopic adrenalectomy (RLA) since the first report of RLA in 1995 [6–15]. Many multicenter retrospective studies have tried to compare the surgical results of the two approaches [8–11]. TLA is thought to be feasible for bilateral adrenal lesions, but RLA is considered to involve less intestinal manipulation than TLA. All of these studies have compared the two approaches without considering the laterality of the adrenal gland [7–12]. Anatomical differences, such as the position of the adrenal gland and the length of the adrenal vein, exist between both sides. It is
P.H.C. and C.J.Y. contribute equally to this paper.
Po Hui Chiang, MD, PhD Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 106, Jhong Jheng 3rd Rd Kaohsiung (Taiwan) E-Mail cphtem @ yahoo.com.tw
Downloaded by: University of Tokyo 157.82.153.40 - 5/13/2015 7:26:16 PM
Abstract Introduction: There is a lack of data regarding the appropriateness of transperitoneal and retroperitoneal approaches for right-sided laparoscopic adrenalectomy. The aim of this study was to determine whether there is any difference between right-sided transperitoneal laparoscopic adrenalectomy (TLA) and retroperitoneal laparoscopic adrenalectomy (RLA). Material and Methods: Our surgery database was reviewed to identify patients who underwent right-sided laparoscopic adrenalectomy with a retroperitoneal or transperitoneal approach since 2000. Fifty-five patients were enrolled (31 RLA and 24 TLA). Patient characteristics, as well as operative and perioperative details, were compared between the two groups. Results: There was no difference in patient characteristics between the groups. There was a statistically significant difference (p = 0.02) in blood loss (31.7 ± 16.4 vs. 56.9 ± 65.5 ml) between RLA and TLA when the patient’s BMI was >26. There was no significant difference in operative time, conversion to open surgery, length of hospitalization, or time to oral intake between the groups. Conclusions: Right-sided laparoscopic adrenalectomy can be performed
Table 1. Patient characteristics
not reasonable to compare the results of these two approaches bilaterally at the same time. Besides, the complications are strongly related to the operator’s experience. Operator biases among multicenter reports cannot be overlooked. There is a great deal of controversy surrounding left-sided laparoscopic adrenalectomy with both approaches. However, ‘right-sided adrenalectomy is somewhat more difficult with a retroperitoneal approach because of the position of the adrenal gland and the length of the adrenal vein in relation to the inferior vena cava’ [16]. Comparisons of only right-sided laparoscopic adrenalectomy with both approaches have rarely been reported. The aim of this study was to determine whether there is any difference between right-sided TLA and RLA.
Patients and Methods This retrospective, nonrandomized study was approved by the institutional review board for data analysis. Fifty-five patients underwent right-sided laparoscopic adrenalectomy and were enrolled between March 2000 and September 2011. Adrenocortical malignancies were excluded from this study. The choice of approach depended on the surgeon’s preference. Ninety-one percent (50/55) of the procedures were performed by two senior faculty members (Chiang and Lee). Transperitoneal Approach Patients were placed in a 45° modified flank position. A Veress needle was placed with rotation of the operating table to allow patients to remain in a supine position. Four trocars were inserted. The primary 10-/12-mm port was placed in the midclavicular line and was commonly used for a harmonic scalpel (Ethicon EndoSurgery, Cincinnati, Ohio, USA) or an endovascular GIA stapler. The superomedial port (10-/12-mm) was used for a large fan retractor which was employed to retract the liver. The third 10-mm
Comparison of RLA and TLA for Right-Sided Benign Tumors
TLA
p value
31 53.15 (25–84) 25.07 (16.5–33.6) 17/14
24 53.3 (34–68) 25.41 (19.6–34.5) 11/13
0.99 0.64 0.44
12 (39) 2 (6) 5 (16) 11 (35) 0 1 (3) 3.5±1.56 (1–9)
8 (33) 0 3 (13) 10 (42) 1 (4) 2 (8) 4.6±0.82 (1–13)
0.570
port was placed 3 cm lateral to the first and was commonly used for a laparoscope. The fourth port (lateral) was 5 mm in the anterior axillary line. The position was returned to the original set-up after all ports had been placed. The dissection was carried out along the ascending colon and medially below the liver. The adrenal vein was identified and divided using clips or, in the case of large tumor with a wide vein, using an endovascular GIA stapler. The tiny adrenal arteries were dissected with a harmonic scalpel. Retroperitoneal Approach Patients were placed in a lateral decubitus position. The primary site was a 2-cm incision placed above the iliac crest along the mid-axillary line. After finger dissection, a balloon was inserted into the retroperitoneal space. Normal saline (300–400 ml) was instilled into the balloon to develop the retroperitoneal space. A Hasson port was placed. Two additional ports were used. One was placed 4 cm anterior and superior to the primary site in the anterior axillary line. The other was placed 3–4 cm posterior and superior to the posterior axillary line, just below the 12th rib. The dissection moved cephalad along the psoas muscle. Once the adrenal gland had been located, it was mobilized and lifted anteriorly to expose the adrenal vein, which could then be clipped or divided with an endovascular GIA stapler. The other part of the adrenal gland was mobilized with a harmonic scalpel. These patients’ charts were reviewed to record data such as preoperative characteristics, intraoperative and perioperative details, and hospital days. Parametric data were compared using a t test. Intraoperative and perioperative factors were analyzed based on the BMI (the cutoff value for obesity in Taiwanese people is 26). For categorical data, a χ2 test (Fisher’s exact test) was used. Calculations were performed using SPSS v.17 (IBM Corp., Somers, N.Y., USA).
