Meta-analysis of two approaches to Laparoscopic Adrenalectomy: lateral transperitoneal versus posterior retroperitoneal approach

DOI: https://doi.org/10.21203/rs.3.rs-18722/v1

Abstract

Background:Even though many studies have reported comparisons of the lateral transperitoneal adrenalectomy (LTA)and posterior retroperitoneal adrenalectomy (PRA) approaches,the conclusions were inconsistent.This meta-analysis aims at a systematic assessment of LTA and PRA.

Methods:We searched MEDLINE, Pubmed, and Embase database and finally obtained 19 studies published since January 2009.Systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses. RevMan 5.3(Cochrane Collaboration) was used for data analysis.

Results:19 studies were included in the meta-analysis.The clinical characteristics of the 2 groups were similar(age, BMI, proportion of right sided, proportion of bilateral lesions,and previous abdominal surgery).There was slightly higher heterogeneity in proportion of male patients (OR 0.87, 95% CI 0.78 to 0.97, P = 0.01) and size of the tumor (MD 0.62, 95% CI 0.16 to 1.08, P = 0.008).The results confirmed that the PRA group was superior to LTA group regarding shorter operative time (MD 17.54, 95% CI 9.67 to 25.40, P < 0.0001),lower estimated blood loss (MD 37.75, 95% CI 18.08 to 57.41, P = 0.0002), shorter hospital stay (MD 1.19, 95% CI 0.76 to 1.63, P < 0.00001) and shorter time to first oral intake(MD 0.48, 95% CI 0.11 to 0.86, P =0.01).There were no statistically significant differences between LTA and PRA regarding overall complication(OR 1.37, 95% CI 0.96 to 1.97, P = 0.08),conversion to open laparotomy (OR 1.16, 95% CI 0.63 to 2.16, P = 0.63) or blood transfusion(OR 2.22, 95% CI 0.51 to 9.57, P = 0.28) .

Conclusion:This meta-analysis suggests that PRA has more advantages over LTA,such as shorter operative time,lower estimated blood loss,shorter hospital stay and shorter time to first oral intake.And there were no statistically significance between LTA and PRA in terms of postoperative outcomes(total complications, conversion rates and blood transfusion). 

Introduction

In the last decades,adrenalectomy has progressed from an operation to minimally invasive surgery[1].Some patients require surgical treatment because of functional or suspected malignancy adrenal tumors [2]. Laparoscopic adrenalectomy is the preferred approach for removal of most adrenal tumors.Various studies demonstrated the safety and efficacy of laparoscopic technique.Among laparoscopic approaches,the lateral transperitoneal adrenalectomy (LTA) and the posterior retroperitoneal adrenalectomy (PRA) are common surgical procedures for the treatment of adrenal tumors.

Since first reported in 1992[3], LTA have been widely increased. LTA offers a wide working space for removal of larger adrenal tumors[4]. Conversely, PRA, first reported in 1995,can provides direct access to the adrenal tumor and avoids potential injury to the intra-abdominal organs.[5] Moreover, in PRA, adhesions can be avoided in patients with previous abdominal interventions, and the surgeon can treat bilateral tumors simultaneously, without changing position[6]. Currently, selection of surgical modalities for adrenal require a comprehensive consideration of the experience of surgeon,anatomical location and size of tumor[7].

Even though many studies have reported comparisons of the two laparoscopic approaches,the conclusions were inconsistent.This meta-analysis aims at a systematic assessment of LTA and PRA.

Methods

Data sources and search

We searched MEDLINE, Pubmed, and Embase database and finally obtained 19 studies published since January 2009.Systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses. The following keywords were used:“transperitoneal”,“retroperitoneal”,and “adrenalectomy”. We also conducted a manual search for related articles from references to identify additional articles. All studies were extracted by two authors separately, and any divergence was resolved through consensus.

