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Copyright 2005 by AMERICAN UROLOGICAL ASSOCIATION DOI: 10.1097/01.ju.0000165336.44836.2d
Oncology: Adrenal/Renal/Upper Tract/Bladder
PROSPECTIVE, RANDOMIZED COMPARISON OF TRANSPERITONEAL VERSUS RETROPERITONEAL LAPAROSCOPIC ADRENALECTOMY MAURICIO RUBINSTEIN, INDERBIR S. GILL,*,† MONISH ARON, METE KILCILER, ANOOP M. MERANEY, ANTONIO FINELLI, ALI MOINZADEH, OSAMU UKIMURA, MIHIR M. DESAI, JIHAD KAOUK AND EMMANUEL BRAVO From the Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio Purpose: We report a prospective, randomized comparison of transperitoneal laparoscopic adrenalectomy (TLA) vs retroperitoneal laparoscopic adrenalectomy (RLA) for adrenal lesionswith long-term followup.
Materials and Methods: Between December 1997 and November 1999, 57 consecutive eligible patients with surgical adrenal disease were prospectively randomized to undergo TLA (25) orRLA (32). Study exclusion criteria were patient age greater than 80 years, body mass indexgreater than 40, bilateral adrenalectomy and significant prior abdominal surgery in the quadrantof interest. Mean followup was 5.96 years in the 2 groups.
Results: The groups were matched in regard to patient age (p ϭ 0.84), body mass index (p ϭ 0.43), American Society of Anesthesiologists class (p ϭ 0.81) and laterality (p ϭ 0.12).
Median adrenal mass size was 2.7 cm (range 1 to 9) in the TLA group and 2.6 cm (range 0.5 to6) in the RLA group (p ϭ 0.83). TLA was comparable to RLA in terms of operative time (130 vs126.5 minutes, p ϭ 0.64), estimated blood loss (p ϭ 0.92), specimen weight (p ϭ 0.81), analgesicrequirements (p ϭ 0.25), hospital stay (p ϭ 0.56) and the complication rate (p ϭ 0.58). One caseper group was electively converted to open surgery. Pathology data on the intact extractedspecimens were similar between the groups. Averaged convalescence was 4.7 weeks in the TLAgroup and 2.3 weeks in the RLA group (p ϭ 0.02). During a mean followup of 6 years 2 patientsin the TLA group had a late complication (port site hernia). Mortality occurred in 5 patients,including 1 with TLA and 4 with RLA, during the 6-year followup.
Conclusions: For most benign adrenal lesions requiring surgery laparoscopic adrenalectomy can be performed safely and effectively by the transperitoneal or the retroperitoneal approach.
KEY WORDS: adrenal glands, adrenalectomy, laparoscopy, retroperitoneal space Since laparoscopic adrenalectomy was first described in neal laparoscopic adrenalectomy (TLA) vs retroperitoneal 1992 by Gagner et al,1 it has become the standard of care for laparoscopic adrenalectomy (RLA) has been published.5 We many patients with benign adrenal disease requiring sur- report our prospective, randomized, single institution com- gery. Evidence from multiple centers is testimony to the parison of transperitoneal vs retroperitoneal laparoscopic ad- feasibility, comparable efficacy and decreased morbidity of renalectomy in 57 consecutive patients with intermediate laparoscopic adrenalectomy compared with the open ap- Laparoscopic adrenalectomy can be performed transperi- toneally or retroperitoneally. The transperitoneal approach has the benefit of a wider working space and readily identi- Between December 1997 and November 1999, 57 consecu- fiable anatomical landmarks. The retroperitoneal approach tive patients were prospectively randomized to undergo has been thought to be associated with earlier recovery of transperitoneal (group 1, 25 patients) or retroperitoneal bowel function, possibly leading to a shorter hospital stay (group 2, 32 patients) laparoscopic adrenalectomy. Study ex- clusion criteria were patient age greater than 80 years, body Most studies comparing the 2 approaches for laparoscopic mass index (BMI) greater than 40, bilateral adrenalectomy adrenalectomy have been retrospective.2Ϫ4 To date only 1 and significant prior abdominal surgery in the quadrant of small, prospective, randomized comparison of transperito- interest. Patients were prospectively randomized by a com-puter generated program. All patients provided consent for Submitted for publication November 16, 2004.
either approach. The primary surgeon (ISG) was informed Study received Institutional Review Board approval.
