Minimally invasive surgery for adrenal masses in children: results of a bi-centric survey and Literature review.

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Francesca Nascimben, Amane Lachkar, Francois Becmeur, Francesco Molinaro, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3809669/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Minimally invasive surgery for adrenal pathologies in children is still developing because of the low incidence of adrenal masses in pediatric population and the discrepancy between the size of the mass and the child’s one. In Literature there are no any guidelines about the use of laparoscopic andrenalectomy in children. The aim of this study is to evaluate the outcomes of minimally invasive surgery through a bi-center data analysis in order to propose a standardized protocol. Materials and methods Children who underwent minimally invasive adrenalectomy between 2000 and 2020 performed by two expert Pediatric surgeons at two European departments of Pediatric Surgery were included in this study. Data were collected and analyzed using X-square, Fisher tests, multiple regression model. Results 34 patients (38 adrenal masse)s were included. Mean age was 52 months 3–176]. Median lesion diameter was 60 mm [40-125mm]. Histological examination revealed 24 neuroblastomas, 11 pheochromocytomas, 1 teratoma, 1 adrenal cyst and 1 Myelolipoma. Laterality was 52.6% left, 36.8% right and 10.5% bilateral. Surgical access was trans-peritoneal in all patients. Mean operative time was 108 min for unilateral lesions and 270 min for bilateral ones. Mean hospital stay was 4.4 days. No major intra operative complications were observed. 21.05% neuroblastomas were preventively approached with a laparoscopic access and were converted to open surgery. Median follow-up was 88 months [24–264]. 4 patients affected by neuroblastoma reported metastatic dissemination and 3 died. Conclusions Pediatric minimally invasive adrenalectomy was a safe and effective procedure, it allows surgeons to reduce the size of laparotomies starting the dissection of the masses and it has low rate of complication if we consider small masses. The only absolute contraindication is persistent IDRF for neuroblastomas. It should be considered the first-line treatment for selected adrenal masses in centers with good experience in laparoscopy. Adrenal mass Laparoscopic adrenalectomy Minimally invasive surgery Children Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction First laparoscopic adrenalectomy was performed in children in 1996 by Yamamoto [ 1 ], but it has developed slower in pediatric population if compared to adult age not only because of the discrepancy between the large dimension of adrenal masses and the small size of patients, but also because of the low incidence of adrenal masses in children and the prevalent malignant nature of tumors [ 2 ]. Main indications for adrenal surgery in children are neoplastic masses [ 3 ] both from the medulla as neuroblastomas (NBs) and pheochromocytoma/para-ganglioma (PHE) [ 4 , 5 ] and from cortex like corticosurrenaloma [ 6 ]. In children adrenalectomy is performed because of bilateral adrenal hyperplasia too [ 3 ]. Main issues for surgery are risk of spillage for corticosurrenaloma, vessel encasement of the tumor for pheocromocytoma [ 7 ], size of the tumor for myelolipoma, pheocromocytoma and neuroblastoma [ 3 , 8 – 10 ] and Image-De Risk Factors (IDRFs) for neuroblastoma [ 8 , 11 ]. There are no guidelines about the specific use of this technique in pediatric population even if the minimally invasive approach to adrenal masses seems to be a safe and effective alternative to the traditional surgery and it is associated to different advantages such as shorter operative time, easier post operative pain control, shorter hospital stay, better cosmetic results, fewer complications and less morbidity [ 12 ]. Aim of the study Primary aim of this study is to evaluate the epidemiology, the characteristics, the surgical indications and the outcomes of adrenal masses treated with minimal invasive surgery in pediatric age through the analysis of the cases of two European centers. Secondary aim is to identify the potential risk factors involved in the outcome of minimal invasive adrenalectomy focus the attention on conversation rate and complications. Materials and Methods A bi-centric study was conducted including all patients younger than 18 years old who underwent minimally invasive adrenalectomy performed by two expert pediatric surgeons (one for each center) working together between January 2000 and December 2020 at University Hospital of Strasbourg and the Departement of Pediatric Surgery of Colmar. Patients older than 18 years old, patients underwent to previous abdominal surgeries, patients followed up less than 1 year or patients with incomplete data were excluded from the study. Demographic data (age, gender, diagnosis, etiology, comorbidities, time at diagnosis and time at surgery, laterality, and pre-operative presentation) were collected. All patients with suspected adrenal mass, either symptomatic or accidentally diagnosed by imaging underwent detailed personal and familiar history, physical examination, laboratory tests including adrenal function test and they were radiologically evaluated (ultrasound, CT scan, and sometimes magnetic resonance imaging). All cases were discussed by a multidisciplinary teams and indications for surgery and / or chemotherapy were defined according to the Oncologic guidelines. Indications for Laparoscopic adrenalectomy included low-risk adrenal masses and prenatally diagnosed tumors which were increased in size during follow-up. Intra-operative parameters including type of performed procedure, operative time and intra-operative complications were evaluated. Institutional Review Board approval was not required for this study because of its retrospective nature. Informed consent has been obtained. Parents of the patients includedn in the study or their caregivers signed a writte consenit for treatment and another one for publication of patients anonimous information (including images). Surgical technique Trans-peritoneal andrenalectomy under general anesthesia was performed in all patients. Patients were placed in lateral decubitus with a costal block to increase the space between the last costs and the iliac crests. Patient’s placement and operating room set up is described in Figure A . A Foley catheter was placed at the beginning of the procedure in order to be used later for bladder hydro-distention. Using open access, four laparoscopic ports were placed; the first 5 or 10 mm trocar for camera port was placed under the umbilicus. Pneumo-peritoneum was induced at 10 or 12 mmHg according to patient’s age. Other 3 trocars were placed. In case of right adrenalectomy a 5 mm working trocar was placed in the midline between the xiphoid and the umbilicus, the second one along the mid-clavicular line on the right flank and the last 3 mm one in the epigastric region to retract the liver ( Figure B ). After an abdominal exploration and the retraction of the liver, surgeons proceeded opening the retroperitoneum. After blind dissection and careful isolation of the inferior vena cava and renal vein, adrenal veins were isolated and sectioned. In case of left adrenalectomy a 5 mm working trocar was placed in the midline between the xiphoid and the umbilicus, the second one along the mid-clavicular line on the left flank and the last 3 mm one in the epigastric region. After an abdominal exploration, surgeons proceeded releasing the spleen through the dissection of the peritoneum and the spleno-diaphragmatic ties; they released the left colic angle and mobilized the spleen and the pancreas tail. After opening of the spleno-renal space, releasing of the upper pole of the left kidney and the lower pole of the spleen, the left adrenal gland was identified. The medial part of the adrenal vein and the upper part of the left renal vein were isolated and sectioned. In both cases, adrenal gland was then dissected starting from medial side through the thermofusion effect of Ligasure® ( Figure C ). The dissected adrenal gland was placed into an Endobag® and removed through the umbelical port. Only in case of huge adrenal masses, they were removed through a mini-Pfannesteil incision. The working ports were removed and the trocar orifices were closed using separate stitches. Postoperative management including time of abdominal drainage removal, time of ureteral catheter removal, length of hospital stay, postoperative outcomes and short and long term follow up was recorded. All patients who were operated weremonitored for at least 1 year. During the follow-up, patients underwent phisical examination, laboratory tests and US evaluation. Statistical analysis All statistical analyses were performed using graph-pad and r . Continuous variables are presented as mean. Categorical variables are presented as frequency and percentage. ANOVA, X-square, and Fisher tests were used for statistical analysis. A stepwise regression model has been created for independent variables. A p value < 0.05 was considered significant. Results A total of 38 minimally invasive adrenalectomies were included in the study, performed from January 2000 to December 2020 at two European Departments of Pediatric Surgery (University Hospital of Strasbourg and Hospital of Colmar) in 34 patients, 10 females (29.4%) and 24 males (70.6%) with a mean age of 52 months [3 months– 176 months]. 1 (2.98%) patient was affected by Von Hippel–Lindau syndrome, but no cases of Li–Fraumeni, Rubin- stein–Taybi, or Prader–Willi syndromes were identified among patients with adrenocortical masses. 