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GoldmanandDmochowski (1997) characterized the voiding dysfunction of 17 patients with gastroparesis who were referred because of voiding symptoms antibiotic resistance and meat 200 mg ofloxacin buy free shipping, 10 of whom had idiopathic gastroparesis and in 7 of whom the condition was secondary to diabetes infection pathophysiology buy generic ofloxacin. Seven patients had abnormal detrusor contraction and delayed sensation, 5 had poor detrusor function and normal sensation, 3 had normal detrusor function and poor sensation, and 2 had normal detrusor contraction and sensation. There was no difference in the occurrence of the dysfunctions between the two groups. Patients with idiopathic gastroparesis were more likely to note difficulty emptying (70%), whereas those with diabetic gastroparesis were more likely to have urinary frequency (71%). The authors postulated an association between idiopathic gastroparesis and bladder dysfunction and proposed that a common autonomic neuropathic syndrome may account for the bladder dysfunction in the idiopathic and the diabetic forms of this syndrome. Hyperthyroidism Patients with thyrotoxicosis often have symptoms caused by sympathetic overactivity and autonomic nervous system imbalance. In an assessment of 65 newly diagnosed untreated women with hyperthyroidism compared with 62 age-matched controls, the women with hyperthyroidism demonstrated significantly higher mean symptom scores for incomplete emptying, frequency, straining, and overall total symptoms. Of the 5 patients who underwent urodynamic studies, all had reduced flow rates, and 4 had a significant postvoid residual volume, 3 of whom had an enlarged bladder capacity and increased perineal electromyographic activity during voiding. A higher incidence of bladder symptoms was noted in patients with thyrotoxicosis: a 7% incidence of urgency with or without hesitancy and a 1% incidence of enuresis. Myasthenia Gravis Any neuromuscular disease that affects the tone of the smooth or striated muscle of the distal sphincter mechanism can predispose an individual to a greater chance of urinary incontinence after even a well-performed transurethral or open prostatectomy. Myasthenia gravis is an autoimmune disease caused by autoantibodies to acetylcholine nicotinic receptors. This leads to neuromuscular blockade and subsequent weakness in a variety of striated muscle groups. The incidence of incontinence after prostatectomy is indeed greatly increased in patients with this disease (Greene et al. Theyhypothesize that such autonomic dysfunction in a patient with myasthenia may indicate a unique subset with a worse prognosis. All of these patients had a history of significant childhood incontinence, urge incontinence, bedwetting, and a diminished bladder capacity. The hypothesis of a neurobiologic correlation between schizophrenia and the occurrence of involuntary bladder contractions is an intriguing one. Another hypothesis is that treatment of schizophrenia with antipsychotics may cause urinary incontinence primarily via -adrenergic blockade and a hypodopaminergic state. In a study of 8 patients on antipsychotic medications underwent urologic evaluation with urodynamic studies. The most common symptom was urinary urgency in 6 (75%) followed by nocturnal enuresis in 4 (50%) and five patients (62. It is caused by antibodies possibly directed against potassium channels on peripheral nerves and is associated with peripheral neuropathy, autoimmune diseases, malignancies, and endocrine disorders. Their patient had painful urinary and fecal retention; the urinary retention was thought to be caused by spasm of the periurethral striated sphincter and was diagnosed by an inability to pass a catheter beyond this area. The condition was treated with plasmapheresis and pharmacologic agents to relax the skeletal muscle. Chapter 116 Neuromuscular Dysfunction of the Lower Urinary Tract 2631 Wernicke Encephalopathy Wernicke encephalopathy is a rare but well-documented condition caused by a deficiency in thiamine (vitamin B1) in alcoholic and nonalcoholic populations. The two major clinical manifestations of thiamine deficiency involve the cardiovascular and neurologic systems, with the latter manifesting in general as a peripheral neuropathy, also known as Wernicke encephalopathy. The initial symptoms of the polyneuropathy range from burning feet to muscle weakness. Tjandra and Janknegt (1997) reported a case of a man with chronic alcoholism with seemingly isolated erectile and voiding dysfunction. The erectile dysfunction was determined to be neurogenic, and