Results
The patient characteristics are listed in table 1. There was no significant difference in age or BMI between the two groups. Conn’s syndrome and nonfunctioning adeUrol Int 2015;94:144–148 DOI: 10.1159/000357627
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Patients, n Mean age (range), years Mean BMI (range) Sex (M/F) Tumor type, n (%) Conn’s syndrome Cushing’s syndrome Pheochromocytoma Nonfunctionng adenoma Ganglioneuroma Myelolipoma Mean tumor size ± SD (range), cm
RLA
Table 2. Operative and perioperative characteristics (mean ± SD)
RLA
TLA
p value
Patients, n Blood loss (BMI >26)a, ml Operative time (BMI >26)a, h
12 31.67±16.42 2.94±1.05
9 56.88±65.52 2.43±0.92
0.020 0.909
Patients, n Blood loss (BMI ≤26)a, ml Operative time (BMI ≤26)a, h Conversion to open surgery, n (%) Time on narcotic analgesics, days Length of hospitalizationa, nights Time to oral intakea, days Blood loss >100 cma, n
19 28.24±20.99 2.64±1.35 1 (3) 1.6±1.28 4.64±3.65 1.62±1.98 1
15 28.38±29.75 1.95±1.78 2 (8) 1.86±1.28 4.95±3.60 1.10±0.83 2
0.766 0.471 0.403 0.482 0.714 0.209
Values are presented as means ± SD unless otherwise stated. a Cases excluded due to conversion to open surgery.
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Urol Int 2015;94:144–148 DOI: 10.1159/000357627
Discussion
Many authors have reported comparisons between RLA and TLA bilaterally. However, there are contradictory conclusions among these papers. Naya et al. [8] reported that TLA tends to be faster than RLA and causes less blood loss. A multicenter comparison also showed that TLA had shorter operative times with less blood loss compared to the retroperitoneal approach [9]. Giger et al. [10] pointed out that they favored the transperitoneal approach for bilateral and left-sided adrenal tumors and that right-sided tumors >8 cm were better removed via the transperitoneal approach. They proposed that the maneuvering space is limited when lesions are >6–8 cm in diameter and the corresponding vessels cannot be safely controlled. Dickson et al. [11] recently reported that the retroperitoneal approach results in decreased operative times, blood loss, and postoperative lengths of stay compared to the transperitoneal approach. Arslan et al. [17] reported that the retroperitoneal approach is superior to the transperitoneal approach for small adrenal masses. Lezoche et al. [12] concluded that the transperitoneal approach is suitable for the removal of larger adrenal masses and the retroperitoneal approach may represent a better option for obese patients or patients with small lesions. One paper compared the two different approaches for right adrenalectomy [13]. Those authors preferred the transperitoneal approach for the management of large adrenal masses (>5 cm) due to shorter operative times, better visibility of familiar anatomic landmarks, easy access to the vessels, and a larger operative field [13]. Takeda et al. [14] reported in a small series (a total of 11 cases) that RLA is feasible for primary aldosteronism and a much more difChiang/Yu/Lee/Wang/Hsu
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noma accounted for the majority of the tumors between two groups. Pheocromocytoma accounted for 16 and 13% of the tumors in each group, respectively. The largest adrenal tumor in the RLA group was 9 cm in diameter, and the pathology was pheochromocytoma. The largest adrenal tumor in the TLA group was 13 cm in size, and the pathology was pheochromocytoma with local kidney invasion. There was a statistically significant difference (p = 0.02) in blood loss (31.7 ± 16.4 vs. 56.9 ± 65.5 ml) between RLA and TLA when the patient’s BMI was >26 (table 2). However, there was no statistical difference in operative time, and there was no statistical difference in operative time or blood loss in patients with a BMI ≤26 between the two groups. Conversion to open surgery occurred in both groups. Conversion occurred in one RLA because of pheochromocytoma with uncontrolled bleeding. Two conversions occurred in TLA due to a 13-cm