9 (26,5%) patients were totally asymptomatic and in 22% of cases tumors were accidentally found out during diagnostic procedures performed for other reasons. Among the symptomatic patients, 14 (41%) had gastrointestinal symptoms. Demographic data and clinical presentation are presented in Table 1. All patients were tested for hormonal profile and were evaluated by ultrasonography (US), 26 (76.4%) by Computed Tomography (CT) and 14 (41.2%) by Magnetic Resonance Imaging (MRI). In 7 patients (20.6%) both CT and MRI were performed. A PET scan was performed in 2 (5.9%) patients and only in one case of pheochromocytoma with neurological impairment a 3D reconstruction imaging was performed to understand both the patient’s surgical anatomy and to plan the surgical procedures especially to determine the optimal port layout. Laterality included 14 (36.8%) right lesions, 20 (52.6%) left lesions and 4 (10.5%) bilateral lesions. The mean diameter of lesions was of 60 mm [40mm-125mm]. Table 2 shows pre operative data (imaging evaluation, laterality and mean diameter). Surgical approach was trans-peritoneal in all 34 patients. Mean operative time was 118.5 min for all procedures, specifically 108 min for unilateral and 270 min for bilateral ones. Mean laparoscopic operative time was of 96 min. No major intra-operative complications were reported. 8 (21.05%) laparoscopic adrenalectomies were converted to open surgery. They were all cases of neuroblastomas with vascular infiltration and 75% of them had positive IDRF. In those cases, the strategy was defined before surgery: laparoscopy was chosen as first approach in order to start the dissection and make easier the laparotomy. Among converted cases, mean age was 19.75 months, mean diameter of the mass was 64mm. Patients were discharged after a mean hospital stay of 4.4 days. The mean follow up was of months 88 months [24-264 months]. Histological analysis confirmed the following results: 24 (63.2%) of all cases were neuroblastomas (NB), 14 of them were associated to Image Defined Risk Factors (IDRF) and 3 to the amplification of N-MYC. 11 (28.9%) cases were pheochromocytomas, 1 (2.6%) teratoma, 1 (2.6%) adrenal cyst and 1 (2.6%) Myelolipoma. Post operative complications included 1 case of arterial hypertension 11 years after surgery for pheochromocitoma and elevated catecholamine with a 31 mm adrenal left mass in 1 patient affected by Von Hippel Lindau and 1 case of paraganglioma and an adrenal hyperplasia accidentally found out 7 years after surgery for pheochromocitoma in 1 patient affected by multiple endocrine neoplasia type 2A. 4 out 8 patients affected by NB grade IV with positive IDRF presented metastatic dissemination despite of complete resection of the mass during the first surgery confirmed also by the histological analysis, after a mean time of 11 months [4-24months]. Finally 3 (8.8%) patients died, 2 of them because infectious complications associated to chemotherapy and the last one because of a severe deshydratation due to acute gastroenteritis. Surgical data, post operative management, intra and post operative complications are reported in Table 3 . Table 4 shows all data about 24 neuroblastomas and all their characteristics in term of OT, conversion rate, recurrences and incidence of death. Discussion Many studies on minimally invasive surgery for adrenal masses in pediatric age have been already published [ 9 , 13 , 14 ]. They demonstrated an increasing use of minimally invasive surgery for adrenal masses in pediatric patients, especially for small and benign tumors [ 3 , 8 ]. Advantages associated to laparoscopic adrenalectomy are different: it allows a smaller incision and better exposition with an easier and more precise dissection to reach the gland [ 15 , 16 ]. Post operative hospital stay is reduced, cosmetic results are better and post operative pain control are easier if compared to open surgery [ 17 ]. Neuroblastic tumors have been the most treated adrenal masses with minimally invasive surgery at our centers, followed by pheocromocitoma; perfectly in line with data showed in Literature [ 18 ]. Median age at surgery of 34 patients involved in this study is significantly lower if compared to that reported in Literature (mean age 52 months vs. 106) [ 18 – 20 ], but on range if considered only the cases of neuroblastomas (36 vs. 38 months) [ 9 ]. There is still no current approved consensus about the indications of minimally invasive surgery for adrenal masses in pediatric age, but it has been demonstrated to be superior to open surgery for small size masses (< 5 cm) and benign tumors [ 3 , 21 – 23 ]. Precisely according to the International Pediatric Endosurgery Group Guidelines (IPEG), laparoscopic adrenalectomy can be safely performed for benign tumors and for malignant ones smaller than 60 mm [ 24 ]. Also in our series, mass volume is a significant risk factor for conversion to open surgery (p = 0.002), even if there is no association between mass volume and recurrence risk. IPEG confirmed that there are no absolute contraindications to laparoscopy unless radical excision is ensured [ 24 ]. In case of malignant tumors it should be considered as starting approach to allow a minimal open access and make easier the dissection with the traditional approach after conversion. Vascular infiltration is the only real absolute contraindication for laparoscopic adrenalectomy because of the high risk of intra-operative bleeding and conversion rate [ 25 ]. Moreover, Shirota et al. and Catellani et al. suggested to limit the use of laparoscopy in case of neuroblastoma with positive pre-operative IDRFs because its proximity to vital structures [ 26 , 27 ]. As we can see in Figure D , there is a dependent relationship between preoperative pre-chemotherapy positivity of IDRF and conversion rate / recurrences without a statistically significant difference (42.85% vs 20%; p = 0.23 and 28.57% vs 0%; p < 0.09). There is no significant difference in term of operative time and length of hospital stay too. The International Neuroblastoma Risk Group proposed IDRF as risk factor resulting in subtotal tumor excision [ 28 , 29 ]. Surgical approach was trans-peritoneal in 100% of patients included in the study. According to literature review it has become the standard procedure for adrenal masses because it makes abdominal lymph node sampling and cancer staging easier and it allows good exposition through a direct access to the gland and bilateral control, avoiding the need of colon mobilization with a low risk of intra-abdominal organ damages [ 3 , 20 ]; it has different anatomical landmarks and it is technically easier [ 30 ]. Retroperitoneal approach can be proposed only for masses smaller than 5 cm [ 3 ]; working place is very small and its related learning curve extremely low [ 3 ]. In our cohort, we did not report any major intra-operative complications vs 7.5% of intra-operative complication rate reported in Literature (p = 0.03) [ 14 ]. On the other hand, total conversion rate was higher if compared to the mean conversion rate reported in Literature (21.05 vs 3.75%, p = 0.0003) [ 9 , 14 , 16 , 31 ]. Conversion rate for neuroblastomas is 33.33%; specifically 42.85% for neuroblastoma with pre-operative IDRF-positive vs. 20% for those with IDRF negative (p = 0.23). These data are in accordance with those reported in Literature: In Tanaka et al. conversion rate is 40% for IDRF positive neuroblastomas and 0% for IDRF negative ones which means that positivity of IDRF should be considered as a risk factor for conversion in laparoscopic adrenalectomies [ 32 ]. We know that these are not real conversions due to the impossibility to complete surgery laparoscopically. It is a choice of our center to approach also big masses with positive IDRF with minimally invasive surgery in order to convert to a minimal open surgery and make the open dissection easier after conversion. Recurrence rate of laparoscopic adrenalectomy for IDRF positive - neuroblastomas is 28.57% vs 0% of laparoscopic adrenalectomy for IDRF negative – ones vs 8.33% for open adrenalectomy reported in Literature (p < 0.0001) [ 33 ]. Even if the results proposed by our Literature review would make us to consider the positivity for IDRF as a contraindication for laparoscopy; in our cohort we can not confirm this statistical significant difference, probably because there are other bias such as different mass volume and histological grading. We know there is a direct correlation, but we do not have enough data to get a good quality statistical analysis. IDRF-positive neuroblastomas completely treated with MIS have a risk of recurrence of 37.5%, instead for those started with MIS and then converted the risk decreases up to 16%. Moreover, if we compare the recurrence rate of our neuroblastomas with preoperative positivity of IDRF who were approached with laparoscopic surgery then converted to open one and the recurrence rate of neuroblastomas with preoperative positivity of IDRF directly treated with open surgery reported in Literature (16.67% vs 10.8%; p = 0.22) [ 34 ], we can see that there is no a statistically significant difference. These data allow us to conclude that the use of minimally invasive surgery is justified and is a safe approach also for this subtype of adrenal mass. In this study the mean operative times were of 108 min and 270 min respectively for unilateral and bilateral lesions, perfectly on range with operative time of other multicenter studies [ 9 , 18 , 21 , 22 , 35 ]. Operative time increases up to 91 min in case of organs or vascular infiltration with a rupture and bleeding risk of 20%. There