What medical specialty performs surgical management of an adrenal mass?

Surgical Management of Adrenal Masses: Specialty Considerations

Adrenal surgery should be performed by surgeons with specialized expertise in adrenal surgery, typically urologists, endocrine surgeons, or surgical oncologists, depending on institutional practice and the nature of the adrenal mass. 1, 2

Specialty Distribution for Adrenal Surgery

• Urologists are often the primary surgical specialists managing adrenal masses due to their extensive knowledge of retroperitoneal anatomy and experience with the adrenal region 3
• Endocrine surgeons (specialized general surgeons with focused training in endocrine surgery) commonly perform adrenal surgeries, particularly for functional tumors
• Surgical oncologists may be involved when adrenal malignancy is suspected, especially for adrenocortical carcinoma cases

Surgical Expertise Requirements

• Guidelines recommend that adrenal surgery be performed only by surgeons with appropriate expertise and experience 1
• The European Society of Endocrinology (ESE) suggests a minimal annual workload of six adrenalectomies per year, with a preference for >20 surgeries annually 1
• For optimal outcomes, the entire operative team (including anesthesiologists) should be well-trained in adrenal surgery 1

Surgical Approach Considerations

• Laparoscopic adrenalectomy has become the procedure of choice for most benign adrenal lesions 4

  • Appropriate for smaller, contained masses
  • Associated with better intraoperative hemodynamic stability in pheochromocytoma patients
  • Requires advanced laparoscopic skills

• Open adrenalectomy is indicated for:

  • Larger masses (>6 cm)
  • Locally advanced tumors
  • Suspected adrenocortical carcinoma
  • Cases requiring en bloc resection

Multidisciplinary Approach

• Management of adrenal masses requires collaboration between:
  • Radiologists (for proper imaging characterization)
  • Endocrinologists (for hormonal evaluation and perioperative management)
  • Surgeons with adrenal expertise
  • Anesthesiologists (especially important for pheochromocytoma cases)

Critical Considerations Before Surgery

• Complete hormonal evaluation is mandatory before any intervention 2

  • 1mg overnight dexamethasone suppression test (for cortisol)
  • Plasma or 24-hour urinary metanephrines (for pheochromocytoma)
  • Aldosterone-to-renin ratio (if hypertension/hypokalemia present)

• Failure to rule out pheochromocytoma before surgery can lead to life-threatening crisis 2

• Perioperative hydrocortisone replacement is required for patients with autonomous cortisol secretion 2

Institutional Considerations

• Complex cases, particularly suspected adrenocortical carcinoma, should be referred to high-volume multidisciplinary centers 5
• The surgical approach should be determined based on surgeon expertise, tumor characteristics, and patient factors 5

In conclusion, while urologists often manage adrenal surgery due to their familiarity with retroperitoneal anatomy, the specialty performing adrenal surgery may vary by institution and case complexity. The critical factor is that the surgeon possesses specific expertise in adrenal surgery, with appropriate multidisciplinary support for optimal patient outcomes.