Short- and long-term outcomes of adrenalectomy for Primary Aldosteronism in a single UK centre: Rear Mirror View.

Short- and long-term outcomes of adrenalectomy for Primary Aldosteronism in a single UK centre: Rear Mirror View. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Short- and long-term outcomes of adrenalectomy for Primary Aldosteronism in a single UK centre: Rear Mirror View. Tarek Abdel-Aziz, Alaa Abdelsalam, Teng-Teng Chung, Umasuthan Srirangalingam, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4697365/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Nov, 2024 Read the published version in Hormones → Version 1 posted 5 You are reading this latest preprint version Abstract Purpose: Primary Aldosteronism (PA) is the commonest cause of secondary hypertension and can be cured by unilateral adrenalectomy. We report the short and long-term outcomes after adrenalectomy performed at a single UK centre over a period of 24 years. Methods: Retrospective analysis of biochemical (potassium, aldosterone, renin and ARR) radiological (CT/MRI, AVS, nuclear scans) and clinical (surgical complications, blood pressure, number of antihypertensive medications) short and long terms outcomes in patients who underwent adrenalectomy for PA between 1998 and 2021. Standardised PASO and Clavien-Dindo criteria to assess biochemical, clinical and surgical outcomes were used. Results: 82 patients treated with adrenalectomy for PA over a 24 year period, short term follow up data (within 3 months from surgery) was available for 82 patients (M45, F37, mean age 51.7 years), 24 of them were followed at least 60 months( range 60 to 72 months) 77 (93.9%) patients had laparoscopic surgery (1 conversion). 7 patients had postoperative complications classified as Clavien-Dindo II(4), IIIa(1) and IVa(2). Median LOS was 2.5 days (1-12). Complete and partial clinical success was achieved in 29% and 58.3% and 41.7% and 45.8% of patients in short and long term respectively. Clinical benefit was observed in 88% of patients. Complete biochemical success was achieved in 95.8% of patients in short and long term. Conclusion : Unilateral adrenalectomy in patients with PA achieved clinical benefit in 88% and biochemical cure in almost all of them. Our data suggest that these benefits persisted for at least 5 years. Primary Aldosteronism Adrenalectomy Conn’s syndrome Biochemical cure Introduction Primary hyperaldosteronism (PA) is the commonest cause of secondary hypertension and can be successfully treated by adrenalectomy if excessive secretion of aldosterone is confirmed to be from a unilateral source[1, 2]. Estimates of the prevalence of PA have varied considerably over the last 70 years, but recent data suggest that it affects 3.2% to 12.7% of patients in primary care and 1% to 29.8% referred to hypertension units[3, 4]. The incidence of PA rises with the severity of hypertension , from 2% in patients with grade 1 hypertension to 20% in those with resistant hypertension[4] Patients with PA have increased risk of myocardial infarction, stroke, atrial fibrillation and higher prevalence of metabolic syndrome in comparison to patients with essential hypertension[3]. Recent metanalysis showed that patients with PA treated with adrenalectomy had better outcomes in comparison to patients treated with medications alone[5]. This is because surgery can not only restore normal blood pressure and obviate the need for antihypertensive medications, but also by removing the source of aldosterone over-secretion, it can normalise the renin-angiotensin-aldosterone system and correct concomitant abnormalities of hypokalaemia, alkalosis and fibrosis in multiple organs like heart, kidney and pancreas caused by high levels of aldosterone[6-8]. Introduction of minimally invasive techniques had huge positive impact on outcomes after adrenalectomies in reducing postoperative pain, length of hospital stay and improved cosmesis. Cure rates after adrenalectomy for PA range from 32% to 42% at 6 months after surgery but data on long-term outcomes are relatively scarce and often consist of small cohort studies[9-13]. It is not clear whether short term benefits of adrenalectomy persist in longer term and whether clinical and biochemical cure go hand in hand or have separate course[14]. Interest in PA has heightened in recent years and research into this condition has experienced what can be called a “Renaissance period” leading to the development of new functional imaging and adrenal ablative techniques as an alternative to surgical resection[15-18]. Understanding the value of new and emerging diagnostic and therapeutic techniques and their place in the context of current practice can be informed by reviewing outcome data achieved in the preceding decades characterised by a relatively stable diagnostic and therapeutic ‘best practice’ pathway. Our study aims to evaluate the “real life experience” of diagnosing and treating patients with PA in a single tertiary referral centre in the United Kingdom over 24 years with a focus on the short and long-term outcomes of adrenalectomy for PA and the introduction of laparoscopic approach as a treatment for this condition. Material and methods Retrospective analysis of data from a prospectively maintained database of patients with PA who underwent surgery between 1st January 1998 and 31st December 2022 at University College London Hospital, a tertiary referral centre for endocrinology and endocrine surgery. The clinical pathway for screening, diagnosis and stratification for adrenalectomy varied through the 24 years and was based on concurrent recommendations, published evidence, changing local expertise and best practice at the time. Throughout this period diagnosis of PA in our centre was based on the presence of hypertension and hypokalaemia, high aldosterone level, supressed renin activity and aldosterone and renin ratio (ARR) above 850. Currently a confirmatory test (for example, saline suppression test) recommended if the aldosterone is < 550pmol/L but in the upper third of the normal range or the plasma renin is non-suppressed unless the patient presents with spontaneous hypokalaemia, plasma renin below detection levels and aldosterone concentration more than 550 pmol/L. Stratification for adrenalectomy, once a diagnosis of PA was confirmed, included cross sectional imaging of adrenals with CT or MRI [ 2 ]. Adrenal venous sampling (AVS) and/or later 11 C Metomidate PET-CT was performed if imaging showed bilateral adrenal nodules[ 2 ]. Surgery was recommended after discussion in the multidisciplinary team meeting (endocrinologist, endocrine surgeon, biochemists and radiologist). During the very beginning of the study laparoscopic adrenalectomy was introduced in our centre and transperitoneal lateral technique was used to perform laparoscopic adrenalectomy using 3 ports on the left and 4 ports on the right side. Patients included in the study were characterised preoperatively by their demographics (age, sex and ethnicity) clinical presentation (blood pressure), number of antihypertensive medications and biochemical tests (potassium, aldosterone, renin, ARR ratio). Number and type of investigations (CT, MRI, AVS, Metomidate) used to stratify for surgery and the size of the adrenal nodules on cross sectional imaging was recorded. Process of stratification was presented as lateralisation to the left or right reached as a consensus between cross sectional imaging, AVS and nuclear medicine imaging. Data on post operative surgical outcomes included conversion rate to open adrenalectomy, postoperative complications (Clavien-Dindo) [ 19 ] and length of hospital stay. Postoperative outcomes were assessed within 3 months of surgery (short term) and at least 60 months (long term). Data collected were blood pressure, number of antihypertensive medications, plasma concentration of potassium, aldosterone, renin and ARR ratio. Surgical outcomes were categorised using PASO criteria of complete, partial or absent success for both clinical and biochemical cure which reflected remission, improvement or persistence of disease [ 6 ]. Statistical analysis of the data Data was analysed using IBM SPSS software package version 20.0. (Armonk, NY: IBM Corp). Qualitative data were described using numbers and percent. The Kolmogorov-Smirnov test and The Shapiro-Wilk test were used to verify the normality of distribution. Quantitative data were described using range (minimum and maximum), mean, standard deviation and median. Paired t-test was assessed for comparison between two periods for normally distributed quantitative variables, while Wilcoxon signed ranks test was assessed for comparison between two periods for abnormally distributed quantitative variables. Anova with repeated measures for normally distributed quantitative variables, to compare more than two periods or stages. While Friedman test for abnormally distributed quantitative variables, to compare between more than two periods or stages and Post Hoc Test (Dunn's) for pairwise comparisons. Marginal Homogeneity Test was used to analyse the significance between the different stages. The significance of the obtained results was judged at the 5% level. Results Demographics, presentation, biochemistry and stratification for surgery for the whole cohort of 82 patients Eighty-two patients diagnosed with PA were included in the study. Forty-five (54.9%) of them were male, 37 (45.1%) female and their mean age was 51.7 years (16.2-75.7). Forty-three (52.4%) patients were white, 18 (21.9%) African/Caribbean, 6 (7.3%) mixed white/black, 9 (10.9%) Asian and in 6 patients’ ethnicity was unknown (7.3%). Seventy-seven patients (93.9%) presented with hypertension and 61 (74.4%) had hypokalaemia. Three (3.7%) patients had adrenal incidentalomas which led to the diagnosis of PA. Patients’ mean (SD) systolic and diastolic blood pressure were 165.1mmHg (23.7) and 93mmHG (14.9) respectively and mean (SD) potassium level was 3.1mmol/L (0.7). Median aldosterone level was 932 pmol/L (450-2900), renin 0.3 nmolL/H (0.1-2.7) and ARR 2824 (2444-9233). Fifty-five (67%) patients underwent CT scan and 10 (12.1%) MRI only while 17 (20%) had both. 46 patients (50%) were stratified for surgery following biochemical assessment and imaging with CT or MRI only. Median size of adrenal nodules on cross sectional imaging was 1.8 cm (range 0.4-7.5). Twenty-six (31.7%) patients had AVS in addition to imaging with an 84.8 % success rate, 7 (8.5%) had both AVS and 11 C Metomidate PET-CT while 3 (3.6%) had 11 C Metomidate PET-CT scan alone. Surgery, histology and surgical outcomes for the whole cohort of 82 patients Laparoscopic adrenalectomy was performed in 77 patients (93.9%) and 4 (4.9%) had open procedures. Laparoscopic adrenalectomy was converted to open surgery in one patient due to bleeding (1.2%). 45 patients had a right (54.8%) and 37 left adrenalectomy (45.1%). Four patients had postoperative infections treated with antibiotics (Clavien-Dindo II) and one (1.2%) had infected fluid collection in adrenal bed which required antibiotics and percutaneous drainage (Clavien-Dindo IIIa). Two patients (2.4%) in whom spironolactone had not been discontinued, developed hyperkalaemia with an acute kidney injury (Clavien-Dindo IVa), both were treated conservatively and fully recovered. Median hospital stay was 2.5 days (1 – 12). Histopathology reported 71 adenomas, 6 cases of multinodular hyperplasia and 5 adenomas with nodular hyperplasia. The mean (SD) dimension of adenomas’ on histology examination was 2.3 (1.6) cm (range 0.6–7.5 cm). Short term biochemical and clinical outcomes at 3 months for 82 patients (Whole cohort) (Table 1) There was statistically significant improvement in mean systolic and diastolic blood pressure postoperatively from 165 mmHg to 131 mmHg and from 93 mmHg to 82 mmHg respectively. All patients who presented with hypokalaemia had normal potassium postoperatively with the mean potassium rising from 3.1 to 4.5 mmol/L. Short and long term clinical and biochemical outcomes at 5 years in the cohort of 24 patients (Table 2,3,4.5) Our results showed that the subgroup of 24 patients with at least 5 years follow-up, similarly to the whole cohort of 82 patients, significant clinical and biochemical benefit from adrenalectomy in a short term and that this effect was sustained at 5 years. Preoperative hypokalaemia was cured in all, aldosterone levels was significantly reduced, renin became unsuppressed, and because of these changes, the ARR normalised (Table 2). Interestingly and very importantly biochemical cure was sustained 5 years later as indicated by lack of statistical significance when comparing short- and long-term outcomes. Similarly, patterns of preoperative short- and long-term data suggests that adrenalectomy significantly reduced both systolic and diastolic blood pressure in the short term and that this benefit