In 1992 laparoscopic adrenalectomy was first described by Gagner, and since then is has become the gold standard of care for adrenal tumours. The 6-8 cm size is the cut-off for minimally invasive surgery (laparoscopy or retroperitoneoscopy), and open surgery is the preferred approach for bigger lesions or suspect of harbouring a cancer.
Because retroperitoneoscopy has several advantages over laparoscopy (read post "Retroperitoneoscopic adrenalectomy has advantages over laparoscopic transperitoneal adrenalectomy"), since 2014 the Surgery C department of "Centro Hospitalar e Universitário de Coimbra - Hospital Geral (Covões)", Portugal, uses posterior retroperitoneoscopic approach as the gold standard to treat adrenal masses smaller than 6-8 cm and without suspicious criteria of malignancy.
Adrenal giant cystic pheochromocytoma (> 10 cm) is a rare entity with only a few cases described in the literature. Because it may not demonstrate the clinical (tachycardia, headache, sweating), radiological and biochemical features of a pheochromocytoma, it is very difficult to make a correct preoperative diagnosis. To allow a secure R0 resection of such a huge mass and without rupture, open surgery is traditionally the preferred approach. However there are no studies comparing R0 resection rate and cystic rupture rate between open and minimally invasive surgery. So...
Why not using posterior retroperitoneoscopic adrenalectomy?
In June 2016 I had the opportunity to treat a patient with a right adrenal giant cystic pheochromocytoma (14 cm). Although open surgery would be the preferred approach for the majority of surgeons, posterior retroperitoneoscopic adrenalectomy was performed. The entire mass was resected but an unintended rupture occurred. Pathology was consistent with a benign cystic pheochromocytoma (PASS score of 3). Patient was discharged home in the 4th post-op day, and is asymptomatic up to this day.
Figure from CE Costa Almeida et al.
After a review of literature, only 20 case reports of adrenal giant cystic pheochromocytoma were found, and none was treated by this technique. Being this the first case report of a giant cystic pheochromocytoma treated by posterior retroperitoneoscopy, and although the rupture may be a factor against this technique, it was a pleasure to see it published in the International Journal of Surgery Case Reports with the title "Adrenal giant cystic pheochromocytoma treated by posterior retroperitoneoscopic adrenalectomy", and is open access.
Because knowledge is lacking on rare lesions, it is crucial to report and publish such rare cases so that surgeons worldwide can learn from each other experience.
Link to article:
Dr. Carlos Eduardo Costa Almeida
General Surgeon