HORMONES 2017, 16(4):388-395

Research paper

Surgery for : A 20-year experience of a single institution

Chrysanthi Aggeli,1 Alexander M. Nixon,1 Christos Parianos,1 Georgios Vletsis,1 Labrini Papanastasiou,2 Athina Markou,2 Theodora Kounadi,2 Georgrios Piaditis,2 Georgios N. Zografos1

1Third Department of Surgery, Athens General Hospital “G. Gennimatas”, Greece; 2Department of Endocrinology and Diabetes Center, Athens General Hospital “G. Gennimatas”, Greece

ABSTRACT OBJECTIVE: Resection of is a challenging procedure due to hemodynamic lability. Our aim was to evaluate surgical outcomes in 67 patients with pheochromocytoma and to validate the role of laparoscopic surgery in the treatment of these tumors. DESIGN: This study is a retrospective review. A total of 68 procedures for pheochromocytoma were performed between June 1997 and February 2017. All patients were investigated and operated on using an established departmental protocol. Relevant data were retrieved from the hospital records of 533 patients who underwent 541 for benign and malignant adrenal tumors in the same period. RESULTS: Sixty-nine tumors were removed from 67 patients. One patient with/MEN2A underwent bilateral resection of pheochromocytomas in two stages. Tumor size in laparoscopic procedures ranged from 1.2 cm to 11.0 cm (mean 5.87 cm). Thirty-seven patients had benign disease, 31 potentially malignant (based on PASS) and 1 malignant with metastasis. Eight were in the context of a familial syndrome. Forty-nine patients underwent laparoscopic , 8 patients had open approach from the start for recurrent pheochromocytoma or large benign tumor, 1 patient had open approach due to inoperable malignant pheochromo- cytoma and 10 patients had conversions from laparoscopic to open procedure. Nine patients received sodium nitroprusside intraoperatively to treat hypertension. One patient developed pulmonary embolism and succumbed 1 month later. There were no recurrences of the benign or potentially malignant tumors during the follow-up period. CONCLUSIONS: Laparoscopic resection of pheochromocytomas, despite its increased level of difficulty compared to that of other adrenal tumors, is a safe and effective procedure. Key words: Endocrine surgery, Laparoscopic adrenalectomy, Pheochromocytoma

Address for correspondence: INTRODUCTION *HRUJH1=RJUDIRV0'&RQVXOWDQW6XUJHRQ.2XUDQL6WU $WKHQV*UHHFH7HO Pheochromocytoma (PHEO) is a tumor derived )D[(PDLOJQ]RJUDIRV#\DKRRFRP from chromaffin cells of the sympathetic nervous Received: 14-03-2017, Accepted: 11-11-2017 system and its clinical symptoms are associated with Surgery for pheochromocytoma 389 excessive production and release of catecholamines netic resonance imaging (MRI), while iodine-123 which can cause arterial hypertension and symptoms metaiodobenzylguanidine (MIBG) scan was reserved attributed to paroxysmal stimulation of the adrenergic for ambiguous cases where paraganglioma or metastatic V\VWHP1,2 