Short- and long-term outcomes of adrenalectomy for Primary Aldosteronism in a single UK centre: Rear Mirror View.

doi:10.21203/rs.3.rs-4697365/v1

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Short- and long-term outcomes of adrenalectomy for Primary Aldosteronism in a single UK centre: Rear Mirror View.

https://doi.org/10.21203/rs.3.rs-4697365/v1

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Purpose: Primary Aldosteronism (PA) is the commonest cause of secondary hypertension and can be cured by unilateral adrenalectomy. We report the short and long-term outcomes after adrenalectomy performed at a single UK centre over a period of 24 years.

Methods: Retrospective analysis of biochemical(potassium, aldosterone, renin and ARR) radiological (CT/MRI, AVS, nuclear scans) and clinical (surgical complications, blood pressure, number of antihypertensive medications) short and long terms outcomes in patients who underwent adrenalectomy for PA between 1998 and 2021. Standardised PASO and Clavien-Dindo criteria to assess biochemical, clinical and surgical outcomes were used.

Results: 82 patients treated with adrenalectomy for PA over a 24 year period, short term follow up data (within 3 months from surgery) was available for 82 patients (M45, F37, mean age 51.7 years), 24 of them were followed at least 60 months( range 60 to 72 months) 77 (93.9%) patients had laparoscopic surgery (1 conversion). 7 patients had postoperative complications classified as Clavien-Dindo II(4), IIIa(1) and IVa(2). Median LOS was 2.5 days (1-12).

Complete and partial clinical success was achieved in 29% and 58.3% and 41.7% and 45.8% of patients in short and long term respectively. Clinical benefit was observed in 88% of patients. Complete biochemical success was achieved in 95.8% of patients in short and long term.

Conclusion: Unilateral adrenalectomy in patients with PA achieved clinical benefit in 88% and biochemical cure in almost all of them. Our data suggest that these benefits persisted for at least 5 years.

Primary Aldosteronism

Adrenalectomy

Conn’s syndrome

Biochemical cure

Primary hyperaldosteronism (PA) is the commonest cause of secondary hypertension and can be successfully treated by adrenalectomy if excessive secretion of aldosterone is confirmed to be from a unilateral source[1, 2]. Estimates of the prevalence of PA have varied considerably over the last 70 years, but recent data suggest that it affects 3.2% to 12.7% of patients in primary care and 1% to 29.8% referred to hypertension units[3, 4]. The incidence of PA rises with the severity of hypertension , from 2% in patients with grade 1 hypertension to 20% in those with resistant hypertension[4]

Patients with PA have increased risk of myocardial infarction, stroke, atrial fibrillation and higher prevalence of metabolic syndrome in comparison to patients with essential hypertension[3]. Recent metanalysis showed that patients with PA treated with adrenalectomy had better outcomes in comparison to patients treated with medications alone[5]. This is because surgery can not only restore normal blood pressure and obviate the need for antihypertensive medications, but also by removing the source of aldosterone over-secretion, it can normalise the renin-angiotensin-aldosterone system and correct concomitant abnormalities of hypokalaemia, alkalosis and fibrosis in multiple organs like heart, kidney and pancreas caused by high levels of aldosterone[6-8].

Introduction of minimally invasive techniques had huge positive impact on outcomes after adrenalectomies in reducing postoperative pain, length of hospital stay and improved cosmesis. Cure rates after adrenalectomy for PA range from 32% to 42% at 6 months after surgery but data on long-term outcomes are relatively scarce and often consist of small cohort studies[9-13]. It is not clear whether short term benefits of adrenalectomy persist in longer term and whether clinical and biochemical cure go hand in hand or have separate course[14].

Interest in PA has heightened in recent years and research into this condition has experienced what can be called a “Renaissance period” leading to the development of new functional imaging and adrenal ablative techniques as an alternative to surgical resection[15-18]. Understanding the value of new and emerging diagnostic and therapeutic techniques and their place in the context of current practice can be informed by reviewing outcome data achieved in the preceding decades characterised by a relatively stable diagnostic and therapeutic ‘best practice’ pathway.