was sustained in the long term (Table 3). The number of antihypertensive medications prescribed before and after surgery, an important measure of clinical success of treatment, is shown in Tables 4 and 5. Before surgery a 1/3 of the patients required 1-2 medications with a majority (2/3) needing 3-6 antihypertensives to control their blood pressure. Within 3 months of adrenalectomy about 1/3 did not take any and a half were able to reduce medications and had blood pressure controlled with 1-2 medications. Only 2 patients (10%) needed 3 medications, and none required more than that. These differences between number of tablets taken before and after surgery were statistically significant. At 5 years more patients were able to stop or reduce their medications with some carrying on with the same tablets and only one patient had to increase medications. Twenty-one patients (87.55%) had clinically benefited from surgery and showed, both in short and long term, complete or partial clinical success according to PASO criteria (Table 6). More patients were classified as complete cure at 5 years as 3 patients who were classified as partial success in short term did not require antihypertensives at 5 years. Biochemical success was unequivocal with all, but one patient classified as complete biochemical success. The only patient, a 23 year old women with 2.4 cm adrenal adenoma, who was not cured biochemically in the short. In the long term treatment continued with 100 mg of Spironolactone. Discussion Rapid advances in the field of PA is coming mostly from basic scientific research in molecular biology and genetics but more recently also in the form of new ideas about functional imaging and novel therapeutic interventions in this condition[ 1 , 16 – 18 , 20 ]. These concepts are now moving from the bench to the bedsides of our patients and are being assessed prospectively in clinical trials, but it will be some time before their impact on clinical practice is known[ 16 , 17 ]. While speeding down the lane of progress we should not lose the sight of milestones already reached as they will help us to judge benefits of new inventions. Our study, which presents short- and long-term outcomes of adrenalectomy in patient with PA in a single centre over the last 24 years, contribute to the current debate about PA by providing such a rear mirror view. Firstly , one might consider that only 82 adrenalectomies for PA performed over a 24 year period in a tertiary centre is a relatively limited number of cases given the predicated prevalence. To our knowledge, low number of adrenalectomies for PA is not particular to our centre but universal and common experience both in UK and Abroad [ 21 ]. As predicted by J.W. Conn in 1955, around 10% of hypertensive patients have PA but the reality is that we are only diagnosing and operating on about 1% of patients with this condition. Clearly case identification needs to increase which will be achieved by improving awareness amongst patients and doctors but also by simplifying the current diagnostic pathways. Secondly , our paper describes a pragmatic approach to localisation for surgical management which was used during the study period. The pivotal investigation in our localisation strategy was CT or MRI to identify adrenal nodules. Patients with convincing biochemistry and clear unilateral nodules were offered surgery, especially if young. Patients with bilateral nodules or over 35 years of age were tested further with a combination of AVS and functional imaging. Since this approach did not offer AVS routinely but selectively, it is interesting to compare outcomes to other studies where AVS utilised more comprehensively Overall cure rate in such studies published in the past, which took into account biochemical and clinical outcomes, have typically been reported to vary between 32% − 47%[ 1 , 6 , 14 , 21 , 22 ]. More recent PASO study showed complete, partial or absent biochemical and clinical success in 94%, 4%, 2% and 37%, 47%, 16% of patients respectively [ 6 ]. This study concludes that biochemical and clinical benefit was observed in 98% and 84% of patients. In a MATCH study complete biochemical and clinical success was achieved in 88% and 31% of patients respectively[ 16 ]. In our study outcomes at 3 months for the whole cohort of 82 patients showed that hypokalaemia was cured in all patients and statistically significant reduction in blood pressure was achieved. Short term results in 24 patients with long term follow up available showed that all but one patient achieved statistically significant decrease of aldosterone levels, normalisation of ARR, improvement in blood pressure and reduction of medications were observed. At three months complete biochemical success was achieved in 95.8% and complete and partial clinical success in 29.2% and 58.35%, suggesting clinical benefit in 87.55% of our patients. What is remarkable is that these benefits were sustained or even improved at 5 years and only patients who were not cured at three months remained so at 5 years. All patients cured biochemically and clinically in short term remained cured at 5 years. Clinical benefit in long term remained the same as in short term (87.5%) but more patients achieved complete cure (41.7%), perhaps reflecting the need for long term follow up as blood pressure improves and medications reduced. What are the possible explanations that our outcomes are not inferior to results from series where routine AVS was used? Perhaps it is the fact that AVS is less than perfect “gold standard” in predicting cure. Spartacus study found no difference in cure rate whether AVS was used or not, although was criticised for its design and underpower [ 23 ]. Recently published MATCH study shown that AVS predicted biochemical and clinical cure with 63.3% and 61.5% accuracy[ 16 ]. Metomidate was just marginally with accuracy of 72,7% and 65.4%. CT and AVS discrepancy are known to vary from 30–40% but does that always mean that patients who have not met strict criteria for lateralisation (LI > 4) and are not offered surgery would not have benefited? Published evidence on unilateral adrenalectomy in patients with known bilateral PA suggest otherwise, as they reveal biochemical and clinical benefit of what is known as debulking effect and some of our patients might have benefited from it [ 24 ]. It is also likely that our good outcomes were the results of stratification based on presence of radiologically obvious and sizable adrenal nodules. Recent studies showed that patients with classic histopathology who form adenomas, are more likely to have unilateral disease and are associated with better chances of cure if adrenalectomy is performed[ 25 , 26 ]. Non classical histopathology associated with hyperplasia and formation of APMs (formerly APCC) which are not visible on CT, tend to be bilateral and are less likely to be cured by unilateral adrenalectomy[ 25 , 26 ]. The fact that in our series 76 (93%) patients had sizable adenomas and only 6 had hyperplasia would suggest that our population was artificially enriched by this kind of selection choosing patients who were more likely to be cured. Future studies into somatic mutations responsible for formation of either radiologically detectable or “invisible” adenomas and APMs will help to clarify aetiology of these distinct forms of the PA. It is also known that results are better in women and younger people but sex and age distribution in our study does not explain that and neither does ethnic mix. Thirdly , our results strongly confirm that unilateral adrenalectomy is currently the gold standard therapy for patients with PA. There is consensus that in comparison to medical therapy, adrenalectomy offers better management of hypertension, hypokalaemia, and left ventricular hypertrophy [ 21 ]. Present series concurred with the introduction of laparoscopic adrenalectomy in our centre, one of the first in the UK. Some open adrenalectomies were performed during transitional period but most operations were laparoscopic procedures with only one conversion. Low complication rate confirmed a safe profile for the laparoscopic approach and the associated short post-operative stay (shorter recently) contributes to its cost-effectiveness[ 27 , 28 ]. New approaches, such as partial adrenalectomy or ablative techniques using extreme temperatures causing freezing or boiling of adrenal tissue, carry significant risk of not achieving cure in first place or early recurrence of PA[ 18 ]. Ablative approaches also have very high cost (catheters, probes), take long time, are associated with increase in radiation, requirement for general anaesthetics and are not currently performed as a day cases, so they might not be cost effective at all. We acknowledge that the present study has certain limitations. The retrospective design could have affected accuracy of collected data especially as it was carried over a long period of time. Availability of long term follow up data in only a third of our patients is also a limitation In summary, our single centre results showed that good biochemical and clinical outcomes in patients with PA were achieved in the past 24 years period, coinciding with the switch to laparoscopic adrenalectomy. These good results were almost certainly due to a highly selected population of patients with PA with sizable and radiologically visible adrenal nodules, who were more likely to benefit from adrenalectomy, even if AVS was used selectively rather than routinely. Future developments should focus on identifying the vast majority of subjects with PA who are not currently diagnosed or offered surgery. The current existing pathway for screening, confirming and localising disease are complex, time consuming and inconvenient. AVS, which is sixty years old and one of the oldest procedures still performed by interventional radiologists, is unlikely to be perfected any further and new solutions are needed. Novel molecular imaging of the adrenal glands could provide a solution with the potential to reshape the scientific and clinical landscape of Primary Aldosteronism. Cholesterol imaging used in the past had very limited accuracy and Metomidate and its derivatives has well known limitations due to its non-selectivity for enzymes involved in aldosterone pathway and difficulty with isotope production 15 . However, recent research involving tracers based on highly selective aldosterone synthase blockers, showed that such tracers could reliably detect not only adenomas but also aldosterone producing microadenomas (APMs) in human adrenals both in vitro and in vivo 17 . Perhaps imaging based on this technology could shorten diagnostic pathway by making confirmatory step unnecessary and merge subtyping investigations into a single scan. Such transformation of PA diagnostic pathway should improve accuracy of diagnosis, efficiency of stratification for surgery and would be beneficial to patients in the future. Declarations Conflict of interest: all authors declare that they have no conflict of interest. There is no financial conflict of interest. Compliance with ethical standards: Ethical Approval: Letter from Medical Research council and Health Research authority Informed Consent: Consent was given by patients References Reincke M, Bancos I, Mulatero P, Scholl UI, Stowasser M, Williams TA (2021) Diagnosis and treatment of primary aldosteronism. lancet Diabetes Endocrinol 9(12):876–892 Funder JW, Carey RM, Mantero F, Murad MH, Reincke M, Shibata H, Stowasser M, Young WF Jr (2016) The management of primary aldosteronism: case detection, diagnosis, and treatment: an endocrine society clinical practice guideline. J Clin Endocrinol Metabolism 101(5):1889–1916 Monticone S, Burrello J, Tizzani D, Bertello C, Viola A, Buffolo F, Gabetti L, Mengozzi G, Williams TA, Rabbia F (2017) Prevalence and clinical manifestations of primary aldosteronism encountered in primary care practice. J Am Coll Cardiol 69(14):1811–1820 Käyser SC, Dekkers T, Groenewoud HJ, van der Wilt GJ, Carel Bakx J, van der Wel MC, Hermus AR, Lenders JW, Deinum J (2016) Study heterogeneity and estimation of prevalence of primary aldosteronism: a systematic review and meta-regression analysis. J Clin Endocrinol Metabolism 101(7):2826–2835 Ahmed S, Hundemer GL (2022) Benefits of surgical over medical treatment for unilateral primary aldosteronism. Front Endocrinol 13:861581 Williams TA, Lenders JW, Mulatero P, Burrello J, Rottenkolber M, Adolf C, Satoh F, Amar L, Quinkler M, Deinum J (2017) Outcomes after adrenalectomy for unilateral primary aldosteronism: an international consensus on outcome measures and analysis of remission rates in an international cohort. lancet Diabetes Endocrinol 5(9):689–699 Morisaki M, Kurihara I, Itoh H, Naruse M, Takeda Y, Katabami T, Ichijo T, Wada N, Yoshimoto T, Ogawa Y (2019) Predictors of clinical success after surgery for