First-Line Management of Unilateral Aldosterone-Producing Adenoma
Laparoscopic adrenalectomy is the first-line treatment for patients with unilateral aldosterone-producing adenomas, and should be performed after confirming lateralization with adrenal vein sampling. 1
Diagnostic Confirmation Before Surgery
Before proceeding to surgery, you must confirm both the diagnosis of primary aldosteronism and lateralization of aldosterone production:
Biochemical confirmation requires demonstrating autonomous aldosterone production through saline suppression testing or oral salt loading after an elevated aldosterone-to-renin ratio (typically >30) 1, 2
Adrenal vein sampling (AVS) is mandatory before offering adrenalectomy, even when imaging clearly shows a unilateral mass, because CT imaging alone would lead to inappropriate surgery in approximately 25% of cases 1, 3
The rationale for mandatory AVS is critical: it distinguishes unilateral adenomas (surgical candidates) from bilateral hyperplasia (medical management), and cortisol measurement in catheterization samples confirms proper catheter placement 1, 2
Surgical Approach
Minimally invasive laparoscopic adrenalectomy should be performed when feasible for unilateral aldosterone-secreting adenomas 1:
This approach is recommended by multiple guideline societies including the CUA (endorsed by AUA), AACE/AAES, KES, and NCCN 1
Surgery improves blood pressure in virtually 100% of patients and achieves complete cure of hypertension in approximately 50% of cases 3, 2, 4
Open adrenalectomy should be reserved for larger tumors or those with local invasion 1
Expected Outcomes
The benefits of surgical treatment are substantial and evidence-based:
Hypertension improvement occurs in 78.2% of surgically treated patients compared to 55.6% with medical management 5
Hypokalemia resolution is achieved in 97.1% of surgical patients 5
Surgery reverses end-organ damage caused by aldosterone excess 4
Alternative: Medical Management
If surgery is not possible, contraindicated by AVS showing bilateral disease, or declined by the patient, treat with mineralocorticoid receptor antagonists 1:
Spironolactone is first-line medical therapy, starting at 25-50 mg daily (some sources recommend 50-100 mg daily), titrating up to 100-400 mg daily as needed 6, 7, 4
Eplerenone (50-100 mg daily) is an alternative with fewer anti-androgenic side effects 7, 8
Close monitoring of serum potassium and creatinine is essential when initiating therapy 7
Critical Pitfalls to Avoid
Do not proceed to surgery based on imaging alone - this is the most important caveat, as approximately 25% of patients would receive inappropriate adrenalectomy without AVS confirmation 3
Three key patient populations warrant special consideration 5:
- Patients >60 years old may have similar outcomes with medical versus surgical treatment
- Those with impaired renal function (eGFR 30-50 mL/min/1.73m²) show comparable hypertension and hypokalemia resolution with either approach
- Post-surgical patients may develop hyperkalemia and decreased eGFR, requiring monitoring 5
Preoperative preparation includes using spironolactone to normalize blood pressure and potassium levels before surgery, though mineralocorticoid antagonists must be withdrawn at least 4 weeks before AVS testing 2
Post-Surgical Management
Postoperative corticosteroid supplementation may be required until recovery of the hypothalamus-pituitary-adrenal axis 1
Monitor for hyperkalemia and renal function changes post-operatively 5
Early diagnosis and treatment improve cure rates, as late diagnosis allows vascular remodeling that can cause residual hypertension even after successful surgery 4