GLVHDVHZDVVXVSHFWHG$OOSDWLHQWVZHUHLQYHVWLJDWHG according to an established protocol drawn up by the Since the first report on laparoscopic adrenalectomy Department of Endocrinology and Diabetes Center by Gagner in 1992, this approach has increasingly DWRXU+RVSLWDO become the gold standard for excision of benign functioning and non-functioning tumors of the adrenal Endocrinological evaluation and complete adrenal JODQG3 Laparoscopic adrenalectomy compared to dynamic testing were performed to determine whether traditional open resection has proven equally safe and WKHWXPRUZDVIXQFWLRQDORUQRW$OOSDWLHQWVXQGHUZHQW efficient, offering a number of significant advantages basal adrenal hormonal investigation including serum such as improved access to the surgical area, less cortisol, adrenocorticotropin (ACTH), dehydroepian- blood loss, decreased requirement for postoperative drosteronesulphate, renin and aldosterone levels, and analgesia, shorter hospital stay and earlier return to WKHDOGRVWHURQH»UHQLQUDWLR7KHHYDOXDWLRQRIFRUWLVRO QRUPDOGLHWDQGDFWLYLWLHV4-6 hypersecretion included 24-h urinary free cortisol and On the other hand, in large PHEOs technical dif- measurement of serum cortisol and ACTH levels after ficulties increase due to possible hemodynamic in- an overnight dexamethasone suppression test (1mg VWDELOLW\WXPRUYDVFXODULW\DQGPDOLJQDQWSRWHQWLDO of dexamethasone administrated at midnight, before Given the technical challenges for resection of large WKHPRUQLQJEORRGVDPSOH 7KHHYDOXDWLRQRI3+(2V PHEOs, there were hesitations about using a lapa- included the measurement of urinary fractioned meta- roscopic approach for these tumors during the first nephrines (normetanephrines and metanephrines) as GHFDGHRIODSDURVFRSLFVXUJHU\0HDQZKLOHKRZHYHU SHUORFDODYDLODELOLW\RIGLDJQRVWLFWHVWV0HDVXUHPHQWV improvement in imaging modalities, better pharma- of plasma free or urinary fractionated metanephrines cological preparation, advances in anaesthesia and are superior to other tests of catecholamine excess 8 laparoscopic surgery as well as evolving technology for the diagnosis of pheochromocytomas and, until rendered laparoscopic surgery for PHEO safe and there are data directly comparing plasma and urinary HIILFLHQW7 measurements, there is no recommendation that one WHVWLVVXSHULRUWRWKHRWKHU MATERIALS AND METHODS ,QDOOSDWLHQWVĮDGUHQHUJLFEORFNDGHZLWKDWLWUDWLRQ dose of phenoxybenzamine (starting dose 10mg - mean A total of 68 procedures for PHEO were performed dose 100mg - max dose 200mg) was administered for EHWZHHQ-XQHDQG)HEUXDU\)RXUDEGRPLQDO 7-14 days prior to surgery to achieve a blood pressure paragangliomas operated on during the same period RIDSSUR[LPDWHO\PP+J+LJKVRGLXPGLHWDQG DUHQRWLQFOXGHGLQWKLVVHULHV7KHSUHRSHUDWLYHGL- intravenous fluids were administered after the second agnosis, operative details, complications, length of or third day of the initiation of medical treatment in hospital stay, morbidity and follow-up were retrieved order to achieve volume expansion and