primary aldosteronism in the Japanese nationwide cohort. J Endocr Soc 3(11):2012–2022 Utsumi T, Kamiya N, Endo T, Yano M, Kamijima S, Kawamura K, Imamoto T, Naya Y, Ichikawa T, Suzuki H (2014) Development of a novel nomogram to predict hypertension cure after laparoscopic adrenalectomy in patients with primary aldosteronism. World J Surg 38:2640–2644 Zarnegar R, Young WF Jr, Lee J, Sweet MP, Kebebew E, Farley DR, Thompson GB, Grant CS, Clark OH, Duh Q-Y (2008) The aldosteronoma resolution score: predicting complete resolution of hypertension after adrenalectomy for aldosteronoma. Ann Surg 247(3):511–518 Wachtel H, Cerullo I, Bartlett EK, Kelz RR, Cohen DL, Karakousis GC, Roses RE, Fraker DL (2014) Long-term blood pressure control in patients undergoing adrenalectomy for primary hyperaldosteronism. Surgery 156(6):1394–1403 Hannon M, Sze W, Carpenter R, Parvanta L, Matson M, Sahdev A, Druce M, Berney D, Waterhouse M, Akker S (2017) Clinical outcomes following unilateral adrenalectomy in patients with primary aldosteronism. QJM: Int J Med 110(5):277–281 Wierdak M, Sokołowski G, Natkaniec M, Morawiec-Sławek K, Małczak P, Major P, Hubalewska-Dydejczyk A, Budzyński A, Pędziwiatr M (2018) Short-and long-term results of laparoscopic adrenalectomy for Conn’s syndrome. Videosurgery Other Miniinvasive Techniques 13(3):292–298 Lo CY, Tam PC, Kung A, Lam K, Wong J (1996) Primary aldosteronism. Results of surgical treatment. Ann Surg 224(2):125 O’Toole SM, Hornby C, Sze WCC, Hannon MJ, Akker SA, Druce MR, Waterhouse M, Dawnay A, Sahdev A, Matson M (2021) Performance evaluation of scoring systems for predicting post-operative hypertension cure in primary aldosteronism. Clin Endocrinol 95(4):576–586 Burton TJ, Mackenzie IS, Balan K, Koo B, Bird N, Soloviev DV, Azizan EA, Aigbirhio F, Gurnell M, Brown MJ (2012) Evaluation of the sensitivity and specificity of 11C-metomidate positron emission tomography (PET)-CT for lateralizing aldosterone secretion by Conn's adenomas. J Clin Endocrinol Metabolism 97(1):100–109 Wu X, Senanayake R, Goodchild E, Bashari WA, Salsbury J, Cabrera CP, Argentesi G, O’Toole SM, Matson M, Koo B (2023) [11C] metomidate PET-CT versus adrenal vein sampling for diagnosing surgically curable primary aldosteronism: a prospective, within-patient trial. Nat Med 29(1):190–202 Sander K, Gendron T, Cybulska KA, Sirindil F, Zhou J, Kalber TL, Lythgoe MF, Kurzawinski TR, Brown MJ, Williams B (2021) Development of [18F] AldoView as the first highly selective aldosterone synthase PET tracer for imaging of primary hyperaldosteronism. J Med Chem 64(13):9321–9329 Liu S, Chu C, Kong A, Wong S, Chiu P, Chow F, Ng E (2016) Radiofrequency ablation compared with laparoscopic adrenalectomy for aldosterone-producing adenoma. J Br Surg 103(11):1476–1486 Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205 Young W Jr (2019) Diagnosis and treatment of primary aldosteronism: practical clinical perspectives. J Intern Med 285(2):126–148 Muth A, Ragnarsson O, Johannsson G, Wängberg B (2015) Systematic review of surgery and outcomes in patients with primary aldosteronism. J Br Surg 102(4):307–317 Vorselaars WM, Nell S, Postma EL, Zarnegar R, Drake FT, Duh Q-Y, Talutis SD, McAneny DB, McManus C, Lee JA (2019) Clinical outcomes after unilateral adrenalectomy for primary aldosteronism. JAMA Surg 154(4):e185842–e185842 Dekkers T, Prejbisz A, Kool LJS, Groenewoud HJ, Velema M, Spiering W, Kołodziejczyk-Kruk S, Arntz M, Kądziela J, Langenhuijsen JF (2016) Adrenal vein sampling versus CT scan to determine treatment in primary aldosteronism: an outcome-based randomised diagnostic trial. lancet Diabetes Endocrinol 4(9):739–746 Sukor N, Gordon RD, Ku YK, Jones M, Stowasser M (2009) Role of unilateral adrenalectomy in bilateral primary aldosteronism: a 22-year single center experience. J Clin Endocrinol Metabolism 94(7):2437–2445 Meyer LS, Handgriff L, Lim JS, Udager AM, Kinker I-S, Ladurner R, Wildgruber M, Knösel T, Bidlingmaier M, Rainey WE (2021) Single-center prospective cohort study on the histopathology, genotype, and postsurgical outcomes of patients with primary aldosteronism. Hypertension 78(3):738–746 Williams TA, Gomez-Sanchez CE, Rainey WE, Giordano TJ, Lam AK, Marker A, Mete O, Yamazaki Y, Zerbini MCN, Beuschlein F (2021) International histopathology consensus for unilateral primary aldosteronism. J Clin Endocrinol Metabolism 106(1):42–54 Elfenbein DM, Scarborough JE, Speicher PJ, Scheri RP (2013) Comparison of laparoscopic versus open adrenalectomy: Results from american college of surgeons-national surgery quality improvement project. J Surg Res 184(1):216–220 Duncan IIIJL, George MF, John SB, William SR (2000) Laparoscopic adrenalectomy is superior to an open approach to treat primary hyperaldosteronism. Am Surg 66(10):932–936 Tables Table 1: Pre and 3 months post operative blood pressure and potassium levels in the 82 patients (whole cohort) following adrenalectomy for PA. Preoperative Postoperative T p Potassium (mmol/L) Low <3.5 61 (74.4%) 0 14.269 5.3) 0 6 (7.3%) Mean ± SD 3.1 ± 0.7 4.5 ± 0.6 Blood pressure (mmHg) Systolic Mean ± SD 165.1 ± 23.7 131.7 ± 16.1 11.424 * <0.001 * Diastolic Mean ± SD 93 ± 14.9 82 ± 10.7 7.105 * <0.001 * SD: Standard deviation , t: Paired t-test , Z: Wilcoxon signed ranks test p: p value for comparing between preoperative and postoperative *: Statistically significant at p ≤ 0.05 Table (2) Pre , 3 months and 5 year post operative biochemical outcomes in the 24 patients following adrenalectomy for PA Lab Preoperative Postoperative Follow up Test of sig. p Potassium Median (Min. – Max.) 3.2 (2.4–4.9) 4.8 (3.6–5.9) 4.6 (3.4–5.5) F= 47.519 * <0.001 * Mean ± SD. 3.3 ± 0.6 4.7 ± 0.6 4.6 ± 0.5 Sig. bet. periods p 1 <0.001 * , p 2 <0.001 * , p 3 =0.752 Aldosterone (pmol/L) Median (Min. – Max.) 932 (450–2900) 115 (60–723) 205 (70 – 1480) Fr= 37.130 * <0.001 * Mean ± SD. 1206.1 ± 729.9 161.8 ± 137 259.4 ± 279.5 Sig. bet. periods p 1 <0.001 * , p 2 <0.001 * , p 3 =0.112 Renin (nmol/L/H) Median (Min. – Max.) 0.3 (0.1–2.7) 1 (0.2–3.9) 1.5 (0.4–8.4) Fr= 13.640 * 0.001 * Mean ± SD. 0.8 ± 0.9 1.2 ± 0.8 1.8 ± 1.5 Sig. bet. periods p 1 =0.036 * , p 2 <0.001 * , p 3 =0.149 ARR Fr= 34.522 * <0.001 * Median (Min. – Max.) 2824.5(244.4–9233) 104.5(23–2410) 127.5(23.8–510) Mean ± SD. 3413.1 ± 2873.4 280.9 ± 512.8 169.8 ± 114.5 Sig. bet. periods p 1 <0.001 * , p 2 <0.001 * , p 3 =0.885 SD: Standard deviation , Fr : Friedman test , Sig. bet. periods was done using Post Hoc Test ( Dunn's) , F: F test (ANOVA) with repeated measures, Sig. bet. periods was done using Post Hoc Test ( adjusted Bonferroni) p: p value for comparing between the different studied periods p 1 : p value for comparing between Preoperative and 3 months p 2 : p value for comparing between Preoperative and 5 years p 3 : p value for comparing between Postoperative and 5 years *: Statistically significant at p ≤ 0.05 Table (3): Pre , 3 months and 5 year post operative clinical outcomes in the 24 patients following adrenalectomy for PA Blood pressure Preoperative 3 months 5 years F p Systolic (mmHg) Mean ± SD. 158.4 ± 25 131.8 ± 14.2 132.5 ± 11.2 23.318 * <0.001 * Sig. bet. periods p 1 <0.001 * , p 2 <0.001 * , p 3 =1.000 Diastolic (mmHg) Mean ± SD. 93 ± 14.9 82 ± 10.7 81 ± 9.4 10.670 * <0.001 * Sig. bet. periods p 1 =0.008 * , p 2 =0.003 * , p 3 =1.000 SD: Standard deviation , F: F test (ANOVA) with repeated measures, Sig. bet. periods was done using Post Hoc Test ( adjusted Bonferroni) p: p value for comparing between the different studied periods p 1 : p value for comparing between Preoperative and 3 months p 2 : p value for comparing between Preoperative and 5 years p 3 : p value for comparing between Postoperative and 5 years *: Statistically significant at p ≤ 0.05 Table (4): Pre , 3 months and 5 year post operative Number of antihypertensive medications outcomes in the cohort of 24 patients Number of medications Preoperative 3 months 5 years Fr p 0 0 (0%) 7 (29.2%) 10 (41.7%) 35.686 * <0.001 * 1 5 (20.8%) 6 (25%) 10 (41.7%) 2 4 (16.7%) 9 (37.5%) 2 (8.3%) 3 8 (33.3%) 2 (8.3%) 2 (8.3%) 4 4 (16.7%) 0 (0%) 0 (0%) 5 2 (8.3%) 0 (0%) 0 (0%) 6 1 (4.2%) 0 (0%) 0 (0%) Sig. bet. periods p 1 <0.001 * , p 2 <0.001 * , p 3 =0.312 Fr : Friedman test , Sig. bet. periods was done using Post Hoc Test ( Dunn's) p: p value for comparing between the different studied periods p 1 : p value for comparing between Preoperative and 3 months p 2 : p value for comparing between Preoperative and 5 years p 3 : p value for comparing between Postoperative and 5 years *: Statistically significant at p ≤ 0.0 Table (5): Comparison between the two studied periods according to medication in the cohort of 24 patients Medication 3 months 5 years MH p Stopped Reduced 7 (29.2%) 14 (58.3%) 10 (41.7%) 5 (20.8%) 20.0 * 0.008 * Same 3 (12.5%) 8 (33.3%) Increased 0 (0%) 1 (4.2%) MH: Marginal Homogeneity Test p: p value for comparing between Postoperative and 5 years *: Statistically significant at p ≤ 0.05 Table (6) Comparison between short and long term outcomes according to PASO criteria in the cohort of 24 patients PASO group 3 months 5 years Complete clinical success 7 (29.2%) 10 (41.7%) Partial clinical success 14 (58.3%) 11 (45.8%) Absent clinical success 3 (12.5%) 3 (12.5%) Complete biochemical success 23 (95.8%) 23 (95.8%) Partial biochemical success 0 (0%) 0 (0%) Absent biochemical success 1(4.2%) 1(4.2%) Cite Share Download PDF Status: Published Journal Publication published 18 Nov, 2024 Read the published version in Hormones → Version 1 posted Reviewers agreed at journal 11 Jul, 2024 Reviewers invited by journal 11 Jul, 2024 Editor invited by journal 10 Jul, 2024 Editor assigned by journal 08 Jul, 2024 First submitted to journal 08 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies 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-4697365","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":325562837,"identity":"4d1b9e55-9f37-46b7-81b5-c681f590305e","order_by":0,"name":"Tarek Abdel-Aziz","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYHACNgYeBgsgzdjA8IGBQQYieAC3eh6IFgmwFsYZYAHitTAwMPMQo8WegfnZgzcVEgz8/YebP9u22fEwsB9+wMxzBp8tbOaGc85IMEgcONhgnNuWzMPAk2bAzHMDr8PMpHnbJOobDjY2JOe2HQAK5ABd+AGfFvZv0rz/JBjkDzM2HLYEaeF/Q0gLD9CWBgkGg2OMjc2MIC0SIFvwOewwT7nhnGMSDIZnGJsZe84l87BJPDM4OAeP99nb27c9eFNjwyB3/vjjDz/K7OT4+ZMfPnhzDLcWBmZ0ATYGvLEyCkbBKBgFo4AYAABPIUP03SLRtgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-7630-9985","institution":"University College London - Bloomsbury Campus: University College London","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Tarek","middleName":"","lastName":"Abdel-Aziz","suffix":""},{"id":325562838,"identity":"370198c1-5363-4a7a-a083-750fb428a482","order_by":1,"name":"Alaa Abdelsalam","email":"","orcid":"","institution":"University College London - Bloomsbury Campus: University College London","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Alaa","middleName":"","lastName":"Abdelsalam","suffix":""},{"id":325562839,"identity":"062276cc-5b14-4b13-b36d-c37b059638ff","order_by":2,"name":"Teng-Teng Chung","email":"","orcid":"","institution":"University College London - Bloomsbury Campus: University College London","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Teng-Teng","middleName":"","lastName":"Chung","suffix":""},{"id":325562840,"identity":"5211fafd-d1d9-4b29-bc5c-1089625475fc","order_by":3,"name":"Umasuthan Srirangalingam","email":"","orcid":"","institution":"University College London - Bloomsbury Campus: University College London","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Umasuthan","middleName":"","lastName":"Srirangalingam","suffix":""},{"id":325562841,"identity":"11021b13-ec8a-4fe6-94b3-d234f3ca26dc","order_by":4,"name":"Steven Hurel","email":"","orcid":"","institution":"University College London - Bloomsbury Campus: University College London","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Steven","middleName":"","lastName":"Hurel","suffix":""},{"id":325562842,"identity":"627e6fbc-c221-4711-8007-8d63ae19a9c9","order_by":5,"name":"Gerard Conway","email":"","orcid":"","institution":"University College London - Bloomsbury Campus: University College London","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Gerard","middleName":"","lastName":"Conway","suffix":""},{"id":325562843,"identity":"3e942fda-c534-4b01-97b0-59a8619aca02","order_by":6,"name":"Stephanie E. Baldeweg","email":"","orcid":"","institution":"University College London - Bloomsbury Campus: University College London","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Stephanie","middleName":"E.","lastName":"Baldeweg","suffix":""},{"id":325562844,"identity":"581e4216-3402-4ceb-ae03-2fcc522dc765","order_by":7,"name":"Tom R Kurzawinski","email":"","orcid":"","institution":"University College London - Bloomsbury Campus: University College London","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tom","middleName":"R","lastName":"Kurzawinski","suffix":""}],"badges":[],"createdAt":"2024-07-06 