Impact of laparoscopic adrenalectomy on renal function. Results of a prospective randomized clinical trial.

Abstract

INTRODUCTION\nLaparoscopic adrenalectomy is the gold standard management of benign adrenal masses and isolated metastases to adrenal gland. Two techniques of endoscopic adrenalectomy: lateral transperitoneal approach (LTA) and posterior retroperitonel approach (PRA) seem to be equally safe and effective. Recent studies suggest advantages of PRA over LTA in terms of lower intensity of postoperative pain, shorter hospital stay, faster recovery and lower early morbidity. However, PRA involves high insufflation pressure of CO2 within a limited retroperitoneal space. The aim of our study was to prospectively assess the effect of LTA versus PRA laparoscopic adrenalectomies on renal function.\n\n\nMATERIAL AND METHODS\nWe randomly assigned patients referred for unilateral adrenalectomy to either LTA (n=33) or PRA (n=44). The inclusion criteria were: hormonal activity and/or tumor diameter > 4 cm and/or suspicion of metastasis to adrenal gland. The exclusion criteria comprised: tumors > 8 cm, results of imaging studies suggesting primary invasive malignancy and refusal to undergo randomization. The patients were prospectively followed for a minimum of 6 months. Serum creatinine, cystatin C and urinary neutrophil gelatinase-associated lipocalin (NGAL) were measured preoperatively and at postoperative days: 1, 7 and 30.\n\n\nRESULTS\nWe found increased concentrations of urinary NGAL at day 1 following laparoscopic adrenalectomy using PRA, as compared to LTA. Patients undergoing right-sided PRA had increased creatinine concentrations, as compared to left-sided PRA. Patients with aldosterone-producing adenoma had decreased preoperative eGFR as compared to subjects with non-functioning incidentaloma. NGAL increased significantly in this group postoperatively. All the disturbances normalized within one month postoperatively.\n\n\nCONCLUSIONS\nRenal function impairment after PRA may result from compression of inferior vena cava by high retroperitoneal pressure during right-sided adrenalectomy. Despite transient character of observed abnormalities, we suggest that patients with high risk of acute kidney injury may benefit from alternative technique of adrenalectomy using LTA.