What are the indications and management strategies for adrenalectomy?

Indications and Management Strategies for Adrenalectomy

Adrenalectomy is definitively indicated for functional adrenal tumors including unilateral cortisol-secreting adenomas with Cushing's syndrome, aldosterone-secreting adenomas, pheochromocytomas, and suspected adrenocortical carcinoma, with minimally invasive surgical approaches preferred for most cases. 1

Primary Indications for Adrenalectomy

Functional Adrenal Tumors

• Cortisol-secreting adenomas:

  • Unilateral cortisol-secreting masses with clinical Cushing's syndrome require adrenalectomy 1
  • Younger patients with mild autonomous cortisol secretion (MACS) and progressive metabolic comorbidities (diabetes, hypertension, osteoporosis) may benefit from adrenalectomy after shared decision-making 1

• Aldosterone-secreting adenomas:

  • Adrenalectomy is indicated for unilateral aldosterone-producing adenomas 1
  • Adrenal vein sampling (AVS) should be performed before surgery to confirm lateralization 1
  • Postoperative hormonal work-up is only needed short-term to confirm resolution of hyperfunction 1

• Pheochromocytomas:

  • All pheochromocytomas require surgical removal 1
  • Preoperative alpha-blockade for 1-3 weeks is essential to prevent intraoperative catecholamine surge 1

Suspected Malignancy

• Adrenocortical carcinoma (ACC):

  • Surgical resection is indicated for suspected ACC 1
  • Complete surgical extirpation (R0 resection) is the mainstay of potentially curative approaches 1
  • Locoregional lymphadenectomy is recommended 1

• Size criteria:

  • Adrenal masses >4 cm have higher risk of malignancy and should be considered for surgical removal 1
  • Masses with suspicious imaging features (heterogeneity, irregular margins, invasion) require surgical management regardless of size 1

Surgical Approach Selection

Minimally Invasive Surgery (MIS)

• Preferred approach for:
  • Benign functional tumors (cortisol, aldosterone-secreting, pheochromocytomas) 1
  • Tumors <6 cm without evidence of local invasion 1, 2
  • Benefits include excellent visualization, less postoperative pain, shorter hospital stay (mean 3.2 days vs. longer for open), and faster recovery 3

Open Adrenalectomy

• Indicated for:
  • Large tumors (>6-8 cm) 4
  • Suspected ACC with local invasion or venous involvement 1
  • Cases where tumor capsule integrity cannot be maintained laparoscopically 1
  • The European Society of Endocrinology suggests open approach for tumors >6 cm, though this is not based on high-quality evidence 1

Perioperative Management

Preoperative Considerations

• Hormonal evaluation:
  • All adrenal incidentalomas require screening for autonomous cortisol secretion 1
  • Patients with hypertension/hypokalemia should be screened for primary aldosteronism 1
  • Patients with adrenal masses >10 HU on non-contrast CT or symptoms of catecholamine excess require screening for pheochromocytoma 1

Special Considerations

• Pheochromocytoma management:

  • Alpha-blockade is mandatory before surgery 1
  • Beta-blockers can be added only after adequate alpha-blockade to control reflex tachycardia 1

• Cushing's syndrome:

  • Perioperative glucocorticoid replacement is necessary 2
  • Postoperative steroid dependence should be anticipated

Follow-up After Adrenalectomy

• Functional tumors:

  • Clinical and biochemical follow-up to confirm resolution of hormonal excess 5
  • For aldosteronoma patients, 72% may have persistent hypertension requiring medication, though 92% show improved blood pressure control 5

• Malignant tumors:

  • Regular follow-up every 2-4 months during the first year for ACC 1
  • Lifelong surveillance for malignant pheochromocytoma/paraganglioma 1

Common Pitfalls and Caveats

• Adrenal biopsy should be avoided in the initial workup of adrenal masses as it has limited clinical value and potential risks 1

• Bilateral adrenal masses should be evaluated and treated individually; bilateral adrenalectomy for asymptomatic cortisol-secreting adenomas should be avoided 1

• Size alone is not an absolute determinant for surgical approach; tumor characteristics and surgeon expertise are equally important 1

• Special populations (pregnant women, children, adults <40 years) require urgent assessment due to higher risk of malignancy 1

• Conversion to open surgery may be necessary in approximately 3% of laparoscopic cases, particularly with large tumors (>6-7 cm) 3