Published online before print October 2, 2003, 10.1148/radiol.2292021390
(Radiology 2003;229:581-586.)
© RSNA, 2003
Three-dimensional Volume-rendered Helical CT before Laparoscopic Adrenalectomy1
Maja E. Hurley, MD2,
Brian R. Herts, MD,
Erick M. Remer, MD,
Diane Dylinski, RT and
Inderbir S. Gill, MD
1 From the Department of Radiology (M.E.H., B.R.H., E.M.R., D.D.) and Glickman Urological Institute (B.R.H., I.S.G.), the Cleveland Clinic Foundation, 9500 Euclid Ave, Desk Hb6, Cleveland, OH 44195. Received October 28, 2002; revision requested January 8, 2003; revision received January 21; accepted March 4. Address correspondence to B.R.H. (e-mail: hertsb@ccf.org).
 |
ABSTRACT
|
|---|
Use of three-dimensional (3D) volume-rendered helical computed tomography (CT) in surgical planning before laparoscopic adrenalectomy was evaluated in a retrospective study. In 35 consecutive patients before laparoscopic adrenalectomy, 3D volume-rendered CT scans were created from helical CT scans. Videotapes that showed anterior, lateral, posterior, and posterocephalic approaches were assessed retrospectively. The relationship (not contacting, abutting, displacing, or invading) of adrenal masses to adjacent organs (diaphragm, liver, spleen, kidneys, stomach, pancreas, and vessels) was recorded and compared with findings in surgery reports. When such findings were available, they corresponded to those in the videotape. Three-dimensional volume-rendered CT successfully displayed the relationship of adrenal masses to adjacent anatomic structures and organs before laparoscopic adrenalectomy.
Supplemental material: radiology.rsnajnls.org/cgi/content/full/2292021390/DC1
© RSNA, 2003
Index terms: Adrenal gland, CT, 86.12115, 86.12117 • Adrenal gland, neoplasms, 86.5411
|
INTRODUCTION
|
|---|
Laparoscopic adrenalectomy was described by Gagner et al in 1992 (1) and has since found widespread acceptance as the standard minimally invasive procedure for resection of adrenal masses (2–4). Laparoscopic adrenalectomy is less invasive, has equivalent or better complication rates and, in terms of overall hospital expenses, is more cost-effective (5–8) than surgical adrenalectomy. Five laparoscopic approaches are described: anterior and lateral transperitoneal, lateral and posterior retroperitoneal, and thoracoscopic transdiaphragmatic (9–14).
One key to diminishing surgical time and reducing complications is familiarity with the anatomy at surgery (15). Radiographic findings that confirm laparoscopic resectability are inclusion of fat planes between the adrenal gland and inferior vena cava or aorta, exclusion of local invasion into adjacent organs, and exclusion of venous thrombus (2). Knowledge of the position and longest dimension of the adrenal gland and the position of the adrenal lesion relative to adjacent diaphragm or organs is important to the success of the procedure because it facilitates dissection, allows the surgeon to anticipate potential complications, and helps the surgeon choose the best approach. Three-dimensional (3D) CT can simulate the dissection from any potential laparoscopic approach.
Computed tomography (CT) and magnetic resonance (MR) imaging of the adrenal glands have been used traditionally to localize hyperfunctioning adrenal neoplasms and to characterize adrenal masses found either incidentally or as part of a staging evaluation in patients with a primary neoplasm (16–21). CT and MR imaging have also been used for surgical planning in a number of areas in the abdomen: laparoscopic donor nephrectomy (22,23), partial nephrectomy (24–27), and living related liver donor resection (28). The purpose of this retrospective study was to evaluate the use of 3D volume-rendered helical CT in surgical planning before laparoscopic adrenalectomy.
|
Materials and Methods
|
|---|
Patients and Diagnoses
From April 2000 until March 2002, three-phase adrenal and renal helical CT examinations were performed in 35 consecutive patients before planned laparoscopic adrenalectomy. Patients were identified from our database of 3D volume-rendered images. Three-dimensional rendering is performed as a standard clinical service to the urologists and is not part of any investigative protocol. This database has security protection measures for patient confidentiality, and we have institutional review board approval to maintain and renew the database. Informed consent was waived by the review board.