15:08:52","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4697365/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4697365/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s42000-024-00613-3","type":"published","date":"2024-11-18T15:57:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":69835196,"identity":"6f30d571-3772-492f-a69b-cf1b242f8818","added_by":"auto","created_at":"2024-11-25 16:12:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1064868,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4697365/v1/28dba8a6-84aa-44c1-9e3b-e166106de1c2.pdf"}],"financialInterests":"","formattedTitle":"Short- and long-term outcomes of adrenalectomy for Primary Aldosteronism in a single UK centre: Rear Mirror View.","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePrimary hyperaldosteronism (PA) is the commonest cause of secondary hypertension and can be successfully treated by adrenalectomy if excessive secretion of aldosterone is confirmed to be from a unilateral source[1, 2]. Estimates of the prevalence of PA have varied considerably over the last 70 years, but recent data suggest that it affects 3.2% to 12.7% of patients in primary care and 1% to 29.8% referred to hypertension units[3, 4]. The incidence of PA rises with the severity of hypertension , from 2% in patients with grade 1 hypertension to 20% in those with resistant hypertension[4]\u003c/p\u003e\n\u003cp\u003ePatients with PA have increased risk of myocardial infarction, stroke, atrial fibrillation and higher prevalence of metabolic syndrome in comparison to patients with essential hypertension[3]. Recent metanalysis showed that patients with PA treated with adrenalectomy had better outcomes in comparison to patients treated with medications alone[5]. This is because surgery can not only restore normal blood pressure and obviate the need for antihypertensive medications, but also by removing the source of aldosterone over-secretion, it can normalise the renin-angiotensin-aldosterone system and correct concomitant abnormalities of hypokalaemia, alkalosis and fibrosis in multiple organs like heart, kidney and pancreas caused by high levels of aldosterone[6-8]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIntroduction of minimally invasive techniques had huge positive impact on outcomes after adrenalectomies in reducing postoperative pain, length of hospital stay and improved cosmesis. Cure rates after adrenalectomy for PA range from 32% to 42% at 6 months after surgery but data on long-term outcomes are relatively scarce and often consist of small cohort studies[9-13].\u0026nbsp;It is not clear whether short term benefits of adrenalectomy persist in longer term and whether clinical and biochemical cure go hand in hand or have separate course[14].\u003c/p\u003e\n\u003cp\u003eInterest in PA has heightened in recent years and research into this condition has experienced what can be called a \u0026ldquo;Renaissance period\u0026rdquo; leading to the development of new functional imaging and adrenal ablative techniques as an alternative to surgical resection[15-18]. Understanding the value of new and emerging diagnostic and therapeutic techniques and their place in the context of current practice can be informed by reviewing outcome data achieved in the preceding decades characterised by a relatively stable diagnostic and therapeutic \u0026lsquo;best practice\u0026rsquo; pathway.\u003c/p\u003e\n\u003cp\u003eOur study aims to evaluate the \u0026ldquo;real life experience\u0026rdquo; of diagnosing and treating patients with PA in a single tertiary referral centre in the United Kingdom over 24 years with a focus on the short and long-term outcomes of adrenalectomy for PA and the introduction of laparoscopic approach as a treatment for this condition.\u0026nbsp;\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003eRetrospective analysis of data from a prospectively maintained database of patients with PA who underwent surgery between 1st January 1998 and 31st December 2022 at University College London Hospital, a tertiary referral centre for endocrinology and endocrine surgery.\u003c/p\u003e \u003cp\u003e The clinical pathway for screening, diagnosis and stratification for adrenalectomy varied through the 24 years and was based on concurrent recommendations, published evidence, changing local expertise and best practice at the time. Throughout this period diagnosis of PA in our centre was based on the presence of hypertension and hypokalaemia, high aldosterone level, supressed renin activity and aldosterone and renin ratio (ARR) above 850. Currently a confirmatory test (for example, saline suppression test) recommended if the aldosterone is \u0026lt;\u0026thinsp;550pmol/L but in the upper third of the normal range or the plasma renin is non-suppressed unless the patient presents with spontaneous hypokalaemia, plasma renin below detection levels and aldosterone concentration more than 550 pmol/L.\u003c/p\u003e \u003cp\u003eStratification for adrenalectomy, once a diagnosis of PA was confirmed, included cross sectional imaging of adrenals with CT or MRI [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Adrenal venous sampling (AVS) and/or later \u003csup\u003e11\u003c/sup\u003eC Metomidate PET-CT was performed if imaging showed bilateral adrenal nodules[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Surgery was recommended after discussion in the multidisciplinary team meeting (endocrinologist, endocrine surgeon, biochemists and radiologist).\u003c/p\u003e \u003cp\u003eDuring the very beginning of the study laparoscopic adrenalectomy was introduced in our centre and transperitoneal lateral technique was used to perform laparoscopic adrenalectomy using 3 ports on the left and 4 ports on the right side.\u003c/p\u003e \u003cp\u003ePatients included in the study were characterised preoperatively by their demographics (age, sex and ethnicity) clinical presentation (blood pressure), number of antihypertensive medications and biochemical tests (potassium, aldosterone, renin, ARR ratio).\u003c/p\u003e \u003cp\u003eNumber and type of investigations (CT, MRI, AVS, Metomidate) used to stratify for surgery and the size of the adrenal nodules on cross sectional imaging was recorded. Process of stratification was presented as lateralisation to the left or right reached as a consensus between cross sectional imaging, AVS and nuclear medicine imaging.\u003c/p\u003e \u003cp\u003eData on post operative surgical outcomes included conversion rate to open adrenalectomy, postoperative complications (Clavien-Dindo) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and length of hospital stay.\u003c/p\u003e \u003cp\u003ePostoperative outcomes were assessed within 3 months of surgery (short term) and at least 60 months (long term). Data collected were blood pressure, number of antihypertensive medications, plasma concentration of potassium, aldosterone, renin and ARR ratio. Surgical outcomes were categorised using PASO criteria of complete, partial or absent success for both clinical and biochemical cure which reflected remission, improvement or persistence of disease [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis of the data\u003c/h2\u003e \u003cp\u003eData was analysed using IBM SPSS software package version 20.0. (Armonk, NY: IBM Corp). Qualitative data were described using numbers and percent. The Kolmogorov-Smirnov test and The Shapiro-Wilk test were used to verify the normality of distribution. Quantitative data were described using range (minimum and maximum), mean, standard deviation and median. Paired t-test was assessed for comparison between two periods for normally distributed quantitative variables, while Wilcoxon signed ranks test was assessed for comparison between two periods for abnormally distributed quantitative variables. Anova with repeated measures for normally distributed quantitative variables, to compare more than two periods or stages. While Friedman test for abnormally distributed quantitative variables, to compare between more than two periods or stages and Post Hoc Test (Dunn's) for pairwise comparisons. Marginal Homogeneity Test was used to analyse the significance between the different stages. The significance of the obtained results was judged at the 5% level.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eDemographics, presentation, biochemistry and stratification for surgery for the whole cohort of 82 patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEighty-two patients diagnosed with PA were included in the study. Forty-five\u0026nbsp;(54.9%)\u0026nbsp;of them were male, 37\u0026nbsp;(45.1%)\u0026nbsp;female and their mean age was 51.7 years (16.2-75.7). Forty-three (52.4%) patients were white, 18 (21.9%) African/Caribbean, 6 (7.3%) mixed white/black, 9 (10.9%) Asian and in 6 patients\u0026rsquo; ethnicity was unknown (7.3%).\u003c/p\u003e\n\u003cp\u003eSeventy-seven patients (93.9%) presented with hypertension and 61 (74.4%) had hypokalaemia. Three (3.7%) patients had adrenal incidentalomas which led to the diagnosis of PA. Patients\u0026rsquo; mean (SD) systolic and diastolic blood pressure were 165.1mmHg (23.7) and 93mmHG (14.9) respectively and mean (SD) potassium level was\u0026nbsp;3.1mmol/L (0.7). Median aldosterone level was 932 pmol/L (450-2900), renin 0.3 nmolL/H (0.1-2.7) and ARR 2824 (2444-9233).\u003c/p\u003e\n\u003cp\u003eFifty-five (67%) patients underwent CT scan and 10 (12.1%) MRI only while 17 (20%) had both. 46 patients (50%) were stratified for surgery following biochemical assessment and \u0026nbsp;imaging with CT or MRI only.\u0026nbsp;Median size of adrenal nodules on cross sectional imaging was 1.8 cm (range 0.4-7.5).\u003c/p\u003e\n\u003cp\u003eTwenty-six (31.7%) patients had AVS in addition to imaging with an 84.8 % success rate, 7 (8.5%) had both AVS and \u003csup\u003e11\u003c/sup\u003eC Metomidate PET-CT while 3 (3.6%) had \u003csup\u003e11\u003c/sup\u003eC Metomidate PET-CT scan alone.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgery, histology and surgical outcomes for the whole cohort of 82 patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLaparoscopic adrenalectomy was performed in 77 patients (93.9%) and 4 (4.9%) had open procedures. Laparoscopic adrenalectomy was converted to open surgery in one patient due to bleeding (1.2%). 45 patients had a right (54.8%) and 37 left adrenalectomy (45.1%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFour patients had postoperative infections treated with antibiotics (Clavien-Dindo II) and one (1.2%) had infected fluid collection in adrenal bed which required antibiotics and percutaneous drainage (Clavien-Dindo IIIa). Two patients (2.4%) in whom spironolactone had not been discontinued, developed hyperkalaemia with an acute kidney injury (Clavien-Dindo IVa), both were treated conservatively and fully recovered. Median hospital stay was 2.5 days (1 \u0026ndash; 12).\u003c/p\u003e\n\u003cp\u003eHistopathology reported 71 adenomas, 6 cases of multinodular hyperplasia and 5 adenomas with nodular hyperplasia. The mean (SD) dimension of adenomas\u0026rsquo; \u0026nbsp;on histology examination was 2.3 (1.6) cm (range 0.6\u0026ndash;7.5 cm).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eShort term biochemical and clinical outcomes at 3 months for 82 patients (Whole cohort) (Table 1)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was statistically significant improvement in mean systolic and diastolic blood pressure postoperatively from 165 mmHg to 131 mmHg and from 93 mmHg to 82 mmHg respectively. All patients who presented with hypokalaemia had normal potassium postoperatively with the mean potassium rising from 3.1 to 4.5 mmol/L.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eShort and long term clinical and biochemical outcomes at 5 years in the cohort of 24 patients (Table 2,3,4.5)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur results showed that the subgroup of 24 patients with at least 5 years follow-up, similarly to the whole cohort of 82 patients, significant clinical and biochemical benefit from adrenalectomy in a short term and that this effect was sustained at 5 years.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePreoperative hypokalaemia was cured in all, aldosterone levels was significantly reduced, renin became unsuppressed, and because of these changes, the ARR normalised \u003cstrong\u003e(Table 2).\u003c/strong\u003e Interestingly and very importantly biochemical cure was sustained 5 years later as indicated by lack of statistical significance when comparing short- and long-term outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSimilarly, patterns of preoperative short- and long-term data suggests that adrenalectomy significantly reduced both systolic and diastolic blood pressure in the short term and that this benefit was sustained in the long term \u003cstrong\u003e(Table 3).