* Correspondence and requests for reprints: Section of Laparo- about the preselected laparoscopic approach for each individ- scopic and Robotic Surgery, Glickman Urological Institute, A100, ual patient in the operating suite immediately prior to posi- Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, Ohio Laparoscopic techniques for the lateral retroperitoneal6 † Financial and/or other relationship with Baxter and Pfizer.
and transperitoneal7, 8 approaches for adrenalectomy have TRANSPERITONEAL VERSUS RETROPERITONEAL LAPAROSCOPIC ADRENALECTOMY been previously described. Intraoperative data were docu- Mean followup was 5.9 years in the retroperitoneal and mented by the primary surgeon in the operating room imme- transperitoneal groups. During this time late complications diately at the end of the procedure using a statistically val- occurred in 2 patients in the transperitoneal group, who had idated data sheet. All data were prospectively maintained in port site hernia. Mortality due to various unrelated causes a computerized database with Institutional Review Board occurred in 5 patients, including 1 in the transperitoneal and 4 in the retroperitoneal group, during the 6-year followup.
Information analyzed included patient demographics, pre- operative adrenal characteristics, intraoperative and postop- erative outcomes, and pathological adrenal features. Conva- Minimal access surgery has inherent appeal for a small, lescence was defined as the period needed for complete deeply seated target organ such as the adrenal gland, which recovery from the physical aftereffects of surgery. Current would otherwise necessitate a large abdominal skin incision followup was obtained by telephone contact with individual for open surgical access. Reports from multiple institutions worldwide confirm the technical feasibility, safety and effi- Summary statistics are presented as the median and quar- cacy of the laparoscopic approach.7, 8 Additionally, the de- tiles, that is the 25th (Q1) and 75th (Q3) percentiles, when creased morbidity, more rapid recovery and superior cosme- the Wilcoxon rank sum test was used. Statistics were per- sis of laparoscopic adrenalectomy vs traditional open surgery formed with SPSS software (SPSS, Chicago, Illinois) using are well established. This has resulted in laparoscopic adre- the Wilcoxon rank sum test for continuous variables and the nalectomy becoming the treatment of choice for the majority chi-square or Fisher exact test for categorical variables with of benign adrenal lesions requiring surgery.
p Ͻ0.05 considered statistically significant.
There are 4 laparoscopic approaches to the adrenal gland, namely transperitoneal (conventional laparoscopic or needle- scopic9), lateral retroperitoneal,6 posterior retroperitoneal Baseline demographics were comparable in groups 1 and 2 and transthoracic transdiaphragmatic.10 The transperito- with respect to patient age (57 vs 57.5 years, p ϭ 0.841), BMI neal route is often preferred by many surgeons because of its (29.1 vs 30.4, p ϭ 0.426), American Society of Anesthesiolo- wider working space and familiar anatomy. However, retro- gists class (3 vs 3, p ϭ 0.811), laterality (right side 48% vs peritoneal laparoscopic adrenalectomy has gained in popu- 28.1%, p ϭ 0.123) and adrenal tumor size (2.7 vs 2.6 cm, larity because it provides direct access to the adrenal gland, p ϭ 0.825) (table 1). Laparoscopic adrenalectomy was suc- and avoids bowel handling and the potential for injury to the cessfully performed in 55 patients with 1 elective open con- version per group because of failure to progress. TLA was This prospective, randomized study was designed to objec- comparable to RLA in terms of total operative time (130 vs tively assess whether the transperitoneal vs the lateral ret- 126.5 minutes, p ϭ 0.640), estimated blood loss (50 vs 50 ml, roperitoneal approach for laparoscopic adrenalectomy trans- p ϭ 0.922) and specimen weight (24 vs 29 grams, p ϭ 0.809) lated into any practical clinical differences in patient (table 2). The open conversion in group 1 was in a patient outcomes. To this end specific factors that were known to with a 9 cm right adrenocortical carcinoma with dense peri- increase the difficulty of either approach, such as morbid tumor adhesions and in group 2 open conversion was done in obesity and prior surgery in the area of interest, were ex- a patient with a 6 cm right pheochromocytoma because of cluded from study. Additionally, patient demographics and baseline characteristics were comparable.