Our study aims to evaluate the “real life experience” of diagnosing and treating patients with PA in a single tertiary referral centre in the United Kingdom over 24 years with a focus on the short and long-term outcomes of adrenalectomy for PA and the introduction of laparoscopic approach as a treatment for this condition.

Retrospective analysis of data from a prospectively maintained database of patients with PA who underwent surgery between 1st January 1998 and 31st December 2022 at University College London Hospital, a tertiary referral centre for endocrinology and endocrine surgery.

The clinical pathway for screening, diagnosis and stratification for adrenalectomy varied through the 24 years and was based on concurrent recommendations, published evidence, changing local expertise and best practice at the time. Throughout this period diagnosis of PA in our centre was based on the presence of hypertension and hypokalaemia, high aldosterone level, supressed renin activity and aldosterone and renin ratio (ARR) above 850. Currently a confirmatory test (for example, saline suppression test) recommended if the aldosterone is < 550pmol/L but in the upper third of the normal range or the plasma renin is non-suppressed unless the patient presents with spontaneous hypokalaemia, plasma renin below detection levels and aldosterone concentration more than 550 pmol/L.

Stratification for adrenalectomy, once a diagnosis of PA was confirmed, included cross sectional imaging of adrenals with CT or MRI [2]. Adrenal venous sampling (AVS) and/or later ¹¹C Metomidate PET-CT was performed if imaging showed bilateral adrenal nodules[2]. Surgery was recommended after discussion in the multidisciplinary team meeting (endocrinologist, endocrine surgeon, biochemists and radiologist).

During the very beginning of the study laparoscopic adrenalectomy was introduced in our centre and transperitoneal lateral technique was used to perform laparoscopic adrenalectomy using 3 ports on the left and 4 ports on the right side.

Patients included in the study were characterised preoperatively by their demographics (age, sex and ethnicity) clinical presentation (blood pressure), number of antihypertensive medications and biochemical tests (potassium, aldosterone, renin, ARR ratio).

Number and type of investigations (CT, MRI, AVS, Metomidate) used to stratify for surgery and the size of the adrenal nodules on cross sectional imaging was recorded. Process of stratification was presented as lateralisation to the left or right reached as a consensus between cross sectional imaging, AVS and nuclear medicine imaging.

Data on post operative surgical outcomes included conversion rate to open adrenalectomy, postoperative complications (Clavien-Dindo) [19] and length of hospital stay.

Postoperative outcomes were assessed within 3 months of surgery (short term) and at least 60 months (long term). Data collected were blood pressure, number of antihypertensive medications, plasma concentration of potassium, aldosterone, renin and ARR ratio. Surgical outcomes were categorised using PASO criteria of complete, partial or absent success for both clinical and biochemical cure which reflected remission, improvement or persistence of disease [6].

Statistical analysis of the data

Data was analysed using IBM SPSS software package version 20.0. (Armonk, NY: IBM Corp). Qualitative data were described using numbers and percent. The Kolmogorov-Smirnov test and The Shapiro-Wilk test were used to verify the normality of distribution. Quantitative data were described using range (minimum and maximum), mean, standard deviation and median. Paired t-test was assessed for comparison between two periods for normally distributed quantitative variables, while Wilcoxon signed ranks test was assessed for comparison between two periods for abnormally distributed quantitative variables. Anova with repeated measures for normally distributed quantitative variables, to compare more than two periods or stages. While Friedman test for abnormally distributed quantitative variables, to compare between more than two periods or stages and Post Hoc Test (Dunn's) for pairwise comparisons. Marginal Homogeneity Test was used to analyse the significance between the different stages. The significance of the obtained results was judged at the 5% level.