pheochromocytoma with local kidney invasion and a previous appendectomy with an intra-abdominal adhesion, respectively. There was no significant difference in length of hospitalization, duration (days) of postoperative narcotic analgesic use, or time to oral intake between the two approaches. Since there were 2 cases with Cushing’s syndrome in the RLA group, longer hospitalization times (18 and 24 hospital days, respectively) due to metabolic disorders and other medical problems were noted and excluded from the analysis of hospitalization days in this study. No delay in oral intake occurred in the TLA group (1.6 days in RLA and 1.1 days in TLA). There were no major complications or mortality in either group.
Comparison of RLA and TLA for Right-Sided Benign Tumors
Table 3. Pros and cons of both approaches
RLA
TLA
Anatomic landmark Access to the adrenal vein Operation time Injury to neighboring organs
+ – + seldom
Trocars, n
3–4
+++ ++ + possible (liver, duodenum, and colon) 4–5
+++ = Very good; ++ = good; + = fair; – = poor.
in the TLA group. Conversion to an open procedure was performed to ensure a sound oncologic resection. All of these patients were discharged without complications. Adrenal masses >8 cm are technically more difficult to remove because the tumor limits manipulation with devices and obstructs the operative field. Ito et al. [19] reported that the LigaSure sealing system or an ultrasounddriven scalpel can be used for enucleation of adrenal tumor lesions. More collateral vessels are noted in greater adrenal tumors, and we used Endo GIA in some cases to control the vessels effectively. Greater tumors have a greater likelihood of representing an adenocortical carcinoma. However, 15 cm was used as the upper limit by one group of surgeons [20]. Malignant pheochromocytoma is defined by the presence of metastasis rather than histologic criteria. If there is no evidence of metastasis, size alone does not predict malignancy in pheochromocytomas [21]. Greco et al. [22] conducted a multicenter study and reported that the upper limit for adrenalectomy could be as high as 10–14 cm for very experienced surgeons. In our series, a pheochromocytoma measuring 9 cm in diameter was removed successfully using the retroperitoneal approach with a blood loss of 50 ml. Like TLA, RLA could be used by experienced physicians for tumors >8 cm. Although tumors >8 cm were uncommon in our series, we did not find any influence of tumor size on the surgical approach. Blood loss correlated positively with BMI >26 only for the transperitoneal approach. However, the difference in mean blood loss (31.67 vs. 56.88 ml) between the two groups was insubstantial and not clinically relevant to the decision of which approach to choose. Previous studies and our data are summarized in table 3, which integrates the advantages and disadvantages of both approaches. Right-sided TLA is easier for beginners, and experienced surgeons achieve equally effective and safe performances with either approach. Urol Int 2015;94:144–148 DOI: 10.1159/000357627
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ficult indication for Cushing’s syndrome. Chee et al. [15] reported that both approaches were safe in a total of 14 cases series. Agha et al. [18] reported that TLA and RLA are also feasible and effective procedures. It is difficult to conclude on the differences between the two approaches based on previous reports due to bilateral comparisons, different operators, multicenter experiences, and small case numbers. Besides, the learning curve for the retroperitoneal approach is more technically challenging for beginners, particularly due to the need for familiarity with the retroperitoneum given that there are fewer anatomical landmarks and the work space is relatively small. In our series, although there was no significant difference in operative times between the two approaches, with RLA it was indeed more difficult to access the adrenal vessel underneath bigger adrenal tumors. Moreover, the right kidney occupies the retroperitoneal