Selection criteria

Inclusion criteria were: (1) Comparison of clinical characteristics and perioperative outcomes of patients with LTA and PRA;(2) studies having full-text and relevant data were included;(3)studies published in English language;(4)All included studies provide the following data: basic characteristics of patients (age, gender [Male/ Female] ,body mass index [BMI], previous abdominal surgery), characteristics of tumor (size, side, and type of endocrine disorder), surgical outcomes (operative time, blood loss, time to oral intake, and duration of hospital stay), and postoperative outcomes (total complications, conversion, blood transfusion and mortality). The flow chart of study selection is shown in Figure1.The meta-analyses were based on published researches,so ethical approval was not required for our study.

Quality assessment

As shown in Figure 2 and Figure 3,Cochrane 'Risk of bias' assessment tool was used for quality assessment in this meta-analysis.Evaluation based on:A:Sequence generation;B:Allocation concealment;C: Blinding of participants,personnel;D: Blinding of outcome assessment;E:Incomplete outcome data;F:Selective reporting;G: Other sources of bias.All authors were involved in the quality assessment of articles included, and any divergence was resolved through consensus.Finally everyone agreed on the quality assessment.

Statistical analyses

RevMan 5.3(Cochrane Collaboration)[8] was used for data analysis.Variables were pooled only when more than 3 studies were evaluated.The odds ratio(OR) and the corresponding 95% confidence interval [CI] [8] were used to assess the differences. We considered the study present significant heterogeneity if P<0.05.Statistical heterogeneity was measured with the I2 statistic.The random-effects model was used when I2>50%.

If original articles did not provide means and standard deviations (SDs) or we did not get the data we needed from authors, we used median, range, and sample size to estimate the means and SDs[9].

Results

Study Characteristics

Of 592 retrieved studies, 573 articles were excluded for different reasons.Finally, 19 studies [10-28] were included in our analysis.Table 1 lists the basic characteristics of the included studies in the meta-analysis,and Table 2 shows the clinical and pathologic characteristics of the included studies.The two groups were similar in age (MD -4.03, 95% CI -8.82 to 0.76, P = 0.10), BMI (MD 0.17, 95% CI -0.53 to 0.87, P = 0.64), proportion of right sided (OR 0.91, 95% CI 0.74 to 1.12, P = 0.35), proportion of bilateral lesions (OR 1.21, 95% CI 0.52 to 2.80, P = 0.65),and previous abdominal surgery (OR 0.91, 95% CI 0.59 to 1.43, P = 0.70),as shown in Fig.4A-E.

The heterogeneity between the two groups was slightly higher in proportion of male patients (OR 0.87, 95% CI 0.78 to 0.97, P = 0.01)(Fig.4F);in addition,the tumor in the PRA group was slightly smaller (MD 0.62, 95% CI 0.16 to 1.08, P = 0.008) (Fig.4G).

  The pathologic characteristics of patients(Cushing’s syndrome (OR 1.16, 95% CI 0.79 to 1.71,P = 0.46), primary aldosteronism (OR 0.67, 95% CI 0.47 to 0.94,P = 0.02), pheochromocytoma (OR 1.09, 95% CI 0.79 to 1.51,P = 0.59), and nonfunctioning tumor (OR 1.05, 95% CI 0.75 to 1.48,P = 0.76)) and proportion of malignant tumor (OR 1.11, 95% CI 0.64 to 1.92,P = 0.72) are shown in Table 3 (Fig7A-E).

Comparison of surgical outcomes between LTA and PRA

Operative time

18 studies including 1663 patients were pooled to evaluate operative time. The heterogeneity among studies was high(P <0.00001, I2 = 95%).The PRA group was associated with a significantly shorter operative time (MD 17.54, 95% CI 9.67to 25.40, P < 0.0001) (Fig.5A).

Blood loss

14 studies including 1168 patients were pooled to evaluate blood loss.Significant heterogeneity was shown among studies (P<0.00001, I2 = 97%). The results showed greater estimated blood loss in the LTA group with a random-effects model(MD 37.75, 95% CI 18.08 to 57.41, P = 0.0002) (Fig.5B).

