Laparoscopic transperitoneal adrenalectomy in the large adrenal tumor from single center experience

Abstract Background The role of laparoscopic adrenalectomy (LA) in a large adrenal tumor is controversial due to the risk of malignancy and technical difficulty. In this study, we compared the perioperative outcomes and complications of LA on large (≥ 6 cm) and (< 6 cm) adrenal tumors. Methods We retrospectively reviewed all clinical data of patients who underwent unilateral transperitoneal LA in our institution between April 2000 and June 2019. Patients were classified by tumor size into 2 groups. Patients in group 1 had tumor size < 6 cm (n = 408) and patient in group 2 had tumor size ≥ 6 cm (n = 48). Demographic data, perioperative outcomes, complications, and pathologic reports were compared between groups. Results Patients in group 2 were significant older (p = 0.04), thinner (p = 0.001) and had lower incident of hypertension (p = 0.001), with a significantly higher median operative time (75 vs 120 min), estimated blood loss (20 vs 100 ml), transfusion rate (0 vs 20.8%), conversion rate (0.25 vs 14.6%) and length of postoperative stays ( 4 vs 5.5 days) than in group 2 (all p < 0.001). Group 2 patients also had significantly higher frequency of intraoperative complication (4.7 vs 31.3%; adjust Odds Ratio [OR] = 9.67 (95% CI 4.22–22.17), p-value < 0.001) and postoperative complication (5.4 vs 31.3%; adjust OR = 5.67 (95% CI 2.48–12.97), p-value < 0.001). Only eight (1.8%) major complications occurred in this study. The most common pathology in group 2 patient was pheochromocytoma and metastasis. Conclusions Laparoscopic transperitoneal adrenalectomy in large adrenal tumor ≥ 6 cm is feasible but associated with significantly worse intraoperative complications, postoperative complications, and recovery. However, most of the complications were minor and could be managed conservatively. Careful patient selection with the expert surgeon in adrenal surgery is the key factor for successful laparoscopic surgery in a large adrenal tumor. Trial registration: This study was retrospectively registered in the Thai Clinical Trials Registry on 02/03/2020. The registration number was TCTR20200312004.

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Feasibility and Safety of Laparoscopic Transperitoneal Adrenalectomy in Large Adrenal Tumor From 20 Years Single-center Experiences- A Retrospective Cohort Study

10.21203/rs.3.rs-109193/v1 ◽

2020 ◽

Author(s):

Thanasit Prakobpon ◽

Apirak Santi-ngamkun ◽

Manint Usawachintachit ◽

Supoj Ratchanon ◽

Dutsadee Sowanthip ◽

...

Keyword(s):