space and often crosses the path of control of the adrenal vessel. These factors may have influenced the preference for the transperitoneal approach expressed in most earlier papers. Our group benefited from performing both approaches at almost the same time (1994 and 1995, respectively). Four operators performed right-sided laparoscopic adrenalectomies in this study. Three of them (Chiang, Wang, and Cheng) preferred TLA for right-sided adrenal tumors. They considered that with TLA it was easier to control the adrenal vein and the operation field was larger than with RLA. Besides, there were many anatomical landmarks to be identified during TLA, making it especially easier for young doctors (Wang and Cheng). On the other hand, Dr. Lee exclusively used the retroperitoneal approach for adrenal tumors because of his training, and he believed that RLA resulted in less manipulation of the intestine and intraperitoneal organs. Some papers have also expressed concerns that the intestinal manipulation during TLA could result in postoperative intestinal symptoms and a delayed oral intake [1]. In this series, the time to oral intake was 1.1 and 1.62 days for the transperitoneal and retroperitoneal approaches, respectively. The intestinal manipulation during the TLA approach seemed not to result in an impairment of bowel function after the operation. The surgery for pheochromocytoma was more challenging than that for adenoma because pheochromocytomas are highly vascular and generally larger [11]. Oozing and vessel tearing were also noted during the surgery, and uncontrolled bleeding occasionally resulted in conversion to open surgery. There was one conversion due to severe bleeding from a 5.5-cm pheochromocytoma in the RLA group. There was also one conversion due to a large pheochromocytoma (13 cm) with local invasion of the kidneys
Though many reports have compared RLA with TLA, we analyzed our data at a single institute and unilaterally within the last decade. However, it is important to understand that our study was not a prospective randomized trial, and the limitation of this study is that the choice of operative method depended only on the operator’s preference. We believe this study provides reliable data with minimal biases from the laterality of the tumor and intercenter differences.
Conclusion
We believe that right-sided laparoscopic adrenalectomy could be performed safely and effectively either via RLA or TLA, and surgeons can adopt either approach with confidence depending on their preference if they are familiar with that approach.
References
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9 Ramacciato G, Nigri GR, Petrucciani N, Santo VD, Piccoli M, Buniva P, et al: Minimally invasive adrenalectomy: a multicenter comparison of transperitoneal and retroperitoneal approaches. Am Surg 2011;77:409–416. 10 Giger U, Vonlanthen R, Michel JM, Krähenbühl L: Trans- and retroperitoneal endoscopic adrenalectomy: experience in 26 consecutive adrenalectomies. Dig Surg 2004; 21: 28– 32. 11 Dickson PV, Alex GC, Grubbs EG, AyalaRamirez M, Jimenez C, Evans DB, et al: Posterior retroperitoneoscopic adrenalectomy is a safe and effective alternative to transabdominal laparoscopic adrenalectomy for pheochromocytoma. Surgery 2011;150:452–458. 12 Lezoche E, Guerrieri M, Feliciotti F, Paganini AM, Perretta S, Baldarelli M, et al: Anterior, lateral, and posterior retroperitoneal approaches in endoscopic adrenalectomy. Surg Endosc 2002;16:96–99. 13 Papalia R, Simone G, Leonardo C, Loreto A, Coppola R, Guaglianone S, et al: Laparoscopic transperitoneal right adrealectomy for ‘large‘ tumors. Urol Int 2008:437–440. 14 Takeda M, Go H, Watanabe R, Kurumada S, Obara K, Takahashi E, et al: Retroperitoneal laparoscopic adrenalectomy for functioning adrenal tumors: comparison with conventional transperitoneal laparoscopic adrenalectomy. J Urol 1997;157:19–23. 15 Chee C, Ravinthiran T, Cheng C: Laparoscopic adrenalectomy: experience with transabdominal and retroperitoneal approaches. Urology 1998;51:29–32.
