actas urol esp. 2010;34(7):586–591 Revista Oficial de la AEU y de la CAU
ACTAS
ACTAS UROLÓGICAS ESPAÑOLAS
Actas Urológicas Españolas
Vol. 34. Núm. 2.
UROLÓGICAS E S PA Ñ O L A S
EDITORIALES 129
¿Es realmente el cistocele un factor de obstrucción infravesical?
¿Entran el axonema y las mitocondrias espermáticas en el oocito durante el proceso de la fecundación?
132
ORIGINAL BREVE- CÁNCER DE TESTÍCULO
134
ORIGINAL BREVE- SUPRARRENAL
Infarto testicular segmentario: un pseudotumor infrecuente
REVISIÓN- CÁNCER RENAL Tratamiento de los tumores renales localmente avanzados
Adrenalectomía laparoscópica por metástasis metácrona. Experiencia en 12 casos
ORIGINALES- HISTORIA Treinta años del Grupo de Trabajo de Urología Oncológica de la Asociación Española de Urología (1978-2008) Baltasar Llopis Mínguez (1934-1990). Pionero en la investigación del cáncer vesical y en la introducción de la informática en Urología
142
158
ORIGINAL- CÁNCER UROTELIO SUPERIOR Abordaje del uréter distal en la nefroureterectomía laparoscópica
165
ORIGINAL- ENDOUROLOGÍA Fotovaporización prostática láser Greenlight HPS en régimen de cirugía mayor ambulatoria
170
ORIGINAL- DISFUNCIÓN MICCIONAL Distribución demográfica y prevalencia de la vejiga hiperactiva en Venezuela
176
ORIGINAL- SUPRARRENAL
www.elsevier.es/actasuro
Febrero 2010
ORIGINAL BREVE- DISFUNCIÓN MICCIONAL
Comentario editorial al trabajo “Nefrectomía laparoscópica asistida por la mano”
Suprarrenalectomía laparoscópica. Experiencia de 5 años
181
ORIGINAL BREVE- CÁNCER RENAL Nefrectomía laparoscópica asistida por la mano en casos difíciles
194
201
206
Tumor adenomatoide de túnica albugínea. Caso clínico
208
Seminoma testicular bilateral sincrónico en un paciente adulto con criptorquidia bilateral: reporte de un caso y revisión de la literatura
210
Blastomicosis prostática: presentación de un caso y revisión de la literatura 212 Fractura de pene. A propósito de dos casos
213
Malformación arteriovenosa renal congénita: utilidad de la resonancia magnética para el diagnóstico y abordaje endovascular
215
IMÁGENES EN UROLOGÍA Hernia paraestomal gigante en paciente con derivación urinaria ileal
218
Carcinoma epidermoide balanoprepucial de nueva aparición tras circuncisión 218 219
Perlas escrotales o escrotolitos 186
189
CARTAS CIENTÍFICO-CLÍNICAS Tumor fibroso solitario vesical
Exéresis de masa residual retroperitoneal: vena renal retro-aórtica
219
Edición electrónica: Free Full Text Español/Inglés www.elsevier.es/actasuro
Special article
Management of adrenal mass: What urologist should know M. Hevia Suáreza, J.M. Abascal Junqueraa,*, P. Boixb, M. Dieguezb, E. Delgadob, J.M. Abascal Garcíaa, and R. Abascal Garcíaa aUrology
Service, Hospital Universitario Central de Asturias, Oviedo, Spain Service, Hospital Universitario Central de Asturias, Oviedo, Spain
bEndocrinology
ARTICLE INFORMATION
A B S T R A C T
Article history:
Adrenal incidentaloma’s prevalence is rising because of the big volume of radiologic
Received 26 November, 2009
explorations that we daily do. No comprehensive guidelines have been published by
Accepted 27 November, 2009
professional societies to guide the evaluation of patients with adrenal incidentalomas. All adrenal masses should be inspected for malignancy or hypersecreting disorders. In
Keywords:
our point of view, adrenal surgery should be performed by the urologist, because it’s the
Incidentaloma
medical speciality which knows the best this anatomical region. The objective of this
Diagnosis
review is to present the main points that the urologist may know in the management
Presurgical management
of adrenal masses. Together with the department of Endocrinology of our hospital, we describe the main studies to perform in front of adrenal mass diagnosis and the current therapeutical diagram utilized in our center. © 2009 AEU. Published by Elsevier España, S.L. All rights reserved.
