PARTIAL ADRENALECTOMY: THE NATIONAL CANCER INSTITUTE EXPERIENCE ERIC K. DINER, MICHAEL E. FRANKS, ASHISH BEHARI, W. MARSTON LINEHAN, AND MCCLELLAN M. WALTHER ABSTRACT Objectives. To report our experience of partial adrenalectomy and demonstrate whether adrenal function can be preserved in patients with hereditary adrenal pheochromocytoma. Total adrenalectomy has largely been used in the treatment of patients with hereditary adrenal pheochromocytomas. Adrenal cortical- sparing surgery is an alternative approach that aims to balance tumor removal with preservation of adrenocortical function. Methods. From 1995 to 2004, 33 patients with hereditary pheochromocytoma presented with adrenal masses. Partial adrenalectomy (open or laparoscopic) was performed if normal adrenocortical tissue was evident on preoperative imaging or intraoperative ultrasonography. Various operative parameters, as well as postoperative function of the residual adrenal remnants, were determined. Results. Of the 33 patients, 8 underwent open partial adrenalectomy and 25 laparoscopic partial adrenal- ectomy during a 10-year period. Ten patients underwent simultaneous, bilateral partial adrenalectomy and 8 underwent surgery on a solitary adrenal gland, 4 of whom received postoperative steroid replacement (stopped in 3 after 1 to 3 months). All other patients had normal catecholamine levels and remained tumor free by imaging at a mean follow-up of 36 months (range 3 to 102). Conclusions. Partial adrenalectomy can preserve adrenal function in patients with adrenal masses. The laparoscopic approach is technically safe and associated with less morbidity without compromising tumor removal. With careful surgical planning, especially in patients with tumors in solitary glands, adrenocortical function may be preserved, thereby avoiding the morbidity associated with medical adrenal replacement. UROLOGY 66: 19–23, 2005. © 2005 Elsevier Inc. P atients with von Hippel-Lindau disease (VHL) and multiple endocrine neoplasia type 2 (MEN2) are at risk of the development of adrenal pheochromocytomas, with both glands commonly affected during the patient’s lifetime. 1 Bilaterality occurred in up to 47% of affected patients with VHL in one series, and contralateral lesions de- velop in up to 60% of patients with VHL and MEN2. 1 Historically, total adrenalectomy was used in the management of adrenal masses in this hered- itary setting. Several series have reported on the oncologic efficacy of total adrenalectomy in hered- itary tumor syndromes, with local recurrence rates reported to be 14% to 22%. 2,3 More recently, lapa- roscopic adrenalectomy has become the new stan- dard for management of adrenal masses owing to the reduced morbidity and improved outcomes in several large reports. 4,5 A clear drawback of bilateral adrenalectomy is permanent adrenal insufficiency and the subse- quent risks of life-long steroid use, including de- creased quality of life, osteoporosis, weight gain, and addisonian crisis. 6,7 Because of the typical be- nign behavior of hereditary tumors, including pheochromocytomas in VHL and MEN2, and the adverse consequences of steroid replacement, we have favored the use of laparoscopic partial adre- nalectomy in young patients who will likely re- quire future adrenal operations. We report the fea- sibility and outcomes of a contemporary series of open and laparoscopic partial adrenalectomy mostly in hereditary patients. The utility of various From the Urologic Oncology Branch, Center for Cancer Re- search, National Cancer Institute, Bethesda, Maryland E. K. Diner is currently at Department of Urology, Washington Hospital Center, Washington, DC. Reprint requests: McClellan M. Walther, M.D., Urologic On- cology Branch, Center for Cancer Research, National Cancer In- stitute, 9000 Rockville Pike, Building 10, Room 2B-43, Bethesda, MD 20892. E-mail: ericdiner@hotmail.com Submitted: November 29, 2004, accepted (with revisions): Jan- uary 6, 2005 ADULT UROLOGY © 2005 ELSEVIER INC. 0090-4295/05/$30.00 ALL RIGHTS RESERVED doi:10.1016/j.urology.2005.01.009 19