The 2 approaches were similar in regard to time to oral Our study showed no significant differences in operative intake resumption (p ϭ 0.86), time to ambulation (p ϭ 0.86), time, estimated blood loss, specimen weight or complication analgesic (Toradol®) requirements (p ϭ 0.25), hospital stay rates between the 2 groups. These data confirm that, the (p ϭ 0.56) and convalescence (p ϭ 0.86) (table 2). Postopera- constraints of a limited working space notwithstanding, the tive complications occurred in 2 patients (8%) undergoing retroperitoneal approach is technically efficient because it transperitoneal laparoscopy and in 1 (3.2%) undergoing the takes advantage of naturally existing anatomical planes. Af- retroperitoneal approach (p ϭ 0.576). Average convalescence ter initial balloon dilation of the retroperitoneum laparo- was 4.7 weeks in the transperitoneal group and 2.3 weeks in scopic examination through the transparent balloon confirms the retroperitoneal group (p ϭ 0.02).
proper creation of the working space. Anatomical landmarks, Pathological data on the intact extracted specimens were such as the psoas muscle posterior, Gerota’s fascia anterior similar in the 2 groups (table 3). Two patients, including 1 and the diaphragm superior, facilitate operator orientation with adrenocortical carcinoma and 1 with leiomyosarcoma, in the retroperitoneum. Our analysis of 404 retroperitoneal died 2 and 31 months after surgery, respectively.
laparoscopic renal and adrenal surgeries demonstrated a low TABLE 1. Demographic and preoperative data Median American Society of Anesthesiologists class (Q1, Q3) Median cm computerized tomography size (Q1, Q3)* * Incomplete data set since some patients did not have a discrete mass on computerized tomography.
TRANSPERITONEAL VERSUS RETROPERITONEAL LAPAROSCOPIC ADRENALECTOMY Median mg analgesic Toradol௡ requirement (Q1, Q3) of the right gland. During left adrenalectomy the left main adrenal vein is visualized to be horizontally oriented and it is identified early along the cephalad aspect of and anterior to the vertically oriented left renal artery. The left main adre- nal vein courses obliquely toward the left renal vein from the inferomedial aspect of the gland. Adrenal specimen mobili- zation requires constant anatomical orientation and it should be performed cautiously outside of the peri-adrenal fat. Oc- casionally with larger specimens entrapment may be more difficult in the somewhat smaller retroperitoneal space. We believe that the retroperitoneal approach can be applied with equivalent efficacy to the right or left adrenal gland.