counteract the from the hospital records of 533 patients who under- RUWKRVWDVLVDVVRFLDWHGZLWKĮDGUHQHUJLFEORFNDGH,Q went 541 adrenalectomies for benign and malignant FDVHVRIWDFK\DUUK\WKPLDVDȕDGUHQRFHSWRUEORFNHU DGUHQDOWXPRUVLQWKHVDPHSHULRG6LQFHGDWD ZDVDGGHGDIWHUWKHĮDGUHQHUJLFEORFNDGH have been retrieved from our Department database LQFOXGLQJSURVSHFWLYHSDWLHQWUHFRUGV All patients had blood pressure less than 140/80mm Hg, to omit orthostatic hypotension not exceeding One patient with MEN2A syndrome underwent 80/45mmHg, no more than one ventricular extrasys- bilateral tumor resection with left cortex-preserving tole every 5 minutes and ECG without nonspecific DGUHQDOHFWRP\ ST segment elevations or depression as well as T Preoperative localization was established in all wave inversions, thus ensuring adequate preopera- patients by computerized tomography (CT) or mag- WLYHSUHSDUDWLRQ 390 &$**(/,(7$/

SURGICAL TECHNIQUE FP 2SHUDWLYHWLPHUDQJHGIURPWRPLQXWHV PHDQPLQXWHV  All the operations, open or laparoscopic, were performed with the patient in the lateral decubitus Forty-eight patients underwent laparoscopic adre- SRVLWLRQ7KHUHIRUHWKHUHZDVQRQHHGWRFKDQJHWKH nalectomy, 1 patient underwent hand-assisted laparo- position of the patient in the event of a conversion to scopic adrenalectomy, 8 patients had an open approach DQRSHQRSHUDWLRQ$WUDQVSHULWRQHDOODWHUDODSSURDFK from the beginning due to either recurrent or large ZDVXVHGWRSHUIRUPODSDURVFRSLFDGUHQDOHFWRP\ WXPRUV PHDQWXPRUVL]H FP SDWLHQWKDGDQ High technology instruments and equipment are open biopsy due to inoperable malignant PHEO and PDQGDWRU\DQGDYDLODEOHLQWKHRSHUDWLQJWKHDWHU there were 10 conversions from laparoscopic to open We use a monitor tower and gas insufflator set at an DGUHQDOHFWRP\6L[FRQYHUVLRQVZHUHSHUIRUPHGIRU intra-abdominal pressure of 14mmHg and a 300 10mm KHPRVWDVLVDQGGXHWRSHULDGUHQDOWLVVXHLQYDVLRQ ODSDURVFRSH:HSUHIHUWRFUHDWHSQHXPRSHULWRQHXP The relative majority of conversions (5 out of 8 lapa- with the Hasson technique to avoid any relevant mor- URVFRSLHV RFFXUUHGLQWKHILUVW\HDUVRIWKLV ELGLW\7KHDGUHQDOJODQGLVQHYHUJUDVSHGHVSHFLDOO\ VHULHV,QWKHODVW\HDUVWKHFRQYHUVLRQUDWHGURSSHG in cases of PHEOs, to avoid hemodynamic instability, VLJQLILFDQWO\ RXWRIODSDURVFRSLHV 7KHVH WURXEOHVRPHEOHHGLQJRUWXPRUGLVUXSWLRQ:HOLJDWH conversions were undertaken in order to achieve safe small vessels with clips or the harmonic scissors/ oncological margins and only one for hemorrhage VFDOSHO:HXVHDGGLWLRQDOSRUWVLQREHVHSDWLHQWVRU FRQWURO ZKHQWKHUHLVDVSHFLDOQHHG2FFDVLRQDOO\LQODUJH Blood transfusion was needed only in 2 patients, tumors we use the hand-assisted technique as the last 1 with resection of recurrent malignancy and 1 due to HIIRUWWRDYRLGFRQYHUVLRQ7KHVSHFLPHQLVSODFHGLQ SUHRSHUDWLYHDQHPLDDQGPLQLPDOFRQWUROOHGEOHHGLQJ a special bag and extracted through minimal extension RIWKHLQLWLDOLQFLVLRQ Nine patients (5 laparoscopic adrenalectomies and 4 open) received sodium nitroprusside because We consider