Minimally Invasive Adrenalectomy: A Multicenter Comparison of Transperitoneal and Retroperitoneal Approaches GIOVANNI RAMACCIATO, M.D.,* GIUSEPPE R. NIGRI, M.D., PH.D.,* NICCOLO ` PETRUCCIANI, M.D.,* VINCENZO DI SANTO, M.D.,† MICHAELA PICCOLI, M.D.,‡ PAOLO BUNIVA, M.D.,‡ STEFANO VALABREGA, M.D.,* FRANCESCO D’ANGELO, M.D., PH.D.,* PAOLO AURELLO, M.D., PH.D.,* PAOLO MERCANTINI, M.D., PH.D.,* MASSIMO DEL GAUDIO, M.D.,* GIANLUIGI MELOTTI, M.D.‡ From the *Department of Surgery, St. Andrea Hospital, II School of Medicine, Sapienza University, Rome, Italy; the †Department of Urology, Trani Hospital, Trani, Italy; and the ‡Department of General Surgery, Ospedale S. Agostino-Estense, Modena, Italy Minimally invasive adrenalectomy (MIA) is both feasible and safe with either transperitoneal or retroperitoneal entry. However, only a few studies have rigorously compared these two tech- niques. The aim of the current study is to compare transperitoneal and retroperitoneal adrenal- ectomy to detect significant differences in patient selection and perioperative outcomes. Between 1995 and 2009, 171 patients underwent MIA through transperitoneal (n 5 127) or retroperitoneal access (n 5 44). The respective cohorts were then examined retrospectively through matched and unmatched comparisons. Multivariate analyses of intraoperative blood loss, postoperative mor- bidity, and length of hospital stay were performed. Surgical indications were benign lesions (70.2%), malignant tumors (11.1%), and pheochromocytomas (18.7%). The postoperative morbidity rate was 15.8 per cent, but mortality was null. The rate of conversion to open surgery was 5.3 per cent. Blood loss and operative time were significantly lower with the transperitoneal approach, whereas time to oral intake was shorter for the retroperitoneal group. Tumor size less than 4.5 cm was associated with less blood loss, shorter hospital stay, and lower postoperative morbidity. Laparoscopic and retroperitoneal routes are both effective and safe for excising adrenal lesions. In the present study, however, laparoscopic adrenalectomy demonstrated shorter operative times with less blood loss. Regardless of this, we remain cautious in recommending one procedure preferentially. Other important measures of clinical outcome such as required pain control, ease of patient recovery, and cost considerations were not included in this analysis. Further randomized trials, with large patient numbers, are therefore desirable for defining an optimal surgical method. M INIMALLY INVASIVE ADRENALECTOMY (MIA) was first introduced into clinical practice by Gagner and colleagues in 1992. 1 Soon thereafter, numerous studies attested to the feasibility and safety of this tech- nique, which conferred decisive benefits compared with an open procedure: shorter hospital stay, faster recovery, decreased pain and narcotic use, and fewer perioperative and postoperative complications. 2–4 MIA is therefore considered the current reference standard for treatment of benign adrenal masses. 5 Various minimally invasive approaches have sub- sequently been devised to reach and remove the adrenal glands. 6–8 Of these, lateral transperitoneal, 8, 9 posterior retroperitoneal (with patient in lateral de- cubitus), 10, 11 and anterior transperitoneal (with the patient supine) 12, 13 routes of access are the most frequently used. Although results reported with either lateral transperitoneal or retroperitoneal access have been favorable, patient volumes in prior series were generally low, and few studies have conducted in- depth comparisons of both procedures. In this study, we analyzed a prospectively collected database from three referral centers. Our aim was to as- sess the clinicopathologic characteristics and short-term outcomes of patients undergoing transperitoneal and ret- roperitoneal adrenalectomy by conducting matched and unmatched comparisons of both procedures. In doing so, criteria for patient selection might then be identified and the advantages/disadvantages of each technique clarified. Address correspondence and reprint requests to Giuseppe R. Nigri, M.D., Ph.D., Sapienza University, II School of Medicine, Department of Surgery, St. Andrea Hospital, Via di Grottarossa, 1035-39, 00189 Rome, Italy. E-mail: giuseppe.nigri@uniroma1.it. 409