Although cost data were not collected for this specific study, at our institution a recent cost analysis of 3 ap- proaches for laparoscopic adrenalectomy (transperitoneal,lateral retroperitoneal and posterior retroperitoneal) showedno significant cost differences.13 The study indicated thatoperating costs should not be a factor in selecting the lapa- incidence of intraoperative vascular (1.7%) and bowel (0.25%) complications.11 Seven of the 8 cases with vascular injury Although our study demonstrates the comparable safety were managed laparoscopically or through the created ex- and efficacy of either approach, some particular clinical sit- traction incision. Thus, we believe that retroperitoneal lapa- uations should be kept in mind. In our hands patients with roscopy is a reliable and safe approach with adequate work- prior intra-abdominal surgery in the area of interest are ing space, reliable anatomical landmarks and operator preferentially approached retroperitoneoscopically. In mor- bidly obese patients the abdominal pannus fat tends to fall Groups 1 and 2 were similar in terms of analgesia require- away from the operative site when the patient is in the full ments, resumption of ambulation and oral intake, and dura- 90-degree flank position. Thus, we believe that in the obese tion of hospitalization. Thus, contrary to our belief and that patient retroperitoneal adrenalectomy may be somewhat of others, the transperitoneal approach was not associated technically simpler than the transperitoneal approach. Con- with a higher incidence of paralytic ileus or longer hospital versely the transperitoneal approach may be advantageous stay. However, convalescence was significantly more rapid in in patients with prior retroperitoneal renal surgery and in patients undergoing the retroperitoneal approach (2 to 3 vs patients with larger (greater than 10 cm) adrenal masses.
4.7 weeks, p ϭ 0.02). Also, we did not note any increased Moinzadeh and Gill reported on 31 patients who had under- incidence of flank neuralgia syndromes in the retroperitoneal gone a total of 32 laparoscopic adrenalectomies for malignan- group during the intermediate or long-term followup. Patho- cy.14 The laparoscopic approach was retroperitoneal in 15 logical characteristics and the weight of the intact extracted patients, transperitoneal in 13 and transthoracic in 2. Mean specimen were comparable in groups 1 and 2.
adrenal tumor size on preoperative computerized tomogra- In our study 4 patients undergoing RLA and 3 undergoing phy was 5 cm (range 1.8 to 10). This study demonstrated that TLA had tumors 5 cm or greater. At our institution Hobart et with adequate experience laparoscopic adrenalectomy by the al compared laparoscopic adrenalectomy for large volume (5 transperitoneal or retroperitoneal approach can achieve good cm or greater) adrenal tumors.12 They concluded that the results for select, small, organ confined malignant tumors of feasibility of the laparoscopic approach was not impacted by the adrenal gland. Finally, it is important to note that the adrenal mass size. The presence of local invasion and com- current prospective series reported comes from a surgeon promised peri-adrenal tissue planes were more important who has extensive experience and facility with retroperito- concerns regarding the technical feasibility of laparoscopic neal laparoscopic adrenal and renal surgery.
Certain technical aspects of the retroperitoneal approach require emphasis. During right adrenalectomy the first step is usually identification of the right renal artery. Dissection Laparoscopic adrenalectomy can be performed safely and is then performed along the lateral surface of the inferior effectively by the transperitoneal or the retroperitoneal ap- vena cava to expeditiously control the main adrenal vein, proach. Operative parameters, perioperative morbidity and which in our experience drains from the superomedial aspect pathological characteristics of the intact extracted specimen TRANSPERITONEAL VERSUS RETROPERITONEAL LAPAROSCOPIC ADRENALECTOMY were similar with the 2 approaches. In the end the choice of adrenalectomy: the initial experience. J Urol, 165: 1875, 2001
