An audit of the diagnostic usefulness of PRL and TSH responses to domperidone and high resolution magnetic resonance imaging of the pituitary in the evaluation of hyperprolactinaemia.

BACKGROUND AND OBJECTIVE: The usefulness of dynamic tests of PRL release in determining underlying pathology in hyperprolactinaemic patients is not well recognized by endocrinologists, only 15% of whom routinely perform such tests. High resolution pituitary magnetic resonance imaging (MRI) has become more widely available during the past 5 years and is now generally regarded as the pituitary imaging method of choice. Since few prolactinoma patients are now submitted to surgery, it is important to ascertain the usefulness of these techniques in suggesting a pathological diagnosis. DESIGN: A 3 year retrospective audit of the information derived from measurement of PRL and TSH responses to the dopamine antagonist domperidone and from high resolution pituitary MRI in patients being investigated for hyperprolactinemia in regional endocrine unit. PATIENTS: Eighty-four patients (10 male, 74 female) whose investigation of hyperprolactinaemia included a domperidone test and high resolution pituitary MRI. Patients who had domperidone tests performed after pituitary surgery or who did not have pituitary MRI were excluded from the analysis. MEASUREMENTS: PRL and TSH were measured basally and at 30 and 60 minutes following domperidone (10 mg i.v.) and gadolinium-enhanced pituitary MRI was performed in all patients. RESULTS: 20 patients had a normal PRL response to domperidone (defined as PRL30/PRL0 > 3) and this group included five patients in whom hyperprolactinaemia was not sustained. Pituitary MRI showed evidence of a microadenoma in only two patients, imaging being unequivocally normal in the majority. Sixty-four patients had an abnormal PRL response to domperidone and 18 of these had a macrolesion (nine prolactinomas, nine other tumours). Pituitary MRI was performed in the remaining 46 patients with abnormal PRL response to domperidone and suggested microadenoma in 29 (63%), identified other structural abnormalities in six cases but was entirely normal in 11 cases. Neither the basal PRL level nor the TSH response could refine the diagnosis further because of overlap between the various subgroups. CONCLUSIONS: The majority of patients with a normal dynamic response of PRL to domperidone had a normal or near normal pituitary MRI scan. In the two cases where an abnormality was detected it could have been an incidental microadenoma or cyst, thus suggesting that pituitary scanning could normally be omitted in patients whose PRL response to domperidone is normal (24% of our total). The group of patients with an abnormal dynamic response of PRL to domperidone was not generally amenable to further diagnostic refinement by considering the degree of hyperprolactinaemia or the TSH response to domperidone because of overlap of these parameters between the diagnostic subgroups. Therefore any degree of hyperprolactinaemia associated with a blunted PRL response to domperidone warrants pituitary imaging.

Laparoscopic trans-peritoneal adrenalectomy: a preliminary report of 14 adrenalectomies.

OBJECTIVES: Laparoscopic adrenalectomy offers the potential benefits of a smaller operation with more rapid hospital discharge, compared to open surgery. Only a few small series have been reported so far. We describe our preliminary experience of 14 adrenalectomies using this new technique. DESIGN: Review of all adrenalectomies (with the preoperative intention of laparoscopic removal) performed in an endocrine unit whose surgeon already had abdominal laparoscopic experience, particularly with cholecystectomy. PATIENTS AND MEASUREMENTS: Twelve patients (3 with Conn's syndrome, 3 Cushing's syndrome, 1 Cushing's disease, 2 phaeochromocytomas and 3 adrenal incidentalomas) were operated between September 1993 and February 1996. Operating times, operative technique, time from surgery to discharge, outcome and all complications were recorded prospectively. Comparative data were obtained from 14 consecutive open adrenalectomies performed by the same surgeon between February 1989 and February 1995. RESULTS: Fourteen glands were removed, two with a cholecystectomy, in 12 operations. Operating time (mean (range) 120 (60-225) min) was reduced with experience. Positioning the patient in the right lateral position facilitated left adrenalectomy. Time to discharge (mean (range)) was 5.3 (1-12) days. There were relatively minor complications in three patients, including two with Cushing's syndrome: a hernia at a port site, intra-peritoneal/wound haemorrhage and a pressure sore. Time to discharge for open adrenalectomy (mean (range)) was 6.5 (2-11) days and one case was complicated by wound infection. CONCLUSIONS: Laparoscopic adrenalectomy is a practical technique for appropriately trained surgeons who regularly undertake adrenalectomy. The smaller incisions offer potential advantages, particularly for patients with poor tissue quality due to Cushing's syndrome, but tissue haemorrhage may still be a problem in these patients. Time to hospital discharge was similar to that for open surgery.