both resolved with thiamine replacement. The diverticulum enlarged with voiding, and the patient had a high postvoid residual volume. Myotonic Dystrophy Myotonic dystrophy is an autosomal dominant hereditary multi-organ disease characterized by myotonia and distal muscle atrophy. In addition, this condition in later stages is characterized by cataracts, endocrine disturbances, mental retardation or dementia, testicular atrophy and infertility, progressive frontal alopecia, and disturbances in cardiac conduction. Thus such patients must be characterized urodynamically before any assumptions are made regarding therapy based on symptoms alone. Systemic Sclerosis (Scleroderma) Scleroderma is a disease of the connective tissue characterized by thickening and fibrosis of the skin, abnormalities of the small arteries, and involvement of the gastrointestinal tract, heart, lung, and kidneys. They were unable to correlate voiding symptoms, urodynamic changes, and the degree of bladder wall fibrosis or visceral involvement. Evidence of autonomic nervous system dysfunction was found outside the urinary tract in 13 of these patients. Corticobasal Degeneration Corticobasal degeneration is a rare neurodegenerative disorder of the corticobasal tracts in the cerebral cortex and basal ganglia. The disorder tends to have a unilateral predominance and is most likely present in the supranuclear parasympathetic system. Cortical, extrapyramidal, long-tract, and urinary symptoms are commonly notedinthisdiseaseprocess. As compared with controls, the degeneration patients had more common urinary symptoms (80% of study group). Urinary symptoms usually appeared within 1 to 3 years after onset of the disease and became more common with longer disease duration. Nocturnal frequency tended to be the initial urinary symptom, followed by incontinence, urgency, and frequency.

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Yono M antimicrobial susceptibility ofloxacin 400 mg purchase mastercard, Tanaka T antibiotic vs antiviral generic 400 mg ofloxacin visa, Tsuji S, et al: Effects of age and hypertension on alpha1adrenoceptors in the major source arteries of the rat bladder and penis, Eur J Pharmacol 670(1):260­265, 2011. Yoshida M, Homma Y, Inadome A, et al: Age-related changes in cholinergic and purinergic neurotransmission in human isolated bladder smooth muscles, Exp Gerontol 36(1):99­109, 2001. Yoshida M, Inadome A, Maeda Y, et al: Non-neuronal cholinergic system in human bladder urothelium, Urology 67(2):425­430, 2006. Yoshimura N, Kaiho Y, Miyazato M, et al: Therapeutic receptor targets for lower urinary tract dysfunction, Naunyn Schmiedebergs Arch Pharmacol 377(4­6):437­448, 2008. Yoshimura N: Bladder afferent pathway and spinal cord injury: possible mechanisms inducing hyperreflexia of the urinary bladder, Prog Neurobiol 57(6):583­606, 1999. Wagner G, Husslein P, Enzelsberger H: Is prostaglandin E2 really of therapeutic value for postoperative urinary retention Results of a prospectively randomized double-blind study, Am J Obstet Gynecol 151(3):375­379, 1985. Walter S, Kjaergaard B, Lose G, et al: Stress urinary incontinence in postmenopausal women treated with oral estrogen (estriol) and an alphaadrenoceptor-stimulating agent (phenylpropanolamine): a randomised double-blind placebo-controlled study, Int Urogynecol J 1:74­79, 1990. Xiao N, Wang Z, Huang Y, et al: Roles of polyuria and hyperglycemia in bladder dysfunction in diabetes, J Urol 189(3):1130­1136, 2013. Chapter 110 Zderic S, Levin R, et al: Voiding function and dysfunction: relevant anatomy, physiology, pharmacology and molecular biology. In Gillenwater J, editor: Adult and pediatric urology, Chicago, 1996, Mosby, pp 1159­1219. For the purposes of description and teaching, the micturition cycle is best divided into two relatively discrete phases: bladder filling/ urine storage and bladder emptying/voiding. The micturition cycle normally displays these two modes of operation in a simple on-off fashion. The cycle involves switching from inhibition of the voiding reflex and activation of the storage reflexes to inhibition of the storage reflexes and activation of the voiding reflex and back again. A simple way of looking at the pathophysiology of all types of voiding dysfunction is then presented, followed by a discussion of various systems of classification and categorization. Consistent with prior attempts to make the understanding, evaluation, and management of voiding dysfunction as logical and simple as possible (Wein, 1981, 2002; Wein and Barrett, 1988), a functional and practical approach is favored. This is a physiologic