The 35 patients included 19 men and 16 women (median age, 51 years; age range, 27–80 years). Thirteen patients (seven men and six women) underwent right adrenalectomy, and 22 patients (12 men and 10 women) underwent left adrenalectomy. Sixteen patients underwent transperitoneal laparoscopic adrenalectomy, which was lateral in 13 patients and anterior in three. Nineteen patients underwent retroperitoneal adrenalectomy. In 13 of the 19 patients, a lateral retroperitoneal approach was used. In two of the 19 patients, a thoracoscopic transdiaphragmatic approach was used. The remaining four of the 19 patients underwent open retroperitoneal adrenalectomy.
Pathologic diagnoses were pheochromocytoma (11 patients); benign adenoma, unspecified (eight patients); adrenal cell carcinoma (six patients); nonspecific necrotic-fibrotic tissue (three patients); aldosteronoma (two patients); nodular adrenal hyperplasia (two patients); and myelolipoma, adrenal pseudocyst, and primary retroperitoneal leiomyosarcoma (one patient each).
Imaging
First, all patients underwent nonenhanced helical CT. Then, contrast material–enhanced CT was performed in the vascular phase after intravenous injection of 150 mL of contrast material (Ultravist 300; Berlex Laboratories, Wayne, NJ) at a rate of 4 mL/sec at a delay time based on a timing injection. Next, contrast-enhanced CT was performed in the renal parenchymal phase, beginning approximately 120 seconds after initiation of the contrast material injection. All scans were obtained at 120 kVp with 2.5-mm section thickness, 3-mm reconstructed section thickness, and 2.5-mm reconstruction interval. Scans were obtained with either a single–detector row helical CT scanner (Somatom Plus 4; Siemens Medical Systems, Forchheim, Germany) (n = 10) or a four–detector row helical CT scanner (Volume Zoom; Siemens Medical Systems) (n = 25). No oral contrast material was given.
Image Preparation and Review
Scans were reviewed with a picture archiving and communication system, or PACS, workstation (MagicView 1000; Siemens Medical Systems) for standard diagnostic interpretation. Subsequently, images were transferred to a dedicated 3D workstation (Virtuoso; Siemens Medical Systems) for 3D volume rendering. In all patients, three-dimensional volume-rendered CT videotapes were created for intraoperative use by one radiologist (B.R.H.), who was experienced with volume rendering. Each videotape depicted the anatomy required for surgical planning for laparoscopic adrenalectomy. The format of the 3D volume-rendered images and videotape was based on specific discussions with an experienced laparoscopic urologist (I.S.G.), who designated the information that needed to be included in the 3D images.
Three-dimensional volume-rendered images that simulated the surgical dissection were created by the scrolling of cut planes through the region of interest to simulate the anterior, posterior, lateral, and posterocephalic (transdiaphragmatic) approaches [Movies 1 and 2, radiology.rsnajnls.org/cgi/content/full/2292021390/DC1]). Voice narration on the videotape described the adjacent structures and pertinent anatomy. Window, center, and brightness were set to maximize depiction of the retroperitoneal soft tissues and vasculature for each patient, and the opacity transfer function was typically set between 90 and 100 (mostly opaque). The time needed to acquire each videotape (recorded to the nearest 5-second interval) and the physician time needed to create a videotape (recorded to the nearest minute) were recorded prospectively when the tape was created. Mean videotape time and mean physician time to create a videotape were calculated from these data.