early ligation of the adrenal vein to of intraoperative hypertensive crisis (defined as a UHGXFHWKHULVNRIKHPRG\QDPLFLQVWDELOLW\+RZ- systolic blood pressure over 220mmHg sustained ever, delayed adrenal vein ligation, following tumor RYHUPLQXWHV $OOVLJQLILFDQWHSLVRGHVZHUHQRWHG mobilization, is equally safe provided that efficient during manipulation of the tumor and before ligation SKDUPDFRORJLFDOSUHSDUDWLRQLVFRPSOHWHG RIWKHDGUHQDOYHLQ6KRUWHUHSLVRGHVRIK\SHUWHQVLRQ that did not require pharmacological treatment with RESULTS YDVRGLODWRUVZHUHQRWLQFOXGHGLQWKHVHUHVXOWV6RGLXP Sixty-nine tumors were removed from 67 patients nitroprusside has a rapid onset of action but also end/ PHQZRPHQ ZLWKDPHDQDJHRI\HDUV termination of effect and should only be administered UDQJH 7KHPHDQKRVSLWDOVWD\ZDVGD\V XQGHUFORVHPRQLWRULQJ$OOSDWLHQWVKDGEHHQWUHDWHG UDQJHGD\V IRUWKHODSDURVFRSLFSURFHGXUHV with the same protocol of phenoxybenzamine titration DVGHVFULEHGDERYH The diagnosis included 37 benign PHEOs, 31 SRWHQWLDOO\PDOLJQDQW EDVHGRQ3$66• DQG Transient episodes of arrhythmia or tachycardia PDOLJQDQWZLWKPHWDVWDVLV0DOLJQDQF\ZDVGHILQHG (duration <30s) were not documented as part of the solely based on the presence of metastasis and not study protocol and no sustained episodes (duration on a history of local recurrence, in accordance with >30s) of abnormal cardiac rhythm or frequency were the World Health Organization’s classification of REVHUYHG$QLQWHUHVWLQJH[FHSWLRQZDVDIHPDOHSDWLHQW WXPRUV9 One patient had von Recklinghausen disease with a negative preoperative work-up for PHEO and DQGSDWLHQWVKDG9RQ+LSSHO/LQGDXV\QGURPH2QH therefore no blockade, who presented hemodynamic patient with MEN2A underwent bilateral resection instability during the operation and finally proved to RI3+(2VLQWZRVWDJHV7XPRUVL]HLQODSDURVFRSLF have a potentially malignant PHEO with a PASS = 6 SURFHGXUHVUDQJHGIURPFPWRFP PHDQ 3+(2RIWKH$GUHQDOJODQG6FDOHG6FRUH  Surgery for pheochromocytoma 391

Postoperatively, there were no life-threatening sion with crystalloids (2000ml/day starting on the day complications, except for one patient who after right EHIRUHVXUJHU\ LVRIFULWLFDOLPSRUWDQFH&RQWLQXRXV laparoscopic adrenalectomy developed pulmonary invasive monitoring and pharmacologic intervention HPEROLVP7KHSDWLHQWZDVKRVSLWDOL]HGLQWKHLQWHQVLYH by an experienced anesthetic team perioperatively FDUHXQLWDQGVXFFXPEHGDPRQWKODWHU are necessary to avoid substantial cardiovascular LQVWDELOLW\19 When the main adrenal vein is ligated, All patients showed remarkable improvements DQWLK\SHUWHQVLYHGUXJVDQGȕEORFNHUVDGPLQLVWUDWLRQ in hypertension and reversal of the characteristic DUHVWRSSHGDQGKHPRG\QDPLFVDUHUHDVVHVVHG20,21 symptoms of constant adrenoreceptor stimulation E\FDWHFKRODPLQHV At our institution we avoid aggressive pharma- cological vasodilation, especially before ligation of No clinically significant episodes of postoperative the adrenal vein, in order to avoid an abrupt drop in K\SRJO\FHPLDZHUHGRFXPHQWHG