\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe number of antihypertensive medications prescribed before and after surgery, an important measure of clinical success of treatment, is shown in \u003cstrong\u003eTables 4 and 5.\u003c/strong\u003e Before surgery a 1/3 of the patients required 1-2 medications with a majority (2/3) needing 3-6 antihypertensives to control their blood pressure. Within 3 months of adrenalectomy about 1/3 did not take any and a half were able to reduce medications and had blood pressure controlled with 1-2 medications. Only 2 patients (10%) needed 3 medications, and none required more than that. These differences between number of tablets taken before and after surgery were statistically significant. At 5 years more patients were able to stop or reduce their medications with some carrying on with the same tablets and only one patient had to increase medications.\u003c/p\u003e\n\u003cp\u003eTwenty-one patients (87.55%) had clinically benefited from surgery and showed, both in short and long term, complete or partial clinical success according to PASO criteria \u003cstrong\u003e(Table 6).\u003c/strong\u003e More patients were classified as complete cure at 5 years as 3 patients who were classified as partial success in short term did not require antihypertensives at 5 years.\u003c/p\u003e\n\u003cp\u003eBiochemical success was unequivocal with all, but one patient classified as complete biochemical success. The only patient, a 23 year old women with 2.4 cm adrenal adenoma, who was not cured biochemically in the short. In the long term treatment continued with 100 mg of Spironolactone.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eRapid advances in the field of PA is coming mostly from basic scientific research in molecular biology and genetics but more recently also in the form of new ideas about functional imaging and novel therapeutic interventions in this condition[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. These concepts are now moving from the bench to the bedsides of our patients and are being assessed prospectively in clinical trials, but it will be some time before their impact on clinical practice is known[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. While speeding down the lane of progress we should not lose the sight of milestones already reached as they will help us to judge benefits of new inventions. Our study, which presents short- and long-term outcomes of adrenalectomy in patient with PA in a single centre over the last 24 years, contribute to the current debate about PA by providing such a rear mirror view.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFirstly\u003c/span\u003e, one might consider that only 82 adrenalectomies for PA performed over a 24 year period in a tertiary centre is a relatively limited number of cases given the predicated prevalence. To our knowledge, low number of adrenalectomies for PA is not particular to our centre but universal and common experience both in UK and Abroad [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. As predicted by J.W. Conn in 1955, around 10% of hypertensive patients have PA but the reality is that we are only diagnosing and operating on about 1% of patients with this condition. Clearly case identification needs to increase which will be achieved by improving awareness amongst patients and doctors but also by simplifying the current diagnostic pathways.\u003c/p\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSecondly\u003c/span\u003e, our paper describes a pragmatic approach to localisation for surgical management which was used during the study period. The pivotal investigation in our localisation strategy was CT or MRI to identify adrenal nodules. Patients with convincing biochemistry and clear unilateral nodules were offered surgery, especially if young. Patients with bilateral nodules or over 35 years of age were tested further with a combination of AVS and functional imaging. Since this approach did not offer AVS routinely but selectively, it is interesting to compare outcomes to other studies where AVS utilised more comprehensively\u003c/p\u003e \u003cp\u003eOverall cure rate in such studies published in the past, which took into account biochemical and clinical outcomes, have typically been reported to vary between 32% \u0026minus;\u0026thinsp;47%[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. More recent PASO study showed complete, partial or absent biochemical and clinical success in 94%, 4%, 2% and 37%, 47%, 16% of patients respectively [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This study concludes that biochemical and clinical benefit was observed in 98% and 84% of patients. In a MATCH study complete biochemical and clinical success was achieved in 88% and 31% of patients respectively[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study outcomes at 3 months for the whole cohort of 82 patients showed that hypokalaemia was cured in all patients and statistically significant reduction in blood pressure was achieved. Short term results in 24 patients with long term follow up available showed that all but one patient achieved statistically significant decrease of aldosterone levels, normalisation of ARR, improvement in blood pressure and reduction of medications were observed. At three months complete biochemical success was achieved in 95.8% and complete and partial clinical success in 29.2% and 58.35%, suggesting clinical benefit in 87.55% of our patients. What is remarkable is that these benefits were sustained or even improved at 5 years and only patients who were not cured at three months remained so at 5 years. All patients cured biochemically and clinically in short term remained cured at 5 years. Clinical benefit in long term remained the same as in short term (87.5%) but more patients achieved complete cure (41.7%), perhaps reflecting the need for long term follow up as blood pressure improves and medications reduced.\u003c/p\u003e \u003cp\u003eWhat are the possible explanations that our outcomes are not inferior to results from series where routine AVS was used?\u003c/p\u003e \u003cp\u003ePerhaps it is the fact that AVS is less than perfect \u0026ldquo;gold standard\u0026rdquo; in predicting cure. Spartacus study found no difference in cure rate whether AVS was used or not, although was criticised for its design and underpower [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Recently published MATCH study shown that AVS predicted biochemical and clinical cure with 63.3% and 61.5% accuracy[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Metomidate was just marginally with accuracy of 72,7% and 65.4%. CT and AVS discrepancy are known to vary from 30\u0026ndash;40% but does that always mean that patients who have not met strict criteria for lateralisation (LI\u0026thinsp;\u0026gt;\u0026thinsp;4) and are not offered surgery would not have benefited? Published evidence on unilateral adrenalectomy in patients with known bilateral PA suggest otherwise, as they reveal biochemical and clinical benefit of what is known as debulking effect and some of our patients might have benefited from it [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is also likely that our good outcomes were the results of stratification based on presence of radiologically obvious and sizable adrenal nodules. Recent studies showed that patients with classic histopathology who form adenomas, are more likely to have unilateral disease and are associated with better chances of cure if adrenalectomy is performed[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Non classical histopathology associated with hyperplasia and formation of APMs (formerly APCC) which are not visible on CT, tend to be bilateral and are less likely to be cured by unilateral adrenalectomy[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe fact that in our series 76 (93%) patients had sizable adenomas and only 6 had hyperplasia would suggest that our population was artificially enriched by this kind of selection choosing patients who were more likely to be cured. Future studies into somatic mutations responsible for formation of either radiologically detectable or \u0026ldquo;invisible\u0026rdquo; adenomas and APMs will help to clarify aetiology of these distinct forms of the PA.\u003c/p\u003e \u003cp\u003eIt is also known that results are better in women and younger people but sex and age distribution in our study does not explain that and neither does ethnic mix.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eThirdly\u003c/span\u003e, our results strongly confirm that unilateral adrenalectomy is currently the gold standard therapy for patients with PA. There is consensus that in comparison to medical therapy, adrenalectomy offers better management of hypertension, hypokalaemia, and left ventricular hypertrophy [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Present series concurred with the introduction of laparoscopic adrenalectomy in our centre, one of the first in the UK. Some open adrenalectomies were performed during transitional period but most operations were laparoscopic procedures with only one conversion. Low complication rate confirmed a safe profile for the laparoscopic approach and the associated short post-operative stay (shorter recently) contributes to its cost-effectiveness[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. New approaches, such as partial adrenalectomy or ablative techniques using extreme temperatures causing freezing or boiling of adrenal tissue, carry significant risk of not achieving cure in first place or early recurrence of PA[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAblative approaches also have very high cost (catheters, probes), take long time, are associated with increase in radiation, requirement for general anaesthetics and are not currently performed as a day cases, so they might not be cost effective at all.\u003c/p\u003e \u003cp\u003eWe acknowledge that the present study has certain limitations. The retrospective design could have affected accuracy of collected data especially as it was carried over a long period of time. Availability of long term follow up data in only a third of our patients is also a limitation\u003c/p\u003e \u003cp\u003eIn summary, our single centre results showed that good biochemical and clinical outcomes in patients with PA were achieved in the past 24 years period, coinciding with the switch to laparoscopic adrenalectomy. These good results were almost certainly due to a highly selected population of patients with PA with sizable and radiologically visible adrenal nodules, who were more likely to benefit from adrenalectomy, even if AVS was used selectively rather than routinely. Future developments should focus on identifying the vast majority of subjects with PA who are not currently diagnosed or offered surgery. The current existing pathway for screening, confirming and localising disease are complex, time consuming and inconvenient. AVS, which is sixty years old and one of the oldest procedures still performed by interventional radiologists, is unlikely to be perfected any further and new solutions are needed.\u003c/p\u003e \u003cp\u003eNovel molecular imaging of the adrenal glands could provide a solution with the potential to reshape the scientific and clinical landscape of Primary Aldosteronism. Cholesterol imaging used in the past had very limited accuracy and Metomidate and its derivatives has well known limitations due to its non-selectivity for enzymes involved in aldosterone pathway and difficulty with isotope production\u003csup\u003e15\u003c/sup\u003e. However, recent research involving tracers based on highly selective aldosterone synthase blockers, showed that such tracers could reliably detect not only adenomas but also aldosterone producing microadenomas (APMs) in human adrenals both in vitro and in vivo\u003csup\u003e17\u003c/sup\u003e. Perhaps imaging based on this technology could shorten diagnostic pathway by making confirmatory step unnecessary and merge subtyping investigations into a single scan. Such transformation of PA diagnostic pathway should improve accuracy of diagnosis, efficiency of stratification for surgery and would be beneficial to patients in the future.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cb\u003eConflict of interest:\u003c/b\u003e all authors declare that they have no conflict of interest. There is no financial conflict of interest.