“Leave No Adrenal Behind” – Still the Right Policy?

Answer: D For many years since Robson's initial description of radical nephrectomy, removal of the ipsilateral adrenal gland was an integral part of radical renal surgery.  Over time, the necessity of adrenalectomy at the time of nephrectomy has been challenged.1  In...

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Answer: D 

For many years since Robson’s initial description of radical nephrectomy, removal of the ipsilateral adrenal gland was an integral part of radical renal surgery.  Over time, the necessity of adrenalectomy at the time of nephrectomy has been challenged.¹  In fact, recent recommendations suggest that the adrenal should be uniformly spared except when: (1) imaging indicates or cannot rule out adrenal involvement by RCC; (2) tumor thrombus is present to the level of the adrenal vein; and (3) when the renal tumor is ≥7 cm and is in the upper pole. Recent data from our institution suggest that if the adrenal gland is unremarkable on cross-sectional imaging, it can be safely spared even in patients with large upper pole renal tumors.²  Furthermore, an analysis of a large cohort from the Mayo Clinic indicates that 6% of patients with >7cm renal tumors develop contralateral adrenal metastasis at long-term follow-up, providing additional support for the need to spare normal ipsilateral adrenal tissue during renal surgery.³

The case was prepared by Alexander Kutikov, MD, of Fox Chase Cancer Center in Philadelphia.

1. O’Malley RL, Godoy G, Kanofsky J A. et al.: The necessity of adrenalectomy at the time of radical nephrectomy: a systematic review. J Urol 2009;181:2009-2017.
2. Kutikov A, Piotrowski ZJ, Canter, DJ, et al. Routine adrenalectomy is unnecessary during surgery for large and/or upper pole renal tumors: When the adrenal gland is radiographically normal. J Urol 2011;185:1198-1203.
3. Weight CJ, Kim SP, Lohse CM, et al. Routine adrenalectomy in patients with locally advanced renal cell cancer does not offer oncologic benefit and places a significant portion of patients at risk for an asynchronous metastasis in a solitary adrenal gland. Eur Urol 2011;60:458-464.