1517Vol. 11 | No. 02 | March- April 2014 |U R O LO G Y J O U R N A L Laparoscopic Management of Symptomatic Giant Adrenal Pseudocyst: A Case Report Mohammad AsalZare,1 Behnam Shakiba,2 Amir Abbas Asadpour,1 Alireza Ghoreifi2 Corresponding Author: Behnam Shakiba, MD Department of Urology, Imam Reza Hospital, Razi St., Mashhad, Iran. Tel: +98 511 8022553 E-mail: B_shakiba@razi.tums.ac.ir Received January 2013 Accepted July 2013 1 Department of Urology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran. 2 Department of Urology, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran. CASE REPORT Keywords:‎adrenal‎gland‎diseases;‎cysts;‎laparoscopy;‎treatment‎outcome. INTRODUCTION Cystic‎lesions‎of‎the‎adrenal‎gland‎are‎rare‎entities‎with‎an‎estimated‎incidence‎of‎0.064-0.18%‎in‎autopsy‎series.(1)‎There‎are‎four‎categories‎of‎adrenal‎gland‎cyst:‎epithelial, endothelial, parasitic and pseudocyst.(2)‎Adrenal‎pseudocysts‎are‎fibrous‎ surrounded‎cysts‎without‎any‎endothelial‎or‎epithelial‎lining,‎and‎are‎generally‎filled‎with‎ fresh‎blood‎or‎clots‎due‎to‎hemorrhage‎into‎the‎cysts.(3)‎The‎majority‎of‎adrenal‎pseudocysts‎ are‎asymptomatic‎and‎of‎limited‎clinical‎significance.‎These‎asymptomatic‎simple‎pseudo- cysts‎require‎no‎further‎evaluation.‎Treatment‎of‎adrenal‎pseudocysts‎usually‎indicated‎in‎ large‎and‎complicated‎cysts.(4)‎We‎report‎a‎symptomatic‎huge‎adrenal‎pseudocyst‎measuring‎ about‎19‎cm‎in‎largest‎diameter,‎which‎managed‎with‎laparoscopic‎excision.‎ CASE REPORT A‎35‎year-old‎woman‎was‎referred‎to‎our‎hospital‎with‎the‎chief‎complaint‎of‎pain‎and‎feeling‎ of‎pressure‎in‎the‎left‎upper‎quadrant‎since‎six‎months‎earlier.‎Personal‎and‎Family‎history‎had‎ not‎relevant‎information.‎On‎physical‎examination,‎the‎patient‎had‎normal‎blood‎pressure‎and‎ 1518 | in‎the‎abdominal‎examination‎there‎was‎a‎palpable‎mass‎in‎ the‎left‎flank‎and‎left‎upper‎quadrant‎without‎tenderness.‎The‎ patient‎was‎admitted‎for‎further‎investigation.‎The‎results‎of‎ laboratory‎studies‎including‎blood‎counts,‎blood‎chemistry‎ and‎electrolytes‎were‎within‎normal‎limits.‎Abdominal‎ul- trasonography‎demonstrated‎a‎17‎cm‎unilocular‎cystic‎mass‎ occupying‎the‎left‎abdomen.‎Abdominal‎computed‎tomogra- phy‎(CT)‎scan‎showed‎a‎19‎×‎17‎×‎13‎cm‎suprarenal‎well- defined‎cystic‎mass‎(Figure‎1).‎This‎cyst‎located‎between‎the‎ spleen,‎left‎kidney,‎and‎pancreas‎and‎arising‎from‎the‎left‎ adrenal‎gland.‎The‎left‎kidney‎was‎displaced‎downward‎to‎ the‎left‎lower‎quadrant‎of‎the‎abdomen‎by‎the‎mass.‎There‎ was‎no‎septation,‎calcification‎and‎contrast‎enhancement‎in‎ the‎mass.