Tumor Size ◽

Adrenal Tumor ◽

Intraoperative Complications ◽

Perioperative Outcomes ◽

P Value ◽

Transfusion Rate ◽

Intraoperative Complication ◽

Estimated Blood Loss ◽

Group 2 ◽

Laparoscopic Transperitoneal

Abstract Background: The role of laparoscopic adrenalectomy (LA) in a large adrenal tumor is controversial due to the risk of malignancy and technical difficulty. In this study, we compared the perioperative outcomes and complications of LA on large (≥ 6 cm) and (< 6 cm) adrenal tumors.Methods: We retrospectively reviewed all clinical data of patients who underwent unilateral LA in our institution between April 2000 and June 2019. Patients were classified by tumor size into 2 groups. Patients in group 1 had tumor size < 6 cm (n=408) and patient in group 2 had tumor size ≥ 6 cm (n=48). Demographic data, perioperative outcomes, complications, and pathologic reports were compared between groups.Results: Patients in group 2 were significant older (p=0.04), thinner (p=0.001) and had lower incident of hypertension (p=0.001), with a significantly higher median operative time (75 vs 120 min), estimated blood loss (20 vs 100 ml), transfusion rate (0 vs 20.8%), conversion rate (0.25 vs 14.6%) and length of stays (6 vs 9 days) than in group 2 (all p<0.001). Group 2 patients also had significantly higher frequency of intraoperative complication (4.7 vs 31.3%; adjust Odds Ratio [OR] =7.73 (95% CI 3.35-17.84), p-value < 0.001) and postoperative complication (5.4 vs 31.3%; adjust OR=6.06, 95% CI 2.84-13.73, p-value < 0.001). Only eight (1.8%) major complications occurred in this study. The most common pathology in group 2 patient was pheochromocytoma and metastasis. Conclusions: Laparoscopic transperitoneal adrenalectomy in large adrenal tumor ≥ 6 cm is feasible but associated with significantly worse intraoperative complications, postoperative complications and recovery. However, most of the complications were minor and could be managed conservatively. Careful patient selection with the expertise surgeon in adrenal surgery are the key factors for successful laparoscopic surgery in a large adrenal tumor. Trial registration: This study was retrospectively registered in the Thai Clinical Trials Registry on 02/03/2020. The registration number was TCTR20200312004.

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Retrospective comparison of three minimally invasive approaches for adrenal tumors: perioperative outcomes of transperitoneal laparoscopic, retroperitoneal laparoscopic and robot-assisted laparoscopic adrenalectomy

BMC Urology ◽

10.1186/s12894-020-00637-y ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Changwei Ji ◽

Qun Lu ◽

Wei Chen ◽

Feifei Zhang ◽

Hao Ji ◽

...

Keyword(s):

Length Of Stay ◽

Blood Loss ◽

Minimally Invasive ◽

Laparoscopic Adrenalectomy ◽

Perioperative Outcomes ◽

Adrenal Tumors ◽

Transfusion Rate ◽

Robot Assisted ◽

Estimated Blood Loss ◽

Minimally Invasive Adrenalectomy

Abstract Background To compare the perioperative outcomes of transperitoneal laparoscopic (TLA), retroperitoneal laparoscopic (RLA), and robot-assisted transperitoneal laparoscopic (RATLA) adrenalectomy for adrenal tumors in our center. Methods Between April 2012 and February 2018, 241 minimally invasive adrenalectomies were performed. Cases were categorized based on the minimally invasive adrenalectomy technique. Demographic characteristics, perioperative information and pathological data were retrospectively collected and analyzed. Results This study included 37 TLA, 117 RLA, and 87 RATLA procedures. Any two groups had comparable age, ASA score, Charlson Comorbidity Index, and preoperative hemoglobin. The tumor size for RLA patients was 2.7 ± 1.1 cm, which was significantly smaller compared to patients who underwent TLA/RATLA (p = 0.000/0.000). Operative time was similar in any two groups, while estimated blood loss was lower for RATLA group (75.6 ± 95.6 ml) compared with the TLA group (131.1 ± 204.5 ml) (p = 0.041). Conversion to an open procedure occurred in only one (2.7%) patient in the TLA group for significant adhesion and hemorrhage. There were no significant differences between groups in terms of transfusion rate and complication rate. Length of stay was shorter for the RATLA group versus the TLA/RLA group (p = 0.000/0.029). In all groups, adrenocortical adenoma and pheochromocytoma were the most frequent histotypes. Conclusions Minimally invasive adrenalectomy is associated with expected excellent outcomes. In our study, the RATLA approach appears to provide the benefits of decreased estimated blood loss and length of stay. Robotic adrenalectomy appears to be a safe and effective alternative to conventional laparoscopic adrenalectomy.

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Laparoscopic transperitoneal adrenalectomy: The gold standard treatment.

The Professional Medical Journal ◽

10.29309/tpmj/2019.26.09.1843 ◽

2019 ◽

Vol 26 (09) ◽

pp. 1440-1444

Author(s):

Mohammad Zarin ◽

Maham Qazi ◽

Sayed Asad Maroof ◽

Junaid Zeb ◽

Muhammad Ishfaq Ahmad ◽

...