Hospital stay

16 studies including 1466 patients were pooled to evaluate hospital stay. Length of hospital stay was significantly less in the PRA group (MD 1.19, 95% CI 0.76 to 1.63, P < 0.00001) (Fig.5C).

Time to first oral intake

6 studies including 521 patients were pooled to evaluate time to first oral intake. The results showed a significantly shorter time to first oral intake in the PRA group(MD 0.48, 95% CI 0.11 to 0.86, P =0.01) (Fig.5D).

Postoperative outcomes

Results of postoperative complications were shown in Table 3.There was no statistical significance between LTA and PRA for overall complication(OR 1.37, 95% CI 0.96 to 1.97, P = 0.08) (Fig.6A) ,conversion to open laparotomy(OR 1.16, 95% CI 0.63 to 2.16, P = 0.63) (Fig.6B) or blood transfusion(OR 2.22, 95% CI 0.51 to 9.57, P = 0.28) (Fig.6C). Only Two patients in the LTA group (Berber et al19) died postoperatively from cardiac and pulmonary causes. No mortality was encountered in PRA group.

 

Discussion

Laparoscopic adrenalectomy has become an accepted surgical procedure world wide for adrenal gland disease.Despite LTA has advantages of wide surgical space and familiarity of anatomy,PRA are equally effective and safe because of the superiority of direct approach to adrenal lesions[6,21,22].Besides,PRA,which can avoid injury to abdominal organs[29] ,perhaps should be preferred for patients with a history of abdominal surgery and in bilateral adrenal lesions.

Although numerous reports have identified PRA seems more desirable compared with LTA,most of them have the disadvantage of small sample size or stringent inclusion criteria in a single-institution. To overcome these limitations, we performed this meta-analysis.Although no difference was shown in most clinical characteristics (age, BMI, proportion of right sided, proportion of bilateral lesions,and previous abdominal surgery),the heterogeneity was found in the proportion of male patients and size of the tumor between 2 groups. Both procedures were confirmed the safety and efficacy.The results showed PRA has more advantages over LTA,such as shorter operative time ,lower estimated blood loss,shorter hospital stay and shorter time to first oral intake.The meta-analysis showed that there were no statistically significance between LTA and PRA in terms of postoperative outcomes( total complications, conversion rates and blood transfusion).

Rates of conversion to laparotomy of LTA and PRA were 3.1% (23/753) and 2.6% (16/614), respectively.And the reasons for conversion were different. Conversion occurred in LTA due to the large tumor (which could not be separated safely from the undersurface of the liver laparoscopically), extensive adhesions from prior abdominal surgery,and malignancy with renal vasculature;Whereas the reason of conversion in RLA are uncontrolled bleeding, adhesions by intraoperatively suspected malignant pheochromocytoma ,secondary adrenal metastases with invasion, a large primary tumor and inadequate visualization, BMI of 40 had failure to progress, and inability to maintain adequate retroperitoneal insufflation due to a small tear in the peritoneum.

Complications occurred in both groups. The reported complications in LTA included episode of postoperative pneumonia,symptomatic port-site incisional hernia, colon injury,spleen injury,a pulmonary embolism,symptomatic atrial fibrillation, pneumothorax, and hematoma.The complication in RLA included neuromuscular pain (which was temporary in most patients),peritoneum injury,pleura injury, retroperitoneal hematoma, permanent blindness(unexplained thromboembolism to the retinal artery).

There were certain limitations in our analysis:the 10-year study may results in the risk of potential confounding variables and biases.In addition,the higher heterogeneity was found in the size of the tumor ,which demonstrate PRA perhaps superior in smaller tumours. Further studies are needed to confirm the results of larger adrenal tumors.

Conclusions

This meta-analysis suggests that PRA has more advantages over LTA,such as shorter operative time,lower estimated blood loss,shorter hospital stay and shorter time to first oral intake.And there were no statistically significance between LTA and PRA in terms of postoperative outcomes(total complications, conversion rates and blood transfusion).