Manejo de la masa suprarrenal: lo que el urólogo debe saber R E S U M E N
Palabras clave:
El incidentaloma suprarrenal es una entidad en aumento en la práctica clínica habi-
Incidentaloma
tual debido al gran número de exploraciones radiológicas que se realizan. No existen
Diagnóstico
guías clínicas publicadas sobre el manejo del incidentaloma suprarrenal apoyadas por
Manejo preoperatorio
ninguna sociedad científica. Toda masa suprarrenal debe ser estudiada para descartar malignidad o hipersecreción hormonal. Creemos que la patología suprarrenal quirúrgica debe ser manejada por el urólogo, por ser la especialidad que mayor relación tiene con el retroperitoneo alto. El objetivo de esta revisión es desarrollar los aspectos fundamentales que el urólogo debe saber en el manejo de las masas suprarrenales. Conjuntamente con el servicio de endocrinología de nuestro hospital describimos los principales estudios a realizar ante el diagnóstico de una masa suprarrenal y el esquema terapéutico vigente en nuestro centro. © 2009 AEU. Publicado por Elsevier España, S.L. Todos los derechos reservados.
*Corresponding author. E-mail:
[email protected] (J.M. Abascal Junquera). 0210-4806/$ - see front matter © 2009 AEU. Published by Elsevier España, S.L. All rights reserved.
587
actas urol esp. 2010;34(7):586–591
laboratory and radiologic tests used in daily practice, and to describe the therapeutic regimen currently used at our hospital.
Introduction An adrenal incidentaloma is an adrenal tumor larger than 1 cm, incidentally detected in imaging studies; it is appearing with increasing frequency in clinical practice due to the large number of radiologic explorations performed. The prevalence of adrenal incidentalomas in autopsies ranges from 1.4 to 8.7%, with a mean of approximately 2.3%. The mean prevalence of adrenal incidentalomas found in CT scans is 1% (0.4-4.4%). Some studies have found a higher prevalence in women and in individuals older than 50 years. Bilateral involvement occurs in 2-10% of cases.1 Most adrenal incidentalomas are benign, hormonally inactive adenomas; however, potentially lethal lesions such as adrenal carcinoma (0.3-12%) and functioning adrenal tumors (2.6-13%) should be properly diagnosed and treated.1 In our country, most patients undergoing laparoscopic adrenalectomy are referred from the endocrinology service, where the imaging and functional tests of the tumor were done. The clinical history, physical examination, and imaging tests are aimed at ruling out adrenal function and malignancy of the tumor. Given the anatomical location of the lesion and urologists’ surgical familiarity with the area, in our opinion it is important that urology services assume more responsibility for the management of this condition. The objective of this study is to describe the diagnostic process of adrenal incidentaloma, to present the main
Preoperative assessment of adrenal masses Firstly, the clinical history and physical examination shall focus on ruling out signs and symptoms of adrenal hypersecretion or malignancy. Secondly, we must answer the two fundamental questions that arise when an adrenal mass is found: Is it malignant? and, Is it functional? Table 1 summarizes the main signs and symptoms of the most common pathologies.
Malignancy Adrenal carcinoma is very rare (0.5-2 cases per million inhabitants per year); however, other tumors, especially lung cancer, can metastasize to the gland.2 The size and characteristics of the radiologic image can help to determine whether the tumor is benign or malignant. Size. The widest diameter of the adrenal mass predicts malignancy. This was shown in a study in which 90% of adrenal carcinomas were larger than 4 cm.3 Moreover, the smaller the carcinoma at the time of diagnosis, the better the prognosis. In a retrospective analysis of 62 patients with
Table 1 – Signs and symptoms of the main adrenal disorders Disease
Symptoms
Cushing’s syndrome Asymptomatic if the condition is subclinical Weight gain, central obesity, moon face, plethora, easy bruising, thin and delicate skin, poor wound healing, skin stretch marks, proximal muscle weakness, emotional and cognitive changes, opportunistic infections, reproductive function disorders, acne, hirsutism Pheochromocytoma Asymptomatic Pulsating headache, palpitations, sweating, tremor Crises may be spontaneous or triggered by postural changes, anxiety, medication (metoclopramide, anesthetics), valsalva Primary aldosteronism Abdominal pain (mass effect) If there is associated cortisol hypersecretion (Cushing) If there is androgen hypersecretion: hirsutism, acne, amenorrhea, increased libido, greasy skin If there is estrogen hypersecretion: gynecomastia Adrenal carcinoma History of extra-adrenal tumor Metastasis
Signs HT Osteopenia, osteoporosis Hyperglycemia, diabetes mellitus, hypokalemia, hyperlipemias, leukocytosis with lymphocytopenia
HT Orthostatic hypotension Pallor Retinopathy I - IV Tremor Fever HT Hypokalemia Slight hypernatremia
HT Osteopenia, osteoporosis Hyperglycemia, diabetes mellitus, hypokalemia, hyperlipemias, leukocytosis with lymphocytopenia Signs specific for the primary tumor
588
actas urol esp. 2010;34(7):586–591
adrenal carcinoma, the 5-year overall survival was 16% for patients with large tumors vs. 42% for those with tumors 6 cm
4-6 cm
10 HU, contrast washout
