Surgical Treatment for Hyperaldosteronism
Adrenalectomy should be performed for patients with unilateral aldosterone-secreting adrenal masses, with minimally-invasive surgery (laparoscopic approach) as the preferred technique when feasible. 1
Pre-Surgical Diagnostic Requirements
Before proceeding to surgery, specific diagnostic steps are mandatory:
Adrenal vein sampling (AVS) is required prior to offering adrenalectomy to confirm lateralization of aldosterone production and distinguish unilateral from bilateral disease. 1 This is critical because up to 25% of patients might undergo unnecessary adrenalectomy based on CT findings alone. 2
The exception to mandatory AVS is patients <40 years old when imaging shows a single affected gland, as bilateral hyperplasia is rare in this population. 2
Initial screening should include aldosterone-to-renin ratio (ARR) in patients with hypertension and/or hypokalemia. 1
Confirmatory testing (such as saline suppression test) should be performed after positive screening to demonstrate autonomous aldosterone secretion. 1
Surgical Approach
Minimally-invasive surgery (laparoscopic adrenalectomy) is the treatment of choice for unilateral aldosterone-producing adenomas:
Laparoscopic transperitoneal adrenalectomy should be performed when feasible, with mean hospital stays of 2-4 days and minimal morbidity (5-14%). 1, 3, 4, 5
Mortality is below 1% with the laparoscopic approach. 5
Adrenal-sparing surgery (partial adrenalectomy or enucleation) can be considered for small, well-localized adenomas, particularly when the adenoma is located at the anterior margin of the gland. 3
Expected Outcomes
Understanding realistic expectations is crucial for patient counseling:
Biochemical cure (normalization of aldosterone and potassium) occurs in approximately 95-100% of patients. 4, 6
Complete cure of hypertension (no medications required) occurs in only 34-50% of patients. 4, 6, 5 This is a critical point—most patients will still require some antihypertensive medication post-operatively.
Improvement in blood pressure control with reduced medication requirements occurs in an additional 51% of patients. 6
Significant decreases in both systolic (average 20 mmHg reduction) and diastolic blood pressure (average 9 mmHg reduction) are typical. 6
Antihypertensive medication requirements typically decrease from an average of 2.6 medications preoperatively to 1.4 medications at long-term follow-up. 6
Predictors of Persistent Hypertension
Duration of hypertension before surgery is the most significant risk factor for persistent hypertension post-operatively. 4
Additional factors associated with persistent hypertension include:
- Older age at time of surgery is an independent predictor of sustained hypertension. 6, 5
- Larger adrenal gland size predicts persisting hypertension. 6
- Male gender, obesity, long-standing high-grade hypertension, and family history of hypertension are associated with lower cure rates. 5
- Young, lean women with recent low-grade hypertension have the highest likelihood of normotension without treatment. 5
Important caveat: Individual prediction of blood pressure outcome is not accurate, and predictors of hypertension cure should not be used to exclude patients from surgery. 5 Age, associated health conditions, and patient preferences are more relevant for surgical decision-making. 5
Post-Operative Management
Post-operative imaging is not necessary following resection of aldosterone-secreting adenomas. 1
Short-term hormonal work-up is required to confirm resolution of hyperfunction. 1
Lack of biochemical cure should raise concern for bilateral disease, recurrence (rare), or inadvertent removal of the wrong gland if surgery was not guided by AVS. 1
Alternative to Surgery
When surgery is not possible or AVS does not indicate unilateral disease:
Mineralocorticoid receptor antagonists (MRAs) are the cornerstone of medical therapy for bilateral disease or when surgery is contraindicated. 1, 2, 7
Spironolactone is first-line treatment (starting dose 12.5-25 mg/day, titrated up to 100 mg/day). 7
Eplerenone (50-100 mg/day) is an alternative with fewer anti-androgenic side effects. 8, 2, 7