16 Blake D: Hamilton: Laparoscopic adrenalectomy: transperitoneal and retroperitoneal approaches; in Bishoff JT, Kavoussi LR (eds): Atlas of Laparoscopic Retroperitoneal Surgery. Philadelphia, Saunders, 2000, pp 191– 208. 17 Arslan M, Akin Y, Ates M, Degirmenci T, Kozacioglu Z, Ors B, et al: Changing surgical approaches for laparoscopic adrenalectomy: single-surgeon data of a 6-year experience. Urol Int 2013;91:304–309. 18 Agha A, Hornung M, Iesalnieks I, Glockzin G, Schlitt HJ: Single-incision retroperitoneoscopic adrenalectomy and single-incision laparoscopic adrenalectomy. J Endourol 2010; 24:1765–1770. 19 Ito K, Yoshii T, Shinmoto H, Kanbara T, Sumitomo M, Kaji T, Tanaka Y, Asano T: Laparoscopic enucleation of macronodules in a patient with ACTH-independent macronodular adrenal hyperplasia7 years after unilateral adrenalectomy: consideration of operative procedure. Urol Int 2013;90:253–258. 20 Gagner M, Pomp A, Heniford BT, Pharand D, Lacroix A: Laparoscopic adrenalectomy: lessons learned from 100 consecutive procedures. Ann Surg 1997;226:238–246. 21 Shen WT, Sturgeon C, Clark OH, Duh QY, Kebebew E: Should pheochromocytoma size influence surgical approach? A comparison of 90 malignant and 60 benign pheochromocytoma. Surgery 2004;136:1129–1137. 22 Greco F, Hoda MR, Rassweiler J, Fahlenkamp D, Neisius DA, Kutta A, et al: Laparoscopic adrenalectomy in urological centres – the experience of the German Laparoscopic Working Group. BJU Int 2011;108:1646–1651.
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Urologia Internationalis
Received: September 30, 2013 Accepted after revision: November 6, 2013 Published online: January 23, 2015
Urol Int 2015;94:144–148 DOI: 10.1159/000357627
Comparison of Retroperitoneoscopic and Transperitoneal Laparoscopic Adrenalectomy for Right-Sided Benign Tumors: A Single-Institute Experience Po Hui Chiang Cheng Jen Yu Wei Ching Lee Hung Jen Wang Wu Chi Hsu Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
Key Words Transperitoneal · Retroperitoneal · Laparoscopic · Adrenalectomy
safely and effectively via either RLA or TLA. Surgeons can adopt either approach with confidence depending on their preference if they are familiar with that approach. © 2015 S. Karger AG, Basel
© 2015 S. Karger AG, Basel 0042–1138/15/0942–0144$39.50/0 E-Mail [email protected] www.karger.com/uin
Introduction
Since the first report of laparoscopic adrenalectomy in 1992 [1], several advantages of this procedure over open adrenalectomy for benign adrenal disease have been proven [2–5]. Several studies have compared transperitoneal laparoscopic adrenalectomy (TLA) versus retroperitoneal laparoscopic adrenalectomy (RLA) since the first report of RLA in 1995 [6–15]. Many multicenter retrospective studies have tried to compare the surgical results of the two approaches [8–11]. TLA is thought to be feasible for bilateral adrenal lesions, but RLA is considered to involve less intestinal manipulation than TLA. All of these studies have compared the two approaches without considering the laterality of the adrenal gland [7–12]. Anatomical differences, such as the position of the adrenal gland and the length of the adrenal vein, exist between both sides. It is
P.H.C. and C.J.Y. contribute equally to this paper.
Po Hui Chiang, MD, PhD Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 106, Jhong Jheng 3rd Rd Kaohsiung (Taiwan) E-Mail cphtem @ yahoo.com.tw
Downloaded by: University of Tokyo 157.82.153.40 - 5/13/2015 7:26:16 PM
Abstract Introduction: There is a lack of data regarding the appropriateness of transperitoneal and retroperitoneal approaches for right-sided laparoscopic adrenalectomy. The aim of this study was to determine whether there is any difference between right-sided transperitoneal laparoscopic adrenalectomy (TLA) and retroperitoneal laparoscopic adrenalectomy (RLA). Material and Methods: Our surgery database was reviewed to identify patients who underwent right-sided laparoscopic adrenalectomy with a retroperitoneal or transperitoneal approach since 2000. Fifty-five patients were enrolled (31 RLA and 24 TLA). Patient characteristics, as well as operative and perioperative details, were compared between the two groups. Results: There was no difference in patient characteristics between the groups. There was a statistically significant difference (p = 0.02) in blood loss (31.7 ± 16.4 vs. 56.9 ± 65.5 ml) between RLA and TLA when the patient’s BMI was >26. There was no significant difference in operative time, conversion to open surgery, length of hospitalization, or time to oral intake between the groups. Conclusions: Right-sided laparoscopic adrenalectomy can be performed
Table 1. Patient characteristics
not reasonable to compare the results of these two approaches bilaterally at the same time. Besides, the complications are strongly related to the operator’s experience. Operator biases among multicenter reports cannot be overlooked. There is a great deal of controversy surrounding left-sided laparoscopic adrenalectomy with both approaches. However, ‘right-sided adrenalectomy is somewhat more difficult with a retroperitoneal approach because of the position of the adrenal gland and the length of the adrenal vein in relation to the inferior vena cava’ [16]. Comparisons of only right-sided laparoscopic adrenalectomy with both approaches have rarely been reported. The aim of this study was to determine whether there is any difference between right-sided TLA and RLA.