Keyword(s):

Intraoperative Complications ◽

Adrenal Tumors ◽

Cross Sectional ◽

Intraoperative Complication ◽

Intraoperative Bleeding ◽

Bleeding Vessel ◽

Operative Complications ◽

The Right ◽

Operative Recovery ◽

Laparoscopic Transperitoneal

Objectives: The aim of our study was to evaluate safety and outcomes of laparoscopic transperitoneal adrenalectomy in the treatment of adrenal tumors in terms of peri operative complications. Moreover we have also focused on frequency of tumors presented with adrenal masses. Study Design: Cross sectional study. Setting: Khyber Teaching Hospital, Peshawar Pakistan. Period: 20th October 2014 to 30th January 2018. Material and Methods: Total of 43 patients were included in study after informed consent to participate in the study. Data was collected by predesigned questionnaire and analyzed by SPSS 20. Results: A total of 43 Laparoscopic transperitoneal adrenalectomies were performed, predominantly for pheochromocytomas (19 cases). Out of all cases operated 24 laparoscopic transperitoneal adrenalectomies were performed on the right side and 19 on the left side. According to the tumor localization, the mean operative time was 90± 9.5 minutes. Intraoperative complications occurred in five cases 11.6%. The common intraoperative complication was intraoperative bleeding (9.3%). The intraoperative complication rate on the right side was 9.3% due to intra-operative hemorrhage and the corresponding rate on left was 2.3% due to inra-operative diaphragh tear. In one case (2.3%) we could not control intraoperative hemorrhage laparoscopically and it got converted to open surgery for control of bleeding, whereas rest of the three cases with intraoperative bleeding were controlled by identifying the bleeding vessel and clipping it. Post-operative complications occurred in 7 patients (16.27%). Conclusion: Laparoscopic transperitoneal Adrenalectomy is safe, feasible procedure with decrease morbidity and early post operative recovery and discharge from hospital with no mortality.

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Analysis of predictors of adherent perinephric fat and its impact on perioperative outcomes in laparoscopic partial nephrectomy: a retrospective case–control study

World Journal of Surgical Oncology ◽

10.1186/s12957-021-02429-6 ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Lu Fang ◽

Huan Li ◽

Tao Zhang ◽

Rui Liu ◽

Taotao Zhang ◽

...

Keyword(s):

Blood Loss ◽

Partial Nephrectomy ◽

Univariate Analysis ◽

Warm Ischemia ◽

Laparoscopic Partial Nephrectomy ◽

Renal Tumors ◽

Perioperative Outcomes ◽

Transfusion Rate ◽

Estimated Blood Loss ◽

Perinephric Fat

Abstract Background Adherent perinephric fat (APF), characterized by inflammatory fat surrounding the kidney, can limit the isolation of renal tumors and increase the operative difficulty in laparoscopic partial nephrectomy (LPN). The aim of this study was to investigate the predictors of APF and its impact on perioperative outcomes during LPN. Methods A total of 215 consecutive patients undergoing LPN for renal cell carcinoma (RCC) from January 2017 to June 2019 at our institute were included. We divided these patients into two groups according to the presence of APF. Radiographic data were retrospectively collected from preoperative cross-sectional imaging. The perioperative clinical parameters were compared between the two groups. Univariate and multivariate analyses were performed to evaluate the predictive factors of APF. Results APF was identified in 41 patients (19.1%) at the time of LPN. Univariate analysis demonstrated that APF was significantly correlated with the male gender (P = 0.001), higher body mass index (P = 0.002), lower preoperative estimated glomerular filtration rate (P = 0.004), greater posterior perinephric fat thickness (P< 0.001), greater perinephric stranding (P< 0.001), and higher Mayo Adhesive Probability (MAP) score (P< 0.001). The MAP score (P< 0.001) was the only variable that remained an independent predictor for APF in multivariate analysis. We found that patients with APF had longer operative times (P< 0.001), warm ischemia times (P = 0.001), and greater estimated blood loss (P = 0.003) than those without APF. However, there were no significant differences in surgical approach, transfusion rate, length of postoperative stay, complication rate, or surgical margin between the two groups. Conclusions Several specific clinical and radiographic factors including the MAP score can predict APF. The presence of APF is associated with an increased operative time, warm ischemia time, and greater estimated blood loss but has no impact on other perioperative outcomes in LPN.

