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While laparoscopic adrenalectomy (LA) is considered the standard of care for removal of small adrenal masses, there are minimal data describing the feasibility and outcomes of LA after previous ipsilateral nephrectomy (PIN). The purpose of the study was to describe the perioperative outcomes in a series of patients who were undergoing LA after PIN.
Using an institutional database, we identified patients who underwent LA since 2002 by a single surgeon. Clinical and pathologic data were collected and analyzed. To evaluate outcomes, patients undergoing LA after PIN were compared with patients undergoing LA without PIN.
Of 54 consecutive patients undergoing LA, 8 had PIN for renal-cell carcinoma (RCC). Estimated blood loss was not significantly greater in patients with PIN: 50mL vs 100mL, P=0.109. Operative time was longer in patients with PIN: 120 minutes vs 156 minutes, P=0.015. There was no difference in length of hospital stay between groups: Median 2 days for both groups, P=0.635. One patient in the PIN group had a conversion to open adrenalectomy and needed blood transfusion. Perioperative complications were seen in 5/46 (10.6%) patients without and in 1/8 (12.5%) patients with PIN. Surgical margins were negative in all patients.
To the authors' knowledge, this study represents the largest experience with adrenalectomy in the reoperative setting. LA after PIN is associated with a longer operative time. While the potential for conversion is possible, it is technically feasible in selected patients and thus far appears to be associated with similar perioperative outcomes compared with patients without PIN.
Surgical resection of metastases from renal-cell carcinoma (RCC) remains a valid option in the era of targeted molecular therapies, especially as accumulating data show that complete responses are rare with these new agents.1 Several small series have noted the association between metastasectomy and prolonged survival2,3 independent of other known risk factors,4 although patients with a good performance status and a solitary site of metastasis or low volume disease appear to be ideal candidates for metastasectomy. Therefore, surgery may be recommended to patients with metachronous ipsilateral adrenal metastasis5,6 either with or in the absence of systemic therapy.
Laparoscopic adrenalectomy (LA) is considered the standard of care for patients with small adrenal masses.7 In patients who have undergone previous ipsilateral radical or partial nephrectomy (PIN), laparoscopic approaches may not be considered because of obliteration of the retroperitoneal landmarks, intraperitoneal adhesions, and scarring at the potential operative site. In addition, several series of patients with locally recurrent tumors after PIN have suggested increased morbidity with reoperation.8
The purpose of this article was to review our experience with and describe the perioperative outcomes of patients who were undergoing laparoscopic adrenalectomy for metastatic RCC (mRCC) after PIN.
We reviewed the medical records of all patients who had undergone LA by a single surgeon and identified patients with adrenal metastases from RCC and PIN. Clinical and pathologic data were collected for each patient. Institutional Review Board approval was granted for this retrospective study.
To evaluate perioperative outcomes, patients undergoing LA for mRCC after PIN were compared with all patients who underwent LA. Continuous variables were summarized using the median and range, and compared using the Mann-Whitney U test for nonparametric variables. Categorical variables were compared using the chi-square test, or Fisher exact test when appropriate. SPSS version 17 was used for all statistical analyses.
The technique of LA is well described and may be performed using a transperitoneal or retroperitoneal approach.9 In patients who have undergone nephrectomy, however, the retroperitoneum is obliterated. Therefore, a lateral transperitoneal approach is used for all patients with PIN. Positioning of the patient is more lateral (about 70–90-degree lateral decubitus position), similar to the lateral peritoneal approach as described by Shichman and associates.10 This provides certain advantages—namely, greater retraction of bowel by gravity, avoidance of most intraperitoneal adhesions (which are usually, but not always, more medially located), and a more direct approach to the adrenal gland. Trocars are placed as per routine LA except more laterally, consisting of one 5- or 12-mm port for the dominant hand and one 12-mm port for the camera, and additional 3-mm, 5-mm, or 12-mm port placed for the nondominant hand, a 3-mm or 5-mm port for lateral retraction for the kidney (in selective cases), and, in right-sided cases, a 3-mm or 5-mm port for retraction for the liver.