laparoscopic approach for adrenalectomy should depend on 11. Meraney, A.M., Abd-el Samee, A. and Gill, I. S.: Vascular and the personal experience and preference of the laparoscopic bowel complications during retroperitoneal laparoscopic sur- surgeon. Familiarity and expertise with the transperitoneal gery. J Urol, 168: 1941, 2002
and retroperitoneal techniques will allow the laparoscopic 12. Hobart, M. G., Gill, I. S., Schweizer, D., Sung, G. T. and Bravo, surgeon to select the optimal approach for an individual E. L.: Laparoscopic adrenalectomy for large-volume (Ͼ or ϭ 5 cm) adrenal masses. J Endourol, 14: 149, 2000
13. Farres, H., Felsher, J., Brodsky, J., Siperstein, A., Gill, I. and Brody, F.: Laparoscopic adrenalectomy: a cost analysis of three approaches. J Laparoendosc Adv Surg Tech A, 14: 23, 2004
1. Gagner, M., Lacroix, A. and Bolte, E.: Laparoscopic adrenalec- 14. Moinzadeh, A. and Gill, I. S.: Laparoscopic radical adrenalec- tomy in Cushing’s syndrome and pheochromocytoma. New tomy for malignancy in 31 patients. J Urol, 173: 519, 2005
Engl J Med, 327: 1033, 1992
2. Guazzoni, G., Montorsi, F., Bocciardi, A., Da Pozzo, L., Rigatti, P., Lanzi, R. et al: Transperitoneal laparoscopic versus openadrenalectomy for benign hyperfunctioning adrenal tumors: a Prospective, randomized studies comparing the transperitoneal vs comparative study. J Urol, 153: 1597, 1995
the retroperitoneal approach for laparoscopic surgery are difficult to 3. Brunt, L. M., Doherty, G. M., Norton, J. A., Soper, N. J., perform and, therefore, they are rarely found in the literature. How- Quasebarth, M. A. and Moley, J. F.: Laparoscopic adrenalec- ever, it is important information such as presented in this report that tomy compared to open adrenalectomy for benign adrenal neo- helps formulate clinical laparoscopic surgery practice. These authors plasms. J Am Coll Surg, 183: 1, 1996
provide a comprehensive and well designed study comparing these 2 4. Takeda, M., Go, H., Watanabe, R., Kurumada, S., Obara, K., approaches for laparoscopic adrenalectomy. The results of their Takahashi, E. et al: Retroperitoneal laparoscopic adrenalec- study are reinforced by the large number of patients, the prospective tomy for functioning adrenal tumor: comparison with conven- randomized format and the long-term followup. All operative param- tional transperitoneal laparoscopic adrenalectomy. J Urol, eters, including operative time, were similar for the 2 approaches.
157: 19, 1997
However, it must be recognized that the retroperitoneal approach 5. Fernandez-Cruz, L., Saenz, A., Benarroch, G., Astudillo, E., has been demonstrated to be technically efficient in this study in the Taura, P. and Sabater, L.: Laparoscopic unilateral and bilat- hands of an expert surgeon extensively experienced and facile with eral adrenalectomy for Cushing’s syndrome. Transperitoneal the retroperitoneal approach. It is of interest that, while periopera- and retroperitoneal approaches. Ann Surg, 224: 727, 1996
tive morbidity, including the analgesia requirement, was similar for 6. Sung, G. T., Hsu, T. H. S. and Gill, I. S.: Retroperitoneoscopic the transperitoneal and retroperitoneal approaches, convalescence adrenalectomy: lateral approach. J Endourol, 15: 505, 2001
was significantly more rapid in the retroperitoneal group than in the 7. Terachi, T., Matsuda, T., Terai, A., Ogawa, O., Kakehi, Y., transperitoneal laparoscopic adrenalectomy group.
Kawakita, M. et al: Transperitoneal laparoscopic adrenalec- There is no question that laparoscopy has become the surgical tomy: experience with 100 patients. J Endourol, 11: 361, 1997
technique of choice for adrenalectomy. The choice of transperitoneal 8. Gill, I. S.: The case for laparoscopic adrenalectomy. J Urol, 166:
vs retroperitoneal rests entirely on surgeon preference and the de- termined indication of the surgical procedure for each individual 9. Gill, I. S., Soble, J. J., Sung, G. T., Winfield, H. N., Bravo, E. L.
and Novick, A. C.: Needlescopic adrenalectomy—the initialseries: comparison with conventional laparoscopic adrenalec- tomy. Urology, 52: 180, 1998
10. Gill, I. S., Meraney, A. M., Thomas, J. C., Sung, G. T., Novick, University of California Irvine Medical Center A. C. and Lieberman, I.: Thoracoscopic transdiaphragmatic



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