Demographics, presentation, biochemistry and stratification for surgery for the whole cohort of 82 patients

Eighty-two patients diagnosed with PA were included in the study. Forty-five (54.9%) of them were male, 37 (45.1%) female and their mean age was 51.7 years (16.2-75.7). Forty-three (52.4%) patients were white, 18 (21.9%) African/Caribbean, 6 (7.3%) mixed white/black, 9 (10.9%) Asian and in 6 patients’ ethnicity was unknown (7.3%).

Seventy-seven patients (93.9%) presented with hypertension and 61 (74.4%) had hypokalaemia. Three (3.7%) patients had adrenal incidentalomas which led to the diagnosis of PA. Patients’ mean (SD) systolic and diastolic blood pressure were 165.1mmHg (23.7) and 93mmHG (14.9) respectively and mean (SD) potassium level was 3.1mmol/L (0.7). Median aldosterone level was 932 pmol/L (450-2900), renin 0.3 nmolL/H (0.1-2.7) and ARR 2824 (2444-9233).

Fifty-five (67%) patients underwent CT scan and 10 (12.1%) MRI only while 17 (20%) had both. 46 patients (50%) were stratified for surgery following biochemical assessment and imaging with CT or MRI only. Median size of adrenal nodules on cross sectional imaging was 1.8 cm (range 0.4-7.5).

Twenty-six (31.7%) patients had AVS in addition to imaging with an 84.8 % success rate, 7 (8.5%) had both AVS and ¹¹C Metomidate PET-CT while 3 (3.6%) had ¹¹C Metomidate PET-CT scan alone.

Surgery, histology and surgical outcomes for the whole cohort of 82 patients

Laparoscopic adrenalectomy was performed in 77 patients (93.9%) and 4 (4.9%) had open procedures. Laparoscopic adrenalectomy was converted to open surgery in one patient due to bleeding (1.2%). 45 patients had a right (54.8%) and 37 left adrenalectomy (45.1%).

Four patients had postoperative infections treated with antibiotics (Clavien-Dindo II) and one (1.2%) had infected fluid collection in adrenal bed which required antibiotics and percutaneous drainage (Clavien-Dindo IIIa). Two patients (2.4%) in whom spironolactone had not been discontinued, developed hyperkalaemia with an acute kidney injury (Clavien-Dindo IVa), both were treated conservatively and fully recovered. Median hospital stay was 2.5 days (1 – 12).

Histopathology reported 71 adenomas, 6 cases of multinodular hyperplasia and 5 adenomas with nodular hyperplasia. The mean (SD) dimension of adenomas’ on histology examination was 2.3 (1.6) cm (range 0.6–7.5 cm).

Short term biochemical and clinical outcomes at 3 months for 82 patients (Whole cohort) (Table 1)

There was statistically significant improvement in mean systolic and diastolic blood pressure postoperatively from 165 mmHg to 131 mmHg and from 93 mmHg to 82 mmHg respectively. All patients who presented with hypokalaemia had normal potassium postoperatively with the mean potassium rising from 3.1 to 4.5 mmol/L.

Short and long term clinical and biochemical outcomes at 5 years in the cohort of 24 patients (Table 2,3,4.5)

Our results showed that the subgroup of 24 patients with at least 5 years follow-up, similarly to the whole cohort of 82 patients, significant clinical and biochemical benefit from adrenalectomy in a short term and that this effect was sustained at 5 years.

Preoperative hypokalaemia was cured in all, aldosterone levels was significantly reduced, renin became unsuppressed, and because of these changes, the ARR normalised (Table 2). Interestingly and very importantly biochemical cure was sustained 5 years later as indicated by lack of statistical significance when comparing short- and long-term outcomes.

Similarly, patterns of preoperative short- and long-term data suggests that adrenalectomy significantly reduced both systolic and diastolic blood pressure in the short term and that this benefit was sustained in the long term (Table 3).