was not a direct correlation between age, symptoms at presentation, laterality, histology and surgical technique or operative time. Follow up outcomes were worse than those reported in Literature with a not insignificant procedure and tumors – related morbidity and mortality. Median hospital stay in our study was 4.4 days [2–6 days], perfectly on range with that reported in Literature. According to several authors laparoscopic adrenalectomy is associated to a significantly shorter hospital stay compared to that with open surgery [ 19 , 36 – 38 ]. According to Mirallie et al. Shirota et al. laparocopic adrenalectomies also reduce laparotomy-related complications: wound infection, post operative pain control, cosmetic results [ 26 , 39 ]. In our study group, complications were observed in 3 (8.8%) patients: 1 case of arterial hypertention, 1 case of paraganglioma and 1 adrenal hyperplasia accidentally found out 7 years after surgery. On the other hand, mortality and recurrence rates are higher than those reported in Literature, 8.8% vs 0% in Fascetti et al. study and Dukumcu’s one [ 14 , 40 ], 11.7% vs 2.9% [ 14 ]. Kelleher et al. and Shirota et al. compared the recurrence rate after open and laparoscopic adrenalectomy for adrenal neuroblastomas and they both emphasized the importance of limiting the use of laparoscopy in case of positive IDRF neuroblastomas [ 26 , 36 ]. In Keller et al. there is a comparison between high and low risk neuroblastomas treated by laparoscopic or open surgery, but there is no a specific differentiation between IDRF positive and IDRF negative adrenal masses [ 36 ]; while Shirata et al. divided their sample in IDRF positive and IDRF negative neuroblastoma, but they compared the results between the laparoscopic and the open group only for the IDRF-negative patients concluding that recurrence rate was higher after the open approach than after the minimally invasive one (22% vs 0% p = 0.47) [ 26 ]. There was no study in Literature that has previously compared the recurrence rate of IDRF – positive Neuroblastomaa treated by minimally invasive surgery and open adrenalectomy. In our study, 4 children with neuroblastoma had metastatic dissemination and they were all IDRF – positive. Also in our data IDRF –negative neuroblastoma can be safety approached with MIS. It could be useful to understand if there is an association between the metastatic dissemination and the laparoscopic approach; if it were proved, it would be as a possible limitation of the minimally invasive surgery in this group of patients. Future studies will probably standardize the use of pre-operative 3D reconstruction, especially for malign and hyper vascularized tumors such as pheochromocitoma in order to better define the vascularization and to simulated the operative steps [ 30 , 41 ]. Another innovation could be standardized especially in pediatric complex adrenal masses is the intra-operative use of Indocyanine green (ICG) to make easier the surgical dissection [ 42 – 44 ]. Finally robotic – assisted approach to pediatric adrenal masses would be proposed too. It has already been demonstrated in adult age to be associated to higher cost, similar operative time and conversion rate if compared to laparoscopic adrenalectomies, but hospital stay and intra operative bleeding is significantly reduced [ 3 , 45 ]. Conclusion Laparoscopic adrenalectomy in pediatric age has developed over the last 25 years and it is now the gold standard in the management of adrenal pathologies in children. Because of the low incidence of these diseases in the pediatric population, the present series could be considered one of the largest and heterogeneous one about the minimally invasive approach to the adrenal glands in pediatric patients. The limitations of this approach depend on the aggressiveness and loco-regional invasion of the tumor, and the surgeon's experience. The results show that Minimally invasive adrenalecomy can be safely and effective for children affected by benign and small masses (inferior to 5 cm). Probably surgeons should start improving their skills in laparoscopic adrenalectomies with unilateral, benign, small masses (no phrecromocitomas) and approach malignant masses only when sufficiently expert. Laparoscopic adrenalectomy requires advanced endoscopic skills, especially for the resection of malignant lesions. In our cohort conversion rate is not insignificant, but in 75% of cases it involves adrenalectomies for neuroblastomas with positive IDRF: in these cases laparoscopy has been chosen as starting approach to make the open dissection easier; but it was not a definitive surgery. We can conclude that IDRF-negative neuroblastomas can be safety approached with MIS, instead IDRF-positive ones could be dissected with laparoscopy but they need to be converted. Further studies should be conducted on the role of robotic adrenalectomies with or without the use of Indocyanine. Limits of the study The first limit of the study is related to its retrospective nature. Our sample is relatively small, but this is explained by the extremely low incidence of adrenal masses in pediatric age. Finally it would have been useful to demonstrate the eventual association between the laparoscopic approach and the metastatic dissemination through a comparison with metastatic rate after an open adrenalectomy. Abbreviations NB= neuroblastomas IDRF = Image Defined Risk Factors PHE = pheochromocytoma/paraganglioma US = Ultrasounds CT = computed tomography MRI = magnetic resonance imaging IPEG = International Pediatric Endosurgery Group Guidelines ICG = Indocyanine green Declarations Acknowledgment All the authors who contributed to this study are acknowledged for their work. Disclosure The authors Dr Francesca Nascimben, Dr. Amane Lachkar, Prof. Francois Becmeur, Prof. Francesco Molinaro, Prof. Rossella Angotti, Dr. Ciro Andolfi, Dr. Stephan Geiss and Prof. Isabelle Talon declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Funding information No funding sources have been accepted for this work. References Yamamoto H, Yoshida M, Sera Y (1996) Laparoscopic surgery for neuroblastoma identified by mass screening. J Pediatr Surg mars 31(3):385–388 Murphy MM, Witkowski ER, Ng SC, McDade TP, Hill JS, Larkin AC et al (2010) Trends in adrenalectomy: a recent national review. Surg Endosc oct 24(10):2518–2526 Heloury Y, Muthucumaru M, Panabokke G et al (2012) Minimally invasive adrenalectomy in children. J Pediatr Surg. ;47(2):415–21. https://doi.org/10.1016/j.jpedsurg . 2011.08.003 Balassy C, Navarro OM, Daneman A (2011) Adrenal masses in children. 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J Pediatr Surg 39:764–767 43., Steyaert H, Juricic M, Hendrice C, Lembo MA (2004) Al Mohaidly M Kelleher CM, Smithson L, Nguyen LL, Casadiego G, Nasr A, Irwin MS, Gerstle JT (2013) Clinical outcomes in children with adrenal neuroblastoma undergoing open versus laparoscopic adrenalectomy. J Pediatr Surg 48:1727–1732 Nerli RB, Reddy MN, Guntaka A et al (2011) Laparoscopic adrenalectomy for ad- renal masses in children. J Pediatr Urol 7(2):182–186. 10.1016/j. jpurol.2010.04.006 Miller KA, Albanese C, Harrison M et al (2002) Experience with laparoscopic ad- renalectomy in pediatric patients. J Pediatr Surg 37(7):979–982. 10.1053/jpsu.2002.33822 Mirallié E, Leclair MD, de Lagausie P et al (2001) Laparoscopic adrenalectomy in children. Surg Endosc 15(2):156–160. 10.1007/s004640000335 Dokumcu Z, Divarci E, Ertan Y, Celik A (2018) Laparoscopic adrenalectomy in children: A 25-case series and review of the literature. J Pediatr Surg 53(9):1800–1805 Epub 2017 Nov 28. PMID: 29254846 Fuchs J, Warmann SW, Szavay P, Kirschner HJ, Schäfer JF, Hennemuth A et al (2005) Three-dimensional visualization and virtual simulation of resections in pediatric solid tumors. J Pediatr Surg févr 40(2):364–370 Manny TB, Pompeo AS, Hemal AK (2013) Robotic Partial Adrenalectomy Using Indocyanine Green Dye With Near-infrared Imaging: The Initial Clinical Experience. Urol sept 82(3):738–742 Sound S, Okoh AK, Bucak E, Yigitbas H, Dural C, Berber E (2016) Intraoperative tumor localization and tissue distinction during robotic adrenalectomy using indocyanine green fluorescence imaging: a feasibility study. Surg Endosc févr 30(2):657–662 Esposito C, Del Conte F, Cerulo M, Gargiulo F, Izzo S, Esposito G et al (2019) Clinical application and technical standardization of indocyanine green (ICG) fluorescence imaging in pediatric minimally invasive surgery. Pediatr Surg Int. 4 juill. Brandao LF, Autorino R, Laydner H, Haber G-P, Ouzaid I, De Sio M et al (2014) Robotic versus laparoscopic adrenalectomy: a systematic review and meta-analysis. Eur Urol juin 65(6):1154–1161 Tables Table1: It shows demographic data and clinical presentation. Number of patients, N (%) Tot. 34 Sex Female Male 10 (29.4%) 24 (70.6%) Age (months) 52 [3-176] Clinical presentation Asymptomatic Abdominal compression Abdominal pain Hypertension Articular pain Thoraci pain /dyspnea Anemia Virilization Hedache Sweating Obesity Opsoclonus myoclonus 9 (26.5%) 10 (29.4%) 4 (11.8%) 7 (20.6%) 3 (8%) 2 (6%) 1 (2.9%) 0 0 0 0 0 Associated morbidities Von Hippel Lindau sdr Li Fraumeni syndrome Rubin-Stein- Taybi Predr Willi syndrome 1 (2.9%) 0 0 0 Table 2: it shows pre operative data (imaging evaluation, laterality and mean diameter). Number of patients, N (%) Imaging exams US CT MRI PET scan 3D- reconstruction 34 (100%) 26 (76.4%) 14 (41.2%) 2 (5.9%) 1 (2.9%) Laterality Left Right Bilateral 20 (51.2%) 14 (36.8%) 4 (10.5%) Mean diameter (mm) 60 Table 3: It reports surgical data, post operative management, intra and post operative complications. Number of patients, N (%) Surgical