Minimally Invasive Partial vs. Total Adrenalectomy for the Treatment of Unilateral Primary Aldosteronism: A Systematic Review and Meta-Analysis

Abstract

Background: This systematic review and metanalysis was conducted to assess differences between perioperative and functional outcomes in patients undergoing minimally-invasive partial (mi-PA) and total adrenalectomy (mi-TA) for unilateral primary aldosteronism (uPHA).

Material and methods: Multiple scientific databases (PUBMED, Web of Science, and Cochrane Library) were searched up to November 2021 for surgical series comparing mi-PA vs. mi-TA for uPHA according to the PRISMA statement. Primary outcomes of interest were perioperative and functional outcomes.

Results: Overall, a total of 802 patients from six eligible studies were identified, with mi-PA and mi-TA performed in 40.4% (n = 324) and 59.6% (n = 478) of cases, respectively. No differences were recorded between the two groups according to number of transfusions, EBL and Clavien-Dindo complications ≥2. Similarly, no differences in clinical success, persistence of postoperative hypokalemia and improvement in HTN were reported between mi-PA and mi-TA.

Conclusions: In a uPHA setting, mi-PA and mi-TA provide comparable perioperative and functional outcomes despite the use of mi-PA remains limited to patients with small adenoma size, or hereditary/bilateral disease. Due to limited use of standardized reporting criteria in most of current series, the quest for a superiority of mi-PA over mi-TA in the treatment of uPHA still remains open.

Keywords: Conn’s syndrome; PASO; partial adrenalectomy; total adrenalectomy; unilateral primary aldosteronism.

Figure 1

PRISMA flow chart.

Figure 2

Cumulative analysis of eligible studies comparing mi-PA vs. mi-TA in terms of (a) operative time, (b) transfusion rate, (c) blood loss, (d) hospital stay, (e) overall complication, and (f) Clavien–Dindo ≥ 2. IV = inverse variance; SD = standard deviation; CI = confidence interval; M–H = Mantel–Haenszel. Each studies is represented by a square incorporating confidence intervals represented by horizontal lines. The area of each square is proportional to the study’s weight in the meta-analysis. The meta-analysed measure of effect is plotted as a diamond with lateral points indicating confidence intervals.

Figure 2

Cumulative analysis of eligible studies comparing mi-PA vs. mi-TA in terms of (a) operative time, (b) transfusion rate, (c) blood loss, (d) hospital stay, (e) overall complication, and (f) Clavien–Dindo ≥ 2. IV = inverse variance; SD = standard deviation; CI = confidence interval; M–H = Mantel–Haenszel. Each studies is represented by a square incorporating confidence intervals represented by horizontal lines. The area of each square is proportional to the study’s weight in the meta-analysis. The meta-analysed measure of effect is plotted as a diamond with lateral points indicating confidence intervals.

Figure 3

Cumulative analysis of eligible studies comparing mi-PA vs. mi-TA in terms of (a) complete clinical success according to PASO criteria, (b) partial clinical success according to PASO criteria, (c) absent clinical success according to PASO criteria, (d) no-standardized complete clinical success, (e) no-standardized absent clinical success, (f) postoperative SBP, (g) postoperative DBP, (h) postoperative mean potassium serum levels, (i) postoperative persistent hypokalemia, (j) postoperative improved hypertension, and (k) postoperative plasma renin activity. IV = inverse variance; SD = standard deviation; CI = confidence interval; M-H = Mantel-Haenszel. Each studies is represented by a square incorporating confidence intervals represented by horizontal lines. The area of each square is proportional to the study’s weight in the meta-analysis. The meta-analysed measure of effect is plotted as a diamond with lateral points indicating confidence intervals.

Figure 3

Cumulative analysis of eligible studies comparing mi-PA vs. mi-TA in terms of (a) complete clinical success according to PASO criteria, (b) partial clinical success according to PASO criteria, (c) absent clinical success according to PASO criteria, (d) no-standardized complete clinical success, (e) no-standardized absent clinical success, (f) postoperative SBP, (g) postoperative DBP, (h) postoperative mean potassium serum levels, (i) postoperative persistent hypokalemia, (j) postoperative improved hypertension, and (k) postoperative plasma renin activity. IV = inverse variance; SD = standard deviation; CI = confidence interval; M-H = Mantel-Haenszel. Each studies is represented by a square incorporating confidence intervals represented by horizontal lines. The area of each square is proportional to the study’s weight in the meta-analysis. The meta-analysed measure of effect is plotted as a diamond with lateral points indicating confidence intervals.

Figure 3

Cumulative analysis of eligible studies comparing mi-PA vs. mi-TA in terms of (a) complete clinical success according to PASO criteria, (b) partial clinical success according to PASO criteria, (c) absent clinical success according to PASO criteria, (d) no-standardized complete clinical success, (e) no-standardized absent clinical success, (f) postoperative SBP, (g) postoperative DBP, (h) postoperative mean potassium serum levels, (i) postoperative persistent hypokalemia, (j) postoperative improved hypertension, and (k) postoperative plasma renin activity. IV = inverse variance; SD = standard deviation; CI = confidence interval; M-H = Mantel-Haenszel. Each studies is represented by a square incorporating confidence intervals represented by horizontal lines. The area of each square is proportional to the study’s weight in the meta-analysis. The meta-analysed measure of effect is plotted as a diamond with lateral points indicating confidence intervals.