Improved and individualized approach to adrenal surgery

Abstract

Adrenal surgery has undergone significant advancements, driven by technological innovations, enhanced surgical techniques, and a deeper understanding of adrenal gland pathophysiology. This review highlights the transition toward modern, individualized adrenal surgery, emphasizing minimally invasive techniques, precision medicine, and the development of specialized centers performing more than 500 adrenalectomies a year. Minimally invasive adrenalectomy, specifically the mini back scope adrenalectomy (MBSA, also known as posterior retroperitoneoscopic adrenalectomy), has become the standard of care for most adrenal pathologies, enabling precise function-preserving (partial) adrenalectomy, and offering reduced morbidity, shorter hospital stays, and faster recovery compared to open and transabdominal surgery, whether robotic or laparoscopic. Molecular pathology and enhanced imaging modalities have improved preoperative planning and intraoperative decision-making, allowing for precise tumor localization and preservation of adrenal function. Molecular profiling of adrenal tumors has provided insights into tumor behavior, enabling tailored surgical approaches. In addition, multidisciplinary collaboration has been crucial in developing comprehensive treatment strategies, particularly for complex cases such as familial pheochromocytomas, equivocal unilateral and bilateral primary hyperaldosteronism, and ACTH-independent adrenal hypercortisolism due to bilateral adrenal lesions, adrenocortical carcinoma, and metastatic adrenal disease. Patient-specific factors, including genetic predispositions and comorbidities, are increasingly considered to optimize surgical outcomes and personalize postoperative care. As we enter this improved and individualized era of adrenal surgery, ongoing research and technological advancements are expected to continue to enhance patient outcomes and expand the indications for adrenal surgery.