approach Trans-peritoneal Retro-peritoneal 34 (100%) 0 Operative time (minutes) Total Monolateral Bilateral 118.5 108 270 Intra-operative complications Blood loss Mass rupture /dissemination Internal organ injuries Conversion 0 0 0 8 (21-6%) Post operative management Mean hospital stay (days) Mean follow up (months) 4.4 88 (24-264) Histopathology of the mass Neuroblastoma Pheocromocitoma Teratoma Adrenal cyst Myelolipoma 24 (63.2%) 11 (28.9%) 1 (2.6%) 1 (2.6%) 1 (2.6%) Post-operative complications Local recurrence Metastatic dissemination Death 2 (5.9%) 4 (11.7%) 3 (8.8%) Table 4: it reports data about 24 neuroblastomas and all their characteristics in term of OT, conversion rate, recurrences and incidence of death. Role of pre and postoperative IDRF as risk factor for conversion and recurrence Stade INRG Preoperative IDRF Mass volume OT (days) Conversion Postoperative IDRF LOS (days) Recurrence Death 1 0 60x45x35 90 0 0 4 0 1 1 1 70x60x40 130 1 1 5 0 0 1 0 65x35x25 70 0 0 3 0 0 1 0 70x50x47 90 1 0 3 0 0 1 0 66x42x47 95 0 0 3 0 0 4 0 50x29x34 300 0 0 7 0 1 4 1 52x38x22 55 0 0 3 0 0 4 1 45x40x25 70 0 0 2 1 1 4 0 40x30x20 70 0 0 4 0 0 4 1 60x45x45 120 0 0 5 1 0 1 0 90x80x50 120 1 0 6 0 0 1 1 70x40x40 150 1 1 5 0 0 1 1 55x50x37 150 1 0 4 0 0 1 0 50x12x18 90 0 0 2 0 0 1 1 70x45x45 120 1 1 3 0 0 1 1 45x30x20 60 0 0 4 0 0 4 1 45x33x19 60 0 0 3 0 0 4 1 75x20x17 120 1 1 5 1 0 1 1 50x24x20 120 0 0 4 0 0 1 0 70x65x25 180 0 0 3 0 0 4 1 43x32x17 160 0 0 8 0 0 1 0 50x35x30 120 0 0 3 0 0 4 1 60x47x42 120 1 1 3 0 0 4 1 45x30x18 80 0 1 3 1 0 * OT = operative time **LOS = length of hospital stay Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3809669","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":263737301,"identity":"91a8ff5d-b433-4969-9d92-86b0b0dae6e2","order_by":0,"name":"Francesca 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up.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"FigureA.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3809669/v1/27688397bc65551f4008403a.jpg"},{"id":49089336,"identity":"4b1fa36a-9600-4ca4-94f7-b2ae6c9e8268","added_by":"auto","created_at":"2024-01-03 01:35:16","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":10563,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eLaparoscopic Ports placement.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"FgiureB.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3809669/v1/63762981746c6070ea31be68.jpg"},{"id":49088711,"identity":"83323226-9a50-43cf-b33f-8fc2dd122517","added_by":"auto","created_at":"2024-01-03 01:27:16","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":14495,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eLaparoscopic dissection of the adrenal gland.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"FigureC.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3809669/v1/b77851a3e30992297ae983cc.jpg"},{"id":49088713,"identity":"b9e1d93b-d70d-477a-846f-d8a323b5c09c","added_by":"auto","created_at":"2024-01-03 01:27:16","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":33769,"visible":true,"origin":"","legend":"\u003cp\u003ecomparison between neuroblastome with pre-operative positive IDRF and with pre-operative negative IDRF in term of conversion rate, recurrences and death.\u003c/p\u003e","description":"","filename":"FigureD.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3809669/v1/f93b4a57c0ab773d7860ea58.jpg"},{"id":49830986,"identity":"a6e74195-c1da-49c5-bf65-3fa8ceeadb78","added_by":"auto","created_at":"2024-01-18 16:37:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":376772,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3809669/v1/abd59975-09d9-40b4-b453-dd6d8ff09bcb.pdf"},{"id":49088716,"identity":"d47cfa9b-43c0-413e-bb39-a7bf66c4ec74","added_by":"auto","created_at":"2024-01-03 01:27:16","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":546050,"visible":true,"origin":"","legend":"","description":"","filename":"ListofFiguresMIS.docx","url":"https://assets-eu.researchsquare.com/files/rs-3809669/v1/ff9e0972d3600e1b230d1a2e.docx"},{"id":49089337,"identity":"cc6ceb3f-7911-47c2-871d-f9fcc7968679","added_by":"auto","created_at":"2024-01-03 01:35:16","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":70315,"visible":true,"origin":"","legend":"","description":"","filename":"ListofTablesMIS.docx","url":"https://assets-eu.researchsquare.com/files/rs-3809669/v1/4bd9ae72d749eaa2efc25da3.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Minimally invasive surgery for adrenal masses in children: results of a bi-centric survey and Literature review.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFirst laparoscopic adrenalectomy was performed in children in 1996 by Yamamoto [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], but it has developed slower in pediatric population if compared to adult age not only because of the discrepancy between the large dimension of adrenal masses and the small size of patients, but also because of the low incidence of adrenal masses in children and the prevalent malignant nature of tumors [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Main indications for adrenal surgery in children are neoplastic masses [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] both from the medulla as neuroblastomas (NBs) and pheochromocytoma/para-ganglioma (PHE) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and from cortex like corticosurrenaloma [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In children adrenalectomy is performed because of bilateral adrenal hyperplasia too [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Main issues for surgery are risk of spillage for corticosurrenaloma, vessel encasement of the tumor for pheocromocytoma [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], size of the tumor for myelolipoma, pheocromocytoma and neuroblastoma [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] and Image-De Risk Factors (IDRFs) for neuroblastoma [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. There are no guidelines about the specific use of this technique in pediatric population even if the minimally invasive approach to adrenal masses seems to be a safe and effective alternative to the traditional surgery and it is associated to different advantages such as shorter operative time, easier post operative pain control, shorter hospital stay, better cosmetic results, fewer complications and less morbidity [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eAim of the study\u003c/h3\u003e\n\u003cp\u003ePrimary aim of this study is to evaluate the epidemiology, the characteristics, the surgical indications and the outcomes of adrenal masses treated with minimal invasive surgery in pediatric age through the analysis of the cases of two European centers. Secondary aim is to identify the potential risk factors involved in the outcome of minimal invasive adrenalectomy focus the attention on conversation rate and complications.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eA bi-centric study was conducted including all patients younger than 18 years old who underwent minimally invasive adrenalectomy performed by two expert pediatric surgeons (one for each center) working together between January 2000 and December 2020 at University Hospital of Strasbourg and the Departement of Pediatric Surgery of Colmar. Patients older than 18 years old, patients underwent to previous abdominal surgeries, patients followed up less than 1 year or patients with incomplete data were excluded from the study.\u003c/p\u003e \u003cp\u003eDemographic data (age, gender, diagnosis, etiology, comorbidities, time at diagnosis and time at surgery, laterality, and pre-operative presentation) were collected. All patients with suspected adrenal mass, either symptomatic or accidentally diagnosed by imaging underwent detailed personal and familiar history, physical examination, laboratory tests including adrenal function test and they were radiologically evaluated (ultrasound, CT scan, and sometimes magnetic resonance imaging). All cases were discussed by a multidisciplinary teams and indications for surgery and / or chemotherapy were defined according to the Oncologic guidelines. Indications for Laparoscopic adrenalectomy included low-risk adrenal masses and prenatally diagnosed tumors which were increased in size during follow-up. Intra-operative parameters including type of performed procedure, operative time and intra-operative complications were evaluated.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInstitutional Review Board\u003c/b\u003e approval was not required for this study because of its retrospective nature. \u003cb\u003eInformed consent\u003c/b\u003e has been obtained. Parents of the patients includedn in the study or their caregivers signed a writte consenit for treatment and another one for publication of patients anonimous information (including images).