title: Adrenal giant cystic pheochromocytoma treated by posterior retroperitoneoscopic adrenalectomy.
abstract: BACKGROUND
  Giant cystic pheochromocytoma (>10cm) is rare with only a few cases described in the literature. Preoperative diagnosis is very difficult because clinical, biochemical and radiologic finds are usually not consistent with a pheochromocytoma. Open surgery is traditionally the gold standard.
  
  
  METHODS
  A 51 year-old male patient resorted to surgery department with an adrenal cystic incidentaloma. He was asymptomatic, mild hypertension easily controlled, with increased plasma fractionated metanephrines. MRI and MIBG scans confirmed the presence of a right adrenal giant cystic pheochromocytoma (14cm). A right posterior retroperitoneoscopic adrenalectomy was performed, complicated with an unintended disruption. At follow-up he was asymptomatic and with plasma fractionated metanephrines normalized.
  
  
  CONCLUSIONS
  Although laparoscopic surgery is effective and safe, traditional open surgery is the gold standard in the presence of adrenal tumours with suspicion of malignancy, like masses larger than 8cm (including giant cystic pheochromocytomas). Minimal invasive techniques have the advantages of less postoperative pain and ileus, less morbidity, improved cosmetics, and faster recovery, but with the negative impact in R0 resection and probably a higher risk of cystic rupture. However comparisons between open and minimally invasive surgery are lacking. Additionally posterior retroperitoneoscopic approach has several advantages over laparoscopic transperitoneal method.
  
  
  CONCLUSIONS
  This is the first case report of a giant cystic pheochromocytoma treated by posterior retroperitoneoscopic adrenalectomy, but the occurrence of the unintended rupture may be a factor against this approach. More studies are needed to compare open and minimally invasive techniques in terms of resectability and cystic rupture rate.
authors.affiliation: Surgery C, Centro Hospitalar e Universitário de Coimbra, Hospital Geral (Covões), Portugal. Electronic address: carloscostaalmeida@yahoo.com.
authors.forename: Carlos E
authors.initials: CE
authors.lastname: Costa Almeida
authors.affiliation: Surgery C, Centro Hospitalar e Universitário de Coimbra, Hospital Geral (Covões), Portugal. Electronic address: mafr.silva@gmail.com.
authors.forename: Marta
authors.initials: M
authors.lastname: Silva
authors.affiliation: Surgery C, Centro Hospitalar e Universitário de Coimbra, Hospital Geral (Covões), Portugal. Electronic address: luisfcarvalho@netcabo.pt.
authors.forename: Luis
authors.initials: L
authors.lastname: Carvalho
authors.affiliation: Surgery C, Centro Hospitalar e Universitário de Coimbra, Hospital Geral (Covões), Portugal. Electronic address: c.m.costa.almeida@gmail.com.
authors.forename: Carlos Manuel
authors.initials: CM
authors.lastname: Costa Almeida
keywords: Adrenal; Giant cystic pheochromocytoma; Posterior retroperitoneoscopy; Retroperitoneoscopic adrenalectomy