Two radiologists (M.E.H., B.R.H.), who were blinded to the surgical findings, retrospectively reviewed each videotape in consensus. The position of the adrenal mass relative to retroperitoneal and peritoneal structures was recorded as not contacting or as abutting, displacing, or grossly invading. For the right side, the relationships to the diaphragm, inferior vena cava, right kidney, renal vessels, and liver were recorded. On the left side, the relationships to the diaphragm, aorta, left kidney, renal vessels, pancreas, spleen, splenic artery and vein, stomach, and colon were recorded. The relationships were determined on the basis of both the voice narration and retrospective interpretation of the rendering shown in the videotape. While the videotape depicted the data for the surgeon’s intraoperative use, the voice narration did not always specifically refer to each piece of information that was recorded for the study. Whether or not the adrenal arteries and veins were demonstrated was recorded. The longest dimension of the adrenal mass and the number of renal arteries were reported prospectively when the diagnostic CT scan was obtained and when the videotape was created; these data were also recorded for the study.
Comparison with Surgical and Pathologic Findings
One author (M.E.H.) compared all imaging findings with the findings in the surgery and pathology reports. All surgical procedures were performed by the same laparoscopic urologist (I.S.G.), who assisted in devising the format of the rendering. Fellows and residents assisted with the procedures and dictated the surgery reports. No specific dictation format applicable to this study was used by the attending urologist or the fellow or resident who assisted in the case.
|
Results
|
|---|
Anatomic Relationships between Adrenal Masses and Adjacent Structures and Organs
On the right side, 3D volume-rendered CT scans showed the adrenal mass to be most frequently in contact with (abutting, displacing, or invading) the liver and inferior vena cava (Figs 1–3), followed by the diaphragm, the right kidney, and the renal vessels (Table 1). Invasion of any organ or structure was not detected.
View larger version (130K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1a. Right adrenal pheochromocytoma (3.5 cm) (arrows in a-c) in a 64-year-old woman with hypertension. (a) Posterior, (b) anterior, (c) lateral, and (d) posterocephalad views are standard for laparoscopic adrenalectomy approaches in surgical planning. They simulate the anterior transperitoneal (b), lateral transperitoneal and retroperitoneal (c), posterior retroperitoneal (a), and transdiaphragmatic retroperitoneal (d) approaches. Mass abuts the liver (short arrow in d), the inferior vena cava posteriorly (long arrow in d), and the crus of the right hemidiaphragm (arrowhead in a and d).
|
|
View larger version (141K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1b. Right adrenal pheochromocytoma (3.5 cm) (arrows in a-c) in a 64-year-old woman with hypertension. (a) Posterior, (b) anterior, (c) lateral, and (d) posterocephalad views are standard for laparoscopic adrenalectomy approaches in surgical planning. They simulate the anterior transperitoneal (b), lateral transperitoneal and retroperitoneal (c), posterior retroperitoneal (a), and transdiaphragmatic retroperitoneal (d) approaches. Mass abuts the liver (short arrow in d), the inferior vena cava posteriorly (long arrow in d), and the crus of the right hemidiaphragm (arrowhead in a and d).
|
|
View larger version (121K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1c. Right adrenal pheochromocytoma (3.5 cm) (arrows in a-c) in a 64-year-old woman with hypertension. (a) Posterior, (b) anterior, (c) lateral, and (d) posterocephalad views are standard for laparoscopic adrenalectomy approaches in surgical planning. They simulate the anterior transperitoneal (b), lateral transperitoneal and retroperitoneal (c), posterior retroperitoneal (a), and transdiaphragmatic retroperitoneal (d) approaches. Mass abuts the liver (short arrow in d), the inferior vena cava posteriorly (long arrow in d), and the crus of the right hemidiaphragm (arrowhead in a and d).
|
|
View larger version (128K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1d. Right adrenal pheochromocytoma (3.5 cm) (arrows in a-c) in a 64-year-old woman with hypertension. (a) Posterior, (b) anterior, (c) lateral, and (d) posterocephalad views are standard for laparoscopic adrenalectomy approaches in surgical planning. They simulate the anterior transperitoneal (b), lateral transperitoneal and retroperitoneal (c), posterior retroperitoneal (a), and transdiaphragmatic retroperitoneal (d) approaches. Mass abuts the liver (short arrow in d), the inferior vena cava posteriorly (long arrow in d), and the crus of the right hemidiaphragm (arrowhead in a and d).