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSurgical technique\u003c/span\u003e \u003c/p\u003e \u003cp\u003eTrans-peritoneal andrenalectomy under general anesthesia was performed in all patients. Patients were placed in lateral decubitus with a costal block to increase the space between the last costs and the iliac crests. Patient\u0026rsquo;s placement and operating room set up is described in \u003cb\u003eFigure A\u003c/b\u003e. A Foley catheter was placed at the beginning of the procedure in order to be used later for bladder hydro-distention. Using open access, four laparoscopic ports were placed; the first 5 or 10 mm trocar for camera port was placed under the umbilicus. Pneumo-peritoneum was induced at 10 or 12 mmHg according to patient\u0026rsquo;s age. Other 3 trocars were placed. In case of right adrenalectomy a 5 mm working trocar was placed in the midline between the xiphoid and the umbilicus, the second one along the mid-clavicular line on the right flank and the last 3 mm one in the epigastric region to retract the liver (\u003cb\u003eFigure B\u003c/b\u003e). After an abdominal exploration and the retraction of the liver, surgeons proceeded opening the retroperitoneum. After blind dissection and careful isolation of the inferior vena cava and renal vein, adrenal veins were isolated and sectioned. In case of left adrenalectomy a 5 mm working trocar was placed in the midline between the xiphoid and the umbilicus, the second one along the mid-clavicular line on the left flank and the last 3 mm one in the epigastric region. After an abdominal exploration, surgeons proceeded releasing the spleen through the dissection of the peritoneum and the spleno-diaphragmatic ties; they released the left colic angle and mobilized the spleen and the pancreas tail. After opening of the spleno-renal space, releasing of the upper pole of the left kidney and the lower pole of the spleen, the left adrenal gland was identified. The medial part of the adrenal vein and the upper part of the left renal vein were isolated and sectioned.\u003c/p\u003e \u003cp\u003eIn both cases, adrenal gland was then dissected starting from medial side through the thermofusion effect of Ligasure\u0026reg; (\u003cb\u003eFigure C\u003c/b\u003e). The dissected adrenal gland was placed into an Endobag\u0026reg; and removed through the umbelical port. Only in case of huge adrenal masses, they were removed through a mini-Pfannesteil incision. The working ports were removed and the trocar orifices were closed using separate stitches.\u003c/p\u003e \u003cp\u003ePostoperative management including time of abdominal drainage removal, time of ureteral catheter removal, length of hospital stay, postoperative outcomes and short and long term follow up was recorded. All patients who were operated weremonitored for at least 1 year. During the follow-up, patients underwent phisical examination, laboratory tests and US evaluation.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were performed using \u003cem\u003egraph-pad\u003c/em\u003e and \u003cem\u003er\u003c/em\u003e. Continuous variables are presented as mean. Categorical variables are presented as frequency and percentage. ANOVA, X-square, and Fisher tests were used for statistical analysis. A stepwise regression model has been created for independent variables. A p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 38 minimally invasive adrenalectomies were included in the study, performed from January 2000 to December 2020 at two European Departments of Pediatric Surgery (University Hospital of Strasbourg and Hospital of Colmar) in 34 patients, 10 females (29.4%) and 24 males (70.6%) with a mean age of 52 months [3 months\u0026ndash; 176 months]. 1 (2.98%) patient was affected by Von Hippel\u0026ndash;Lindau syndrome, but no cases of Li\u0026ndash;Fraumeni, Rubin- stein\u0026ndash;Taybi, or Prader\u0026ndash;Willi syndromes were identified among patients with adrenocortical masses. 9 (26,5%) patients were totally asymptomatic and in 22% of cases tumors were accidentally found out during diagnostic procedures performed for other reasons. Among the symptomatic patients, 14 (41%) had gastrointestinal symptoms. Demographic data and clinical presentation are presented in \u003cstrong\u003eTable 1.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients were tested for hormonal profile and were evaluated by ultrasonography (US), 26 (76.4%) by Computed Tomography (CT) and 14 (41.2%) by Magnetic Resonance Imaging (MRI). In 7 patients (20.6%) both CT and MRI were performed. A PET scan was performed in 2 (5.9%) patients and only in one case of pheochromocytoma with neurological impairment a 3D reconstruction imaging was performed to understand both the patient\u0026rsquo;s surgical anatomy and to plan the surgical procedures especially to determine the optimal port layout.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLaterality included 14 (36.8%) right lesions, 20 (52.6%) left lesions and 4 (10.5%) bilateral lesions. The mean diameter of lesions was of 60 mm [40mm-125mm].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e shows pre operative data (imaging evaluation, laterality and mean diameter). Surgical approach was trans-peritoneal in all 34 patients. Mean operative time was 118.5 min for all procedures, specifically 108 min for unilateral and 270 min for bilateral ones. Mean laparoscopic operative time was of 96 min.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNo major intra-operative complications were reported. 8 (21.05%) laparoscopic adrenalectomies were converted to open surgery. They were all cases of neuroblastomas with vascular infiltration and 75% of them had positive IDRF. In those cases, the strategy was defined before surgery: laparoscopy was chosen as first approach in order to start the dissection and make easier the laparotomy. Among converted cases, mean age was 19.75 months, mean diameter of the mass was 64mm. Patients were discharged after a mean hospital stay of 4.4 days. The mean follow up was of months 88 months [24-264 months].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHistological analysis confirmed the following results: 24 (63.2%) of all cases were neuroblastomas (NB), 14 of them were associated to Image Defined Risk Factors (IDRF) and 3 to the amplification of N-MYC. 11 (28.9%) cases were pheochromocytomas, 1 (2.6%) teratoma, 1 (2.6%) adrenal cyst and 1 (2.6%) Myelolipoma. Post operative complications included 1 case of arterial hypertension 11 years after surgery for pheochromocitoma and elevated catecholamine with a 31 mm adrenal left mass in 1 patient affected by Von Hippel Lindau and 1 case of paraganglioma and an adrenal hyperplasia accidentally found out 7 years after surgery for pheochromocitoma in 1 patient affected by multiple endocrine neoplasia type 2A. 4 out 8 patients affected by NB grade IV with positive IDRF presented metastatic dissemination despite of complete resection of the mass during the first surgery confirmed also by the histological analysis, after a mean time of 11 months [4-24months]. Finally 3 (8.8%) patients died, 2 of them because infectious complications associated to chemotherapy and the last one because of a severe deshydratation due to acute gastroenteritis. Surgical data, post operative management, intra and post operative complications are reported in \u003cstrong\u003eTable 3\u003c/strong\u003e.\u0026nbsp;\u003cstrong\u003eTable 4\u003c/strong\u003e shows all data about 24 neuroblastomas and all their characteristics in term of OT, conversion rate, recurrences and incidence of death.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMany studies on minimally invasive surgery for adrenal masses in pediatric age have been already published [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. They demonstrated an increasing use of minimally invasive surgery for adrenal masses in pediatric patients, especially for small and benign tumors [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Advantages associated to laparoscopic adrenalectomy are different: it allows a smaller incision and better exposition with an easier and more precise dissection to reach the gland [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Post operative hospital stay is reduced, cosmetic results are better and post operative pain control are easier if compared to open surgery [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNeuroblastic tumors have been the most treated adrenal masses with minimally invasive surgery at our centers, followed by pheocromocitoma; perfectly in line with data showed in Literature [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Median age at surgery of 34 patients involved in this study is significantly lower if compared to that reported in Literature (mean age 52 months vs. 106) [\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], but on range if considered only the cases of neuroblastomas (36 vs. 38 months) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. There is still no current approved consensus about the indications of minimally invasive surgery for adrenal masses in pediatric age, but it has been demonstrated to be superior to open surgery for small size masses (\u0026lt;\u0026thinsp;5 cm) and benign tumors [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Precisely according to the International Pediatric Endosurgery Group Guidelines (IPEG), laparoscopic adrenalectomy can be safely performed for benign tumors and for malignant ones smaller than 60 mm [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Also in our series, mass volume is a significant risk factor for conversion to open surgery (p\u0026thinsp;=\u0026thinsp;0.002), even if there is no association between mass volume and recurrence risk. IPEG confirmed that there are no absolute contraindications to laparoscopy unless radical excision is ensured [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In case of malignant tumors it should be considered as starting approach to allow a minimal open access and make easier the dissection with the traditional approach after conversion. Vascular infiltration is the only real absolute contraindication for laparoscopic adrenalectomy because of the high risk of intra-operative bleeding and conversion rate [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Moreover, Shirota et al. and Catellani et al. suggested to limit the use of laparoscopy in