Department of Surgery, University of Louisville, Louisville, KY, USA.
J Am Coll Surg. 2011 Jul;213(1):106-12; discussion 112-3. doi: 10.1016/j.jamcollsurg.2011.03.007. Epub 2011 Apr 13.
Historically, treatment of confirmed primary aldosteronism has been adrenalectomy for unilateral adenoma; bilateral hypersecretion is treated medically. Increasingly, we use adrenal venous sampling (AVS) to define unilateral hypersecretion. Histology of glands resected based on AVS often reveals multiple nodules or hyperplasia. The aim of this study was to compare patients with multiple nodules or hyperplasia with those with single adenoma with regard to cure, preoperative imaging, AVS ratio, and biochemical evaluation to determine if a nonsingle adenoma (NSA) process could be predicted to impact extent of adrenalectomy.
This was a retrospective study reviewing a single-institutional surgical experience at a tertiary academic center from 1993 to 2008, during which 215 patients with primary aldosteronism underwent unilateral adrenalectomy based on imaging of a single adenoma (normal contralateral gland) or AVS ratios. Histology included single adenoma versus NSA; cure was defined as normal immediate postoperative plasma or urine aldosterone level, normal aldosterone:renin ratio, or normotension without antihypertensive medications.
Follow-up (mean 13 months, range 0 to 185 months) was available for 167 patients: 132 (79%) single adenoma and 35 (21%) NSA. All 35 patients with NSA and 128 patients (97%) with single adenoma were cured. Imaging studies correctly predicted NSA in 29% and 57% when combined with AVS. Identifying patients with NSA preoperatively was impossible biochemically: mean serum and urinary aldosterone levels and AVS ratios were not different than those of the single adenoma group.
Twenty-one percent of patients had NSA, all cured by unilateral adrenalectomy. No preoperative evaluation reliably predicted NSA. Therefore, total unilateral adrenalectomy was safest given the potential for incomplete resection with partial adrenalectomy. Accurate AVS is highly predictive of cure irrespective of the unilateral adrenal histology.
从历史上看，单侧腺瘤所致确诊的原发性醛固酮增多症的治疗方法是肾上腺切除术；双侧过度分泌则采用药物治疗。目前，我们越来越多地使用肾上腺静脉采样（AVS）来确定单侧过度分泌。根据 AVS 进行切除的腺体组织学检查通常显示多个结节或增生。本研究旨在比较单侧多个结节或增生与单侧单个腺瘤患者的治愈率、术前影像学检查、AVS 比值和生化评估，以确定非单个腺瘤（NSA）过程是否可以预测肾上腺切除术的范围。
这是一项回顾性研究，回顾了 1993 年至 2008 年期间在一家三级学术中心的单一机构手术经验，在此期间，215 例原发性醛固酮增多症患者根据单侧腺瘤（对侧正常腺体）的影像学或 AVS 比值进行单侧肾上腺切除术。组织学检查包括单个腺瘤与 NSA；治愈定义为术后即刻血浆或尿液醛固酮水平正常、醛固酮/肾素比值正常或血压正常而无需抗高血压药物。
167 例患者可获得随访（平均随访时间 13 个月，范围 0 至 185 个月）：132 例（79%）为单个腺瘤，35 例（21%）为 NSA。所有 35 例 NSA 患者和 128 例（97%）单个腺瘤患者均治愈。影像学检查与 AVS 联合使用时，正确预测 NSA 的准确率为 29%和 57%。术前无法通过生化指标预测 NSA：平均血清和尿醛固酮水平及 AVS 比值与单个腺瘤组无差异。
21%的患者存在 NSA，单侧肾上腺切除术均治愈。术前无任何评估能可靠预测 NSA。因此，考虑到部分肾上腺切除术可能不完整，单侧肾上腺全切除术是最安全的。无论单侧肾上腺组织学如何，准确的 AVS 对治愈率具有高度预测性。