EORRGSUHVVXUH16 Transient spikes in blood pressure At a mean follow-up interval of 152 months after DUHXVXDOO\PDQDJHGE\OLPLWLQJWXPRUPDQLSXODWLRQ ODSDURVFRSLFDGUHQDOHFWRP\ UDQJHPRQWKV± Guiding this practice is the fact that tumor manipula- years), resolution of hormonal activity and no evi- tion has been shown to be the most significant intra- GHQFHRIWXPRUUHFXUUHQFHZHUHGRFXPHQWHG7KH operative stimulus for catecholamine release during patient with the recurrent malignant PHEO survived ERWKRSHQDQGODSDURVFRSLFUHVHFWLRQV27,30 Limiting IRU\HDUVDIWHUWKHODVWRSHUDWLRQ7KLUW\RQHWXPRUV tumor manipulation and applying pharmacological with potentially malignant features on pathology as vasodilation when hypertension is persistent has assessed by PASS were identified, but follow-up has resulted in no cardiovascular morbidity or mortality not demonstrated thus far any evidence of recurrence LQRXUVHULHV7KHVROHH[FHSWLRQZDVRQHSDWLHQW RUPHWDVWDVLV who developed a severe pulmonary embolus and GLHGDIWHUEHLQJKRVSLWDOL]HGIRUDPRQWK,WVKRXOG DISCUSSION be noted that no intraoperative hemodynamic labil- LW\ZDVREVHUYHG7RRXUNQRZOHGJHQRRWKHUSDWLHQW We reviewed our experience with operative treat- developed any form of clinically evident deep vein ment of pheochromocytoma to demonstrate the safety WKURPERVLV,QWHUHVWLQJO\WKHLQFLGHQFHRIFOLQLFDOO\ and efficacy of the laparoscopic approach and to present evident deep vein thrombosis has been reported to some noteworthy issues concerning the management EHDVKLJKDVLQODSDURVFRSLFDGUHQDOHFWRP\31 RIWKHVHSDWLHQWV%HIRUHWKHDGYHQWRISUHRSHUDWLYH adrenergic blockade, morbidity and mortality asso- It has been suggested that the laparoscopic approach ciated with hemodynamic lability due to excessive to PHEO may decrease the intraoperative release FDWHFKRODPLQHVHFUHWLRQZHUHSURKLELWLYHO\KLJK2S- of catecholamines, compared with open surgery, erative mortality in the pre-blockade era was reported WKXVUHGXFLQJWKHULVNRIDK\SHUWHQVLYHFULVLV32 This DWSULPDULO\GXHWRP\RFDUGLDOLQIDUFWLRQDQG may be a result of fewer operative manipulations, FHUHEURYDVFXODUDFFLGHQWV15 Preoperative blockade DOWKRXJKLWVHHPVDVRPHZKDWK\SHUEROLFVXJJHVWLRQ has significantly reduced adverse outcomes but has Laparoscopy offers improved visualization and faster not completely eliminated episodes of hemodynamic access to the adrenal vein further reducing the risk ODELOLW\16 RIFDWHFKRODPLQHUHOHDVH2WKHUVWXGLHVVXJJHVWWKDW intra-abdominal insufflation during laparoscopy may Proper preparation of the patient before surgery DORQHFDXVHDQLQFUHDVHLQVHUXPFDWHFKRODPLQHV28,33 LVFUXFLDO7KHSUHSDUDWLRQLQFOXGHVWKHDGPLQLVWUD- This is probably the result of direct tumor compres- WLRQRIĮZLWKRUZLWKRXWȕEORFNHUVDQGLQWUDYHQRXV VLRQRUDOWHUDWLRQLQWXPRUSHUIXVLRQ28 H[SDQVLRQZLWKFU\VWDOORLGV,QSDUWLFXODUQRQVHOHF- WLYHĮDGUHQHUJLFEORFNDGH SKHQR[\EHQ]DPLQH DQG Early ligation of the adrenal vein has historically VHOHFWLYHĮDGUHQHUJLFEORFNDGH SUD]RFLQ DUHXVHG been suggested as a prophylactic factor