The number of antihypertensive medications prescribed before and after surgery, an important measure of clinical success of treatment, is shown in Tables 4 and 5. Before surgery a 1/3 of the patients required 1-2 medications with a majority (2/3) needing 3-6 antihypertensives to control their blood pressure. Within 3 months of adrenalectomy about 1/3 did not take any and a half were able to reduce medications and had blood pressure controlled with 1-2 medications. Only 2 patients (10%) needed 3 medications, and none required more than that. These differences between number of tablets taken before and after surgery were statistically significant. At 5 years more patients were able to stop or reduce their medications with some carrying on with the same tablets and only one patient had to increase medications.

Twenty-one patients (87.55%) had clinically benefited from surgery and showed, both in short and long term, complete or partial clinical success according to PASO criteria (Table 6). More patients were classified as complete cure at 5 years as 3 patients who were classified as partial success in short term did not require antihypertensives at 5 years.

Biochemical success was unequivocal with all, but one patient classified as complete biochemical success. The only patient, a 23 year old women with 2.4 cm adrenal adenoma, who was not cured biochemically in the short. In the long term treatment continued with 100 mg of Spironolactone.

Rapid advances in the field of PA is coming mostly from basic scientific research in molecular biology and genetics but more recently also in the form of new ideas about functional imaging and novel therapeutic interventions in this condition[1, 16–18, 20]. These concepts are now moving from the bench to the bedsides of our patients and are being assessed prospectively in clinical trials, but it will be some time before their impact on clinical practice is known[16, 17]. While speeding down the lane of progress we should not lose the sight of milestones already reached as they will help us to judge benefits of new inventions. Our study, which presents short- and long-term outcomes of adrenalectomy in patient with PA in a single centre over the last 24 years, contribute to the current debate about PA by providing such a rear mirror view.

Firstly, one might consider that only 82 adrenalectomies for PA performed over a 24 year period in a tertiary centre is a relatively limited number of cases given the predicated prevalence. To our knowledge, low number of adrenalectomies for PA is not particular to our centre but universal and common experience both in UK and Abroad [21]. As predicted by J.W. Conn in 1955, around 10% of hypertensive patients have PA but the reality is that we are only diagnosing and operating on about 1% of patients with this condition. Clearly case identification needs to increase which will be achieved by improving awareness amongst patients and doctors but also by simplifying the current diagnostic pathways.

Secondly, our paper describes a pragmatic approach to localisation for surgical management which was used during the study period. The pivotal investigation in our localisation strategy was CT or MRI to identify adrenal nodules. Patients with convincing biochemistry and clear unilateral nodules were offered surgery, especially if young. Patients with bilateral nodules or over 35 years of age were tested further with a combination of AVS and functional imaging. Since this approach did not offer AVS routinely but selectively, it is interesting to compare outcomes to other studies where AVS utilised more comprehensively

Overall cure rate in such studies published in the past, which took into account biochemical and clinical outcomes, have typically been reported to vary between 32% − 47%[1, 6, 14, 21, 22]. More recent PASO study showed complete, partial or absent biochemical and clinical success in 94%, 4%, 2% and 37%, 47%, 16% of patients respectively [6]. This study concludes that biochemical and clinical benefit was observed in 98% and 84% of patients. In a MATCH study complete biochemical and clinical success was achieved in 88% and 31% of patients respectively[16].

In our study outcomes at 3 months for the whole cohort of 82 patients showed that hypokalaemia was cured in all patients and statistically significant reduction in blood pressure was achieved. Short term results in 24 patients with long term follow up available showed that all but one patient achieved statistically significant decrease of aldosterone levels, normalisation of ARR, improvement in blood pressure and reduction of medications were observed. At three months complete biochemical success was achieved in 95.8% and complete and partial clinical success in 29.2% and 58.35%, suggesting clinical benefit in 87.55% of our patients. What is remarkable is that these benefits were sustained or even improved at 5 years and only patients who were not cured at three months remained so at 5 years. All patients cured biochemically and clinically in short term remained cured at 5 years. Clinical benefit in long term remained the same as in short term (87.5%) but more patients achieved complete cure (41.7%), perhaps reflecting the need for long term follow up as blood pressure improves and medications reduced.