Patients and Methods This retrospective, nonrandomized study was approved by the institutional review board for data analysis. Fifty-five patients underwent right-sided laparoscopic adrenalectomy and were enrolled between March 2000 and September 2011. Adrenocortical malignancies were excluded from this study. The choice of approach depended on the surgeon’s preference. Ninety-one percent (50/55) of the procedures were performed by two senior faculty members (Chiang and Lee). Transperitoneal Approach Patients were placed in a 45° modified flank position. A Veress needle was placed with rotation of the operating table to allow patients to remain in a supine position. Four trocars were inserted. The primary 10-/12-mm port was placed in the midclavicular line and was commonly used for a harmonic scalpel (Ethicon EndoSurgery, Cincinnati, Ohio, USA) or an endovascular GIA stapler. The superomedial port (10-/12-mm) was used for a large fan retractor which was employed to retract the liver. The third 10-mm
Comparison of RLA and TLA for Right-Sided Benign Tumors
TLA
p value
31 53.15 (25–84) 25.07 (16.5–33.6) 17/14
24 53.3 (34–68) 25.41 (19.6–34.5) 11/13
0.99 0.64 0.44
12 (39) 2 (6) 5 (16) 11 (35) 0 1 (3) 3.5±1.56 (1–9)
8 (33) 0 3 (13) 10 (42) 1 (4) 2 (8) 4.6±0.82 (1–13)
0.570
port was placed 3 cm lateral to the first and was commonly used for a laparoscope. The fourth port (lateral) was 5 mm in the anterior axillary line. The position was returned to the original set-up after all ports had been placed. The dissection was carried out along the ascending colon and medially below the liver. The adrenal vein was identified and divided using clips or, in the case of large tumor with a wide vein, using an endovascular GIA stapler. The tiny adrenal arteries were dissected with a harmonic scalpel. Retroperitoneal Approach Patients were placed in a lateral decubitus position. The primary site was a 2-cm incision placed above the iliac crest along the mid-axillary line. After finger dissection, a balloon was inserted into the retroperitoneal space. Normal saline (300–400 ml) was instilled into the balloon to develop the retroperitoneal space. A Hasson port was placed. Two additional ports were used. One was placed 4 cm anterior and superior to the primary site in the anterior axillary line. The other was placed 3–4 cm posterior and superior to the posterior axillary line, just below the 12th rib. The dissection moved cephalad along the psoas muscle. Once the adrenal gland had been located, it was mobilized and lifted anteriorly to expose the adrenal vein, which could then be clipped or divided with an endovascular GIA stapler. The other part of the adrenal gland was mobilized with a harmonic scalpel. These patients’ charts were reviewed to record data such as preoperative characteristics, intraoperative and perioperative details, and hospital days. Parametric data were compared using a t test. Intraoperative and perioperative factors were analyzed based on the BMI (the cutoff value for obesity in Taiwanese people is 26). For categorical data, a χ2 test (Fisher’s exact test) was used. Calculations were performed using SPSS v.17 (IBM Corp., Somers, N.Y., USA).