but not an anatomic sphincter and one that is not under voluntary control. The striated sphincter refers to the striated musculature that is a part of the outer wall of the proximal urethra in males and females (this portion is often referred to as the intrinsic or intramural striated sphincter or rhabdosphincter). The striated sphincter also refers to the bulky skeletal muscle group that closely surrounds the urethra at the level of the membranous portion in males and primarily the middle segment in females (often referred to as the extrinsic or extramural striated sphincter). The extramural portion is the classically described external urethral sphincter and is under voluntary control (for a detailed discussion see Chapter 110) (Birder et al. The general information is consistent with that detailed in Chapter 110 and in previous source materials and their supporting references (Andersson, 2014; Andersson and Arner, 2004; Andersson and Wein, 2004; Beckel and Holstege, 2011; Birder et al. Other specific references are provided only when particularly unique or applicable. The first is that the micturition cycle involves two relatively discrete processes: (1) bladder filling and urine storage and (2) bladder emptying or voiding. During at least the initial stages of bladder filling, after unfolding of the bladder wall from its collapsed state, this high compliance (volume/ pressure) of the bladder is due primarily to its elastic and viscoelastic properties. Elasticity allows the constituents of the bladder wall to stretch to a certain degree without any increase in tension. Viscoelasticity allows stretch to induce an increase in tension followed by a delay ("stress relaxation") when the filling (stretch stimulus) slows or stops. The viscoelastic properties are considered to be primarily due to the characteristics of the extracellular matrix in the bladder wall. Andersson and Arner (2004) cite references demonstrating that the main extracellular components are elastic fibers and collagen fibrils present in the serosa, between muscle 2514 Chapter 111 Pathophysiology and Classification of Lower Urinary Tract Dysfunction: Overview 2515 bundles, and between the smooth muscle cells in the muscle bundles. There may also be a non-neurogenic active component to the storage properties of the bladder. The viscoelastic properties of the stroma (bladder wall less smooth muscle and epithelium) and the urodynamically noncontractile state of the detrusor muscle account for the passive mechanical properties and normal bladder compliance seen during filling. In the usual clinical setting, filling cystometry seems to show a slight increase in intravesical pressure, but Klevmark (1974, 1999) elegantly showed that this pressure increase is a function of the fact that cystometric filling is carried out at a greater-than-physiologic rate and that, at physiologic filling rates, there is essentially no increase in bladder pressure until bladder capacity is reached. This can occur with chronic inflammation, bladder outlet obstruction, neurologic decentralization, and various other types of injury. Bladder muscle hypertrophy, which can result from outlet obstruction, can also result in decreased compliance because hypertrophic muscle is said to be less elastic than normal detrusor; it also can synthesize increased amounts of collagen (Mostwin, 2006). Once decreased compliance has occurred because of a replacement by collagen of other components of the stroma, it is generally unresponsive to pharmacologic manipulation. At a certain level of bladder filling, spinal sympathetic reflexes facilitatory to bladder filling/storage are clearly evoked in animals, a concept developed over the years by de Groat and others (see Chapter 110) (de Groat et al. This inhibitory effect is thought to be mediated primarily by sympathetic modulation of cholinergic ganglionic transmission. Through this reflex mechanism, two other possibilities exist for promoting filling and storage. One is neurally mediated stimulation of the predominantly -adrenergic receptors (1) in the area of the smooth sphincter, the net result of which would be to cause an increase in resistance in that area. The second is neurally mediated stimulation of the predominantly -adrenergic receptors (3 inhibitory) in the bladder body smooth musculature, which would cause a decrease in bladder wall tension, promoting bladder relaxation. Good evidence also seems to support an inhibitory effect of other neurotransmitters. Bladder filling and consequent wall distention may also result in the release of factors from the urothelium that may influence contractility.