|
|
View larger version (159K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2a. Right adrenal mass (6.5 cm) noted incidentally at US of the kidneys in a 66-year-old woman with hypertension. Sagittal (a) multiplanar reformation and (b) 3D volume-rendered CT scans show calcified adrenal mass abutting the liver (short arrow in b) and kidney (long arrow in a and b). In b, note the curved surface of the kidney (arrowhead) in relation to the adrenal mass. Volume rendering provides 3D depth cues not seen on multiplanar reformations. Final diagnosis after successful laparoscopic adrenalectomy was pseudocyst with dystrophic calcification and infarction.
|
|
View larger version (141K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2b. Right adrenal mass (6.5 cm) noted incidentally at US of the kidneys in a 66-year-old woman with hypertension. Sagittal (a) multiplanar reformation and (b) 3D volume-rendered CT scans show calcified adrenal mass abutting the liver (short arrow in b) and kidney (long arrow in a and b). In b, note the curved surface of the kidney (arrowhead) in relation to the adrenal mass. Volume rendering provides 3D depth cues not seen on multiplanar reformations. Final diagnosis after successful laparoscopic adrenalectomy was pseudocyst with dystrophic calcification and infarction.
|
|
View larger version (133K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3a. Incidental adrenal mass (2.5 cm) depicted at CT in a 59-year-old man. Laboratory test results showed catecholamines, which confirmed the presence of right adrenal pheochromocytoma. (a) Anterior oblique and (b) posterocephalic 3D volume-rendered CT scans show the mass abutting the inferior vena cava (arrow), as well as a short right adrenal vein (between arrowheads in b). Right adrenal vein is difficult to visualize but is best seen from the posterocephalic approach.
|
|
View larger version (132K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3b. Incidental adrenal mass (2.5 cm) depicted at CT in a 59-year-old man. Laboratory test results showed catecholamines, which confirmed the presence of right adrenal pheochromocytoma. (a) Anterior oblique and (b) posterocephalic 3D volume-rendered CT scans show the mass abutting the inferior vena cava (arrow), as well as a short right adrenal vein (between arrowheads in b). Right adrenal vein is difficult to visualize but is best seen from the posterocephalic approach.
|
|
View this table:
[in this window]
[in a new window]
|
TABLE 1. Relationship of Right Adrenal Mass (n = 13) to Adjacent Anatomic Structures and Organs at 3D Volume-rendered CT
|
|
On the left side, 3D volume-rendered CT scans showed the adrenal mass to be most frequently in contact with (abutting, displacing, or invading) the left renal vasculature (Figs 4, 5) and spleen, followed by the diaphragm, pancreas, and left kidney (Table 2). No adrenal tumor was in contact with the abdominal aorta. Invasion of any organ or structure was not detected. Normal adrenal tissue was also shown (Fig 6).
View larger version (137K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 4. Elevated urinary catecholamines in a 48-year-old man with hypertension. Three-dimensional volume-rendered CT image shows two left adrenal masses (arrowheads), which were both adrenal pheochromocytomas. More inferior mass was exophytic and rested on the left renal vein (arrow).
|
|
View larger version (155K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5. Left adrenal aldosteronoma (2 cm) (long arrow) in a 55-year-old man. Three-dimensional volume-rendered CT image shows left adrenal mass with fat planes (short arrows) between the adrenal mass and the spleen, diaphragm, and left kidney.
|
|
View this table:
[in this window]
[in a new window]
|
TABLE 2. Relationship of Left Adrenal Mass (n = 22) to Adjacent Anatomic Structures and Organs at 3D Volume-rendered CT
|
|
View larger version (136K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6a. Small left adrenal aldosteronoma in a 71-year-old man with hypertension and hypokalemia. (a) Posterocephalic 3D volume-rendered CT image shows the mass in the medial limb of the left adrenal gland, abutting the diaphragm (arrow). Lateral limb (arrowhead) is normal. (b) Coronal 3D volume-rendered CT image through the normal adrenal gland (arrowheads) and adrenal vein (arrow). The left adrenal vein can almost always be depicted. The normal adrenal limb is flat.
