Do we continue to unnecessarily perform ipsilateral adrenalectomy at the time of radical nephrectomy? A population based study

Abstract

Purpose: Since the mid 1990s evidence has supported ipsilateral adrenal gland sparing radical nephrectomy unless the gland appears involved on imaging or the primary tumor is large and located in the upper pole. However, it is unclear whether this shift in surgical practice has been adopted at the population level.

Materials and methods: Using the Ontario Cancer Registry we identified 5,135 patients in the province of Ontario who underwent radical nephrectomy between 1995 and 2004. Ipsilateral adrenalectomy and tumor involvement of the adrenal gland were ascertained from pathology reports. Further variables analyzed included age, gender, pathology, surgeon year of graduation, academic status of hospital/surgeon, hospital and surgeon volume, and year of surgery. We used multivariable logistic regression to assess outcomes.

Results: The overall rate of adrenal gland involvement with cancer was 1.4%. The adrenal was involved in 3.2% of tumors larger than 7 cm vs only 0.89% of tumors 4 to 7 cm and 0.63% of tumors smaller than 4 cm. Factors predictive of adrenal involvement on multivariable analysis were tumor size greater than 7 cm and fat invasion. The overall adrenalectomy rate was 40.1%, which decreased slightly over time (40.6% in 1995 vs 34.8% in 2004). Variables predictive of adrenal removal on multivariable analysis included tumor size greater than 7 cm, presence of venous thrombus, upper pole location, higher hospital volume, and academic status of hospital or surgeon.

Conclusions: Despite evidence to support preservation of the ipsilateral adrenal gland during radical nephrectomy, the rate of adrenalectomy decreased only slightly in 10 years. Adrenalectomy remains overused in populations that are unlikely to benefit from the procedure.