The Necessity Of Adrenalectomy At The Time Of Radical Nephrectomy: A Systematic Review

Main Category: Urology / Nephrology
Also Included In: Cancer / Oncology
Article Date: 03 Aug 2009 - 2:00 PDT

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UroToday.com - We undertook a systematic review of the literature in reference to the use of ipsilateral adrenalectomy at the time of radical nephrectomy for the treatment of renal cell carcinoma. Important in the understanding of this is accurately defining..

..the incidence of solitary, synchronous, ipsilateral adrenal involvement
..the ability of preoperative imaging to detect this
..the morbidity of removal of the adrenal
..the likelihood of identifying preoperative risk factors for adrenal involvement
..survival outcomes with and without adrenalectomy

While quoting levels of supporting evidence we attempted to systematically investigate these aspects of the debate.

We found that the historical benefit of ipsilateral adrenalectomy does not support it as a standard practice in all patients. The incidence of solitary, synchronous, ipsilateral adrenal involvement, which is potentially curable with ipsilateral adrenalectomy at the time of nephrectomy, is much lower than previously thought at 1 - 5%. Cross-sectional imaging in the current era is accurate in ruling out adrenal involvement but does carry a significant likelihood of false positives. Imaging outcomes are likely to improve with technical advances in imaging. The morbidity and mortality of ipsilateral adrenalectomy are generally minimal, but in those with metastatic disease, especially those developing metachronous contralateral adrenal metastasis, the impact of adrenal insufficiency can be devastating.

In direct comparison, disease-specific and overall survival for individuals undergoing radical nephrectomy, with or without adrenalectomy, are similar. Those with multiple high-risk primary tumor features, including high stage/large lesions, upper pole location, multifocality and/or venous invasion may be considered for concomitant adrenalectomy because of the increased prevalence of adrenal metastasis. However, identifying all of these factors preoperatively may be difficult. The survival of those with lymph node positive or metastatic disease is poor regardless of whether adrenalectomy is performed. In these individuals, decisions regarding adrenalectomy should be based upon the desire or indication for cytoreduction. If nephrectomy is warranted, then adrenalectomy could be considered depending on the normality of the adrenal on preoperative imaging, but the benefit should be weighed against the risk of adrenal insufficiency. There is evidence for a survival advantage in patients with isolated adrenal metastasis. This group comprises no more than 2% of patients undergoing surgery for renal cancer.

Written by Rebecca O'Malley, MD and Samir S. Taneja, MD as part of Beyond the Abstract on UroToday.com

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