|
|
View larger version (141K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6b. Small left adrenal aldosteronoma in a 71-year-old man with hypertension and hypokalemia. (a) Posterocephalic 3D volume-rendered CT image shows the mass in the medial limb of the left adrenal gland, abutting the diaphragm (arrow). Lateral limb (arrowhead) is normal. (b) Coronal 3D volume-rendered CT image through the normal adrenal gland (arrowheads) and adrenal vein (arrow). The left adrenal vein can almost always be depicted. The normal adrenal limb is flat.
|
|
Visualization of Adrenal Vasculature
An adrenal vein was identified on the volume-rendered CT scan in 22 (63%) of 35 patients, more often on the left side (17 [77%] of 22 patients) than on the right (five [38%] of 13 patients) (Figs 3, 6). An adrenal artery was visible less often: It was seen in 10 (29%) of 35 patients (on the left in seven [32%] of 22 patients and on the right in three [23%] of 13 patients).
Comparison with Surgery Reports
Findings in the surgery report included dissection of the adrenal gland away from adjacent organs in 25 patients. Right adrenal masses were in contact with the inferior vena cava in seven patients. Adrenal masses were in contact with the kidney in seven patients and with the renal vessels in five. The adrenal mass was in contact with the diaphragm, liver, and spleen in three patients and with the pancreas or colon in one patient each. The corresponding preoperative volume-rendered CT scan correctly depicted all these cases. However, the overall accuracy of 3D volume rendering could not be assessed because each organ was not specifically mentioned as either in contact or not in contact. In 10 patients, no anatomic details were given concerning the relationship of the adrenal gland to neighboring organs and anatomic structures.
Videotape and Physician Times
Mean videotape duration was 3 minutes (range, 2 minutes 15 seconds to 4 minutes 10 seconds). Mean physician time needed to compose a videotape was 11 minutes 50 seconds (range, 8–19 minutes).
|
Discussion
|
|---|
Adrenalectomy is currently recommended for patients with an adrenal mass that is larger than 4 cm, hormonally active, or enlarging or for those suspected of having a malignancy at CT or MR imaging. Observation is recommended for patients with a hormonally inactive tumor smaller than 3 cm or for those aged 50 years and older with a hormonally inactive 3–5-cm tumor (29). Resection of a solitary adrenal metastasis is recommended in the absence of metastatic disease depicted elsewhere at CT (30,31). In favor of laparoscopic adrenalectomy for metastasis is the fact that metastases rarely penetrate the capsule of the adrenal gland (32). Suspected adrenal malignancy on the basis of mass size larger than 5 cm, periadrenal or inferior vena cava invasion, or venous thrombus remains the main indication for open surgery. Contraindications to laparoscopic surgery include unacceptably high cardiopulmonary risk, uncorrected coagulopathy, ongoing abdominal sepsis, and bowel distention (2). Adrenal masses larger than 5 cm can be resected laparoscopically, but those larger than 10 cm require considerable laparoscopic expertise and may best be resected with open surgery because of an inherent increased risk of cancer (2,4,33).
In general, some indications are defined for each of the five laparoscopic approaches. The transperitoneal approach corresponds most to the pathway of open adrenalectomy. A larger surgical field is used, which is more suitable for the inexperienced surgeon (9). The transperitoneal approach is often favored for right adrenalectomy because the adrenal vein is short. Risks of the transperitoneal approach include subsequent adhesions. The retroperitoneal approach is limited as a result of fewer anatomic landmarks and smaller surgical working space, which restricts mobility of the instruments. The retroperitoneal approach is technically more difficult than the transperitoneal approach. The former is favored (a) in left adrenalectomy because the left adrenal vein is longer and (b) in patients who have previously undergone intraperitoneal surgery. The retroperitoneal approach is also used if the adrenal mass has a retroaortic or retrocaval extension (7,13). Of the two access directions for retroperitoneal laparoscopy (lateral and posterior), the lateral retroperitoneal approach is used more commonly than posterior access (12). The thoracoscopic transdiaphragmatic approach was developed for patients who had previously undergone transperitoneal and retroperitoneal surgery (11).
