title: Laparoscopic upper pole partial nephrectomy with concomitant en bloc adrenalectomy.
abstract: OBJECTIVE
  To report our experience with laparoscopic partial nephrectomy for renal tumor with concomitant adrenalectomy. An upper pole renal tumor may contiguously involve the adrenal gland, requiring concomitant adrenalectomy. Although commonly performed in the setting of laparoscopic radical nephrectomy, concomitant adrenalectomy has not been described during laparoscopic partial nephrectomy.
  
  
  METHODS
  Four patients with an upper pole renal tumor and suspected adrenal involvement underwent laparoscopic partial nephrectomy with concomitant ipsilateral adrenalectomy. Preoperative three-dimensional computed tomography revealed the renal tumor to be closely abutting the adrenal gland in 3 patients and a 4-cm adrenal mass in 1 patient. The mean renal tumor size was 3.2 cm (range 1.4 to 6.6). To maintain oncologic principles, our transperitoneal laparoscopic technique excises the adrenal gland en bloc with the renal tumor. As such, adrenalectomy is performed first, followed by partial nephrectomy, incorporating hilar control, tumor excision, and sutured renal reconstruction.
  
  
  RESULTS
  All four procedures were performed without open conversion or intraoperative complications. The mean renal warm ischemia time was 36 minutes, estimated blood loss 169 mL, total operating time 3.9 hours, and hospital stay 3.2 days. One patient developed a transient urinary leak postoperatively. Pathologic examination of the renal tumor revealed renal cell carcinoma (n = 1), dystrophic calcification with ectopic bone formation (n = 1), adult mesoblastic nephroma (n = 1), and subcapsular heterotopic adrenal cortex with cyst (n = 1), all with negative surgical margins. Pathologic examination of the adrenal gland revealed adenoma in 1 case and a normal adrenal gland without malignant involvement in 3 cases. All patients were disease free at last follow-up (mean 6.2 months, range 2 to 12).
  
  
  CONCLUSIONS
  In patients with an upper pole renal tumor and radiologically suspected adrenal involvement, laparoscopic partial nephrectomy with concomitant adrenalectomy can be performed efficaciously respecting oncologic principles.
authors.affiliation: Section of Laparoscopic and Minimally Invasive Surgery, Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
authors.forename: Anup P
authors.initials: AP
authors.lastname: Ramani
authors.forename: Sidney C
authors.initials: SC
authors.lastname: Abreu
authors.forename: Mihir M
authors.initials: MM
authors.lastname: Desai
authors.forename: Andrew P
authors.initials: AP
authors.lastname: Steinberg
authors.forename: Christopher
authors.initials: C
authors.lastname: Ng
authors.forename: Chia-Hsiang
authors.initials: CH
authors.lastname: Lin
authors.forename: Jihad H
authors.initials: JH
authors.lastname: Kaouk
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
mesh_terms: D000236:Adenoma / Q000175:diagnosis / Q000601:surgery; D000310:Adrenal Gland Neoplasms / Q000175:diagnosis / Q000601:surgery*; D000311:Adrenal Glands / Q000473:pathology / Q000502:physiology / Q000601:surgery; D000315:Adrenalectomy / Q000379:methods*; D000328:Adult; D002292:Carcinoma, Renal Cell / Q000175:diagnosis / Q000601:surgery; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000175:diagnosis / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods*; D018201:Nephroma, Mesoblastic / Q000175:diagnosis / Q000601:surgery