Adrenal surgery is performed by a wide range of providers including urologists, endocrine surgeons, and general surgeons.¹ Indications for adrenal surgery can vary from benign masses that are large or enlarging; to functionally active masses that can cause excess of secretion of catecholamines, cortisol, or aldosterone; to malignant masses such as adrenocortical carcinoma (ACC) or metastases.² The workup of an adrenal mass often requires multidisciplinary team input and coordination. Studies from the last decade suggest that urologists perform a minority of adrenal surgeries in the US as compared to general surgeons, but are more likely to use minimally invasive techniques.^3-5 While these studies are limited by their retrospective nature and likely do not capture all adrenal surgeries performed or surgeon specialty, it appears that urologists play a smaller role in adrenal surgery than general or endocrine surgeons, despite familiarity with retroperitoneal surgery. In terms of resident education, both general surgery and urologic residents have no required minimums in adrenal surgery, although urologic training requires at least 50 retroperitoneal surgeries to be performed, of which 40 cases must involve the kidneys. As minimally invasive surgery (MIS) gains popularity in the treatment of adrenal masses, the urologist’s role should be reevaluated given our experience with MIS in the retroperitoneum.¹

Utilization of MIS for adrenal masses has increased significantly in the past decade; however, the use of MIS techniques for malignant masses remains controversial, and open resection is the standard of care for ACC.^1,6 Additionally, tumor size is often used as an indication for open adrenalectomy, with MIS techniques often recommended for masses less than 6 centimeters in diameter.⁷ However, in practice, many surgeons choose to use an MIS approach for large masses even if suspicious for ACC. A study published by Delman et al in 2022 reviewed 1483 patients who underwent adrenalectomy for ACC, of which 34% underwent MIS resection.⁶ They found that there was no difference in overall survival between MIS and open resection techniques; this remained true for patients with ACC greater than 6 centimeters and greater than 10 centimeters, suggesting that tumor size does not independently impact overall survival and that MIS approach can be considered without risk of oncologic compromise.⁶

MIS techniques encompass both laparoscopic adrenalectomy (LA) and robotic adrenalectomies (RAs). While LA has remained popular among urologists and general surgeons since the first case was performed in 1992, it can be challenging in the case of large masses and obese patients.⁸ RA is able to overcome inherent limitations of LA, such as limited range of motion of surgical instruments and 2D imaging, and therefore has become increasingly adopted for adrenal surgery since 1999.⁸ A study reviewing 477 patients who underwent adrenalectomy via MIS approach, with 110 patients undergoing RA and 367 undergoing LA, showed no difference in intraoperative or postoperative complication rates. Tumor size treated by RA was significantly larger than those treated laparoscopically.⁸ Further studies are needed to examine oncologic outcomes between LA and RA.

Overall, robotic surgery in the retroperitoneum is becoming increasingly utilized by urologists, especially for nephron sparing surgery in patients with localized renal cancers, and there will likely be a similar trend seen in adrenal surgery.⁹ As RA becomes more widely adopted as the preferred method of adrenal surgery for both benign and malignant causes, the urologist’s role should be reevaluated. Given the experience that urologists have with MIS and robotic surgery in the retroperitoneum, there may be a change in practice patterns with increased referrals to urology for adrenal mass treatment. Additional prospective data are needed on oncologic outcomes between open, LA, and RA approaches and to evaluate ongoing shifts in practice trends.

Since 2002, the AUA Residents and Fellows Committee has represented the voice of trainee members. The Committee’s mission is to address the educational and professional needs of urology residents and fellows and promote engagement with the AUA. The Committee welcomes your input and feedback! To contact us, or inquire about ways to be involved, please email rescommittee@AUAnet.org.