Laparoscopic adrenalectomy is less invasive and more cost-effective than surgical adrenalectomy when overall hospital expenses are considered (5,7,8). Although the mean surgical time with the laparoscopic approach is longer, the mean hospital stay and mean convalescence time are shorter (5,7,8). The laparoscopic approach has equivalent or better complication.
Previously described uses of 3D volume-rendered CT in the genitourinary tract include preoperative assessment before donor nephrectomy (22,23) and preoperative assessment of renal tumors before partial nephrectomy (24,25,27). To our knowledge, no other studies have been performed to evaluate 3D volume-rendered CT before laparoscopic adrenalectomy. Intraoperative ultrasonography (US) has been used previously for surgical planning for laparoscopic adrenalectomy (34).
Findings in this study show that 3D volume-rendered CT is useful for the planning of laparoscopic adrenalectomy. The approach to the adrenal gland from all prospective surgical approaches was shown, as were the organs adjacent to the adrenal gland and the renal vasculature. Demonstration of fat planes between the adrenal gland and the aorta, inferior vena cava, and liver is critical for technical success of this minimally invasive procedure. Limitations of volume-rendered CT include the limited ability to see the adrenal arteries because they are small and the inability to depict the right adrenal vein insertion into the inferior vena cava because the vein is short. Of note, in two patients with right adrenal masses, an adrenal artery could be recognized on the transverse CT images but could not be visualized on the corresponding videotape.
We used surgery reports for comparison because they are readily available for each surgery on the hospital information system. Our study was limited, however, because comparison of the 3D volume-rendered CT findings with the surgery reports was hindered by the lack of reference in a few reports to some of the structures evaluated at CT. We believe this happened because residents and fellows with different levels of experience and understanding of the procedure dictated the reports. In each surgery report in which an anatomic structure or organ was reported, however, the volume-rendered CT and surgical findings agreed. Overall, more cases of contact with adjacent organs or structure were reported at imaging than were reported by the surgeons in their surgery report. This might be due in part to the fact that some of the adjacent organs did not present a surgical problem, as these structures were easily dissected away.
Other study limitations include the relatively small number of patients. It is also important to note that our experience with 3D volume rendering can help shorten the physician time and improve the quality of the rendered images. Therefore, these results may not be readily reproduced by others with less experience until the learning curve has been completed. Another limitation of this study is that we were unable to quantify objectively how the 3D rendering assisted surgery (eg, how often the 3D rendering affected or altered the surgical approach). This is an impossible task not only because of the small number of patients but also because of the difficulty of taking into account other variables, such as tumor size, tumor type, and history of retroperitoneal or transperitoneal surgery.
With the growing trend toward minimally invasive adrenal surgery, including 
needlescopic
surgery and futuristic techniques such as robotic adrenalectomy (35), imaging protocols need to incorporate surgical planning techniques into the detection and characterization of adrenal masses. In our experience, this is easily accomplished by using 3D volume-rendered helical CT scans from three-phase adrenal or renal CT scans. Three-dimensional volume-rendered CT can successfully depict the relationship of adrenal masses to the adjacent anatomic structures and organs before laparoscopic adrenalectomy.