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eCompliance with ethical standards:\n\u003cp\u003eEthical Approval: Letter from Medical Research council and Health Research authority\u003cp\u003eInformed Consent: Consent was given by patients\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eReincke M, Bancos I, Mulatero P, Scholl UI, Stowasser M, Williams TA (2021) Diagnosis and treatment of primary aldosteronism. lancet Diabetes Endocrinol 9(12):876\u0026ndash;892\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFunder JW, Carey RM, Mantero F, Murad MH, Reincke M, Shibata H, Stowasser M, Young WF Jr (2016) The management of primary aldosteronism: case detection, diagnosis, and treatment: an endocrine society clinical practice guideline. J Clin Endocrinol Metabolism 101(5):1889\u0026ndash;1916\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMonticone S, Burrello J, Tizzani D, Bertello C, Viola A, Buffolo F, Gabetti L, Mengozzi G, Williams TA, Rabbia F (2017) Prevalence and clinical manifestations of primary aldosteronism encountered in primary care practice. J Am Coll Cardiol 69(14):1811\u0026ndash;1820\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eK\u0026auml;yser SC, Dekkers T, Groenewoud HJ, van der Wilt GJ, Carel Bakx J, van der Wel MC, Hermus AR, Lenders JW, Deinum J (2016) Study heterogeneity and estimation of prevalence of primary aldosteronism: a systematic review and meta-regression analysis. J Clin Endocrinol Metabolism 101(7):2826\u0026ndash;2835\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed S, Hundemer GL (2022) Benefits of surgical over medical treatment for unilateral primary aldosteronism. Front Endocrinol 13:861581\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilliams TA, Lenders JW, Mulatero P, Burrello J, Rottenkolber M, Adolf C, Satoh F, Amar L, Quinkler M, Deinum J (2017) Outcomes after adrenalectomy for unilateral primary aldosteronism: an international consensus on outcome measures and analysis of remission rates in an international cohort. lancet Diabetes Endocrinol 5(9):689\u0026ndash;699\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorisaki M, Kurihara I, Itoh H, Naruse M, Takeda Y, Katabami T, Ichijo T, Wada N, Yoshimoto T, Ogawa Y (2019) Predictors of clinical success after surgery for primary aldosteronism in the Japanese nationwide cohort. J Endocr Soc 3(11):2012\u0026ndash;2022\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUtsumi T, Kamiya N, Endo T, Yano M, Kamijima S, Kawamura K, Imamoto T, Naya Y, Ichikawa T, Suzuki H (2014) Development of a novel nomogram to predict hypertension cure after laparoscopic adrenalectomy in patients with primary aldosteronism. World J Surg 38:2640\u0026ndash;2644\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZarnegar R, Young WF Jr, Lee J, Sweet MP, Kebebew E, Farley DR, Thompson GB, Grant CS, Clark OH, Duh Q-Y (2008) The aldosteronoma resolution score: predicting complete resolution of hypertension after adrenalectomy for aldosteronoma. Ann Surg 247(3):511\u0026ndash;518\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWachtel H, Cerullo I, Bartlett EK, Kelz RR, Cohen DL, Karakousis GC, Roses RE, Fraker DL (2014) Long-term blood pressure control in patients undergoing adrenalectomy for primary hyperaldosteronism. Surgery 156(6):1394\u0026ndash;1403\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHannon M, Sze W, Carpenter R, Parvanta L, Matson M, Sahdev A, Druce M, Berney D, Waterhouse M, Akker S (2017) Clinical outcomes following unilateral adrenalectomy in patients with primary aldosteronism. QJM: Int J Med 110(5):277\u0026ndash;281\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWierdak M, Sokołowski G, Natkaniec M, Morawiec-Sławek K, Małczak P, Major P, Hubalewska-Dydejczyk A, Budzyński A, Pędziwiatr M (2018) Short-and long-term results of laparoscopic adrenalectomy for Conn\u0026rsquo;s syndrome. Videosurgery Other Miniinvasive Techniques 13(3):292\u0026ndash;298\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLo CY, Tam PC, Kung A, Lam K, Wong J (1996) Primary aldosteronism. Results of surgical treatment. Ann Surg 224(2):125\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Toole SM, Hornby C, Sze WCC, Hannon MJ, Akker SA, Druce MR, Waterhouse M, Dawnay A, Sahdev A, Matson M (2021) Performance evaluation of scoring systems for predicting post-operative hypertension cure in primary aldosteronism. Clin Endocrinol 95(4):576\u0026ndash;586\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurton TJ, Mackenzie IS, Balan K, Koo B, Bird N, Soloviev DV, Azizan EA, Aigbirhio F, Gurnell M, Brown MJ (2012) Evaluation of the sensitivity and specificity of 11C-metomidate positron emission tomography (PET)-CT for lateralizing aldosterone secretion by Conn's adenomas. J Clin Endocrinol Metabolism 97(1):100\u0026ndash;109\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu X, Senanayake R, Goodchild E, Bashari WA, Salsbury J, Cabrera CP, Argentesi G, O\u0026rsquo;Toole SM, Matson M, Koo B (2023) [11C] metomidate PET-CT versus adrenal vein sampling for diagnosing surgically curable primary aldosteronism: a prospective, within-patient trial. Nat Med 29(1):190\u0026ndash;202\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSander K, Gendron T, Cybulska KA, Sirindil F, Zhou J, Kalber TL, Lythgoe MF, Kurzawinski TR, Brown MJ, Williams B (2021) Development of [18F] AldoView as the first highly selective aldosterone synthase PET tracer for imaging of primary hyperaldosteronism. J Med Chem 64(13):9321\u0026ndash;9329\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu S, Chu C, Kong A, Wong S, Chiu P, Chow F, Ng E (2016) Radiofrequency ablation compared with laparoscopic adrenalectomy for aldosterone-producing adenoma. J Br Surg 103(11):1476\u0026ndash;1486\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoung W Jr (2019) Diagnosis and treatment of primary aldosteronism: practical clinical perspectives. J Intern Med 285(2):126\u0026ndash;148\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuth A, Ragnarsson O, Johannsson G, W\u0026auml;ngberg B (2015) Systematic review of surgery and outcomes in patients with primary aldosteronism. J Br Surg 102(4):307\u0026ndash;317\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVorselaars WM, Nell S, Postma EL, Zarnegar R, Drake FT, Duh Q-Y, Talutis SD, McAneny DB, McManus C, Lee JA (2019) Clinical outcomes after unilateral adrenalectomy for primary aldosteronism. JAMA Surg 154(4):e185842\u0026ndash;e185842\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDekkers T, Prejbisz A, Kool LJS, Groenewoud HJ, Velema M, Spiering W, Kołodziejczyk-Kruk S, Arntz M, Kądziela J, Langenhuijsen JF (2016) Adrenal vein sampling versus CT scan to determine treatment in primary aldosteronism: an outcome-based randomised diagnostic trial. lancet Diabetes Endocrinol 4(9):739\u0026ndash;746\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSukor N, Gordon RD, Ku YK, Jones M, Stowasser M (2009) Role of unilateral adrenalectomy in bilateral primary aldosteronism: a 22-year single center experience. J Clin Endocrinol Metabolism 94(7):2437\u0026ndash;2445\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeyer LS, Handgriff L, Lim JS, Udager AM, Kinker I-S, Ladurner R, Wildgruber M, Kn\u0026ouml;sel T, Bidlingmaier M, Rainey WE (2021) Single-center prospective cohort study on the histopathology, genotype, and postsurgical outcomes of patients with primary aldosteronism. Hypertension 78(3):738\u0026ndash;746\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilliams TA, Gomez-Sanchez CE, Rainey WE, Giordano TJ, Lam AK, Marker A, Mete O, Yamazaki Y, Zerbini MCN, Beuschlein F (2021) International histopathology consensus for unilateral primary aldosteronism. J Clin Endocrinol Metabolism 106(1):42\u0026ndash;54\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElfenbein DM, Scarborough JE, Speicher PJ, Scheri RP (2013) Comparison of laparoscopic versus open adrenalectomy: Results from american college of surgeons-national surgery quality improvement project. J Surg Res 184(1):216\u0026ndash;220\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuncan IIIJL, George MF, John SB, William SR (2000) Laparoscopic adrenalectomy is superior to an open approach to treat primary hyperaldosteronism. Am Surg 66(10):932\u0026ndash;936\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Pre and 3 months post operative blood pressure and potassium levels in the 82 patients (whole cohort) following adrenalectomy for PA.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"598\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"30%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePotassium (mmol/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow \u0026lt;3.5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e61 (74.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.666666666666666%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e14.269\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.666666666666666%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.17857142857143%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNormal (3.5-5.3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.910714285714285%\" valign=\"top\"\u003e\n \u003cp\u003e21 (25.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.910714285714285%\" valign=\"top\"\u003e\n \u003cp\u003e76 (92.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.17857142857143%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh (\u0026gt;5.3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.910714285714285%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.910714285714285%\" valign=\"top\"\u003e\n \u003cp\u003e6 (7.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.17857142857143%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.910714285714285%\" valign=\"top\"\u003e\n \u003cp\u003e3.1 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.910714285714285%\" valign=\"top\"\u003e\n \u003cp\u003e4.5 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlood pressure (mmHg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSystolic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.333333333333332%\"\u003e\n \u003cp\u003e165.1 \u0026plusmn; 23.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.333333333333332%\"\u003e\n \u003cp\u003e131.7 \u0026plusmn; 16.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e11.424\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiastolic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.333333333333332%\"\u003e\n \u003cp\u003e93 \u0026plusmn; 14.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.333333333333332%\"\u003e\n \u003cp\u003e82 \u0026plusmn; 10.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e7.105\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD: \u003cstrong\u003eStandard deviation\u003c/strong\u003e, t:\u0026nbsp;\u003cstrong\u003ePaired t-test\u003c/strong\u003e, Z: Wilcoxon signed ranks test\u0026nbsp;\u003cbr\u003ep: p value for comparing between \u003cstrong\u003epreoperative and postoperative\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;*: Statistically significant at p \u0026le; 0.05\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (2)\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePre , 3 months and 5 year post operative biochemical outcomes in the 24 patients following adrenalectomy for PA\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"654\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.31192660550459%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLab\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow up\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest of sig.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.31192660550459%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePotassium\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.31192660550459%\"\u003e\n \u003cp\u003eMedian (Min. \u0026ndash; Max.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e3.2 (2.4\u0026ndash;4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e4.8 (3.6\u0026ndash;5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e4.6 (3.4\u0026ndash;5.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\" rowspan=\"2\"\u003e\n \u003cp\u003eF=\u003cbr\u003e47.519\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.45977011494253%\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.18007662835249%\"\u003e\n \u003cp\u003e3.3 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.18007662835249%\"\u003e\n \u003cp\u003e4.7 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.18007662835249%\"\u003e\n \u003cp\u003e4.6 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.31192660550459%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSig. bet. periods\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.5045871559633%\" colspan=\"3\"\u003e\n \u003cp\u003ep\u003csub\u003e1\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e2\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e3\u003c/sub\u003e=0.752\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.31192660550459%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAldosterone (pmol/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.31192660550459%\"\u003e\n \u003cp\u003eMedian (Min. \u0026ndash; Max.