Results
The patient characteristics are listed in table 1. There was no significant difference in age or BMI between the two groups. Conn’s syndrome and nonfunctioning adeUrol Int 2015;94:144–148 DOI: 10.1159/000357627
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Patients, n Mean age (range), years Mean BMI (range) Sex (M/F) Tumor type, n (%) Conn’s syndrome Cushing’s syndrome Pheochromocytoma Nonfunctionng adenoma Ganglioneuroma Myelolipoma Mean tumor size ± SD (range), cm
RLA
Table 2. Operative and perioperative characteristics (mean ± SD)
RLA
TLA
p value
Patients, n Blood loss (BMI >26)a, ml Operative time (BMI >26)a, h
12 31.67±16.42 2.94±1.05
9 56.88±65.52 2.43±0.92
0.020 0.909
Patients, n Blood loss (BMI ≤26)a, ml Operative time (BMI ≤26)a, h Conversion to open surgery, n (%) Time on narcotic analgesics, days Length of hospitalizationa, nights Time to oral intakea, days Blood loss >100 cma, n
19 28.24±20.99 2.64±1.35 1 (3) 1.6±1.28 4.64±3.65 1.62±1.98 1
15 28.38±29.75 1.95±1.78 2 (8) 1.86±1.28 4.95±3.60 1.10±0.83 2
0.766 0.471 0.403 0.482 0.714 0.209
Values are presented as means ± SD unless otherwise stated. a Cases excluded due to conversion to open surgery.
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Discussion
Many authors have reported comparisons between RLA and TLA bilaterally. However, there are contradictory conclusions among these papers. Naya et al. [8] reported that TLA tends to be faster than RLA and causes less blood loss. A multicenter comparison also showed that TLA had shorter operative times with less blood loss compared to the retroperitoneal approach [9]. Giger et al. [10] pointed out that they favored the transperitoneal approach for bilateral and left-sided adrenal tumors and that right-sided tumors >8 cm were better removed via the transperitoneal approach. They proposed that the maneuvering space is limited when lesions are >6–8 cm in diameter and the corresponding vessels cannot be safely controlled. Dickson et al. [11] recently reported that the retroperitoneal approach results in decreased operative times, blood loss, and postoperative lengths of stay compared to the transperitoneal approach. Arslan et al. [17] reported that the retroperitoneal approach is superior to the transperitoneal approach for small adrenal masses. Lezoche et al. [12] concluded that the transperitoneal approach is suitable for the removal of larger adrenal masses and the retroperitoneal approach may represent a better option for obese patients or patients with small lesions. One paper compared the two different approaches for right adrenalectomy [13]. Those authors preferred the transperitoneal approach for the management of large adrenal masses (>5 cm) due to shorter operative times, better visibility of familiar anatomic landmarks, easy access to the vessels, and a larger operative field [13]. Takeda et al. [14] reported in a small series (a total of 11 cases) that RLA is feasible for primary aldosteronism and a much more difChiang/Yu/Lee/Wang/Hsu
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noma accounted for the majority of the tumors between two groups. Pheocromocytoma accounted for 16 and 13% of the tumors in each group, respectively. The largest adrenal tumor in the RLA group was 9 cm in diameter, and the pathology was pheochromocytoma. The largest adrenal tumor in the TLA group was 13 cm in size, and the pathology was pheochromocytoma with local kidney invasion. There was a statistically significant difference (p = 0.02) in blood loss (31.7 ± 16.4 vs. 56.9 ± 65.5 ml) between RLA and TLA when the patient’s BMI was >26 (table 2). However, there was no statistical difference in operative time, and there was no statistical difference in operative time or blood loss in patients with a BMI ≤26 between the two groups. Conversion to open surgery occurred in both groups. Conversion occurred in one RLA because of pheochromocytoma with uncontrolled bleeding. Two conversions occurred in TLA due to a 13-cm pheochromocytoma with local kidney invasion and a previous appendectomy with an intra-abdominal adhesion, respectively. There was no significant difference in length of hospitalization, duration (days) of postoperative narcotic analgesic use, or time to oral intake between the two approaches. Since there were 2 cases with Cushing’s syndrome in the RLA group, longer hospitalization times (18 and 24 hospital days, respectively) due to metabolic disorders and other medical problems were noted and excluded from the analysis of hospitalization days in this study. No delay in oral intake occurred in the TLA group (1.6 days in RLA and 1.1 days in TLA). There were no major complications or mortality in either group.