|
FOOTNOTES
|
|---|
2 Current address: Department of Radiology, Crumlin Hospital, Dublin, Ireland 
Abbreviation: 3D = three-dimensional
Author contributions: Guarantor of integrity of entire study, B.R.H.; study concepts, B.R.H., I.S.G.; study design, M.E.H., B.R.H.; literature research, M.E.H.; clinical studies, M.E.H., B.R.H.; data acquisition, B.R.H., M.E.H., D.D.; data analysis/interpretation, B.R.H.; statistical analysis, M.E.H.; manuscript preparation and definition of intellectual content, M.E.H.; manuscript editing, B.R.H., E.M.R.; manuscript revision/review, E.M.R., I.S.G., B.R.H.; manuscript final version approval, all authors
|
REFERENCES
|
|---|
- Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl J Med 1992; 327:1033.[Medline]
- Gill IS. The case for laparoscopic adrenalectomy. J Urol 2001; 166:429-436.[CrossRef][Medline]
- Smith CD, Weber CJ, Amerson JR. Laparoscopic adrenalectomy: new gold standard. World J Surg 1999; 23:389-396.[CrossRef][Medline]
- Sung GT, Gill IS. Laparoscopic adrenalectomy. Semin Laparosc Surg 2000; 7:211-222.[CrossRef][Medline]
- Thompson GB, Grant CS, van Heerden JA, et al. Laparoscopic versus open posterior adrenalectomy: a case-control study of 100 patients. Surgery 1997; 122:1132-1136.[CrossRef][Medline]
- Schell SR, Talamini MA, Udelsman R. Laparoscopic adrenalectomy for non malignant disease: improved safety, morbidity and cost-effectiveness. Surg Endosc 1999; 13:30-34.[CrossRef][Medline]
- Hobart MG, Gill IS, Schweizer D, Bravo EL. Financial analysis of needlescopic versus open adrenalectomy. J Urol 1999; 162:1264-1267.[CrossRef][Medline]
- Imai T, Kikumori T, Ohiwa M, Mase T, Funahashi H. A case-controlled study of laparoscopic compared with open lateral adrenalectomy. Am J Surg 1999; 178:50-53.[CrossRef][Medline]
- Suzuki K, Kageyama S, Hirano Y, Ushiyama T, Rajamahanty S, Fujita K. Comparison of 3 surgical approaches to laparoscopic adrenalectomy: a nonrandomized, background matched analysis. J Urol 2001; 166:437-443.[CrossRef][Medline]
- Soble JJ, Gill IS. Needlescopic urology: incorporating 2-mm instruments in laparoscopic surgery. Urology 1998; 52:187-194.[CrossRef][Medline]
- Meraney AM, Gill IS, Hsu TH, Sung GT. Thoracoscopic transdiaphragmatic nephrectomy: feasibility study. Urology 2000; 55:443-447.[CrossRef][Medline]
- Gasman D, Droupy S, Koutani A, et al. Laparoscopic adrenalectomy: the retroperitoneal approach. J Urol 1998; 159:1816-1820.[CrossRef][Medline]
- Sung GT, Hsu TH, Gill IS. Retroperitoneoscopic adrenalectomy: lateral approach. J Endourol 2001; 15:505-511.[CrossRef][Medline]
- Gill IS, Meraney AM, Thomas JC, Sung GT, Novick AC, Lieberman I. Thoracoscopic transdiaphragmatic adrenalectomy: the initial experience. J Urol 2001; 165:1875-1881.[CrossRef][Medline]
- Winfield HN, Hamilton BD, Bravo EL, Novick AC. Laparoscopic adrenalectomy: the preferred choice? a comparison to open adrenalectomy. J Urol 1998; 160:325-329.[CrossRef][Medline]
- Szolar DH, Kammerhuber F. Quantitiative CT evaluation of adrenal gland masses: a step forward in the differentiation between adenomas and nonadenomas? Radiology 1997; 202:517-521.[Abstract/Free Full Text]
- Korobkin M, Brodeur FJ, Yutzy GG, et al. Differentiation of adrenal adenomas from nonadenomas using CT attenuation values. AJR Am J Roentgenol 1996; 166:531-536.[Abstract/Free Full Text]