What are the possible explanations that our outcomes are not inferior to results from series where routine AVS was used?

Perhaps it is the fact that AVS is less than perfect “gold standard” in predicting cure. Spartacus study found no difference in cure rate whether AVS was used or not, although was criticised for its design and underpower [23]. Recently published MATCH study shown that AVS predicted biochemical and clinical cure with 63.3% and 61.5% accuracy[16]. Metomidate was just marginally with accuracy of 72,7% and 65.4%. CT and AVS discrepancy are known to vary from 30–40% but does that always mean that patients who have not met strict criteria for lateralisation (LI > 4) and are not offered surgery would not have benefited? Published evidence on unilateral adrenalectomy in patients with known bilateral PA suggest otherwise, as they reveal biochemical and clinical benefit of what is known as debulking effect and some of our patients might have benefited from it [24].

It is also likely that our good outcomes were the results of stratification based on presence of radiologically obvious and sizable adrenal nodules. Recent studies showed that patients with classic histopathology who form adenomas, are more likely to have unilateral disease and are associated with better chances of cure if adrenalectomy is performed[25, 26]. Non classical histopathology associated with hyperplasia and formation of APMs (formerly APCC) which are not visible on CT, tend to be bilateral and are less likely to be cured by unilateral adrenalectomy[25, 26].

The fact that in our series 76 (93%) patients had sizable adenomas and only 6 had hyperplasia would suggest that our population was artificially enriched by this kind of selection choosing patients who were more likely to be cured. Future studies into somatic mutations responsible for formation of either radiologically detectable or “invisible” adenomas and APMs will help to clarify aetiology of these distinct forms of the PA.

It is also known that results are better in women and younger people but sex and age distribution in our study does not explain that and neither does ethnic mix.

Thirdly, our results strongly confirm that unilateral adrenalectomy is currently the gold standard therapy for patients with PA. There is consensus that in comparison to medical therapy, adrenalectomy offers better management of hypertension, hypokalaemia, and left ventricular hypertrophy [21]. Present series concurred with the introduction of laparoscopic adrenalectomy in our centre, one of the first in the UK. Some open adrenalectomies were performed during transitional period but most operations were laparoscopic procedures with only one conversion. Low complication rate confirmed a safe profile for the laparoscopic approach and the associated short post-operative stay (shorter recently) contributes to its cost-effectiveness[27, 28]. New approaches, such as partial adrenalectomy or ablative techniques using extreme temperatures causing freezing or boiling of adrenal tissue, carry significant risk of not achieving cure in first place or early recurrence of PA[18].

Ablative approaches also have very high cost (catheters, probes), take long time, are associated with increase in radiation, requirement for general anaesthetics and are not currently performed as a day cases, so they might not be cost effective at all.

We acknowledge that the present study has certain limitations. The retrospective design could have affected accuracy of collected data especially as it was carried over a long period of time. Availability of long term follow up data in only a third of our patients is also a limitation

In summary, our single centre results showed that good biochemical and clinical outcomes in patients with PA were achieved in the past 24 years period, coinciding with the switch to laparoscopic adrenalectomy. These good results were almost certainly due to a highly selected population of patients with PA with sizable and radiologically visible adrenal nodules, who were more likely to benefit from adrenalectomy, even if AVS was used selectively rather than routinely. Future developments should focus on identifying the vast majority of subjects with PA who are not currently diagnosed or offered surgery. The current existing pathway for screening, confirming and localising disease are complex, time consuming and inconvenient. AVS, which is sixty years old and one of the oldest procedures still performed by interventional radiologists, is unlikely to be perfected any further and new solutions are needed.