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Lepor H antibiotics for feline acne 200 mg ofloxacin order with visa, Sunaryadi I antibiotics drug test generic ofloxacin 200 mg buy, Hartanto V, et al: Quantitative morphometry of the adult human bladder, J Urol 148:414­417, 1992. Mangnall J: Key considerations of intermittent catheterisation, Br J Nurs 21:392­394, 396­398, 2012. Mark S, Gilling P, Van Mastrigt R, et al: Detrusor contractility: age related correlation with urinary flow rate in asymptomatic males, Neurourol Urodyn 11:315­317, 1992. Mitsui T, Tanaka H, Harabayashi T, et al: Changes in urodynamics and lower urinary tract symptoms after radical prostatectomy: implications of preoperative detrusor contractility, Low Urin Tract Symptoms 4:82­86, 2012. Nishijima S, Sugaya K, Miyazato M, et al: Restoration of bladder contraction by bone marrow transplantation in rats with underactive bladder, Biomed Res 28:275­280, 2007. Nomiya M, Yamaguchi O, Akaihata H, et al: Progressive vascular damage may lead to bladder underactivity in rats, J Urol 191:1462­1469, 2014. Gladh G, Mattsson S, Lindstrom S: Intravesical electrical stimulation in the treatment of micturition dysfunction in children, Linköping, Sweden, 2002, Linköping University. Griffiths D: Detrusor contractility: order out of chaos, Scand J Urol Nephrol Suppl 215:93­100, 2004. Comparison of diagnostic criteria based on an urodynamic measure, Investig Clin Urol 58:247­254, 2017. Karami H, Valipour R, Lotfi B, et al: Urodynamic findings in young men with chronic lower urinary tract symptoms, Neurourol Urodyn 30:1580­1585, 2011. Katona F, Berenyi M: Intravesical transurethral electrotherapy of bladder paralysis, Orv Hetil 116:854­856, 1975. Chapter 118 Primus G, Kramer G, Pummer K: Restoration of micturition in patients with acontractile and hypocontractile detrusor by transurethral electrical bladder stimulation, Neurourol Urodyn 15:489­497, 1996. Saito M, Yokoi K, Ohmura M, et al: Effects of partial outflow obstruction on bladder contractility and blood flow to the detrusor: comparison between mild and severe obstruction, Urol Int 59:226­230, 1997. Sauerwein D: Surgical treatment of spastic bladder paralysis in paraplegic patients: sacral deafferentiation with implantation of a sacral anterior root stimulator, Urologe A 29:196­203, 1990. Schäfer W, Watervär F, Langen P-H, et al: A simplified graphic procedure for detailed analysis of detrusor and outlet function during voiding, Neurourol Urodyn 8:405­407, 1989. Schurch B, Hauri D, Rodic B, et al: Botulinum-A toxin as a treatment of detrusor-sphincter dyssynergia: a prospective study in 24 spinal cord injury patients, J Urol 155:1023­1029, 1996. Stenzl A, Ninkovic M, Kolle D, et al: Restoration of voluntary emptying of the bladder by transplantation of innervated free skeletal muscle, Lancet 351:1483­1485, 1998. Sugaya K, Nishijima S, Miyazato M, et al: Central nervous control of micturition and urine storage, J Smooth Muscle Res 41:117­132, 2005. Sugaya K, Ogawa Y, Hatano T, et al: Ascending and descending brainstem neuronal activity during cystometry in decerebrate cats, Neurourol Urodyn 22:343­350, 2003. Tammela T, Kontturi M, Kaar K, et al: Intravesical prostaglandin F2 for promoting bladder emptying after surgery for female stress incontinence, Br J Urol 60:43­46, 1987. Valente S, Dubeau C, Chancellor D, et al: Epidemiology and demographics of the underactive bladder: a cross-sectional survey, Int Urol Nephrol 46(Suppl 1):S7­S10, 2014. Results of a prospectively randomized double-blind study, Am J Obstet Gynecol 151:375­379, 1985. Yamamoto T, Sakakibara R, Uchiyama T, et al: Time-dependent changes and gender differences in urinary dysfunction in patients with multiple system atrophy, Neurourol Urodyn 33:516­523, 2014. Yamanishi T, Yasuda K, Kamai T, et al: Combination of a cholinergic drug and an alpha-blocker is more effective than monotherapy for the treatment of voiding difficulty in patients with underactive detrusor, Int J Urol 11:88­96, 2004. Yoshida M, Homma Y, Inadome A, et al: Age-related changes in cholinergic and purinergic neurotransmission in human isolated bladder smooth muscles, Exp Gerontol 36:99­109, 2001. A systematic approach, including a thorough history and physical examination, is essential to determine conditions contributing to nocturia. Therapeutic options are numerous and include conservative/behavioral management, pharmacotherapy, phytotherapy, and invasive procedures. Tailoring appropriate therapy to accurate diagnosis should lead to effective treatment and patient satisfaction. Some clinicians do not consider one void during the night to be clinically significant. This may be because several studies have shown that less than two voids per night does not generate bother and that two or more voids per night can impair quality of life (Häkkinen et al. For example, one patient who voids once per night may report being very bothered versus another patient who voids two or three times per night who may report little bother. Compared