Abbreviations

LTA:lateral transperitoneal adrenalectomy; PRA: posterior retroperitoneal adrenalectomy BMI:body mass inde ;MD:Mean difference;OR:odds ratio;SD:standard deviation; CI:confidence interval;CT:computed tomography;NA:not available

Declarations

Ethics approval and consent to participate

All analyses were based on previous published studies, thus no ethical approval and patient consent are required.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

LYY, LQ, and LL performed the data extraction, carried out the meta-analysis and drafted the paper.LYY was funded by Natural Science Foundation of Shandong Province(ZR2017LH016), Yantai Science and Technology Bureau(2018SFGY117).

The funding agencies had no role in this meta-analysis.

Authors’contributions

WHT designed the research, interpreted the data and revised the paper. LYY, LQ, and LL performed the data extraction,data analysis and review of drafts. All authors read and approved the final manuscript.

Acknowledgements

Not applicable.

References

[1] Conzo G, Tartaglia E, Gambardella C, Esposito D, Sciascia V, Mauriello C, Nunziata A, Siciliano G, Izzo G, Cavallo F, Thomas G, Musella M, Santini L: Minimally invasive approach for adrenal lesions: Systematic review of laparoscopic versus retroperitoneoscopic adrenalectomy and assessment of risk factors for complications.

[2] Buia A, Stockhausen F, Hanisch E. Laparoscopic surgery: a qualified systematic review. World J Methodol. 2015;5:238–54.

[3]Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl J Med. 1992;327:1033.

[4] Frezza EE, Ikramuddin S, Gourash W, Schauer P: Laparoscopic resection of  a  large periadrenal nonmalignant pheochromocytoma.Surg Endosc 2002, 16, 362– 363.

[5]Mercan S,Seven R,Ozarmagan S et al.Endoscopic retroperitoneal adrenalectomy.Surgery 1995;118:1071-5.

[6] Walz MK, Alesina PF, Wenger FA, Koch JA, Neumann HP, Petersenn S, Schmid KW, Mann K: Posterior retroperitoneoscopic adrenalectomy – results of 560 procedures in 520 patients. Surgery 2006, 30, 899–908.

[7]Shen WT, Grogan R, Vriens M, et al. One hundred two patients with pheochromocytoma treated at a single institution since the introduction of laparoscopic adrenalectomy. Arch Surg. 2010;145:893–7.

[8]DerSimonian R,Laird N. Meta-analysis in clinical trials. Control Clin Trials.1986;7(3):177–88.

[9]Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Medical Research Methodology 2005;5:13.

[10]Kozłowski T, Choromanska B, Wojskowicz P, Astapczyk K, Łukaszewicz J, Rutkowski D, Dadan J, Rydzewska-Rosołowska A, Myśliwiec P. Laparoscopic adrenalectomy: lateral transperitoneal versus posterior retroperitoneal approach - prospective randomized trial. Wideochir Inne Tech Maloinwazyjne. 2019 Apr;14(2):160-169. doi: 10.5114/wiitm.2019.84694. Epub 2019 May 5. PMID: 31118978; PMCID: PMC6528120.

[11] Chai YJ, Yu HW, Song RY, Kim SJ, Choi JY, Lee KE. Lateral transperitoneal adrenalectomy versus posterior retroperitoneoscopic adrenalectomy for benign adrenal gland disease: randomized controlled trial at a single tertiary medical center. Annals of Surgery 2019;269:842-848.

[12]Shiraishi, K; Kitahara, S; Ito, H; Matsuyama, H;et al.Transperitoneal versus retroperitoneal laparoscopic adrenalectomy for large pheochromocytoma: Comparative outcomes.Int J Urol.2019 02 ;26(2):212-216.

[13]Chen W, Liang Y, Lin W, Fu GQ, Ma ZW. Surgical management of large adrenal tumors: impact of different laparoscopic approaches and resection methods on perioperative and long-term outcomes. BMC Urol. 2018 May 8;18(1):31. doi: 10.1186/s12894-018-0349-0. PMID: 29739388; PMCID: PMC5941476.