Novel molecular imaging of the adrenal glands could provide a solution with the potential to reshape the scientific and clinical landscape of Primary Aldosteronism. Cholesterol imaging used in the past had very limited accuracy and Metomidate and its derivatives has well known limitations due to its non-selectivity for enzymes involved in aldosterone pathway and difficulty with isotope production¹⁵. However, recent research involving tracers based on highly selective aldosterone synthase blockers, showed that such tracers could reliably detect not only adenomas but also aldosterone producing microadenomas (APMs) in human adrenals both in vitro and in vivo¹⁷. Perhaps imaging based on this technology could shorten diagnostic pathway by making confirmatory step unnecessary and merge subtyping investigations into a single scan. Such transformation of PA diagnostic pathway should improve accuracy of diagnosis, efficiency of stratification for surgery and would be beneficial to patients in the future.

Conflict of interest: all authors declare that they have no conflict of interest. There is no financial conflict of interest.

Compliance with ethical standards:

Ethical Approval: Letter from Medical Research council and Health Research authority

Informed Consent: Consent was given by patients

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Table 1: Pre and 3 months post operative blood pressure and potassium levels in the 82 patients (whole cohort) following adrenalectomy for PA.

	Preoperative	Postoperative	T	p
Potassium (mmol/L)
Low <3.5	61 (74.4%)	0	14.269	<0.001
Normal (3.5-5.3)	21 (25.6)	76 (92.7%)
High (>5.3)	0	6 (7.3%)
Mean ± SD	3.1 ± 0.7	4.5 ± 0.6
Blood pressure (mmHg)
Systolic
Mean ± SD	165.1 ± 23.7	131.7 ± 16.1	11.424^*	<0.001^*
Diastolic
Mean ± SD	93 ± 14.9	82 ± 10.7	7.105^*	<0.001^*

SD: Standard deviation, t: Paired t-test, Z: Wilcoxon signed ranks test
p: p value for comparing between preoperative and postoperative
*: Statistically significant at p ≤ 0.05

Table (2) Pre , 3 months and 5 year post operative biochemical outcomes in the 24 patients following adrenalectomy for PA

Lab	Preoperative	Postoperative	Follow up	Test of sig.	p
Potassium
Median (Min. – Max.)	3.2 (2.4–4.9)	4.8 (3.6–5.9)	4.6 (3.4–5.5)	F= 47.519^*	<0.001^*
Mean ± SD.	3.3 ± 0.6	4.7 ± 0.6	4.6 ± 0.5	F= 47.519^*	<0.001^*
Sig. bet. periods	p₁<0.001^, p₂<0.001^, p₃=0.752
Aldosterone (pmol/L)
Median (Min. – Max.)	932 (450–2900)	115 (60–723)	205 (70 – 1480)	Fr= 37.130^*	<0.001^*
Mean ± SD.	1206.1 ± 729.9	161.8 ± 137	259.4 ± 279.5	Fr= 37.130^*	<0.001^*
Sig. bet. periods	p₁<0.001^, p₂<0.001^, p₃=0.112
Renin (nmol/L/H)
Median (Min. – Max.)	0.3 (0.1–2.7)	1 (0.2–3.9)	1.5 (0.4–8.4)	Fr= 13.640^*	0.001^*
Mean ± SD.	0.8 ± 0.9	1.2 ± 0.8	1.8 ± 1.5	Fr= 13.640^*	0.001^*
Sig. bet. periods	p₁=0.036^, p₂<0.001^, p₃=0.149
ARR				Fr= 34.522^*	<0.001^*
Median (Min. – Max.)	2824.5(244.4–9233)	104.5(23–2410)	127.5(23.8–510)
Mean ± SD.	3413.1 ± 2873.4	280.9 ± 512.8	169.8 ± 114.5
Sig. bet. periods	p₁<0.001^, p₂<0.001^, p₃=0.885

