Invited review Systematic review of surgery and outcomes in patients with primary aldosteronism A. Muth 1 , O. Ragnarsson 2 , G. Johannsson 2 and B. Wängberg 1 1 Section for Endocrine Surgery and Abdominal Sarcoma, Department of Surgery, Institute of Clinical Sciences, and 2 Section for Endocrinology, Department of Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden Correspondence to: Professor B. Wängberg, Department of Surgery, Blå Stråket 5, 41345 Göteborg, Sweden (e-mail: bo.wangberg@surgery.gu.se) Background: Primary aldosteronism (PA) is the most common cause of secondary hypertension. The main aims of this paper were to review outcome after surgical versus medical treatment of PA and partial versus total adrenalectomy in patients with PA. Methods: Relevant medical literature from PubMed, the Cochrane Library and Embase OvidSP from 1985 to June 2014 was reviewed. Results: Of 2036 records, 43 articles were included in the inal analysis. Twenty-one addressed surgical versus medical treatment of PA, four considered partial versus total adrenalectomy for unilateral PA, and 18 series reported on surgical outcomes. Owing to the heterogeneity of protocols and reported outcomes, only a qualitative analysis was performed. In six studies, surgical and medical treatment had comparable outcomes concerning blood pressure, whereas six showed better outcome after surgery. No differences were seen in cardiovascular complications, but surgery was associated with the use of fewer antihypertensive medications after surgery, improved quality of life, and (possibly) lower all-cause mor- tality compared with medical treatment. Randomized studies indicate a role for partial adrenalectomy in PA, but the high rate of multiple adenomas or adenoma combined with hyperplasia in localized disease is disconcerting. Surgery for unilateral dominant PA normalized BP in a mean of 42 (range 20–72) per cent and the biochemical proile in 96–100 per cent of patients. The mean complication rate in 1056 patients was 4⋅7 per cent. Conclusion: Recommendations for treatment of PA are hampered by the lack of randomized trials, but support surgical resection of unilateral disease. Partial adrenalectomy may be an option in selected patients. Cutting edge articles are invited by the BJS Editorial Team, and focus on how current research and innovation will affect future clinical practice. Paper accepted 11 November 2014 Published online 20 January 2015 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9744 Introduction Primary aldosteronism (PA), or Conn’s syndrome, is the most common cause of secondary hypertension, with an estimated prevalence of 5–13 per cent 1 . PA is caused by overproduction of aldosterone from one or both of the adrenal glands. It typically presents with hypertension but not always with hypokalaemia 2 . Compared with patients with essential hypertension and comparable BP levels, patients with PA have an increased cardiovascular and cerebrovascular risk, and more commonly impaired renal function 1,3 – 6 . The most common (more than 90 per cent) diseases underlying PA are idiopathic bilateral hyperplasia and aldosterone-producing adenoma, although other rare causes exist 7 . The recommended screening method for PA is measurement of aldosterone and renin in plasma, and subsequent calculation of the aldosterone to renin ratio (ARR) 8 – 10 . After conirmatory testing, identiication of the PA subtype is recommended for most patients because unilateral dominant lesions are most commonly treated by surgery. Adrenal venous sampling is the standard investiga- tion for subtype evaluation and can be performed with low morbidity. Patients with bilaterally increased aldosterone production and patients with unilateral disease who are not candidates for surgery are treated with mineralocorti- coid (aldosterone) receptor antagonists (spironolactone or eplerenone) 11 . In unilateral dominant disease, laparoscopic or retroperitoneoscopic surgical approaches have become © 2015 BJS Society Ltd BJS 2015; 102: 307–317 Published by John Wiley & Sons Ltd