[14]Wessel M.C.M. Vorselaars, et al., Hemodynamic instability during surgery for pheochromocytoma: comparing the transperitoneal and retroperitoneal approach in a multicenter analysis of 341 patients, Surgery (2017), doi: 10.1016/j.surg.2017.05.029

[15]M. Marek-Safiejko et al.A Comparison of Two Approaches to Laparoscopic Adrenalectomy: Lateral Transperitoneal Versus Posterior Retroperitoneal Approach.Adv Clin Exp Med 2016, 25, 5, 829–835.

[16]Terry C. Lairmore,Jessica Folek,Cara M. Govednik, Samuel K. Snyder.Improving Minimally Invasive Adrenalectomy: Selection of Optimal Approach and Comparison of Outcomes.World J Surg.2016;40(7):1625-31.

[17]Chiang Po Hui Chiang PH,Yu CJ,Lee WC,Wang HJ,Hsu WC.Comparison of Retroperitoneoscopic and Transperitoneal Laparoscopic Adrenalectomy for Right-Sided Benign Tumors: A Single-Institute Experience.Urol Int 2015;94:144–148.

[18]Barczynski M, Konturek A, Nowak W. Randomized clinical trial of posterior retroperitoneoscopic adrenalectomy versus lateral transperitoneal laparoscopic adrenalectomy with a 5‐year follow‐up. Annals of Surgery 2014;260:740‐7.

[19]Cabalag M. S., Mann G. B., Gorelik A., Miller J. A. Comparison of outcomes after laparoscopic versus posterior retroperitoneoscopic adrenalectomy: a pilot study. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 2014;24(1):62–66.

[20]Mohammadi‐Fallah MR, Mehdizadeh A, Badalzadeh A, Izadseresht B, Dadkhah N, Barbod A. Comparison of transperitoneal versus retroperitoneal laparoscopic adrenalectomy in a prospective randomized study. Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A 2013;23:342‐6.

[21]Constantinides V. A., Christakis I., Touska P., Meeran K., Palazzo F. Retroperitoneoscopic or laparoscopic adrenalectomy? A single-centre UK experience. Surgical Endoscopy. 2013;27(11):4147–4152.

[22]Lee C. R., Walz M. K., Park S., Park J. H., Jeong J. S., Lee S. H., Kang S.-W., Jeong J. J., Nam K.-H., Chung W. Y., Park C. S. A comparative study of the transperitoneal and posterior retroperitoneal approaches for laparoscopic adrenalectomy for adrenal tumors. Annals of Surgical Oncology. 2012;19(8):2629–2634.

[23]Miccoli P,Materazzi G,Brauckhoff M,Ambrosini CE,Miccoli M,Dralle H.No Outcome Differences between a Laparoscopic and Retroperitoneoscopic Approach in Synchronous Bilateral Adrenal Surgery.World J Surg (2011) 35:2698–2702.

[24]Ramacciato G, Nigri GR, Petrucciani N, Di Santo V, Piccoli M, Buniva P, et al. Minimally invasive adrenalectomy: a multicenter comparison of transperitoneal and retroperitoneal approaches. Am Surg 2011;77:409-16.

[25]Kiriakopoulos A., Economopoulos K. P., Poulios E., Linos D. Impact of posterior retroperitoneoscopic adrenalectomy in a tertiary care center: a paradigm shift. Surgical Endoscopy. 2011;25(11):3584–3589.

[26]Dickson P. V., Alex G. C., Grubbs E. G., Ayala-Ramirez M., Jimenez C., Evans D. B., Lee J. E., Perrier N. D. Posterior retroperitoneoscopic adrenalectomy is a safe and effective alternative to transabdominal laparoscopic adrenalectomy for pheochromocytoma. Surgery. 2011;150(3):452–458.

[27]Li QY, Li F. Laparoscopic adrenalectomy in pheochromocytoma: retroperitoneal approach versus transperitoneal approach. J Endourol 2010;24:1441-5.

