Evolution of the surgical management of primary aldosteronism

During the past two decades 50 patients were operated on for primary aldosteronism. Diagnosis was based on high aldosterone excretion or secretion during a high sodium intake and, more recently, low stimulated plasma renin activity. Computed tomography and adrenal venography with selective adrenal vein catheterization for determination of aldosterone/cortisol ratios were helpful in the distinction between adenoma and bilateral hyperplasia. As a result of preoperative localization, unilateral posterior or flank approach to the adrenal has replaced transabdominal as the approach of choice. Overall in-hospital mortality in this series was 10% and occurred exclusively with a transabdominal approach in the early part of the series. Adrenalectomy has been curative in 66% of patients with adenoma and in 38% of patients with hyperplasia which includes patients with adenomatous (dominant macroscopic adenoma, 1 cm or greater) hyperplasia when the cure rate was 75%. Currently, only patients who have unilateral adrenal hyperfunction, who respond to spironolactone with a fall in blood pressure, and who are a good operative risk are considered for operation by posterior or flank approach. These guidelines for the management of primary aldosteronism, used since 1974, have been associated with an excellent response (92%), zero mortality and reduced morbidity.