Perioperative outcomes of adrenal surgery: Does surgical specialty matter?

Introduction: Management of adrenal disease requires a multidisciplinary approach often involving varied specialists. Surgical management has often overlapped between general surgeons, usually with an interest in surgical endocrinology, or urologists with minimally invasive surgical skills. The objectives of this study were to define perioperative outcomes of contemporary Canadian adrenal surgery, and determine whether those outcomes are impacted by surgical subspecialty. As a secondary outcome, an assessment of the variability in the indications for adrenal surgery was carried out between the two surgical subspecialties.

Methods: A retrospective chart review of all adrenalectomies performed at our center from August 2013 to August 2023 was conducted. The only exclusion criterion was when an adrenalectomy was performed secondary to the main procedure. Data was collected and grouped under four categories: patient characteristics, indications for an adrenalectomy, procedural statistics, and perioperative patient outcomes.

Results: A total of 121 adrenalectomies were performed in a period of just over 10 years. Of these, 103 were included in the analysis. Thirty-seven were performed by general surgery, whereas 66 were performed by urology. There were no significant differences in patients' age and Charlson comorbidity score between the two surgical specialties. The indications for the adrenalectomy were similar between the specialties, and were as follows: 32 (31.1%) for pheochromocytoma, 24 (23.3%) for a cortical functional lesion, 19 (18.4%) for a metastatectomy, 16 (15.5%) for size or growth, and 10 (9.7%) for adrenocortical carcinoma. There were no differences in overall operating room time or type of procedure. Most (89.3%) of the procedures were performed laparoscopically. Patients that were operated on by general surgeons were more likely to be readmitted within 30 days than those operated on by urologists (five patients [13.5%] vs. one patient [1.5%], respectively, p=0.04), and more likely to require intensive care unit (ICU)/stepdown ICU admission (19 patients [51.4%] vs. 19 [28.8%], respectively, p=0.04). There was no difference in length of stay or postoperative complications. There was, however, one Clavien-Dindo 5 complication after a procedure performed by general surgery.

Conclusions: Most adrenalectomies at this one Canadian center are performed by urology. Indications for adrenalectomy are similar between the specialties. Although postoperative complication rates are similar, rates of 30-day readmission and ICU/stepdown admission were decreased when urologists performed adrenalectomies. Adrenalectomies may be performed safely by either specialty, and factors such as local expertise and surgical volumes are likely important.