SD: Standard deviation, Fr: Friedman test, Sig. bet. periods was done using Post Hoc Test (Dunn's), F: F test (ANOVA) with repeated measures, Sig. bet. periods was done using Post Hoc Test (adjusted Bonferroni)

p: p value for comparing between the different studied periods
p₁: p value for comparing between Preoperative and 3 months

p₂: p value for comparing between Preoperative and 5 years

p₃: p value for comparing between Postoperative and 5 years

*: Statistically significant at p ≤ 0.05

Table (3): Pre , 3 months and 5 year post operative clinical outcomes in the 24 patients following adrenalectomy for PA

Blood pressure	Preoperative	3 months	5 years	F	p
Systolic (mmHg)
Mean ± SD.	158.4 ± 25	131.8 ± 14.2	132.5 ± 11.2	23.318^*	<0.001^*
Sig. bet. periods	p₁<0.001^, p₂<0.001^, p₃=1.000
Diastolic (mmHg)
Mean ± SD.	93 ± 14.9	82 ± 10.7	81 ± 9.4	10.670^*	<0.001^*
Sig. bet. periods	p₁=0.008^, p₂=0.003^, p₃=1.000

SD: Standard deviation, F: F test (ANOVA) with repeated measures, Sig. bet. periods was done using Post Hoc Test (adjusted Bonferroni)

p: p value for comparing between the different studied periods
p₁: p value for comparing between Preoperative and 3 months

p₂: p value for comparing between Preoperative and 5 years

p₃: p value for comparing between Postoperative and 5 years

*: Statistically significant at p ≤ 0.05

Table (4): Pre , 3 months and 5 year post operative Number of antihypertensive medications outcomes in the cohort of 24 patients

Number of medications	Preoperative	3 months	5 years	Fr	p
0	0 (0%)	7 (29.2%)	10 (41.7%)	35.686^*	<0.001^*
1	5 (20.8%)	6 (25%)	10 (41.7%)
2	4 (16.7%)	9 (37.5%)	2 (8.3%)
3	8 (33.3%)	2 (8.3%)	2 (8.3%)
4	4 (16.7%)	0 (0%)	0 (0%)
5	2 (8.3%)	0 (0%)	0 (0%)
6	1 (4.2%)	0 (0%)	0 (0%)
Sig. bet. periods	p₁<0.001^, p₂<0.001^, p₃=0.312

Fr: Friedman test, Sig. bet. periods was done using Post Hoc Test (Dunn's)

p: p value for comparing between the different studied periods
p₁: p value for comparing between Preoperative and 3 months

p₂: p value for comparing between Preoperative and 5 years

p₃: p value for comparing between Postoperative and 5 years

*: Statistically significant at p ≤ 0.0

Table (5): Comparison between the two studied periods according to medication in the cohort of 24 patients

Medication	3 months	5 years	MH	p
Stopped Reduced	7 (29.2%) 14 (58.3%)	10 (41.7%) 5 (20.8%)	20.0^*	0.008^*

Same	3 (12.5%)	8 (33.3%)
Increased	0 (0%)	1 (4.2%)

MH: Marginal Homogeneity Test

p: p value for comparing between Postoperative and 5 years

*: Statistically significant at p ≤ 0.05

Table (6) Comparison between short and long term outcomes according to PASO criteria in the cohort of 24 patients

PASO group	3 months	5 years
Complete clinical success	7 (29.2%)	10 (41.7%)
Partial clinical success	14 (58.3%)	11 (45.8%)
Absent clinical success	3 (12.5%)	3 (12.5%)
Complete biochemical success	23 (95.8%)	23 (95.8%)
Partial biochemical success	0 (0%)	0 (0%)
Absent biochemical success	1(4.2%)	1(4.2%)

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Reviewers agreed at journal
11 Jul, 2024
Reviewers invited by journal
11 Jul, 2024
Editor invited by journal
10 Jul, 2024
Editor assigned by journal
08 Jul, 2024
First submitted to journal
08 Jul, 2024

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Short- and long-term outcomes of adrenalectomy for Primary Aldosteronism in a single UK centre: Rear Mirror View.

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Abstract

Introduction

Material and methods

Statistical analysis of the data

Results

Discussion

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References

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Status:

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