- Lee MJ, Hahn PF, Papanicolau N, et al. Benign and malignant adrenal masses: CT distinction with attenuation coefficients, size, and observer analysis. Radiology 1991; 179:415-418.[Abstract/Free Full Text]
- Tsushima Y, Ishizaka H, Matsumoto M. Adrenal masses: differentiation with chemical shift, fast low-angle shot MR imaging. Radiology 1993; 186:705-709.[Abstract/Free Full Text]
- Boland GW, Lee MJ. Magnetic resonance imaging of the adrenal gland. Crit Rev Diagn Imaging 1995; 36:115-174.[Medline]
- Gross MD, Shapiro B, Francis IR, et al. Scintigraphic evaluation of clinically silent adrenal masses. J Nucl Med 1994; 35:1145-1152.[Abstract/Free Full Text]
- Smith PA, Ratner LE, Lynch FC, Corl FM, Fishman EK. Role of CT angiography in the preoperative evaluation for laparoscopic nephrectomy. RadioGraphics 1998; 18:589-601.[Abstract]
- Lerner LB, Henriques HF, Harris RD. Interactive three-dimensional computerized tomography reconstruction in the evaluation of the living renal donor. J Urol 1999; 161:403-407.[CrossRef][Medline]
- Coll DM, Uzzo RG, Herts BR, Davros WJ, Wirth SL, Novick AC. 3-dimensional volume rendered computerized tomography for preoperative evaluation and intraoperative treatment of patients undergoing nephron sparing surgery. J Urol 1999; 161:1097-1102.[CrossRef][Medline]
- Smith PA, Marshall FF, Urban BA, Heath DG, Fishman EK. Three-dimensional CT stereoscopic visualization of renal masses: impact on diagnosis and patient treatment. AJR Am J Roentgenol 1997; 169:1331-1334.[Abstract/Free Full Text]
- Chernoff DM, Silverman SG, Kikinis R, et al. Three-dimensional imaging and display of renal tumors using spiral CT: a potential aid to partial nephrectomy. Urology 1994; 43:125-129.[CrossRef][Medline]
- Coll DM, Herts BR, Davros WJ, Uzzo RG, Novick AC. Preoperative use of 3D volume rendering to demonstrate renal tumors and renal anatomy. RadioGraphics 2000; 20:431-438.[Abstract/Free Full Text]
- Bogetti JD, Herts BR, Sands MJ, Carroll JF, Vogt DP, Henderson JM. Accuracy and utility of 3-dimensional computed tomography in evaluating donors for adult living related liver transplants. Liver Transpl 2001; 7:687-692.[CrossRef][Medline]
- Mugiya S, Suzuki K, Masuda H, Ushiyama T, Hata M, Fujita K. Laparoscopic adrenalectomy for nonfunctioning adrenal tumors. J Endourol 1996; 10:539-541.[Medline]
- Elashry OM, Clayman RV, Soble JJ, McDougall EM. Laparoscopic adrenalectomy for solitary metachronous contralateral adrenal metastasis from renal cell carcinoma. J Urol 1997; 157:1217-1222.[CrossRef][Medline]
- Heniford BT, Arca MJ, Walsh M, Gill IS. Laparoscopic adrenalectomy for cancer. Semin Surg Oncol 1999; 16:293-306.[CrossRef][Medline]
- Ayabe H, Tsuji H, Hara S, Tagawa Y, Kawahara K, Tomita M. Surgical management of adrenal metastasis from bronchogenic carcinoma. J Surg Oncol 1995; 58:149-154.[Medline]
- Hobart MG, Gill IS, Schweizer D, Sung GT, Bravo EL. Laparoscopic adrenalectomy for large-volume (
5 cm) adrenal masses. J Endourol 2000; 14:149-154.[Medline]
- Heniford BT, Iannitti DA, Hale J, Ganer M. The role of intraoperative ultrasonography during laparoscopic adrenalectomy. Surgery 1997; 122:1068-1073.[CrossRef][Medline]
- Gill IS, Sung GT, Hsu TH, et al. Robotic, remote laparoscopic nephrectomy and adrenalectomy: the initial experience. J Urol 2000; 164:2082-2085.[CrossRef][Medline]
TOP
ABSTRACT
INTRODUCTION