case of neuroblastoma with positive pre-operative IDRFs because its proximity to vital structures [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. As we can see in \u003cb\u003eFigure D\u003c/b\u003e, there is a dependent relationship between preoperative pre-chemotherapy positivity of IDRF and conversion rate / recurrences without a statistically significant difference (42.85% vs 20%; p\u0026thinsp;=\u0026thinsp;0.23 and 28.57% vs 0%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.09). There is no significant difference in term of operative time and length of hospital stay too. The International Neuroblastoma Risk Group proposed IDRF as risk factor resulting in subtotal tumor excision [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Surgical approach was trans-peritoneal in 100% of patients included in the study. According to literature review it has become the standard procedure for adrenal masses because it makes abdominal lymph node sampling and cancer staging easier and it allows good exposition through a direct access to the gland and bilateral control, avoiding the need of colon mobilization with a low risk of intra-abdominal organ damages [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]; it has different anatomical landmarks and it is technically easier [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Retroperitoneal approach can be proposed only for masses smaller than 5 cm [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]; working place is very small and its related learning curve extremely low [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In our cohort, we did not report any major intra-operative complications vs 7.5% of intra-operative complication rate reported in Literature (p\u0026thinsp;=\u0026thinsp;0.03) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. On the other hand, total conversion rate was higher if compared to the mean conversion rate reported in Literature (21.05 vs 3.75%, p\u0026thinsp;=\u0026thinsp;0.0003) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Conversion rate for neuroblastomas is 33.33%; specifically 42.85% for neuroblastoma with pre-operative IDRF-positive vs. 20% for those with IDRF negative (p\u0026thinsp;=\u0026thinsp;0.23). These data are in accordance with those reported in Literature: In Tanaka et al. conversion rate is 40% for IDRF positive neuroblastomas and 0% for IDRF negative ones which means that positivity of IDRF should be considered as a risk factor for conversion in laparoscopic adrenalectomies [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. We know that these are not real conversions due to the impossibility to complete surgery laparoscopically. It is a choice of our center to approach also big masses with positive IDRF with minimally invasive surgery in order to convert to a minimal open surgery and make the open dissection easier after conversion. Recurrence rate of laparoscopic adrenalectomy for IDRF positive - neuroblastomas is 28.57% vs 0% of laparoscopic adrenalectomy for IDRF negative \u0026ndash; ones vs 8.33% for open adrenalectomy reported in Literature (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Even if the results proposed by our Literature review would make us to consider the positivity for IDRF as a contraindication for laparoscopy; in our cohort we can not confirm this statistical significant difference, probably because there are other bias such as different mass volume and histological grading. We know there is a direct correlation, but we do not have enough data to get a good quality statistical analysis. IDRF-positive neuroblastomas completely treated with MIS have a risk of recurrence of 37.5%, instead for those started with MIS and then converted the risk decreases up to 16%. Moreover, if we compare the recurrence rate of our neuroblastomas with preoperative positivity of IDRF who were approached with laparoscopic surgery then converted to open one and the recurrence rate of neuroblastomas with preoperative positivity of IDRF directly treated with open surgery reported in Literature (16.67% vs 10.8%; p\u0026thinsp;=\u0026thinsp;0.22) [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], we can see that there is no a statistically significant difference. These data allow us to conclude that the use of minimally invasive surgery is justified and is a safe approach also for this subtype of adrenal mass. In this study the mean operative times were of 108 min and 270 min respectively for unilateral and bilateral lesions, perfectly on range with operative time of other multicenter studies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Operative time increases up to 91 min in case of organs or vascular infiltration with a rupture and bleeding risk of 20%. There was not a direct correlation between age, symptoms at presentation, laterality, histology and surgical technique or operative time. Follow up outcomes were worse than those reported in Literature with a not insignificant procedure and tumors \u0026ndash; related morbidity and mortality. Median hospital stay in our study was 4.4 days [2\u0026ndash;6 days], perfectly on range with that reported in Literature. According to several authors laparoscopic adrenalectomy is associated to a significantly shorter hospital stay compared to that with open surgery [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. According to Mirallie et al. Shirota et al. laparocopic adrenalectomies also reduce laparotomy-related complications: wound infection, post operative pain control, cosmetic results [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. In our study group, complications were observed in 3 (8.8%) patients: 1 case of arterial hypertention, 1 case of paraganglioma and 1 adrenal hyperplasia accidentally found out 7 years after surgery. On the other hand, mortality and recurrence rates are higher than those reported in Literature, 8.8% vs 0% in Fascetti et al. study and Dukumcu\u0026rsquo;s one [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], 11.7% vs 2.9% [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Kelleher et al. and Shirota et al. compared the recurrence rate after open and laparoscopic adrenalectomy for adrenal neuroblastomas and they both emphasized the importance of limiting the use of laparoscopy in case of positive IDRF neuroblastomas [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In Keller et al. there is a comparison between high and low risk neuroblastomas treated by laparoscopic or open surgery, but there is no a specific differentiation between IDRF positive and IDRF negative adrenal masses [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]; while Shirata et al. divided their sample in IDRF positive and IDRF negative neuroblastoma, but they compared the results between the laparoscopic and the open group only for the IDRF-negative patients concluding that recurrence rate was higher after the open approach than after the minimally invasive one (22% vs 0% p\u0026thinsp;=\u0026thinsp;0.47) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. There was no study in Literature that has previously compared the recurrence rate of IDRF \u0026ndash; positive Neuroblastomaa treated by minimally invasive surgery and open adrenalectomy. In our study, 4 children with neuroblastoma had metastatic dissemination and they were all IDRF \u0026ndash; positive. Also in our data IDRF \u0026ndash;negative neuroblastoma can be safety approached with MIS. It could be useful to understand if there is an association between the metastatic dissemination and the laparoscopic approach; if it were proved, it would be as a possible limitation of the minimally invasive surgery in this group of patients. Future studies will probably standardize the use of pre-operative 3D reconstruction, especially for malign and hyper vascularized tumors such as pheochromocitoma in order to better define the vascularization and to simulated the operative steps [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Another innovation could be standardized especially in pediatric complex adrenal masses is the intra-operative use of Indocyanine green (ICG) to make easier the surgical dissection [\u003cspan additionalcitationids=\"CR43\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Finally robotic \u0026ndash; assisted approach to pediatric adrenal masses would be proposed too. It has already been demonstrated in adult age to be associated to higher cost, similar operative time and conversion rate if compared to laparoscopic adrenalectomies, but hospital stay and intra operative bleeding is significantly reduced [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eLaparoscopic adrenalectomy in pediatric age has developed over the last 25 years and it is now the gold standard in the management of adrenal pathologies in children. Because of the low incidence of these diseases in the pediatric population, the present series could be considered one of the largest and heterogeneous one about the minimally invasive approach to the adrenal glands in pediatric patients. The limitations of this approach depend on the aggressiveness and loco-regional invasion of the tumor, and the surgeon's experience. The results show that Minimally invasive adrenalecomy can be safely and effective for children affected by benign and small masses (inferior to 5 cm). Probably surgeons should start improving their skills in laparoscopic adrenalectomies with unilateral, benign, small masses (no phrecromocitomas) and approach malignant masses only when sufficiently expert. Laparoscopic adrenalectomy requires advanced endoscopic skills, especially for the resection of malignant lesions. In our cohort conversion rate is not insignificant, but in 75% of cases it involves adrenalectomies for neuroblastomas with positive IDRF: in these cases laparoscopy has been chosen as starting approach to make the open dissection easier; but it was not a definitive surgery. We can conclude that IDRF-negative neuroblastomas can be safety approached with MIS, instead IDRF-positive ones could be dissected with laparoscopy but they need to be converted. Further studies should be conducted on the role of robotic adrenalectomies with or without the use of Indocyanine.