Despite increased survival and improved response rates that are associated with the use of targeted therapies for mRCC, the median overall survival continues to be less than 2 years, with CR being seen rarely.1
After nephrectomy, however, the time course of metastatic disease progression is variable,11
with some patients progressing quickly while other patients slowly progress or stabilize with low volume metastasis. Patients with mRCC who are otherwise healthy and have oligometastatic disease often undergo metastasectomy because they can achieve surgical CR and a prolonged disease-free interval. Although several series have noted the association of surgical resection of metastases with improved survival,2–4
it is difficult to prove the survival benefit of surgery, given that these patients are highly selected. In addition, even with known prognostic factors, it is not straightforward which patients will benefit from metastasectomy.
Adrenal metastases after nephrectomy are rare,12
and adrenalectomy to remove metastases has been associated with prolonged survival.13
The cancer-specific survival of 71.4% at 24 months median follow-up is comparable to previous published results showing 51% to 88% survival in patients with intermediate and high-risk disease undergoing metastasectomy.11
Reoperation after ipsilateral nephrectomy has been associated with significant morbidity in patients with renal fossa recurrence,8
although a recent report demonstrated laparoscopic resection of RCC recurrence had low morbidity and minimal complications in four patients.14
In patients with adrenal metastases after nephrectomy, open adrenalectomy necessitates a large incision to gain access for removal of a small gland. In addition to the possible benefits of less pain and a quicker recovery, patients may be able to return to systemic therapy for mRCC faster when using laparoscopic techniques compared with open surgery. Similarly, percutaneous ablation of metastatic sites may offer advantages in recovery time, although there are minimal data for use in mRCC currently.15,16
Recovery time is an important consideration, because agents are frequently withheld after surgery because of concerns with wound healing while receiving therapies that are targeting angiogenic pathways.17
In the current series, the overall rate of complications is low and compares favorably with similar series.14,18
The only complication in the reoperative group was one case of hemorrhage resulting in conversion to an open procedure and blood transfusion. The possibility of conversion to open surgery is a key aspect of preoperative patient counseling, because this risk may be higher than in patients without PIN. Finally, the median length of hospital stay of 2 days was not different between groups and comparable to other studies.19
The longer operation time is likely a result of more time spent in the lysis of adhesions and sharp dissection through obliterated planes.
The surgical approach for LA can be through a transperitoneal or retroperitoneal approach with similar outcomes for small adrenal masses without PIN.9
For patients after PIN, a lateral transperitoneal approach10,20
is preferred with early identification of landmarks using ultrasonography when necessary for reasons described earlier.
In the classical description of a radical nephrectomy for RCC, Robson and colleagues21
suggested that adrenalectomy should be performed as an integral part of the surgery. Modern series, however, have not shown a benefit to routinely removing the adrenal gland with radical nephrectomy.22
The adrenal gland may become involved by local extension, lymphatic, or hematogenous metastasis with a 1% to 5% incidence of synchronous metastasis.23
While the risk of adrenal insufficiency is low with concurrent adrenalectomy, the low incidence of adrenal metastasis does not justify removal in all patients. At our institution, adrenalectomy is routinely performed in patients with radiographic suspicion of adrenal involvement, clinical T2
cm) or higher stage renal tumors, and upper pole tumors.
To our knowledge, the current series is the largest report demonstrating the feasibility of LA after PIN. In our data, LA is associated with similar perioperative morbidity and outcomes, with a reasonable expectation based on the limited data that there may be a higher rate of conversion to open surgery. Possible weaknesses of this study include its retrospective nature. Given the rarity of the clinical scenario where LA after PIN is indicated, we believe it is an appropriate methodology for this type of report. In addition, we acknowledge that patients are carefully selected for this approach, and the surgeon who performs this procedure should be experienced in standard LA as well as reoperative open and laparoscopic surgery.
At our institution, patients with solitary adrenal metastasis are routinely offered a laparoscopic approach at the discretion of the attending physician. Body habitus, especially elevated body mass index (BMI), and previous surgery may influence a surgeon's decision on type of approach. In the current series, the patients with PIN had a higher median BMI. LA may be technically feasible in selected patients after PIN for mRCC and is associated with similar perioperative outcomes compared with patients without previous nephrectomy.