[28]Berber E, Tellioglu G, Harvey A, Mitchell J, Milas M, Siperstein A. Comparison of laparoscopic transabdominal lateral versus posterior retroperitoneal adrenalectomy. Surgery 2009;146:621-5.

[29] Walz M. K., Peitgen K., Hoermann R., Giebler R. M., Mann K., Eigler F. W. Posterior retroperitoneoscopy as a new minimally invasive approach for adrenalectomy: results of 30 adrenalectomies in 27 patients. World Journal of Surgery. 1996;20(7):769–774.

Tables

Table 1.Characteristics of the included studies

Author

Year

Country

Type of study

Trial period

Inclusion criteria

Exclusion criteria

Sample

LTA

PRA

Kozlowski et al10

2019

Poland

Prospective

randomized

2015.2-2018.6

size of the adrenal tumor for planned unilateral adrenalectomy up to 8 cm

tumors > 8 cm, imaging features suggesting primary invasive malignant tumors and refusal of the patient to undergo randomization

33

44

Chai et al11

2019

Korea

Prospective

randomized

2012.9-2016.2

unilateral benign tumor,BMI≤35kg/m2,age≥18 and age<80,tumor size<7cm in maximal diameter on preoperative CT scan (<5cm for pheochromocytoma),no history of abdominal surgery in the same quadrant of adrenal tumor location, and normal cognitive function.

necessity of additional surgical procedure,pregnancy,ongoing infection,uncontrolled hypertension,or a history of coronary heart disease (CHD), or cerebrovascular disease (CVD)

42

41

Shiraishi et al12

2019

Japan

Retrospective,

non-randomized

2008.1-2017.12

Pheochromocytomas > 5cm

Not specified

12

10

WeiChen

et al13

2018

China

retrospective

2011.1-2015.6

(i) the patient was confirmed as having an adrenal tumor by imaging examination and underwent minimally invasive surgery treatment, (ii) the baseline indicators and perioperative parameters were completely recorded, and (iii) a large adrenal tumor was defined as an adrenal tumor with a diameter larger than 5 cm.

(i) there were no measurable data reported, (ii) the tumor was operated on via open surgery, and (iii) a hand-assisted laparoscopic method was adopted during the surgery.

 

37

41

Vorselaars et al14

2018

Europe,

America,

Canada

Retrospective

non-randomized

2000-2016

All consecutive patients with pheochromocytoma who underwent unilateral laparoscopic adrenalectomy

patients with open,partial,bilateral,or converted procedures

240

101

Marek-Safiejko et al15

2016

Poland

retrospective

2010.2-2015.2

Not specified

All patients with suspected adrenal carcinoma or a  tumor larger than 10 cm were qualified for the conventional method

27

77

Lairmore

et al16

2016

Thailand

retrospective

2005.1-2015.4

Not specified

Primary malignant adrenal tumors, and tumors not felt to be amenable to a minimally invasive approach (generally>8.0cm) were excluded.

67

76

Chiang

et al17

2015

Taiwan

Retrospective,

nonrandomized

2000.3-2011.9

Not specified

Adrenocortical malignancies were excluded

24

31

Barczynski et al18

2014

Poland

Prospective,

randomized

2006.1-2008.6

unilateral adrenal surgery for a benign tumor up to 7 cm in diameter

diffuse peritonitis in history, major abdominal surgery in history, planned bilateral  adrenal surgery, adrenal tumor more than 7cm in diameter,suspected adrenocortical cancer, metastasis to adrenal gland,previous adrenal surgery, pregnancy or lactation, age less than 18 or more than 80 years,American Society of Anesthesiologists fitness grade IV, and inability to comply with the follow-up protocol

32

33

Cabalag

et al19

2014

Australia

Retrospective

Nonrandomized

2009.10-2011.12

functional tumors <8cm without signs of local invasion, nonfunctional tumors between 4 and 8cm, or<4cm with suspicious features on preoperative imaging,and solitary metastasis to the adrenal.