minimizing IRUĮEORFNDGH17,18 In cases of co-existing tachycardia KRUPRQDOVHFUHWLRQ34 By contrast, others endorse the ȕEORFNDGHLVHPSOR\HG,QWUDYHQRXVYROXPHH[SDQ- safety of delayed adrenal vein ligation, challenging 392 &$**(/,(7$/ the importance of the long-standing tradition of early ZLWKWURXEOHVRPHEXWQRWPDVVLYHEOHHGLQJ,WVHHPV DGUHQDOYHLQOLJDWLRQIRUWKHVHSDWLHQWV35,36 In our that laparoscopic adrenalectomy of large PHEOs is opinion, this technique may be even safer because safe as long as the surgeon has the appropriate experi- the tumor is mobilized from the inferior vena cava to HQFH43 When using 4 cm as a cut-off value between the right and the renal vein to the left and thus pos- small and large tumors there does not seem to be a VLEOHKHPRUUKDJHLVEHWWHUFRQWUROOHGE\ODSDURVFRS\ significant difference in operative time and surgical Nonetheless, we always contemplate an initial effort RXWFRPHV44 In light of this, laparoscopic adrenalecto- to dissect the main adrenal vein at an early stage of mies have been performed for non-PHEO tumors up the procedure but, if safety is jeopardized, we follow to 15 cm in diameter without any significant morbid- WKHGHOD\HGYHLQOLJDWLRQWHFKQLTXH37 ity, therefore PHEO size does not seem to preclude DODSDURVFRSLFDSSURDFK45-49 Tumor size is another consideration in laparo- VFRSLFDGUHQDOHFWRP\LQJHQHUDO,QWKHFDVHRI3+(2 Suspected malignancy remains a controversial is- guidelines published by the Endocrine Society sug- VXH50 Thus far, the only universally accepted criterion gest open adrenalectomy as the treatment modality IRUPDOLJQDQF\LQWKHFDVHRI3+(2LVPHWDVWDVLV9 of choice in PHEOs larger than 6 cm due to increased Currently there is no definitive way to predict which concerns for obtaining safe oncological margins and WXPRUVZLOOSURJUHVVWRPDOLJQDQF\,IWKHUHDUHQR WKHSHUFHLYHGLQFUHDVHGULVNRIFDSVXOHUXSWXUH38 metastases it is impossible to precisely evaluate the A recent limited non-randomized controlled study degree of malignancy based on biochemical and of large pheochromocytomas (>6 cm) comparing LPDJLQJWHVWVDORQH51 laparascopic adrenalectomy and open adrenalectomy (YHQSDWKRORJLFHYDOXDWLRQLVQRQGHILQLWLYH7KH indicated that recurrence rates were not statistically most popular scale employed for estimating the risk different between the two groups, thus questioning of malignancy is the PASS, which was developed FXUUHQWJXLGHOLQHV39 However, sample sizes were E\7KRPSVRQLQ51,52 Thompson proposed that relatively small and larger studies are required to WXPRUVZLWKD3$66VFRUH•VKRXOGEHFRQVLGHUHG fully validate laparoscopic adrenalectomy in large ELRORJLFDOO\PRUHDJJUHVVLYH1HYHUWKHOHVVLWLVKDV 3+(2V,WVKRXOGEHKLJKOLJKWHGWKDWWXPRUVL]H been demonstrated that this system cannot precisely has not been conclusively proven to be a reliable predictor of recurrence or malignant potential, with GLIIHUHQWVWXGLHV\LHOGLQJRSSRVLQJFRQFOXVLRQV10,40 In our study the largest PHEO excised laparoscopi- FDOO\ZDVFPLQGLDPHWHU:HKDGFRQYHUVLRQV to an open