\u003c/p\u003e"},{"header":"Limits of the study","content":"\u003cp\u003eThe first limit of the study is related to its retrospective nature. Our sample is relatively small, but this is explained by the extremely low incidence of adrenal masses in pediatric age. Finally it would have been useful to demonstrate the eventual association between the laparoscopic approach and the metastatic dissemination through a comparison with metastatic rate after an open adrenalectomy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eNB= neuroblastomas\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIDRF = Image Defined Risk Factors\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePHE = pheochromocytoma/paraganglioma\u003c/p\u003e\n\u003cp\u003eUS = Ultrasounds\u003c/p\u003e\n\u003cp\u003eCT = computed tomography\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMRI = magnetic resonance imaging\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIPEG =\u0026nbsp;International Pediatric Endosurgery Group Guidelines\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eICG = Indocyanine green\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors who contributed to this study are acknowledged for their work.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors Dr Francesca Nascimben, Dr. Amane Lachkar, Prof. Francois Becmeur, Prof. Francesco Molinaro, Prof. Rossella Angotti, Dr. Ciro Andolfi, Dr. Stephan Geiss and Prof. Isabelle Talon declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding sources have been accepted for this work.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eYamamoto H, Yoshida M, Sera Y (1996) Laparoscopic surgery for neuroblastoma identified by mass screening. 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J Pediatr Surg 37(7):1027\u0026ndash;1029\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiller KA, Albanese C, Harrison M et al (2002) Experience with laparoscopic adrenalec- tomy in pediatric patients. J Pediatr Surg 37(7):979\u0026ndash;982 [discussion 979\u0026ndash;82]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIwanaka T, Arai M, Ito M, Kawashima H, Yamamoto K, Hanada R et al (2001) Surgical treatment for abdominal neuroblastoma in the laparoscopic era. Surg Endosc juill 15(7):751\u0026ndash;754\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRomano P, Avolio L, Martucciello G, Steyaert H, Valla JS (2007) Adrenal masses in children: the role of minimally inva- sive surgery. Surg Laparosc Endosc Percutan Tech 17:504\u0026ndash;507\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLopes RI, Denes FT, Bissoli J, Mendonca BB, Srougi M (2012) Laparoscopic adrenalectomy in children. J Pediatr Urol 8:379\u0026ndash;385\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLopez PJ, Pierro A, Curry JI, Mushtaq I (2007) Retroperitoneoscopic adrenalectomy: an early institutional experience. J Pediatr Urol 3:96\u0026ndash;99\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCastilho LN, Castillo OA, Denes FT et al (2002) Laparoscopic adrenal surgery in children. J Urol 168(1):221\u0026ndash;224\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSteyaert H, Juricic M, Hendrice C et al (2003) Retroperitoneoscopic approach to the adrenal glands and retroperitoneal tumours in children: where do we stand? Eur J Pediatr Surg 13(2):112\u0026ndash;115\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCecchetto G, Riccipetitoni G, Inserra A, Esposito C, Michelazzi A, Ruggeri G, Spinelli C, Lima M, Italian Group of Pediatric Surgical Oncology (2010) Minimally-invasive surgery in paedi- atric oncology: proposal of recommendations. 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J Pediatr Surg f\u0026eacute;vr 40(2):364\u0026ndash;370\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManny TB, Pompeo AS, Hemal AK (2013) Robotic Partial Adrenalectomy Using Indocyanine Green Dye With Near-infrared Imaging: The Initial Clinical Experience. Urol sept 82(3):738\u0026ndash;742\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSound S, Okoh AK, Bucak E, Yigitbas H, Dural C, Berber E (2016) Intraoperative tumor localization and tissue distinction during robotic adrenalectomy using indocyanine green fluorescence imaging: a feasibility study. Surg Endosc f\u0026eacute;vr 30(2):657\u0026ndash;662\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEsposito C, Del Conte F, Cerulo M, Gargiulo F, Izzo S, Esposito G et al (2019) Clinical application and technical standardization of indocyanine green (ICG) fluorescence imaging in pediatric minimally invasive surgery. Pediatr Surg Int. 4 juill.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrandao LF, Autorino R, Laydner H, Haber G-P, Ouzaid I, De Sio M et al (2014) Robotic versus laparoscopic adrenalectomy: a systematic review and meta-analysis. Eur Urol juin 65(6):1154\u0026ndash;1161\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cem\u003eTable1:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eIt shows\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003edemographic data and clinical presentation.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"331\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of patients, N (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"60%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eTot.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40%\" valign=\"top\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"60%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSex\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Female\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Male\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 (29.4%)\u003c/p\u003e\n \u003cp\u003e24 (70.6%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"60%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAge (months)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e52 [3-176]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"60%\" valign=\"top\"\u003e\n \u003cp\u003eClinical presentation\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Asymptomatic\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Abdominal compression\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Abdominal pain\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Hypertension\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Articular pain\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Thoraci pain /dyspnea\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Anemia \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Virilization\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Hedache\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Sweating\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Obesity\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Opsoclonus myoclonus\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9 (26.5%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 (29.4%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (11.8%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7 (20.6%)\u003c/p\u003e\n \u003cp\u003e3 (8%)\u003c/p\u003e\n \u003cp\u003e2 (6%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (2.9%)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"60%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAssociated morbidities\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Von Hippel Lindau sdr\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Li Fraumeni syndrome\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Rubin-Stein- Taybi\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Predr Willi syndrome\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (2.9%)\u003c/p\u003e\n \u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 2: it shows pre operative data (imaging evaluation, laterality and mean diameter).\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"331\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of patients, N (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"60%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eImaging exams\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; US\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; CT\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; MRI\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; PET scan\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 3D- reconstruction\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e34 (100%)\u003c/p\u003e\n \u003cp\u003e26 (76.4%)\u003c/p\u003e\n \u003cp\u003e14 (41.2%)\u003c/p\u003e\n \u003cp\u003e2 (5.9%)\u003c/p\u003e\n \u003cp\u003e1 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"60%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eLaterality\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Left\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Right\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Bilateral\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20 (51.2%)\u003c/p\u003e\n \u003cp\u003e14 (36.8%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (10.5%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"60%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u003cem\u003eMean diameter (mm)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40%\" valign=\"top\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 3: It reports surgical data, post operative management, intra and post operative complications.