Adrenal malignancy: still a contraindication for laparoscopy?

Minimally invasive adrenalectomy represents the gold standard for benign adrenal diseases, while its role in the management of malignant primary and secondary adrenal tumors remains controversial because of the risk of tumor spillage at manipulation, incomplete removal and subsequent recurrences. However, advances in imaging have improved early detection of primary and metastatic adrenal tumors, that might be theoretically removed by minimally invasive adrenalectomy without capsular disruption. Minimally invasive surgical approaches seem to be useful in selected patients with isolated, moderately sized adrenal metastases in patients with good performance status and controlled primary tumor with favorable biology. The open laparotomic approach is still considered the preferred surgical strategy for large and invasive adrenocortical cancer albeit emerging data suggest that laparoscopic surgery might be equivalent for moderately sized and localized primary adrenocortical cancers in terms of oncological benefits. However, the predominant endpoint remains the oncological radicality rather than the surgical approach itself. Multicenter randomized controlled trials with long follow-up time periods evaluating oncological outcomes are required to determine the benefits of the minimally invasive over the open approach in adrenal malignancies.