procedure because of periadrenal tumor LQYDVLRQ'XULQJRXUIROORZXSWKHUHKDYHEHHQQR LQVWDQFHVRIORFDOUHFXUUHQFH+RZHYHU3+(2UHFXU- rence or metastasis can develop as long as 20 years after surgical excision and therefore all patients need WREHPRQLWRUHGORQJWHUP Tumor size may also be a concern regarding conver- VLRQUDWHVLQODSDURVFRSLFVXUJHU\+RZHYHUWKHPRVW common incidental cause of conversion in adrenal- HFWRP\LQJHQHUDOLVLDWURJHQLFYDVFXODULQMXU\14,41,42 As previously mentioned, PHEOs are characterized by a rich network of vessels and thus carry a higher probability of intraoperative troublesome hemorrage FLJXUH 1. %HQLJQDGHQRPDRIWKHULJKWDGUHQDOJODQG+HPRU- )LJXUH ,QRXUVHULHVZHKDGFRQYHUVLRQVWRDQ UKDJLFLQILOWUDWLRQRIWKHDGUHQDOFRUWH[LVHYLGHQW3UHRSHUDWLYH open procedure for successful hemostasis in patients LPDJLQJLQGLFDWHGDSKHRFKURPRF\WRPD Surgery for pheochromocytoma 393 diagnose malignancy or predict the postoperative intraoperative management and adequate postoperative FRXUVHDIWHUDGUHQDOHFWRP\51,53 follow-up are essential to prevent surgery-induced uncontrollable catecholamine secretion and cardio- PHEOs exhibit a modest response to radiotherapy YDVFXODULQVWDELOLW\/DSDURVFRSLFUHVHFWLRQRIODUJH DQGV\VWHPLFWKHUDS\ HJ0,*% 54 Surgical resection PHEOs necessitates experience in open and advanced LVFXUUHQWO\WKHRQO\WKHUDSHXWLFRSWLRQ55 However, ODSDURVFRSLFVXUJHU\3RWHQWLDOO\PDOLJQDQWWXPRUV there are concerns about the ability of minimally should not be accounted as an absolute contrain- invasive techniques to totally remove the malignant dication for laparoscopic excision but oncological lesion and avoid capsular disruption of the tumor GXULQJGLVVHFWLRQ/DSDURVFRSLFDGUHQDOHFWRP\IRU SULQFLSOHVVKRXOGEHVWULFWO\IROORZHG6SHFLDOHIIRUW potentially malignant (or locally aggressive) PHEOs should be made not to damage the capsule of the can be performed in appropriately selected cases, in WXPRU1RQHWKHOHVVODUJHSRWHQWLDOO\PDOLJQDQWRU experienced centers with oncologic outcomes that malignant tumors >10 cm, or those with possible are equivalent to open approaches, while providing organ infiltration must be approached with the open DGYDQWDJHVLQWHUPVRISDWLHQWPRUELGLW\56 Propo- WHFKQLTXHIURPWKHEHJLQQLQJ nents of minimally invasive techniques argue that in the hands of experienced surgeons, laparoscopy can CONFLICT OF INTEREST be safely performed while preserving the principles 7KHDXWKRUVKDYHQRFRQIOLFWRILQWHUHVWWRGHFODUH of oncologic surgery, with results similar to those RIRSHQDFFHVV7KHEDVLFSULQFLSOHVGXULQJVXUJHU\ are to avoid direct manipulation of or application of REFERENCES pressure to the tumor in order to avoid rupture of  3DFDN.