‎Hormonal‎examination,‎including‎24‎hours‎urine‎ catecholamines,‎17-hydroxycorticosteroids,‎17-ketosteroids,‎ adrenocorticotropic‎hormone,‎serum‎catecholamines,‎corti- sol,‎aldosterone,‎24-hour‎urinary‎excretion‎of‎metanephrines‎ and‎vanillylmandelic‎acid‎and‎plasma‎renin‎activities‎were‎ all‎within‎normal‎limits.‎ The‎clinical‎diagnosis‎of‎adrenal‎cyst‎was‎made‎based‎on‎ symptoms,‎radiographic‎findings‎and‎non-functional‎status‎ of‎ the‎ mass.‎A‎ laparoscopic‎ transperitoneal‎ cyst‎ excision‎ with‎preservation‎of‎the‎remaining‎part‎of‎the‎gland‎was‎per- formed‎(Figure‎2).‎The‎cyst‎was‎adherent‎to‎the‎underlying‎ kidney‎and‎left‎adrenal‎gland.‎There‎were‎no‎adhesions‎be- tween the cyst and the pancreatic tail and spleen. It was sepa- rated‎from‎the‎adjacent‎organs‎by‎monopolar‎electrocautery‎ scissor‎without‎any‎difficulties.‎Occasionally,‎for‎dissection‎ we‎used‎bipolar‎electrocautery‎scissor.‎Intra‎operatively,‎after‎ separation‎of‎cyst‎from‎kidney‎and‎spleen,‎we‎performed‎per- cutaneous‎aspiration.‎After‎aspiration,‎the‎cyst‎was‎not‎col- lapsed;‎because‎it‎contained‎degenerated‎old‎clots.‎After‎sep- aration‎the‎cyst‎from‎adjacent‎organs,‎it‎was‎removed‎with‎ an‎open‎incision.‎The‎operative‎time‎was‎about‎two‎hours.‎ The‎blood‎loss‎was‎minimal‎and‎there‎was‎no‎intraoperative‎ complication.‎ Gross‎appearance‎showed‎a‎thin-walled,‎yellowish‎unilocu- lar‎adrenal‎mass‎contained‎hemorrhagic‎fluid‎and‎degener- ated‎old‎clots.‎Pathological‎examination‎revealed‎an‎“adre- nal‎pseudocyst”‎without‎an‎epithelial‎or‎endothelial‎lining‎ (Figure‎3).‎There‎was‎no‎evidence‎of‎malignancy.‎Postop- eratively,‎she‎recovered‎uneventfully‎and‎was‎discharged‎on‎ the‎second‎postoperative‎day.‎The‎left‎abdominal‎pain‎and‎ discomfort‎resolved‎after‎removal‎of‎the‎pseudocyst.‎At‎fol- low-up‎28‎months‎later,‎the‎patient‎was‎asymptomatic‎and‎ without‎pathological‎findings. DISCUSSION Adrenal‎cysts‎originating‎within‎the‎adrenal‎cortex‎or‎medul- la,‎was‎described‎first‎by‎the‎Viennese‎anatomist‎Greiselius‎ in 1670.(5)‎There‎are‎four‎types‎of‎adrenal‎cysts:‎endothelial‎ cysts, pseudocysts, epithelial cysts and parasitic cysts. Ad- renal‎pseudocysts‎represent‎about‎32-80%‎of‎adrenal‎cysts.‎ The‎cause‎and‎mechanism‎of‎adrenal‎pseudocysts‎remains‎ unknown.‎ Possible‎ etiologies‎ include:‎ degeneration‎ of‎ a‎ primary‎adrenal‎neoplasm,‎degeneration‎of‎a‎vascular‎neo- plasm,‎and‎hemorrhage‎within‎normal‎adrenal‎tissue‎or‎into‎ an‎adrenal‎tumor.(4) Although Adrenal pseudocysts can occur at any age, studies have‎showed‎that‎they‎are‎most‎commonly‎diagnosed‎in‎the‎ fourth‎and‎fifth‎decades‎of‎life.‎Pseudocyst‎is‎more‎common‎ Case Report Figure 1. Abdominal computed tomography showed a 19 × 17 × 13 cm suprarenal well-defined cystic mass. 1519Vol. 11 | No. 02 | March- April 2014 |U R O LO G Y J O U R N A L Laparoscopic Management of Adrenal Pseudocyst | AsalZare et al in‎women‎than‎men,‎with‎a‎ratio‎of‎approximately‎2-3:1.