LAPAROSCOPIC UNILATERAL AND BILATERAL ADRENALECTOMY FOR CUSHINGS-SYNDROME - TRANSPERITONEAL AND RETROPERITONEAL APPROACHES

Objective This prospective randomized study compares the safety and ef ficacy of transperitoneal laparoscopic adrenalectomy (TLPA) and retrop eritoneal approach (RLPA) in obese patients with Gushing's syndrome. S ummary Background Data Recently, a retroperitoneal laparoscopic approa ch has been described with benefits of avoiding the respiratory and he modynamic effects of carbon dioxide (GO,) pneumoperitoneum and giving direct access without. the need to mobilize abdominal organs. Methods Twenty-one adrenalectomies were performed in 9 patients (2 men, 7 wome n; mean age, 46.33 +/- 19.41 years old; range, 16 to 74 years old) wit h Cushing's adenoma and in 6 women (mean age, 41.83 +/- 9.97 years old ; range, 34 to 62 years old) with Gushing's disease. Randomization gav e 10 TLPA and 11 RLPA. Arterial blood gas samples, mean arterial press ure, heart: rate, and clinical parameters were evaluated. Results The partial pressure of carbon dioxide (PaCO2) increased in both retroperi toneal and transperitoneal CO2 insufflation compared with basal values (p < 0.01), and the TLPA showed a greater rise in the PaCO2 level com pared with the RLPA at 30 minutes (p < 0.05); simultaneously, a signif icant increase (p < 0.05) of mean arterial pressure was observed in th e TLPA compared with RLPA. No significant changes in heart rate were o bserved in both groups. The operative time with the TLPA and RLPA in p atients with adenoma was 88.75 versus 105 minutes, respectively (p = n ot significant [NS]), and in patients with bilateral hyperplasia was 2 71.66 versus 305 minutes, respectively (p = NS). No patients required blood transfusions. The number of doses of analgesic with TLPA and RLP A in patients with adenoma was 3.25 versus 3.5, respectively (p = NS), and in patients with bilateral hyperplasia was 7.66 versus 7.33, resp ectively (p = NS). The hospital stay with TLPA and RLPA in patients wi th adenoma was 3.0 versus 2.75 days, respectively (p = NS), and in pat ients with bilateral hyperplasia was 6.0 versus 6.66 days, respectivel y (p = NS). The days to return to normal activity with TLPA and RLPA i n patients with adenoma were 12.5 Versus 12.25, respectively (p = NS), and in patients with bilateral hyperplasia were 19.66 versus 19.33, r espectively (p = NS). Two patients with bilateral hyperplasia and TLPA had urinary infection. Conclusions Transperitoneal laparoscopic adren alectomy and RLPA may become the techniques of choice for surgical rem oval of the adrenal lesions in Cushing's syndrome. The retroperitoneos copic approach might be a better option in patients with previous abdo minal surgery and in patients with pre-existing cardiorespiratory dise ase.