title: Applicability of laparoscopic approach to the resection of large adrenal tumours: a retrospective cohort study on 200 patients.
abstract: Controversies exist in the best surgical approach (open vs. laparoscopy) to large adrenal tumours without peri-operative evidence of primary carcinoma, mainly due to possible capsular disruption of an unsuspected malignancy. In addition, intra-operative blood loss, conversion rate, operative time, and hospital stay may be increased with laparoscopy.
  
  
  
  (1) to compare clinical outcomes of laparoscopic adrenalectomy for large versus small adrenal tumours and (2) to identify risk factors associated with increased operative time and hospital stay in laparoscopic adrenalectomy.
  
  
  
  This is a multicentre retrospective cohort study in a large patient population (N = 200) who underwent laparoscopic adrenalectomy in 2004-2014 at three Italian academic hospitals. Patients were divided into two cohorts according to tumour size: "large" tumours were defined as ≥5 cm (N = 50) and "small" tumours as <5 cm (N = 150). Further analysis adopting a ≥8 cm (N = 15) cut-off size was performed.
  
  
  
  The study groups were comparable in age and gender distribution as well as their tumour characteristics. The operative time (p = 0.671), conversion rate (p = 0.488), intra- (p = 0.876) and post-operative (p = 0.639) complications, and hospital stay (p = 0.229) were similar between groups. With a cut-off size ≥5 cm, the early study period (2004-2009), which included operators' learning curve, was associated with increased risk of longer operative time (HR 0.57; 95 % CI 0.40-0.82), while American Society of Anaesthesiology score ≥3 was associated with prolonged hospital stay (HR 0.67; 95 % CI 0.47-0.97). Tumour size ≥8 cm was associated with prolonged operative time (HR 0.47; 95 % CI 0.24-0.94).
  
  
  
  Surgeons skilled in advanced laparoscopy and adrenal surgery can perform laparoscopic adrenalectomy safely in patients with ≥5-cm tumours with no increase in hospital stay, or conversion rate, although operative time may be increased for ≥8-cm tumours. Surgeon' experience, size ≥8 cm, and patient comorbidities have the largest impact on operative time and length of hospital stay in laparoscopic large adrenal tumour resection.
authors.affiliation: Section of Clinica Chirurgica, Department of Morphology, Surgery, and Experimental Medicine, S. Anna University Hospital of Ferrara, University of Ferrara, Ferrara, Italy.
authors.forename: Carlo V
authors.initials: CV
authors.lastname: Feo
authors.affiliation: Section of Clinica Chirurgica, Department of Morphology, Surgery, and Experimental Medicine, S. Anna University Hospital of Ferrara, University of Ferrara, Ferrara, Italy. mattia.portinari@unife.it.|Clinica Chirurgica, Arcispedale S. Anna, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro, 8 | 1C2 Room 2 34 03, 44124, Ferrara (Cona), Italy. mattia.portinari@unife.it.
authors.forename: Mattia
authors.initials: M
authors.lastname: Portinari
authors.affiliation: Department of Surgery, University Hospital of Parma, University of Parma, Parma, Italy.
authors.forename: Umberto
authors.initials: U
authors.lastname: Maestroni
authors.affiliation: Department of Surgery, University Hospital of Parma, University of Parma, Parma, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Del Rio
authors.affiliation: Section of Clinica Chirurgica, Department of Morphology, Surgery, and Experimental Medicine, S. Anna University Hospital of Ferrara, University of Ferrara, Ferrara, Italy.
authors.forename: Silvia
authors.initials: S
authors.lastname: Severi
authors.affiliation: Department of Surgery, University Hospital of Parma, University of Parma, Parma, Italy.
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Viani
authors.affiliation: Section of Clinica Chirurgica, Department of Medical and Biological Science, S. Maria della Misericordia University Hospital of Udine, University of Udine, Udine, Italy.
authors.forename: Riccardo
authors.initials: R
authors.lastname: Pravisani
authors.affiliation: Section of Clinica Chirurgica, Department of Morphology, Surgery, and Experimental Medicine, S. Anna University Hospital of Ferrara, University of Ferrara, Ferrara, Italy.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Soliani
authors.affiliation: Section of Endocrinology and Internal Medicine, Department of Medical Sciences, S. Anna University Hospital of Ferrara, University of Ferrara, Ferrara, Italy.
authors.forename: Maria Chiara
authors.initials: MC
authors.lastname: Zatelli
authors.affiliation: Section of Endocrinology and Internal Medicine, Department of Medical Sciences, S. Anna University Hospital of Ferrara, University of Ferrara, Ferrara, Italy.
authors.forename: Maria Rosaria
authors.initials: MR
authors.lastname: Ambrosio
authors.affiliation: Division of Endocrinology, Duke University, Durham, NC, USA.
authors.forename: Jenny
authors.initials: J
authors.lastname: Tong
authors.affiliation: Section of Clinica Chirurgica, Department of Medical and Biological Science, S. Maria della Misericordia University Hospital of Udine, University of Udine, Udine, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Terrosu
authors.affiliation: Section of Clinica Chirurgica, Department of Medical and Biological Science, S. Maria della Misericordia University Hospital of Udine, University of Udine, Udine, Italy.
authors.forename: Vittorio
authors.initials: V
authors.lastname: Bresadola
mesh_terms: D000236:Adenoma / Q000473:pathology / Q000601:surgery; D000310:Adrenal Gland Neoplasms / Q000473:pathology / Q000601:surgery*; D000315:Adrenalectomy; D016063:Blood Loss, Surgical; D015331:Cohort Studies; D005260:Female; D006801:Humans; D010535:Laparoscopy; D059032:Learning Curve; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D010673:Pheochromocytoma / Q000473:pathology / Q000601:surgery; D012189:Retrospective Studies
keywords: Adrenal cancer; Adrenalectomy; Cohort study; Laparoscopy; Multivariate analysis; Retrospective study