Adrenal Surgery

Specialist assessment and surgery for adrenal incidentalomas, hormone-producing tumours and suspicious adrenal masses.

AI
Adrenal incidentaloma

An adrenal lesion discovered unexpectedly on imaging performed for another reason.

Ald
Conn's syndrome

Excess aldosterone production causing hypertension and, in some patients, low potassium.

Pheo
Phaeochromocytoma

A catecholamine-producing adrenal tumour requiring careful preparation before surgery.

C
Cortisol excess

Adrenal cortisol production ranging from mild autonomous secretion to overt Cushing syndrome.

What are the adrenal glands?

The adrenal glands sit above the kidneys and produce several important hormones involved in blood pressure, metabolism and the body's response to stress.

Adrenal lesions are increasingly found incidentally during CT or MRI scans performed for unrelated reasons.

Most adrenal incidentalomas are benign, but each lesion needs to be considered in terms of both its hormone production and its imaging characteristics.

Adrenal hormones include

  • Cortisol
  • Aldosterone
  • Adrenaline and noradrenaline
  • Adrenal androgens
Adrenal Assessment

Two questions guide the assessment

An adrenal lesion needs both biochemical and radiological assessment.

1

Is it hormonally active?

Hormonal assessment is tailored to the clinical situation and imaging appearance.

  • 1 mg overnight dexamethasone suppression test
  • Plasma or urinary metanephrines where appropriate
  • Aldosterone:renin ratio in hypertension or unexplained hypokalaemia
  • Additional hormone testing in selected cases
2

Does it look suspicious?

CT or MRI characteristics help determine whether a lesion behaves like a benign adrenal adenoma or requires further assessment.

  • Unenhanced CT attenuation in Hounsfield units
  • Homogeneous or heterogeneous appearance
  • Size and morphology
  • Growth on serial imaging
  • Evidence of local invasion or other concerning features
Surgical Assessment

When is adrenal surgery considered?

Conn's syndrome A unilateral aldosterone-producing adrenal adenoma may be treated definitively with adrenalectomy.
Phaeochromocytoma Surgery is generally recommended following appropriate biochemical diagnosis and preoperative preparation.
Cortisol-producing lesions Surgery may be appropriate for overt cortisol excess and selected patients with autonomous cortisol secretion.
Suspicious adrenal mass Lesions with concerning imaging, growth or clinical features may require surgery after specialist assessment.
Surgical Approach

Laparoscopic or open adrenalectomy?

The surgical approach depends on the underlying diagnosis, imaging characteristics, anatomy and concern for malignancy.

Minimally invasive adrenalectomy

Many benign and functioning adrenal tumours can be removed using a minimally invasive approach.

  • Small incisions
  • Reduced postoperative pain
  • Earlier mobilisation
  • Shorter recovery for many patients

Open adrenalectomy

An open approach may be preferable when the lesion is suspicious for adrenocortical carcinoma, locally invasive, very large or technically complex.

The priority in suspected malignancy is safe, complete oncological removal.

The surgical approach is determined by the biology and anatomy of the lesion, not simply by its size.
Before Surgery

Preparation for adrenal surgery

Preparation is tailored to the hormone produced by the tumour and the patient's underlying health.

Biochemical diagnosis Hormone excess should be appropriately assessed before surgery.
Blood pressure Hypertension should be appropriately assessed and optimised.
Electrolytes Potassium and other abnormalities may need correction, particularly in Conn's syndrome.
Phaeochromocytoma Alpha blockade and careful perioperative planning are required before phaeochromocytoma surgery.
After Surgery

Recovery

Hospital stay Many patients undergoing minimally invasive adrenalectomy have a relatively short hospital stay.
Mobilisation Walking and light activity are encouraged early after surgery.
Hormone monitoring Blood pressure, electrolytes or hormone levels may need monitoring depending on the underlying condition.
Return to activity Activity is progressively increased as recovery continues.

Discuss your adrenal lesion

Assessment brings together the imaging, hormonal evaluation and individual clinical circumstances to determine whether observation, further investigation or surgery is most appropriate.

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