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e932 (450\u0026ndash;2900)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e115 (60\u0026ndash;723)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e205 (70 \u0026ndash; 1480)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\" rowspan=\"2\"\u003e\n \u003cp\u003eFr=\u003cbr\u003e37.130\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.45977011494253%\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.18007662835249%\"\u003e\n \u003cp\u003e1206.1 \u0026plusmn; 729.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.18007662835249%\"\u003e\n \u003cp\u003e161.8 \u0026plusmn; 137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.18007662835249%\"\u003e\n \u003cp\u003e259.4 \u0026plusmn; 279.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.31192660550459%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSig. bet. periods\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.5045871559633%\" colspan=\"3\"\u003e\n \u003cp\u003ep\u003csub\u003e1\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e2\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e3\u003c/sub\u003e=0.112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.31192660550459%\"\u003e\n \u003cp\u003e\u003cstrong\u003eRenin (nmol/L/H)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.31192660550459%\"\u003e\n \u003cp\u003eMedian (Min. \u0026ndash; Max.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e0.3 (0.1\u0026ndash;2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e1 (0.2\u0026ndash;3.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e1.5 (0.4\u0026ndash;8.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\" rowspan=\"2\"\u003e\n \u003cp\u003eFr=\u003cbr\u003e13.640\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.45977011494253%\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.18007662835249%\"\u003e\n \u003cp\u003e0.8 \u0026plusmn; 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.18007662835249%\"\u003e\n \u003cp\u003e1.2 \u0026plusmn; 0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.18007662835249%\"\u003e\n \u003cp\u003e1.8 \u0026plusmn; 1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.31192660550459%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSig. bet. periods\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.5045871559633%\" colspan=\"3\"\u003e\n \u003cp\u003ep\u003csub\u003e1\u003c/sub\u003e=0.036\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e2\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e3\u003c/sub\u003e=0.149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.31192660550459%\"\u003e\n \u003cp\u003e\u003cstrong\u003eARR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.501529051987767%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\" rowspan=\"3\"\u003e\n \u003cp\u003eFr=\u003cbr\u003e34.522\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\" rowspan=\"3\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.45977011494253%\"\u003e\n \u003cp\u003eMedian (Min. \u0026ndash; Max.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.18007662835249%\"\u003e\n \u003cp\u003e2824.5(244.4\u0026ndash;9233)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.18007662835249%\"\u003e\n \u003cp\u003e104.5(23\u0026ndash;2410)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.18007662835249%\"\u003e\n \u003cp\u003e127.5(23.8\u0026ndash;510)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.45977011494253%\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.18007662835249%\"\u003e\n \u003cp\u003e3413.1 \u0026plusmn; 2873.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.18007662835249%\"\u003e\n \u003cp\u003e280.9 \u0026plusmn; 512.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.18007662835249%\"\u003e\n \u003cp\u003e169.8 \u0026plusmn; 114.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.31192660550459%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSig. bet. periods\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.5045871559633%\" colspan=\"3\"\u003e\n \u003cp\u003ep\u003csub\u003e1\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e2\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e3\u003c/sub\u003e=0.885\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.091743119266056%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD: \u003cstrong\u003eStandard deviation\u003c/strong\u003e, \u003cstrong\u003eFr\u003c/strong\u003e: \u003cstrong\u003eFriedman test\u003c/strong\u003e, Sig. bet. periods was done using\u003cstrong\u003e\u0026nbsp;Post Hoc Test\u003c/strong\u003e (\u003cstrong\u003eDunn\u0026apos;s)\u003c/strong\u003e, \u003cstrong\u003eF: F test (ANOVA) with repeated measures,\u0026nbsp;\u003c/strong\u003eSig. bet. periods was done using\u003cstrong\u003e\u0026nbsp;Post Hoc Test\u003c/strong\u003e (\u003cstrong\u003eadjusted Bonferroni)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ep: p value for comparing between \u003cstrong\u003ethe different studied periods\u003c/strong\u003e\u003cbr\u003ep\u003csub\u003e1\u003c/sub\u003e: p value for comparing between \u003cstrong\u003ePreoperative\u003c/strong\u003e and \u003cstrong\u003e3 months\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ep\u003csub\u003e2\u003c/sub\u003e: p value for comparing between \u003cstrong\u003ePreoperative\u003c/strong\u003e and \u003cstrong\u003e5 years\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ep\u003csub\u003e3\u003c/sub\u003e: p value for comparing between \u003cstrong\u003ePostoperative\u003c/strong\u003e and \u003cstrong\u003e5 years\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e*: Statistically significant at p \u0026le; 0.05\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (3):\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePre , 3 months and 5 year post operative clinical outcomes in the 24 patients following adrenalectomy for PA\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"665\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.873873873873872%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlood pressure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.76876876876877%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.76876876876877%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.76876876876877%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e5 years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.90990990990991%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.90990990990991%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.873873873873872%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSystolic (mmHg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.76876876876877%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.76876876876877%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.76876876876877%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.90990990990991%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.90990990990991%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.873873873873872%\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.76876876876877%\"\u003e\n \u003cp\u003e158.4 \u0026plusmn; 25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.76876876876877%\"\u003e\n \u003cp\u003e131.8 \u0026plusmn; 14.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.76876876876877%\" valign=\"top\"\u003e\n \u003cp\u003e132.5 \u0026plusmn; 11.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.90990990990991%\" valign=\"top\"\u003e\n \u003cp\u003e23.318\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.90990990990991%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.909774436090224%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSig. bet. periods\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.2406015037594%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003ep\u003csub\u003e1\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e2\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e3\u003c/sub\u003e=1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.924812030075188%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.924812030075188%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.873873873873872%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiastolic (mmHg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.76876876876877%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.76876876876877%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.76876876876877%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.90990990990991%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.90990990990991%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.873873873873872%\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.76876876876877%\"\u003e\n \u003cp\u003e93 \u0026plusmn; 14.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.76876876876877%\"\u003e\n \u003cp\u003e82 \u0026plusmn; 10.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.76876876876877%\" valign=\"top\"\u003e\n \u003cp\u003e81 \u0026plusmn; 9.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.90990990990991%\" valign=\"top\"\u003e\n \u003cp\u003e10.670\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.90990990990991%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.909774436090224%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSig. bet. periods\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.2406015037594%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003ep\u003csub\u003e1\u003c/sub\u003e=0.008\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e2\u003c/sub\u003e=0.003\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e3\u003c/sub\u003e=1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.924812030075188%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.924812030075188%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD: \u003cstrong\u003eStandard deviation\u003c/strong\u003e, \u003cstrong\u003eF: F test (ANOVA) with repeated measures,\u0026nbsp;\u003c/strong\u003eSig. bet. periods was done using\u003cstrong\u003e\u0026nbsp;Post Hoc Test\u003c/strong\u003e (\u003cstrong\u003eadjusted Bonferroni)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ep: p value for comparing between \u003cstrong\u003ethe different studied periods\u003c/strong\u003e\u003cbr\u003ep\u003csub\u003e1\u003c/sub\u003e: p value for comparing between \u003cstrong\u003ePreoperative\u003c/strong\u003e and \u003cstrong\u003e3 months\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ep\u003csub\u003e2\u003c/sub\u003e: p value for comparing between \u003cstrong\u003ePreoperative\u003c/strong\u003e and \u003cstrong\u003e5 years\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ep\u003csub\u003e3\u003c/sub\u003e: p value for comparing between \u003cstrong\u003ePostoperative\u003c/strong\u003e and \u003cstrong\u003e5 years\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e*: Statistically significant at p \u0026le; 0.05\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (4): \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePre , 3 months and 5 year post operative\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eNumber of antihypertensive medications outcomes in the cohort of 24 patients\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"665\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.873873873873872%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of medications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.76876876876877%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.76876876876877%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.76876876876877%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e5 years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.90990990990991%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFr\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.90990990990991%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.873873873873872%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.76876876876877%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.76876876876877%\" valign=\"top\"\u003e\n \u003cp\u003e7 (29.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.76876876876877%\" valign=\"top\"\u003e\n \u003cp\u003e10 (41.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.90990990990991%\" rowspan=\"7\"\u003e\n \u003cp\u003e35.686\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.90990990990991%\" rowspan=\"7\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.775280898876403%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.408239700374533%\" valign=\"top\"\u003e\n \u003cp\u003e5 (20.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.408239700374533%\" valign=\"top\"\u003e\n \u003cp\u003e6 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.408239700374533%\" valign=\"top\"\u003e\n \u003cp\u003e10 (41.