Not specified

13

10

Mohammadi-Fallah et al20

2013

Iran

Prospective,

randomized

2008.9-2011.11

Not specified

patients with morbid obesity (BMI>40kg/m2), prior major abdominal surgery,clinical suspicion of malignancy,tumor size>6cm,and bilateral adrenalectomy

11

13

Constantinides et al21

2013

UK

prospectively

2010.9-2012.9

All adult patients undergoing unilateral adrenalectomy via a minimally invasive approach were eligible for inclusion in the study irrespective of surgical indication

Patients undergoing open adrenalectomy, bilateral adrenal surgery,or paraganglioma resection were excluded

36

35

Lee,CR

et al22

2012

Not specified

retrospective

2009.1-2010.7

Not specified

bilateral pheochromocytoma

26

17

Miccoli

et al23

2011

Italy

Germany

 

retrospective

1994-2008

underwent bilateral synchronous adrenalectomy

Not specified

20

14

Ramacciato et al24

2011

Italy

nonrandomized, retrospective

1995-2009

Not specified

Not specified

127

44

Kiriakopoulos  et al 25

2011

Greece

Prospective

nonrandomized

2008.5-2010.9

Not specified

Not specified

30

30

Dickson et al26

2011

America

retrospectively

2000.5-2009.12

Not specified

Not specified

23

23

Li,QY

et al27

2010

China

retrospective

1999-2008

unilateral benign pheochromocytoma<6cm in diameter have undergone LA for pheochromocytoma

Patients with bilateral pheochromocytoma or malignancy

40

59

Berber

et al28

2009

America

retrospective

1994-2008

Not specified

Not specified

69

90

Total

 

 

 

 

 

 

909

789

LTA:lateral transperitoneal adrenalectomy;PRA:posterior retroperitoneoscopic adrenalectomy.CT:computed tomography

 

 

 

 

Table 2.Clinical characteristics

 

Study

Group

Tumor size

,cm

(±SD)

Age,

mean years

(±SD)

BMI,kg/m2

(±SD)

Gender

(Male

/female)

Tumor location

(Right/Left

/Bilateral)