(6)‎ Most‎cases‎are‎asymptomatic;‎however,‎abdominal‎or‎flank‎ pain,‎a‎fullness‎or‎mass‎in‎abdomen‎or‎flank‎are‎the‎most‎ common‎presenting‎features‎of‎persons‎with‎symptomatic‎ adrenal pseudocysts.(7,8)‎ The‎ differential‎ diagnosis‎ varies‎ based‎on‎location,‎but‎commonly‎includes‎splenic‎cysts,‎he- patic‎cysts,‎renal‎cysts,‎mesenteric‎or‎retroperitoneal‎cysts,‎ urachal‎cysts‎and‎solid‎adrenal‎tumors.(9) A‎variety‎of‎radiologic‎modalities‎like‎ultrasonography‎(US),‎ CT‎scan‎and‎magnetic‎resonance‎imaging‎(MRI)‎are‎used‎for‎ diagnose‎of‎adrenal‎cysts.‎The‎US‎appearances‎of‎adrenal‎ cysts‎are‎unilocular‎or‎multilocular‎cystic‎lesions‎similar‎to‎ those seen elsewhere in the body. CT‎scan‎is‎the‎imaging‎modality‎of‎choice‎for‎diagnosis‎of‎ adrenal‎ cysts.‎ The‎ sensitivity‎ and‎ diagnostic‎ accuracy‎ of‎ preoperative‎CT‎for‎adrenal‎cyst‎are‎96%‎and‎62.5-96%,‎re- spectively.(6,10)‎Usually‎CT‎scan‎of‎pseudocysts‎demonstrates‎ well-demarcated‎round‎or‎oval‎masses‎with‎low‎density.‎In- ternal‎hemorrhage‎may‎due‎to‎some‎atypical‎features‎in‎CT‎ scan‎including,‎thick‎walls,‎internal‎septations‎and‎calcifica- tions.‎Calcification‎may‎be‎present‎ in‎the‎wall‎or‎septum. (2,9,11) Histopathological‎examination‎of‎the‎specimen‎confirms‎the‎ diagnosis‎of‎adrenal‎cysts.‎True‎adrenal‎cysts‎are‎lined‎with‎ endothelial or epithelial cells, but adrenal pseudocysts are de- void‎of‎a‎recognizable‎layer‎of‎lining‎cells‎and‎enclosed‎by‎a‎ fibrous‎tissue‎wall.(7) The‎management‎of‎adrenal‎pseudocysts‎depends‎on‎some‎ factors‎such‎as‎size,‎presence‎of‎symptoms,‎functional‎status‎ and‎probability‎of‎malignancy.‎If‎the‎cysts‎are‎small‎(<‎5-6‎ cm)‎with‎near-water‎density‎and‎have‎a‎thin‎(<‎3‎mm)‎wall,‎ and‎are‎not‎causing‎symptoms,‎careful‎observation‎with‎pe- riodic‎CT‎scans‎is‎often‎done.‎Surgical‎excision‎is‎indicated‎ in‎ the‎ presence‎ of‎ symptoms,‎ suspicious‎ for‎ malignancy,‎ increase‎in‎size‎and‎detection‎of‎a‎functioning‎adrenal‎cyst.‎ Surgical‎treatment‎includes‎open‎or‎laparoscopic‎approach.‎ Some‎studies‎recommended‎that‎open‎resection‎is‎preferred‎ technique‎in‎patients‎with‎large‎sized‎cysts‎(>‎6‎cm)‎and‎the‎ laparoscopic‎approach‎may‎be‎a‎valuable‎treatment‎for‎cysts‎ smaller‎than‎6‎cm.(4,11,12)‎Based‎on‎our‎knowledge,‎there‎are‎ a‎ few‎ reports,‎ that‎ showed‎ the‎ feasibility‎ of‎ laparoscopic‎ technique‎for‎large‎(>‎6‎cm)‎adrenal‎cysts‎and‎masses.(13-15)‎ CONCLUSION In‎present‎report,‎we‎used‎laparoscopic‎resection‎as‎an‎effec- tive‎minimally‎invasive‎approach‎for‎a‎huge‎symptomatic‎ad- renal‎pseudocyst‎measuring‎about‎19‎cm‎in‎largest‎diameter.‎ CONFLICT OF INTEREST None declared. 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