Objectives: We evaluated the technical feasibility and efficacy of laparoscopic enucleation of adrenal macronodules in a patient with ACTH-independent macronodular adrenal hyperplasia (AIMAH). Patient and Methods: A 41-year-old female manifested Cushing's syndrome due to AIMAH in 1999 and underwent a right unilateral adrenalectomy in 2002. Although the patient's symptoms improved postoperatively, in 2005 they began to get worse as her urinary cortisol excretion increased. Computed tomography in 2008 showed four macronodules in the left adrenal gland, and we performed a laparoscopic enucleation of four adrenal nodules in hopes of avoiding the need for lifelong steroid replacement. In the operation we paid special attention to avoiding injuring major adrenal vessels. Nontumorous adrenal tissue was dissected just near the surfaces of the nodules by using a sealing system. The residual adrenal gland was at most left undissected from the surrounding tissues in order to preserve blood supply and preserve small drainage veins. Results: The operation could be performed with minimal blood loss. Plasma cortisol became measurable 22 months after the enucleation and returned to normal level 29 months after the enucleation. Conclusions: The laparoscopic enucleation of hyperplastic nodules is technically feasible and a treatment of choice for AIMAH patients who already underwent unilateral adrenalectomy.

Keywords:
ACTH-independent macronodular adrenal hyperplasia , Cushing’s syndrome, Unilateral adrenalectomy, Laparoscopic enucleation
1.
Shinojima H, Kakizaki H, Usuki T, Harabayashi T, Ameda K, Koyanagi T: Clinical and endocrinological features of adrenocorticotropic hormone-independent bilateral macronodular adrenocortical hyperplasia. J Urol 2001;166:1639-1642.
2.
Mazzuco TL, Chaffanjon P, Martinie M, Sturm N, Chabre O: Adrenal Cushing's syndrome due to bilateral macronodular adrenal hyperplasia: prediction of the efficacy of beta-blockade therapy and interest of unilateral adrenalectomy. Endocr J 2009;56:867-877.
3.
Iacobone M, Albiger N, Scaroni C, Mantero F, Fassina A, Viel G, Frego M, Favia G: The role of unilateral adrenalectomy in ACTH-independent macronodular adrenal hyperplasia (AIMAH). World J Surg 2008;32:882-889.
4.
Kageyama Y, Ishizuka K, Iwashina M, Sasano H, Kihara K: A case of ACTH-independent bilateral macronodular adrenal hyperplasia successfully treated by subtotal resection of the adrenal glands: four-year follow-up. Endocrine J 2002;49:227-229.
5.
Lacroix A, Bolté E, Tremblay J, Dupré J, Poitras P, Fournier H, Garon J, Garrel D, Bayard F, Taillefer R: Gastric inhibitory polypeptide-dependent cortisol hypersecretion - a new cause of Cushing's syndrome. N Engl J Med 1992;327:974-980.
6.
Reznik Y, Allali-Zerah V, Chayvialle JA, Leroyer R, Leymarie P, Travert G, Lebrethon MC, Budi I, Balliere AM, Mahoudeau J: Food-dependent Cushing's syndrome mediated by aberrant adrenal sensitivity to gastric inhibitory polypeptide. N Engl J Med 1992;327:981-986.
7.
Ihara Y, Kodera T, Fujii H, Yamamoto Y, Ogura E, Hyuga T, Ogata T, Seo M, Miyajima A, Hayakawa M, Ogata S, Tamai S, Aiba T, Tanaka Y: A case of food-dependent Cushing's syndrome with bilateral adrenal enlargement. Clinical Endocrinology 2004;52:108-115.
8.
Nambirajan T, Leeb K, Neumann HP, Graubner UB, Janetschek G: Laparoscopic adrenal surgery for recurrent tumours in patients with hereditary phaeochromocytoma. Eur Urol 2005;47:622-626.
9.
Imai T, Tanaka Y, Kikumori T, Ohiwa M, Matsuura N, Mase T, Funahashi H: Laparoscopic partial adrenalectomy. Surg Endosc 1999;13:343-345.
10.
Roukounakis N, Dimas S, Kafetzis I, Bethanis S, Gatsulis N, Kostas H, Kyriakou V, Michas S: Is preservation of the adrenal vein mandatory in laparoscopic adrenal-sparing surgery? JSLS 2007;11:215-218.
11.
Pautler SE, Choyke PL, Pavlovich CP, Daryanani K, Walther MM: Intraoperative ultrasound aids in dissection during laparoscopic partial adrenalectomy. J Urol 2002;168:1352-1355.
12.
Kaouk JH, Matin S, Bravo EL, Gill IS: Laparoscopic bilateral partial adrenalectomy for pheochromocytoma. Urology 2002;60:1100-1103.
13.
Ishidoya S, Ito A, Sakai K, Satoh M, Chiba Y, Sato F, Arai Y: Laparoscopic partial versus total adrenalectomy for aldosterone producing adenoma. J Urol 2005;174:40-43.
© 2013 S. Karger AG, Basel
2013
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.