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"331\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of patients, N (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"60%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSurgical approach \u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Trans-peritoneal\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Retro-peritoneal \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e34 (100%)\u003c/p\u003e\n \u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"60%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eOperative time (minutes)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003eTotal\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Monolateral\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Bilateral\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e118.5\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e108\u003c/p\u003e\n \u003cp\u003e270\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"60%\" valign=\"top\"\u003e\n \u003cp\u003eIntra-operative complications \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Blood loss\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Mass rupture /dissemination\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Internal organ injuries\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Conversion \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e8 (21-6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"60%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePost operative management\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Mean hospital stay (days)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Mean follow up (months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.4\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e88 (24-264)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"60%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eHistopathology of the mass\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Neuroblastoma\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Pheocromocitoma\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Teratoma\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Adrenal cyst\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Myelolipoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e24 (63.2%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11 (28.9%)\u003c/p\u003e\n \u003cp\u003e1 (2.6%)\u003c/p\u003e\n \u003cp\u003e1 (2.6%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (2.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"60%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePost-operative complications \u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Local recurrence \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Metastatic dissemination \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Death\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (5.9%)\u003c/p\u003e\n \u003cp\u003e4 (11.7%)\u003c/p\u003e\n \u003cp\u003e3 (8.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 4: it reports data about 24 neuroblastomas and all their characteristics in term of OT, conversion rate, recurrences and incidence of death.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"9\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRole of pre and postoperative IDRF as risk factor for conversion and recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003eStade INRG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003ePreoperative IDRF \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003eMass volume\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003eOT\u003c/p\u003e\n \u003cp\u003e(days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003eConversion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003ePostoperative IDRF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003eLOS\u003c/p\u003e\n \u003cp\u003e(days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003eRecurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003eDeath\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e60x45x35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e70x60x40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e65x35x25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e70x50x47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e66x42x47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e50x29x34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e52x38x22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e45x40x25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e40x30x20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e60x45x45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e90x80x50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e70x40x40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e55x50x37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e50x12x18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e70x45x45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e45x30x20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e45x33x19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e75x20x17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e50x24x20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e70x65x25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e43x32x17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e50x35x30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e60x47x42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.714285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e45x30x18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.090909090909092%\" valign=\"top\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.5%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.7987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.253246753246753%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.337662337662337%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.62987012987013%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e* OT = operative time\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e**LOS = length of hospital stay\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Adrenal mass, Laparoscopic adrenalectomy, Minimally invasive surgery, Children","lastPublishedDoi":"10.21203/rs.3.rs-3809669/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3809669/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMinimally invasive surgery for adrenal pathologies in children is still developing because of the low incidence of adrenal masses in pediatric population and the discrepancy between the size of the mass and the child\u0026rsquo;s one. In Literature there are no any guidelines about the use of laparoscopic andrenalectomy in children. The aim of this study is to evaluate the outcomes of minimally invasive surgery through a bi-center data analysis in order to propose a standardized protocol.\u003c/p\u003e\u003ch2\u003eMaterials and methods\u003c/h2\u003e \u003cp\u003eChildren who underwent minimally invasive adrenalectomy between 2000 and 2020 performed by two expert Pediatric surgeons at two European departments of Pediatric Surgery were included in this study. Data were collected and analyzed using X-square, Fisher tests, multiple regression model.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e34 patients (38 adrenal masse)s were included. Mean age was 52 months 3\u0026ndash;176]. Median lesion diameter was 60 mm [40-125mm]. Histological examination revealed 24 neuroblastomas, 11 pheochromocytomas, 1 teratoma, 1 adrenal cyst and 1 Myelolipoma. Laterality was 52.6% left, 36.8% right and 10.5% bilateral. Surgical access was trans-peritoneal in all patients. Mean operative time was 108 min for unilateral lesions and 270 min for bilateral ones. Mean hospital stay was 4.4 days. No major intra operative complications were observed. 21.05% neuroblastomas were preventively approached with a laparoscopic access and were converted to open surgery. Median follow-up was 88 months [24\u0026ndash;264]. 4 patients affected by neuroblastoma reported metastatic dissemination and 3 died.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ePediatric minimally invasive adrenalectomy was a safe and effective procedure, it allows surgeons to reduce the size of laparotomies starting the dissection of the masses and it has low rate of complication if we consider small masses. The only absolute contraindication is persistent IDRF for neuroblastomas. It should be considered the first-line treatment for selected adrenal masses in centers with good experience in laparoscopy.\u003c/p\u003e","manuscriptTitle":"Minimally invasive surgery for adrenal masses in children: results of a bi-centric survey and Literature review.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-03 01:27:11","doi":"10.21203/rs.3.rs-3809669/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"12a17af7-f395-4bb9-afcc-a66ef5a197c1","owner":[],"postedDate":"January 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-01-18T16:29:18+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-03 01:27:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3809669","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3809669","identity":"rs-3809669","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}