A key aspect of dissection in patients undergoing LA in the setting of PIN is the liberal use of sharp dissection with endoshears. Just as in open surgery, blunt dissection is avoided in reoperative planes because it can lead to injury of normal organs, dissection into incorrect tissue planes, and potentially tumor violation. Because of the obliterated planes and varied landmarks, laparoscopic ultrasonography is also used liberally. This is performed after elevation of the liver (right side) or mobilization of the splenic flexure and spleen (left side), but before dissection is performed in proximity to the tumor. These maneuvers allow for orientation of the reoperative anatomy and recognition of any critical landmarks on the right side, such as the vena cava, renal artery, and vein stumps, as well as the tumor (which may be difficult to visually identify in those with a small mass surrounded by copious periadrenal fat); on the left side, ultrasonography can aid with identification of critical structures, such as the pancreatic tail, splenic artery, aorta, and celiac axis. The echogenic location of clips and staples is correlated with available axial scans to reinforce the correct orientation (Figs 1, ,22).
Just as with standard LA, a 5-mm bipolar vessel sealing system (Ligasure Atlas, Covidien Corp, Mansfield, MA) was used routinely for dissection of vascular structures. In PIN patients, the remnant stumps of the renal artery and vein were usually clipped more proximally and the more distal segments resected en bloc with the adrenal tumor to ensure negative surgical margins, because the medial limb of the adrenal is typically in close approximation or densely adherent to these structures. The adrenal vein was controlled using a single 5-mm polymer locking clip placed proximally (Teleflex Medical, Research Triangle Park, NC), then sealed and divided using the LigaSure.
From 2002 to 2010, LA was performed in 54 patients by a single surgeon. In eight patients, LA was performed for metachronous adrenal mRCC after PIN. The median time from nephrectomy to adrenalectomy was 57 months (17–246 mos). In all patients, biopsy establishing recurrence was performed, but was nondiagnostic in one patient. Patient characteristics and perioperative results for each group are displayed in Table 1. Two patients underwent bilateral adrenalectomy in the PIN group, one of whom also underwent cholecystectomy; perioperative results for these patients include all performed procedures. All surgical margins after LA were negative in each group. All patients who underwent LA after PIN had surgical pathologic evaluation that demonstrated mRCC. In LA patients without PIN, pathologic evaluation demonstrated adrenal adenoma or benign findings in 22 patients, mRCC in 8 patients, other metastatic primary cancer in 8 patients, pheochromocytoma in 5 patients, and ganglioneuroma in 3 patients. Table 2 summarizes patient characteristics and pathology at the time of LA after PIN.
Estimated blood loss was similar in patients with PIN (P=0.109). Operative time was longer in patients with PIN: Median 156 minutes vs 120 minutes (P=0.015). There was no difference in length of hospital stay between groups: Median 2 days for each group (P=0.635).
One patient in the PIN group had a conversion to open adrenalectomy, while there were no conversions in patients without PIN. This patient underwent bilateral adrenalectomy as well as cholecystectomy. Conversion occurred because of splenic bleeding and prohibitive dense left-sided adhesions in the area of PIN. The single case of blood transfusion and highest blood loss, operative time, and hospitalization was in this one patient. Perioperative complications were seen in 1/8 (12.5%) of patients with PIN and 5/46 (10.6%) of patients without PIN. Complications in patients without PIN included pneumonia, port-site hernia, syncope, superficial wound infection, and urinary tract infection. Four patients in the PIN group achieved complete remission (CR) and had no evidence of disease at last follow-up without any additional systemic therapy (Table 2).
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 (>7cm) 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.
This research is supported in part by the National Institutes of Health through M.D. Anderson Cancer Center Support Grant CA016672.
No competing financial interests exist.