Bilateral Adrenalectomy Riskier Than Unilateral, Study Says

Vanda Pinto, PhD avatar

by Vanda Pinto, PhD |

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A bilateral adrenalectomy — a surgery to remove both adrenal glands — to lower cortisol levels in patients with Cushing’s syndrome was associated with more severe post-surgery complications and a higher mortality rate, compared with unilateral adrenalectomy, a study has found.

“If indicated, bilateral adrenalectomy is a feasible option for otherwise uncontrolled hypercortisolism [excessive cortisol levels]. However, the disproportionately high morbidity and mortality of this intervention must be considered,” the researchers wrote.

The study, “Differences in morbidity and mortality between unilateral adrenalectomy for adrenal Cushing’s syndrome and bilateral adrenalectomy for therapy refractory extra-adrenal Cushing’s syndrome,” was published in the journal Langenbeck’s Archives of Surgery.

Cushing’s syndrome is characterized by the excessive production of the stress hormone cortisol, or hypercortisolism, and it can be classified as adrenocorticotropic hormone (ACTH)-independent or ACTH-dependent. ACTH is a hormone that controls the production of cortisol by the adrenal glands.

ACTH-independent cases are caused by cortisol-producing adrenal adenomas — benign tumors in the adrenal glands. ACTH-dependent Cushing’s can result from tumors located in the brain’s pituitary gland (Cushing’s disease) or outside the pituitary or adrenal glands (ectopic Cushing’s syndrome).

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For some patients with ACTH-dependent Cushing’s, removing the tumor, or taking medications to lower cortisol levels are insufficient to cure or control the condition, putting these patients at a higher risk of death or other health problems, such as infections. That’s why doctors often opt for a bilateral adrenalectomy to avoid potential complications.

However, according to researchers, bilateral adrenalectomy is considered a riskier procedure than unilateral adrenalectomy, which usually is the treatment of choice for people with ACTH-independent Cushing’s syndrome.

To determine whether a unilateral adrenalectomy could be a better surgical option in terms of morbidity and mortality, the research team retrieved patient data from the information system of a hospital in Germany. Adult patients ages 18 or older who had undergone an adrenalectomy for hypercortisolism from 2008 to 2021 were included in the study.

Data from 83 patients were analyzed. More than half (65%) were women, with a median age of 53 years. Most patients (72%) underwent an adrenalectomy to remove an adrenal adenoma. Only one of these surgeries was a bilateral adrenalectomy. Sixteen patients with Cushing’s disease and seven with ectopic Cushing’s had a bilateral adrenalectomy.

Patients with bilateral adrenalectomy had a higher rate of severe complications compared with those who had had a unilateral adrenalectomy (33% vs. 0%) as assessed by the Clavien-Dindo classification system of post-surgery complications.

A delay in recovery was observed in almost 80% of the patients who had a bilateral adrenalectomy, compared with 10% of patients undergoing unilateral adrenalectomy. Additionally, the length of intensive care stay (one day vs. three days), as well as the length of post-surgery stay (six days vs. 14 days) were longer for patients undergoing bilateral adrenalectomy.

In fact, statistical analysis revealed that patients who underwent bilateral adrenalectomy were at a greater risk of having delayed recovery after surgery.

Next, the team evaluated differences in the MTL30 marker, a measure of post-surgical outcomes that takes into account 30-day mortality, transfer within 30 days to another hospital, and a length of stay of more than 30 days. Patients with bilateral adrenalectomy had a worse outcome after surgery than those having unilateral adrenalectomy (MTL30 positive: 25% vs. 7.2%).

Two patients who had a bilateral adrenalectomy died after surgery, while there were no deaths among those in the unilateral adrenalectomy group. In agreement, the risk of mortality after surgery was higher among patients who had bilateral adrenalectomy than in those who underwent unilateral adrenalectomy (8.3% vs. 0%)

“While unilateral adrenalectomy for adrenal Cushing’s syndrome represents a safe and definitive therapeutic option, bilateral adrenalectomy to control ACTH-dependent extra-adrenal Cushing’s syndrome or Cushing’s disease is a more complicated intervention with a mortality of nearly 10%,” the researchers wrote.