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.775280898876403%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.408239700374533%\" valign=\"top\"\u003e\n \u003cp\u003e4 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.408239700374533%\" valign=\"top\"\u003e\n \u003cp\u003e9 (37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.408239700374533%\" valign=\"top\"\u003e\n \u003cp\u003e2 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.775280898876403%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.408239700374533%\" valign=\"top\"\u003e\n \u003cp\u003e8 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.408239700374533%\" valign=\"top\"\u003e\n \u003cp\u003e2 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.408239700374533%\" valign=\"top\"\u003e\n \u003cp\u003e2 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.775280898876403%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.408239700374533%\" valign=\"top\"\u003e\n \u003cp\u003e4 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.408239700374533%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.408239700374533%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.775280898876403%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.408239700374533%\" valign=\"top\"\u003e\n \u003cp\u003e2 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.408239700374533%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.408239700374533%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.775280898876403%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.408239700374533%\" valign=\"top\"\u003e\n \u003cp\u003e1 (4.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.408239700374533%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.408239700374533%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.909774436090224%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSig. bet. periods\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.2406015037594%\" colspan=\"3\"\u003e\n \u003cp\u003ep\u003csub\u003e1\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e2\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e3\u003c/sub\u003e=0.312\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.924812030075188%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.924812030075188%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eFr\u003c/strong\u003e: \u003cstrong\u003eFriedman test\u003c/strong\u003e, Sig. bet. periods was done using\u003cstrong\u003e\u0026nbsp;Post Hoc Test\u003c/strong\u003e (\u003cstrong\u003eDunn\u0026apos;s)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ep: p value for comparing between \u003cstrong\u003ethe different studied periods\u003c/strong\u003e\u003cbr\u003ep\u003csub\u003e1\u003c/sub\u003e: p value for comparing between \u003cstrong\u003ePreoperative\u003c/strong\u003e and \u003cstrong\u003e3 months\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ep\u003csub\u003e2\u003c/sub\u003e: p value for comparing between \u003cstrong\u003ePreoperative\u003c/strong\u003e and \u003cstrong\u003e5 years\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ep\u003csub\u003e3\u003c/sub\u003e: p value for comparing between \u003cstrong\u003ePostoperative\u003c/strong\u003e and 5 years\u003c/p\u003e\n\u003cp\u003e*: Statistically significant at p \u0026le; 0.0\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (5): Comparison between the two studied periods according to medication in the cohort of 24 patients\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"540\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.390018484288355%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.10536044362292%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.10536044362292%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e5 years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.199630314232902%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMH\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.199630314232902%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.390018484288355%\" valign=\"top\"\u003e\n \u003cp\u003eStopped\u003c/p\u003e\n \u003cp\u003eReduced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.10536044362292%\" valign=\"top\"\u003e\n \u003cp\u003e7 (29.2%)\u003c/p\u003e\n \u003cp\u003e14 (58.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.10536044362292%\" valign=\"top\"\u003e\n \u003cp\u003e10 (41.7%)\u003c/p\u003e\n \u003cp\u003e5 (20.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.199630314232902%\" rowspan=\"4\"\u003e\n \u003cp\u003e20.0\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.199630314232902%\" rowspan=\"4\"\u003e\n \u003cp\u003e0.008\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.87530562347188%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56234718826406%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56234718826406%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.87530562347188%\" valign=\"top\"\u003e\n \u003cp\u003eSame\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56234718826406%\" valign=\"top\"\u003e\n \u003cp\u003e3 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56234718826406%\" valign=\"top\"\u003e\n \u003cp\u003e8 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.87530562347188%\" valign=\"top\"\u003e\n \u003cp\u003eIncreased\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56234718826406%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56234718826406%\" valign=\"top\"\u003e\n \u003cp\u003e1 (4.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eMH: Marginal Homogeneity Test\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;p: p value for comparing between Postoperative and 5 years\u003c/p\u003e\n\u003cp\u003e*: Statistically significant at p \u0026le; 0.05\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (6) \u0026nbsp;Comparison between short and long term outcomes according to PASO criteria in the cohort of 24 patients\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"408\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.87530562347188%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePASO group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56234718826406%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56234718826406%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e5 years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.87530562347188%\" valign=\"top\"\u003e\n \u003cp\u003eComplete clinical success\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56234718826406%\" valign=\"top\"\u003e\n \u003cp\u003e7 (29.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56234718826406%\" valign=\"top\"\u003e\n \u003cp\u003e10 (41.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.87530562347188%\" valign=\"top\"\u003e\n \u003cp\u003ePartial clinical success\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56234718826406%\" valign=\"top\"\u003e\n \u003cp\u003e14 (58.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56234718826406%\" valign=\"top\"\u003e\n \u003cp\u003e11 (45.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.87530562347188%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent clinical success\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56234718826406%\" valign=\"top\"\u003e\n \u003cp\u003e3 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56234718826406%\" valign=\"top\"\u003e\n \u003cp\u003e3 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.87530562347188%\" valign=\"top\"\u003e\n \u003cp\u003eComplete biochemical success \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56234718826406%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;23 (95.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56234718826406%\" valign=\"top\"\u003e\n \u003cp\u003e23 (95.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.87530562347188%\" valign=\"top\"\u003e\n \u003cp\u003ePartial biochemical success\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56234718826406%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 0 (0%) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56234718826406%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.87530562347188%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent biochemical success\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56234718826406%\" valign=\"top\"\u003e\n \u003cp\u003e1(4.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.56234718826406%\" valign=\"top\"\u003e\n \u003cp\u003e1(4.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"hormones","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"HORM","sideBox":"Learn more about [Hormones](https://www.springer.com/journal/42000)","snPcode":"42000","submissionUrl":"https://www.editorialmanager.com/horm/default2.aspx","title":"Hormones","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Primary Aldosteronism, Adrenalectomy, Conn’s syndrome, Biochemical cure","lastPublishedDoi":"10.21203/rs.3.rs-4697365/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4697365/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cu\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e\u003c/u\u003e Primary Aldosteronism (PA) is the commonest cause of secondary hypertension and can be cured by unilateral adrenalectomy. We report the short and long-term outcomes after adrenalectomy performed at a single UK centre over a period of 24 years.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/u\u003e Retrospective analysis of \u003cu\u003ebiochemical\u003c/u\u003e(potassium, aldosterone, renin and ARR) \u003cu\u003eradiological\u003c/u\u003e (CT/MRI, AVS, nuclear scans) and \u003cu\u003eclinical \u003c/u\u003e(surgical complications, blood pressure, number of antihypertensive medications) short and long terms outcomes in patients who underwent adrenalectomy for PA between 1998 and 2021. Standardised PASO and Clavien-Dindo criteria to assess biochemical, clinical and surgical outcomes were used.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/u\u003e 82 patients treated with adrenalectomy for PA over a 24 year period, short term follow up data (within 3 months from surgery) was available for 82 patients (M45, F37, mean age 51.7 years), 24 of them were followed at least 60 months( range 60 to 72 months) \u0026nbsp;77 (93.9%) patients had laparoscopic surgery (1 conversion). 7 patients had postoperative complications classified as Clavien-Dindo II(4), IIIa(1) and IVa(2). Median LOS was 2.5 days (1-12).\u003c/p\u003e\n\u003cp\u003eComplete and partial clinical success was achieved in 29% and 58.3% and 41.7% and 45.8% of patients in short and long term respectively. Clinical benefit was observed in 88% of patients. Complete biochemical success was achieved in 95.8% of patients in short and long term.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/u\u003e: Unilateral adrenalectomy in patients with PA achieved clinical benefit in 88% and biochemical cure in almost all of them. Our data suggest that these benefits persisted for at least 5 years.\u003c/p\u003e","manuscriptTitle":"Short- and long-term outcomes of adrenalectomy for Primary Aldosteronism in a single UK centre: Rear Mirror View.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-05 09:41:51","doi":"10.21203/rs.3.rs-4697365/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2024-07-11T07:55:52+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-11T07:09:07+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Hormones","date":"2024-07-10T07:10:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-08T10:10:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"Hormones","date":"2024-07-08T05:24:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"hormones","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"HORM","sideBox":"Learn more about [Hormones](https://www.springer.com/journal/42000)","snPcode":"42000","submissionUrl":"https://www.editorialmanager.com/horm/default2.aspx","title":"Hormones","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f2fcfd11-5ea1-49c4-8711-ed1f6ca204ca","owner":[],"postedDate":"August 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-25T16:07:21+00:00","versionOfRecord":{"articleIdentity":"rs-4697365","link":"https://doi.org/10.1007/s42000-024-00613-3","journal":{"identity":"hormones","isVorOnly":false,"title":"Hormones"},"publishedOn":"2024-11-18 15:57:51","publishedOnDateReadable":"November 18th, 2024"},"versionCreatedAt":"2024-08-05 09:41:51","video":"","vorDoi":"10.1007/s42000-024-00613-3","vorDoiUrl":"https://doi.org/10.1007/s42000-024-00613-3","workflowStages":[]},"version":"v1","identity":"rs-4697365","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4697365","identity":"rs-4697365","version":["v1"]},"buildId":"zQwnuV7TCBrMSSSToR1PI","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}