Open Versus Laparoscopic Adrenalectomy for Adrenocortical Carcinoma: A Meta-analysis of Surgical and Oncological Outcomes

PURPOSE: This study was designed to determine the role of laparoscopic adrenalectomy (LA) in the surgical management of adrenocortical carcinoma (ACC). METHODS: A systematic literature review was performed on January 2, 2015 using PubMed. Article selection proceeded according to PRISMA criteria. Studies comparing open adrenalectomy (OA) to LA for ACC and including at least 10 cases per each surgical approach were included. Odds ratio (OR) was used for all binary variables, and weight mean difference (WMD) was used for the continuous parameters. Pooled estimates were calculated with the fixed-effect model, if no significant heterogeneity was identified; alternatively, the random-effect model was used when significant heterogeneity was detected. Main demographics, surgical outcomes, and oncological outcomes were analyzed. RESULTS: Nine studies published between 2010 and 2014 were deemed eligible and included in the analysis, all of them being retrospective case-control studies. Overall, they included 240 LA and 557 OA cases. Tumors treated with laparoscopy were significantly smaller in size (WMD -3.41 cm; confidence interval [CI] -4.91, -1.91; p < 0.001), and a higher proportion of them (80.8 %) more at a localized (I-II) stage compared with open surgery (67.7 %) (odds ratio [OR] 2.8; CI 1.8, 4.2; p < 0.001). Hospitalization time was in favor of laparoscopy, with a WMD of -2.5 days (CI -3.3, -1.7; p < 0.001). There was no difference in the overall recurrence rate between LA and OA (relative risk [RR] 1.09; CI 0.83, 1.43; p = 0.53), whereas development of peritoneal carcinomatosis was higher for LA (RR 2.39; CI 1.41, 4.04; p = 0.001). No difference could be found for time to recurrence (WMD -8.2 months; CI -18.2, 1.7; p = 0.11), as well as for cancer specific mortality (OR 0.68; CI 0.44, 1.05; p = 0.08). CONCLUSIONS: OA should still be considered the standard surgical management of ACC. LA can offer a shorter hospital stay and possibly a faster recovery. Therefore, this minimally invasive approach can certainly play a role in this setting, but it should be only offered in carefully selected cases to avoid jeopardizing the oncological outcome.