with those with low bother, patients reporting high levels of nocturia-specific bother were found to be significantly more likely to have difficulty initiating sleep (47. The subjective morning fatigue and sleep ratings scale ranges from 1 to 7; higher scores equate to worse fatigue or sleep characteristics (Vaughan et al. In a prospective study of various sleep parameters and nocturia in a cohort of community-dwelling men and women, nocturia, common among older individuals with insomnia, was associated with both increased subjective nocturnal and decreased daytime wakefulness (Zeitzer et al. Prevalence rates in younger women were one or more voids in 20% to 44% and two or more voids in 4% to 18%. In older women, rates were one or more voids in 74% to 77% and two or more voids in 28% to 62%. It is noteworthy that one in every five or six people 20 to 40 years of age wakes two or more times per night and that up to nearly three in every five people older than 70 years of age wake to void two or more times nightly (Bosch and Weiss, 2010). In this population, the prevalence was reported to be 47% at baseline and 50% 1 year later. The authors showed that women and younger patients were more likely to spontaneously remit (Hirayama et al. The prevalence of nocturia in both men and women increases with age (Bosch and Weiss, 2010). In a survey of 1424 elderly individuals (55 to 84 years of age), 53% of the sample listed nocturia as a self-perceived cause of nocturnal sleep disturbance every night or almost every night (Bliwise et al. Data acquisition methodology regarding nocturia may influence calculated prevalence.

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This trial clearly highlights the importance of appropriate patient selection and the need for identifying prognostic factors likely to predict for a favorable outcome bacteria background ofloxacin 200 mg cheap. Given the high morbidity and mortality with this approach bacteria encyclopedia ofloxacin 400 mg buy visa, careful patient selection is of great importance. Immune "Checkpoint" Inhibitors the host immune response to tumors is a highly complex process that is regulated at multiple levels. The interplay between multiple stimulatory and inhibitory processes determines the nature and extent of the antitumor response generated by the host immune system. The most notable side effects associated with this agent included autoimmune events such as enteritis and hypophysitis. Despite the fairly short follow-up, several durable responses were evident, with 5 patients demonstrating a response lasting 1 year or more. Furthermore, stable disease lasting 24 weeks or more was seen in an additional 9 patients (27%). As anticipated, several patients experienced adverse events of possible autoimmune cause, including diarrhea, hypophysitis, and vitiligo. Patients were randomized to receive either 3 mg/kg of nivolumab every 2 weeks or 10 mg of everolimus daily. Kaplan-Meier estimates of overall survival in 821 previously treated patients with metastatic clear cell renal cell cancer receiving either nivolumab or everolimus. Nivolumab was generally well tolerated, with 19% of the patients experiencing a grade 3 to 4 adverse event compared with 37% in patients treated with everolimus. The adverse event profile was consistent with that seen in other studies of similar checkpoint inhibitors and included a variety of autoimmune phenomena and fatigue. The overall response rate in patients receiving bevacizumab was modest (objective response rate of 10%, all in patients assigned to the 10-mg/kg dose). The agent was well tolerated; bleeding, hypertension, fatigue, and proteinuria were some of the more common adverse events reported. Several strategies for improving the efficacy of bevacizumab have been explored, including combination with cytokines (interferon-) and other targeted agents. Both trials reported a higher incidence of some grade 3 adverse events, such as hypertension, fatigue, anorexia, and asthenia in patients receiving combination therapy. However, these trials did not include an arm with bevacizumab alone (because insufficient evidence of single-agent activity at the time these trials were designed to justify a bevacizumab-only arm), making it difficult to determine if inclusion of interferon in this regimen, with its attendant toxicities, adds meaningful clinical benefit. The side effect profile of sorafenib is comparable to that of other agents in this class and includes hypertension, fatigue, rash, hand-foot syndrome, and diarrhea. Although patients receiving sorafenib had a higher likelihood of achieving tumor regression (68% vs. Sunitinib was administered orally at a dose of 50 mg/d during the first 4 weeks of a 6-week cycle on both trials (Table 104. In this study, 750 patients were randomized to receive either sunitinib or interferon-. Gastrointestinal events, particularly diarrhea, dermatologic manifestations such as rash and hand-foot syndrome, constitutional symptoms such as fatigue and asthenia, and hypertension