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A new three-step hybrid approach is a safe procedure for incisional hernia: early experiences with a single centre retrospective cohort

Hernia ◽

10.1007/s10029-020-02300-9 ◽

2020 ◽

Author(s):

L. Matthijs van den Dop ◽

Gijs H. J. de Smet ◽

Michaël P. A. Bus ◽

Johan F. Lange ◽

Sascha M. P. Koch ◽

...

Keyword(s):

Incisional Hernia ◽

Hernia Repair ◽

Intraoperative Complications ◽

Operation Time ◽

Incisional Hernia Repair ◽

Hernia Recurrence ◽

Perioperative Outcomes ◽

Safe Procedure ◽

Intraoperative Complication ◽

Hybrid Repair

Abstract Purpose In this study, a three-step novel surgical technique was developed for incisional hernia, in which a laparoscopic procedure with a mini-laparotomy is combined: so-called ‘three-step incisional hybrid repair’. The aim of this study was to reduce the risk of intestinal lacerations during adhesiolysis and recurrence rate by better symmetrical overlap placement of the mesh. Objectives To evaluate first perioperative outcomes with this technique. Methods From 2016 to 2020, 70 patients (65.7% females) with an incisional hernia of > 2 and ≤ 10 cm underwent a elective three-step incisional hybrid repair in two non-academic hospitals performed by two surgeons specialised in abdominal wall surgery. Intra- and postoperative complications, operation time, hospitalisation time and hernia recurrence were assessed. Results Mean operation time was 100 min. Mean hernia size was 4.8 cm; 45 patients (64.3%) had a hernia of 1–5 cm, 25 patients (35.7%) of 6–10 cm. Eight patients had a grade 1 complication (11.4%), five patients a grade 2 (7.1%), two patients (2.8%) a grade 4 complication and one patient (1.4%) a grade 5 complication. Five patients had an intraoperative complication (7.0%), two enterotomies, one serosa injury, one omentum bleeding and one laceration of an epigastric vessel. Mean length of stay was 3.3 days. Four patients (5.6%) developed a hernia recurrence during a mean follow-up of 19.5 weeks. Conclusion A three-step hybrid incisional hernia repair is a safe alternative for incisional hernia repair. Intraoperative complications rate was low.

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Perioperative Outcomes of Radical Trachelectomy in Early-Stage Cervical Cancer: Vaginal Versus Laparoscopic Approaches

International Journal of Gynecological Cancer ◽

10.1097/igc.0000000000000407 ◽

2015 ◽

Vol 25 (6) ◽

pp. 1051-1057 ◽

Cited By ~ 9

Author(s):

Aera Yoon ◽

Chel Hun Choi ◽

Yoo-Young Lee ◽

Tae-Joong Kim ◽

Jeong-Won Lee ◽

...

Keyword(s):

