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    A surgery underestimated by urology: Adrenalectomy; Clinical experience of Istanbul medical faculty
    (2004) Kandirali, Engin; Erdemir, Fikret; Korgali, Esat; Atilgan, Do?an; Esen, Tarik; Tunç, Murat
    Introduction: The most common adrenal disorder encountered by clinicians today is the incidentally discovered adrenal mass as a result of the more widespread use of enhanced quality of high-resolution radiological techniques. Autopsy series have identified adrenal masses in 1.4% to 9% of patients who had no evidence of adrenal dysfunction prior to death. The incidence of adrenal masses detected by computed tomography scanning has ranged from 0.4% to 4.4%. The etiology of adrenal masses includes benign or malignant adrenal cortical tumors, adrenal medullary tumors, and other benign lesions. An adrenal mass is characterized according to functional status, with a medical history, physical examination, and hormonal assessment, and malignant potential, with an assessment of the imaging phenotype and mass size. Adrenal masses are commonly small (80% smaller than two cm), benign (94%), and non-functioning (%90). Malignant adrenal masses are rare (%2.7), and the most of them are larger than five cm. All adrenal masses require biochemical workup to evaluate adrenal function. Hormonally inactive tumors smaller than five cm. are followed regularly. Surgery is indicated for masses that are larger than five cm. in diameter, hormonally active adrenal masses or malignancy suspicione. The aim of this study is to investigate the features and the preoperative evaluation of patients who have had adrenalectomy in our clinic, to point out how to perform the biochemical evaluation, and to emphasize the importance of adrenal surgery. Materials and Methods: In our department, between January 1997 and December 2003, we performed a total of 13 open adrenalectomies via the retroperitoneal or transperitoneal approach, including eight on the right and five on the left side, in nine men add four women. Ten patients who completed post-operative follow up examination were included in our study. All patients were evaluated with a medical history, physical examination, ultrasonography, computed tomography, magnetic resonance imaging, serum multipl analyses and hormonal activity. Pre-operative and post-operative medical treatments of the patients were done by an endocrinologist. Results: Mean age of our patients was 51.4±7.8 (36-65) years and mean follow up period was 43.1±22.7 (4-78) months. Eight adrenal masses are detected on the right side and five adrenal masses are on the left side, in nine men and four women. One case had hormonally active adrenal mass and 12 cases had hormonally inactive adrenal mass. The average adrenal mass size was 7.9 cm (3-16). Mean operation time was 120 (60-180) minutes and no complication was seen during the operation. Mean duration of hospital stay was six (4-10) days. The most common lesions were benign cortical adenoma (%30.5), metastasis of renal cell carcinoma (%23), primer adrenal carcinoma (%15.2) and son. Ten of 13 operated patients' follow-up visits were done regularly. Two patients who had metastasis of renal cell carcinoma died due to primary illness approximately 9.7 months after the operation. We did not detect recurrence in the other eight patients. Median survival rate was 80%. Conclusion: After a careful clinical, biochemical and radiological evaluation, patients are selected for surgery. Although laparoscopic adrenalectomy has become a standard procedure for the treatment of adrenal tumors, the open surgery can be perform safety with low morbidity rates especially if the tumor size is large and there is malignancy suspicione. Pre-operative, intra-operative and post-operative preparation of the patients is very important. All adrenal masses should be evaluated hormonally. Appearance and clinical history should indicate how to perform the biochemical evaluation keeping in mind that the presence of pheochrocytomas must be ruled out. We believe that the subject of adrenal gland surgery should be considered as a part of urology practice although many other departments such as general surgery, plastic surgery, obstetrics and gynecology and pediatric surgery have a tendency to be involved in many of the subjects included in urology.