were the most commonly adverse events associated with sunitinib, whereas bone marrow suppression and hypothyroidism were other notable side effects. Sunitinib also performed better than interferon in a quality-of-life assessment conducted as part of the study. Currently, sunitinib is largely used in the treatment of good prognosis patients or those unable to receive checkpoint inhibitor-based therapy. Although these agents are relatively well tolerated when compared with conventional cytotoxic chemotherapy, dose reductions and termination of treatment resulting from toxicity are not infrequently warranted in patients receiving these drugs. Furthermore, reported toxicities were mild, with very few grade 3 and 4 adverse events encountered. The efficacy and/or tolerability of pazopanib and sunitinib were subsequently compared in at least two studies. However, differences were noted in the adverse event profile and patient tolerability between the two groups. Quality-oflife assessments related to fatigue or soreness in the mouth, throat, and hands or feet during the first 6 months of treatment favored pazopanib. After completing 22 weeks of therapy, the patients were asked to complete a questionnaire assessing which agent they preferred. Pazopanib was preferred by 70% of the patients, although sunitinib was preferred by 22% of the patients (8% had no specific preference between the agents). Kaplan-Meier analysis of overall survival (A) and progression-free survival (B) in 750 previously untreated patients with metastatic renal cell carcinoma receiving either sunitinib or interferon-. Although pazopanib appears to be better tolerated than sunitinib by the majority of patients, it appears to be associated with an increased incidence of hepatotoxicity and must be used with caution in patients at risk for this complication. With the advent of effective combination therapies containing immune checkpoint inhibitors, the role of single-agent pazopanib is limited, particularly in the first-line setting, largely to good-risk patients. Diarrhea, fatigue, and hypertension were the most commonly encountered grade 3 and 4 events and were amenable to medical management in most patients. Cabozantinib was associated with a higher response rate (21% with cabozantinib vs. Although cabozantinib therapy was associated with significant toxicity (60% of patients required a dose reduction, mostly because of fatigue, diarrhea, or palmar plantar erythrodysesthesia), most patients were managed with dose reductions, with only 10% requiring permanent discontinuation because of toxicity. These data established cabozantinib as a reasonable option in patients who had received a prior angiogenesis inhibitor. Kaplan Meier estimate of progression-free survival in 157 previously untreated patients with metastatic clear cell renal cell carcinoma receiving either sunitinib or cabozantinib.

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A more recent review on the national trends for adrenalectomy in America reported that of 58 bacteria 3162-roclis cheap 200 mg ofloxacin with mastercard,948 adrenalectomies performed between 2002 and 2011 bacteria that live on the ocean floor are sustained by 400 mg ofloxacin order amex, a minimally invasive approach Past Surgical and Medical History Previous abdominal surgeries may lead to intra-abdominal adhesions and scarring, which may render the laparoscopic approach difficult if not impossible. A retroperitoneal laparoscopic approach may be ideal in a patient with history of transperitoneal surgery, whereas a transperitoneal laparoscopic approach may be the approach of choice in a patient with a previous flank, retroperitoneal surgery. Conventionally, laparoscopic surgeries required the establishment of pneumoperitoneum that may lead to hemodynamic, metabolic, and neurologic adverse effects in patients with significant cardiopulmonary and neurologic diseases. Contraindications to establishment of pneumoperitoneum include patients with severe cardiac insufficiency, advanced chronic obstructive bronchitis, renal function insufficiency, acute glaucoma, recurrent spontaneous pneumothorax, vascular endocranial malformation, and hypertensive retinopathy. Preservation of the intact peritoneum on the anterior surface of the adrenal gland if no evidence of invasion through the overlying peritoneal layer 3. Tumor Size Large tumor size is considered a relative contraindication to laparoscopic adrenalectomy. A larger size increases the chance that the tumor is malignant and distorts the regional anatomy, making laparoscopic resection more difficult. Although most laparoscopic surgeons are comfortable with tumor sizes of up to 6 to 7 cm, there is no clear upper limit to the size at which the laparoscopic approach would be contraindicated. However, available literature seems to suggest an arbitrary upper limit of about 10 to 12 cm in diameter (Henry et al. However, they reported that operative time, blood loss, hospital stay, and complication rates were lower with laparoscopic