Type of endocrine disorder

Pheocromocytoma

Malignant

Conn’s disease

Cushing syndrome

Nonfunctioning

Others

Kozlowski et al10

LTA

PRA

4.1*

4.0*

61.2±8.3

59.3±10.2

30.1±6

29.1±5.2

13/20

21/23

11/22/0

18/26/0

4

9

1

3

2

4

5

3

22

28

0

0

Chai et al11

LTA

PRA

2.9±1.4

3.0±1.3

48.0±11.4

46.4±11.0

24.2±3.3

23.6±3.0

14/28

15/26

18/24/0

18/23/0

8

7

NA

20#

16#

7

10

7

8

0

0

Shiraishi et al12

LTA

PRA

6.6*

7.4*

58.8*

56.3*

23.4*

23.2*

7/5

4/6

7/5/0

6/4/0

12

10

NA

0

0

0

0

0

0

0

0

WeiChen et al13

LTA

PRA

5.76±1.34

5.81±1.17

47.92±29.61

44.41±38.90

23.60±2.92

23.52±2.46

23/14

26/15

10/25/2

11/29/1

3

5

4

2

20

18

NA

NA

10

16

Vorselaars et al 14

LTA

PRA

4.52±1.94

3.4±1.9

5.5±15.4

45.3±17.0

25.3±5.3

24.0±3.6

102/138

46/55

130/110/0

45/56/0

240

101

NA

0

0

0

0

NA

0

0

Marek-Safiejko

et al15

LTA

PRA

6.1±2.1

4.6±1.4

53.6±11.5

58.8±10.4

28.8±4.9

30.4±3.8

11/16

32/45

12/15/0

39/38/0

5

16

4

4

1

10

4

7

17

44

0

0

Lairmore et al16

LTA

PRA

3.6±2.1

2.38±1.2

53.5*

52.9*

32.67*

31.23*

23/43

36/36

29/38/0

36/40/0

NA

NA

NA

NA

NA

NA

Chiang et al17

LTA

PRA

4.6±0.82

3.5±1.56

53.3*

53.15*

25.41*

25.07*

11/13

17/14

24/0/0

31/0/0

3

5

NA

8

12

0

2

10

11

3

1

Barczynski et al18

LTA

PRA

4.03*

3.93*

46.6*

47.9*

27.3*

27.6*

9/23

8/25

15/17/0

16/17/0

7

8

NA

7

7

3

4

15

14

0

0

Cabalag et al19

LTA

PRA

3.2*

3.5*

47*

61*

28*

28.9*

5/8

5/5

4/9/0

5/5/0

NA

0

1

NA

NA

NA

NA

Mohammadi-Fallah

et al20

LTA

PRA

2.92*

2.63*

42.9*

42.23*

26,72*

27.46*

5/6

5/8

6/5/0

8/5/0

2

2

NA

2#

1#

3

4

4

6

0

0

Constantinides

et al21

LTA

PRA

4.1±2.31

2.83±1.27

49.52±13.62

49.1±13.55

26.8±4.64

29.8±5.52

15/21

13/22

18/18/0

19/16/0  

7

7

0

0

 

10

10

8

5

4

9

7

4

Lee,CR et al22

LTA

PRA

3.86±3.83

2.64±1.61

53.4±9.9

57.4±13.9

24.49±2.61

24.99±3.18

7/19

6/11

7/18/1

8/9/0

8

2

NA

4#

7#

3

2

11

6

0

0

Miccoli et al23

LTA

 

PRA

L64.06*

R61.1*

L37.4*

R42.8*

48.1*

 

38.9*

29.4*

 

26.3*

7/13

 

6/8

0/0/20

 

0/0/14

4

 

7

NA

0

 

1

16

 

5

NA

 

 

0

 

1

Ramacciato et al24

LTA

PRA

4.4±2.8

4.8±1.9

51.8±14.0

54.3±12.5

NA

52/75

28/16

63/58/6

31/13/0

20

8

14

5

NA

NA

NA

93

31

Kiriakopoulos

et al25

LTA

PRA

4.9*

3.8*

49.5*

53.0*

NA

NA

11/19

9/21

16/14/0

10/20/0

6

6

2

2

4#

4#

18

17

NA

0

1

Dickson,PV et al26

LTA

PRA

4.0±2.2

3.3±1.8

42.0±18.1

47.3±16.1

26.1±5.4

26.2±6.6

7/16

11/12

9/13/1

11/12/0

NA

NA

NA

NA

NA

NA

Li,QY et al27

LTA

PRA

4.5±0.5

4.3±0.8

37.51±5.12

36.74±4.32

25.5±5.78

26.31±6.22

17/23

25/34

22/18/0

34/25/0

NA

NA

NA

NA

NA

NA

Berber et al28

LTA

PRA

4.4±0.3

2.8±0.1

52±14

51±14

32±9

28±6

25/44

43/47

27/38/4

38/43/9

23

12

7

10

3

31

9

15

18

20

9

2

*except median.# aldosteronism

NA:not available.

 

 

 

 

Table 3.Clinical characteristics and postoperative outcomes 

Variable

N

OR

95% CI

P value

Type of endocrine disorder

Pheocromocytoma

 

15

 

1.09

 

0.79 to 1.51

 

0.59

Conn’s disease

14

0.67

0.47 to 0.94

0.02

Cushing syndrome

11

1.16

0.79 to 1.71

0.46

Nonfunctioning

9

1.05

0.75 to 1.48

0.76

Malignant

7

1.11

0.64 to 1.92

0.72

Total complications

14

1.37

0.96 to 1.97

0.08

Conversion to open rates

14

1.16

0.63 to 2.16

0.63

Blood transfusion

7

2.22

0.51 to 9.57

0.28

CI, Confidence interval; N, number of studies reporting the variable; OR, odds ratio.