Comparison of RLA and TLA for Right-Sided Benign Tumors
Table 3. Pros and cons of both approaches
RLA
TLA
Anatomic landmark Access to the adrenal vein Operation time Injury to neighboring organs
+ – + seldom
Trocars, n
3–4
+++ ++ + possible (liver, duodenum, and colon) 4–5
+++ = Very good; ++ = good; + = fair; – = poor.
in the TLA group. Conversion to an open procedure was performed to ensure a sound oncologic resection. All of these patients were discharged without complications. Adrenal masses >8 cm are technically more difficult to remove because the tumor limits manipulation with devices and obstructs the operative field. Ito et al. [19] reported that the LigaSure sealing system or an ultrasounddriven scalpel can be used for enucleation of adrenal tumor lesions. More collateral vessels are noted in greater adrenal tumors, and we used Endo GIA in some cases to control the vessels effectively. Greater tumors have a greater likelihood of representing an adenocortical carcinoma. However, 15 cm was used as the upper limit by one group of surgeons [20]. Malignant pheochromocytoma is defined by the presence of metastasis rather than histologic criteria. If there is no evidence of metastasis, size alone does not predict malignancy in pheochromocytomas [21]. Greco et al. [22] conducted a multicenter study and reported that the upper limit for adrenalectomy could be as high as 10–14 cm for very experienced surgeons. In our series, a pheochromocytoma measuring 9 cm in diameter was removed successfully using the retroperitoneal approach with a blood loss of 50 ml. Like TLA, RLA could be used by experienced physicians for tumors >8 cm. Although tumors >8 cm were uncommon in our series, we did not find any influence of tumor size on the surgical approach. Blood loss correlated positively with BMI >26 only for the transperitoneal approach. However, the difference in mean blood loss (31.67 vs. 56.88 ml) between the two groups was insubstantial and not clinically relevant to the decision of which approach to choose. Previous studies and our data are summarized in table 3, which integrates the advantages and disadvantages of both approaches. Right-sided TLA is easier for beginners, and experienced surgeons achieve equally effective and safe performances with either approach. Urol Int 2015;94:144–148 DOI: 10.1159/000357627
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ficult indication for Cushing’s syndrome. Chee et al. [15] reported that both approaches were safe in a total of 14 cases series. Agha et al. [18] reported that TLA and RLA are also feasible and effective procedures. It is difficult to conclude on the differences between the two approaches based on previous reports due to bilateral comparisons, different operators, multicenter experiences, and small case numbers. Besides, the learning curve for the retroperitoneal approach is more technically challenging for beginners, particularly due to the need for familiarity with the retroperitoneum given that there are fewer anatomical landmarks and the work space is relatively small. In our series, although there was no significant difference in operative times between the two approaches, with RLA it was indeed more difficult to access the adrenal vessel underneath bigger adrenal tumors. Moreover, the right kidney occupies the retroperitoneal space and often crosses the path of control of the adrenal vessel. These factors may have influenced the preference for the transperitoneal approach expressed in most earlier papers. Our group benefited from performing both approaches at almost the same time (1994 and 1995, respectively). Four operators performed right-sided laparoscopic adrenalectomies in this study. Three of them (Chiang, Wang, and Cheng) preferred TLA for right-sided adrenal tumors. They considered that with TLA it was easier to control the adrenal vein and the operation field was larger than with RLA. Besides, there were many anatomical landmarks to be identified during TLA, making it especially easier for young doctors (Wang and Cheng). On the other hand, Dr. Lee exclusively used the retroperitoneal approach for adrenal tumors because of his training, and he believed that RLA resulted in less manipulation of the intestine and intraperitoneal organs. Some papers have also expressed concerns that the intestinal manipulation during TLA could result in postoperative intestinal symptoms and a delayed oral intake [1]. In this series, the time to oral intake was 1.1 and 1.62 days for the transperitoneal and retroperitoneal approaches, respectively. The intestinal manipulation during the TLA approach seemed not to result in an impairment of bowel function after the operation. The surgery for pheochromocytoma was more challenging than that for adenoma because pheochromocytomas are highly vascular and generally larger [11]. Oozing and vessel tearing were also noted during the surgery, and uncontrolled bleeding occasionally resulted in conversion to open surgery. There was one conversion due to severe bleeding from a 5.5-cm pheochromocytoma in the RLA group. There was also one conversion due to a large pheochromocytoma (13 cm) with local invasion of the kidneys
Though many reports have compared RLA with TLA, we analyzed our data at a single institute and unilaterally within the last decade. However, it is important to understand that our study was not a prospective randomized trial, and the limitation of this study is that the choice of operative method depended only on the operator’s preference. We believe this study provides reliable data with minimal biases from the laterality of the tumor and intercenter differences.
Conclusion
We believe that right-sided laparoscopic adrenalectomy could be performed safely and effectively either via RLA or TLA, and surgeons can adopt either approach with confidence depending on their preference if they are familiar with that approach.
References
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