adrenalectomy compared with open surgery. Hence rather than an absolute size cutoff for laparoscopic adrenalectomy, it is mandatory to consider that surgeon experience, hospital volume, and a multidisciplinary approach to patients, which comprises surgeons, anesthesiologists, and endocrinologists, are three important parameters in the selection of patients. Conversion to open surgery has been found to be associated with size of tumor and infiltrative adrenal cortical carcinoma. Adrenal Cortical Carcinoma Laparoscopic adrenalectomy in adrenal cortical carcinoma is currently controversial. In a consensus statement from the Third International Adrenal Cancer Symposium, the oncologic principles for resection of adrenal cortical carcinoma were outlined as summarized in Box 107. Strict adherence to these principles of resection is difficult during laparoscopic adrenalectomy, and thus the open approach seems to be the technique of choice. The thin tumor capsule is prone to rupture during inevitable manipulation of tumor during dissection, resulting in tumor spillage and subsequent recurrence. Furthermore, en bloc dissection of the retroperitoneal fat around the tumor is more difficult using laparoscopic techniques. However, this is often necessary because microscopic tumor extension cannot be accurately identified pre- and intraoperatively, and there are currently no effective adjuvant treatments if margins are positive. A lymph node dissection should include at least the periadrenal fat, perirenal fat, and renal hilum. It is currently still controversial if there is value to a latero-aortic and inter-aorto-caval nodal dissection. To determine whether the surgical approach for adrenal cortical carcinoma is a risk factor for peritoneal carcinomatosis, Leboulleux et al. Of these, 58 patients underwent open adrenalectomy and 6 underwent laparoscopic adrenalectomy. The 4-year rate of peritoneal carcinomatosis was 67% for laparoscopic adrenalectomy and 27% for the open approach, with surgical approach being identified as the only risk factor. Although the local and overall recurrence rates were similar in both groups, they concluded that laparoscopic resection should not be attempted in patients with tumors suspicious for or known to be adrenal cortical carcinoma. More recently, a meta-analysis comprising nine studies published between 2010 and 2014 reported a higher risk of peritoneal carcinomatosis associated with laparoscopic adrenalectomy, although there were no statistical differences in overall recurrence, time to recurrence, and cancer-specific mortality when compared with open adrenalectomy (Autorino et al. However, this study was limited by having more patients with higherstage tumors in the open adrenalectomy group, short follow-up duration, and incomplete data, especially on resection margin status. Similarly, a recent multi-institutional study of 201 patients with adrenal cortical carcinoma reported no difference in 30-day mortality, intraoperative tumor rupture rates, and R0 resection rates between the minimally invasive approach and open approach (Lee et al. A major limitation of this study was that patients who had macroscopically incomplete resection, tumor capsule violation, open conversion from laparoscopic approach, and microscopic periadrenal fat invasion on postoperative pathological examination were excluded, introducing significant selection bias. In addition, the follow-up period of less than 1 year in some patients is relatively short for diagnosis of tumor recurrence. Indeed, a recent review by the European Society of Endocrinology concluded that there were no differences in perioperative mortality or morbidity, completeness of resection, and recurrence-free and overall survival rates between open and minimally invasive adrenalectomy (Fassnacht et al. There is currently no consensus opinion on the role of laparoscopic adrenalectomy in adrenal cortical carcinoma. If a laparoscopic approach is used, the transperitoneal approach in the flank position may be preferable. Mechanical bowel preparation and orogastric/nasogastric tube insertion are recommended in open or laparoscopic transperitoneal surgery and are optional for retroperitoneal approaches. The placement of a urinary catheter before surgery is helpful to measure urine output and to decompress the bladder. Pheochromocytoma Excessive secretion of catecholamines from chromaffin tissue may result in tachycardia, diaphoresis, headache, hypertension, cardiac arrhythmias, left ventricular dysfunction, and impaired glucose tolerance. Preoperative cardiac workup, including electrocardiography and echocardiography, and assessment of hypertension-induced end-organ dysfunction are indicated. Preoperative sympatholytic therapy with -adrenergic blockers for at least 2 weeks before surgery helps in hemodynamic and glucose control and should be continued until the day of surgery. Phenoxybenzamine is time proven to be safe and effective but has its associated problems.

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