(LVHQKRIHU*$KOPDQ+HWDO3KHR- WKHWXPRUFDSVXOH51,57 The is resected chromocytoma: recommendations for clinical practice en bloc with the surrounding adipose tissue and it is IURPWKH)LUVW,QWHUQDWLRQDO6\PSRVLXP2FWREHU always extracted after being placed in a specimen 1DW&OLQ3UDFW(QGRFULQRO0HWDE UHWULHYDOEDJ51  .DOWVDV*$3DSDGRJLDV'*URVVPDQ$%7KH clinical presentation (symptoms and signs) of sporadic PHEO has been proposed as an independent fac- and familial chromaffin cell tumours (phaeochromo- WRUSUHGLFWLQJRSHQFRQYHUVLRQ14 In our series our F\WRPDVDQGSDUDJDQJOLRPDV )URQW+RUP5HV FRQYHUVLRQUDWHUHDFKHGKLJKHUWKDQWKDWRI   *DJQHU0/DFURL[$%ROWH(/DSDURVFRSLF the laparoscopic approach for other benign adrenal adrenalectomy in Cushing’s syndrome and pheochro- OHVLRQV  61 However, after the eighth laparo- PRF\WRPD1(QJO-0HG scopic attempt conversion rates dropped significantly  $VVDOLD$*DJQHU0/DSDURVFRSLFDGUHQDOHF- WR IURP LQGLFDWLQJWKDWIDPLOLDULW\ZLWK WRP\%U-6XUJ the intricacies of this procedure have a profound effect  'XGOH\1(+DUULVRQ%-&RPSDULVRQRIRSHQ on successful completion by laparoscopy and might posterior versus transperitoneal laparoscopic adrenal- HFWRP\%U-6XUJ indicate different learning curves compared to other  :DQJ+6/L&&&KRX<+:DQJ&-:X:-+XDQJ DGUHQDOWXPRUV:KHQWDNLQJLQWRDFFRXQWWKH CH, 2009 Comparison of laparoscopic adrenalectomy conversation rate, no statistical significance is noted ZLWKRSHQVXUJHU\IRUDGUHQDOWXPRUV.DRKVLXQJ-0HG FRPSDUHGWRRWKHUEHQLJQDGUHQDOOHVLRQV7KHHDUO\ 6FL conversion rates may be partially explained by the  %UXQDXG/1JX\HQ7KL3/0LUDOOLH(HWDO low threshold to convert to an open procedure during Predictive factors for postoperative morbidity after laparoscopic adrenalectomy for pheochromocytoma: the first attempts rather than struggle to complete a DPXOWLFHQWHUUHWURVSHFWLYHDQDO\VLVLQSDWLHQWV laparoscopic operation by risking disruption of the 6XUJ(QGRVF WXPRUFDSVXOH  /HQGHUV:0-'XK4XDQ

on Cancer, World Health Organization, International (GZLQ%.D]DU\DQ$00DOD73IHIIHU3)7RQQHVVHQ Academy of Pathology, Pathology and genetics of TI, Fosse E, 2001 Laparoscopic and open surgery for WXPRXUVRIHQGRFULQHRUJDQV SKHRFKURPRF\WRPD%0&6XUJ $PDU/6HUYDLV$*LPHQH]5RTXHSOR$3=LQ]LQGR- ,QDEQHW:%3LWUH-%HUQDUG'&KDSXLV<&RP- KRXH)&KDWHOOLHU*3ORXLQ3)

mocytoma: a prospective, nonrandomized, controlled Laparoscopic transperitoneal lateral adrenalectomy for VWXG\$P-6XUJ PDOLJQDQWDQGSRWHQWLDOO\PDOLJQDQWDGUHQDOWXPRXUV .LP.<.LP-++RQJ$5HWDO'LVHQWDQJOLQJ %0&6XUJ of malignancy from benign pheochromocytomas/para- 7KRPSVRQ/'3KHRFKURPRF\WRPDRIWKHDG- JDQJOLRPDV3OR6RQHH renal gland scaled score (PASS) to separate benign 5DR15DPDFKDQGUDQ57DQGRQ16LQJK3.XPDU from malignant neoplasms: a clinicopathologic and R, 2016 Laparoscopic adrenalectomy for pheochromo- LPPXQRSKHQRW\SLFVWXG\RIFDVHV$P-6XUJ cytoma-does size matter? A single surgeon comparative 3DWKRO VWXG\7UDQVO$QGURO8URO &RQ]R*0XVHOOD0&RUFLRQH)HWDO/DSDUR- +DOOIHOGW..0XVVDFN77UXSND$+RKHQEOHLFKHU scopic adrenalectomy, a safe procedure for pheochro- F, Schmidbauer S, 2003 Laparoscopic lateral adrenal- PRF\WRPD$UHWURVSHFWLYHUHYLHZRIFOLQLFDOVHULHV ectomy versus open posterior adrenalectomy for the ,QW-6XUJ WUHDWPHQWRIEHQLJQDGUHQDOWXPRUV6XUJ(QGRVF )LVKEHLQ/%RQQHU/7RULJLDQ'$HWDO([WHU-  nal beam radiation therapy (EBRT) for patients with %R]NXUW,+$UVODQ0