Contemporary Experience of Posterior Retroperitoneoscopic Adrenalectomy in the US.

BACKGROUND: As the incidence of adrenalectomy increases steadily, so does the use of minimally invasive approaches like posterior retroperitoneoscopic adrenalectomy (PRA). To date, the largest studies of PRA have been from abroad, and we sought to provide a contemporary US update on the outcomes after PRA. METHODS: A retrospective chart review was conducted on all PRAs performed at a single tertiary care institution between 2013 and 2020. Patient demographic characteristics, indication for operation, operative details, and postoperative course were abstracted. Outcomes of interest included 30-day mortality, conversion to open or transabdominal approach, postoperative complication, and 30-day readmission. RESULTS: A total of 249 PRAs were performed between 2013 and 2020. The population was 54.2% women and mean (SD) age was 54.1 (14.1) years. Most lesions (60.6%) were left-sided, and the most common diagnosis was nonfunctioning adenoma (39.4%), followed by pheochromocytoma (21.3%) and aldosteronoma (16.6%). Mean (SD) tumor size was 3.2 cm (range 0.5 to 9.4 cm). Median operative length was 110 minutes (range 30 to 319 minutes). Overall, the complication rate was 6.4%. Nine patients (3.6%) had a minor postoperative complication (Clavien-Dindo I to III) and 5 patients (2.0%) had a major postoperative complication (Clavien-Dindo IV to V), including 1 mortality (0.4%). There were 2 conversions of approach (0.8%). The majority of patients (58.2%) were discharged on postoperative day 1, and 92.0% were discharged by postoperative day 3. The 30-day readmission rate was 1.6%. CONCLUSIONS: Current practice demonstrates that PRA is an extremely safe approach, with a complication rate < 7% and mortality rate < 1%. In addition, the vast majority of patients are able to return home in an expedient manner.

Advances in understanding the molecular underpinnings of adrenocortical tumors.

PURPOSE OF REVIEW: Adrenocortical tumors are divided into benign adenomas and malignant carcinomas. The former is relatively common and carries a favorable prognosis, whereas the latter is rare and frequently presents at an advanced stage, with poor outcomes. Advances in next-generation sequencing, genome analysis, and bioinformatics have allowed for high-throughput molecular characterization of adrenal tumorigenesis. RECENT FINDINGS: Although recent genomic, epigenomic, and transcriptomic studies in large tumor cohorts have confirmed the central roles of aberrant Wnt/ß-catenin signaling, constitutive protein kinase A pathway activation, cell cycle dysregulation, and ion channelopathies in adrenal tumorigenesis, these studies also revealed novel signature events underlying malignant differentiation of adrenocortical carcinomas. SUMMARY: Recent advances in understanding of the molecular mechanisms underlying adrenocortical tumorigenesis provide new molecular diagnostic and prognostic tools and opportunities for novel therapeutic approaches. These findings are particularly important in adrenocortical carcinoma, for which current treatment options are limited.