Blood Loss ◽

Tumor Size ◽

Early Stage ◽

Medical Center ◽

Intraoperative Complications ◽

Outcome Data ◽

Perioperative Outcomes ◽

Surgical Approaches ◽

Radical Trachelectomy ◽

Gynecology And Obstetrics

ObjectiveThis study aimed to compare the laparoscopic-assisted radical vaginal trachelectomy (LARVT) and laparoscopic radical trachelectomy (LRT) surgical approaches and provide outcome data on patients who have undergone radical trachelectomy.MethodsWe identified patients who had undergone LARVT or LRT at Samsung Medical Center between January 2005 and March 2013.ResultsA total of 38 patients were identified, and 21 patients had undergone LARVT, whereas 17 patients had undergone LRT. The median age was 32 years for both groups. Most of the patients had a squamous cell carcinoma (68.4%) and International Federation of Gynecology and Obstetrics stage IB1 disease (76.3%). Twenty (52.6%) of 38 patients had tumor size greater than 2 cm. There were no significant differences between groups in the baseline characteristics except for the tumor size. Patients undergoing LRT had significantly larger tumor size than patients undergoing LARVT (median tumor size, 2.7 cm [range, 1.2–3.7] vs 2.1 cm [range, 0.4–3.0],P= 0.032). Perioperative outcomes were similar between groups except for the decline of hemoglobin after surgery. The median decline of hemoglobin indicating blood loss was significantly smaller in the LRT group than in the LARVT group (1.8 g/dL [range, 0.5–3.5] vs 2.6 g/dL [range, 0.7–6.2],P= 0.017). Intraoperative complications occurred in 2 patients (9.5%, 2/21) in LARVT group. Although 52.6% of tumors were larger than 2 cm, recurrence occurred only in 3 (7.9%) patients who underwent LARVT.ConclusionsThe study shows the feasibility of LRT, with the advantage of reduced blood loss. The LRT could be an alternative option for patients with large tumors. Further researches are needed to investigate the long-term outcomes.

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Adrenal Incidentalomas: Should We Operate on Small Tumors in the Era of Laparoscopy?

International Journal of Endocrinology ◽

10.1155/2014/658483 ◽

2014 ◽

Vol 2014 ◽

pp. 1-5 ◽

Cited By ~ 4

Author(s):

Michał Pędziwiatr ◽

Michał Natkaniec ◽

Mikhail Kisialeuski ◽

Piotr Major ◽

Maciej Matłok ◽

...

Keyword(s):

Surgical Treatment ◽

Operation Time ◽

Adrenal Tumors ◽

Estimated Blood Loss ◽

Important Argument ◽

Risk Of Malignancy ◽

Potentially Malignant ◽

Group 2 ◽

Histopathological Results ◽

Group 1

Tumor size smaller than 4 cm as an indication for surgical treatment of incidentaloma is still a subject of discussion. Our aim was the estimation of the incidence of malignancy and analysis of treatment outcomes in patients with incidentaloma smaller than 4 cm in comparison to bigger lesions. 132 patients who underwent laparoscopic adrenalectomy for nonsecreting tumors were divided into two groups: group 1 (55 pts., size < = 40 mm) and group 2 (77 pts., size > 40 mm). Operation parameters and histopathological results were analyzed. No differences in group characteristics, mean operation time, and estimated blood loss were noted. Complications in groups 1 and 2 occurred in 3.6% and 5.2% of patients, respectively (P=0.67). Malignancy in groups 1 and 2 was present in 1 and 6 patients, respectively (P=0.13). Potentially malignant lesions were identified in 4 patients in group 1 and 4 patients in group 2 (P=0.39). The results do not allow for straightforward recommendations for surgical treatment of smaller adrenal tumors. The safety of laparoscopy and minimal, but impossible to omit, risk of malignancy support decisions for surgery. On the other hand, the risk of malignancy in smaller adrenal tumors is lower than surgical complications, which provides an important argument against surgery.

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Comparison Robotic versus laparoscopic partial nephrectomy for Complex Renal Tumors (with a RENAL nephrometry score≥7): a meta-analysis

10.21203/rs.3.rs-90761/v1 ◽

2020 ◽

Author(s):

Yu-Li Jiang ◽

Xin Xiao ◽

Fu-Sheng Peng ◽

Tian-Li Shi ◽

Xiao-Hui Huang ◽

...

Keyword(s):

Partial Nephrectomy ◽

Operating Time ◽

Surgical Margin ◽

Laparoscopic Partial Nephrectomy ◽

Renal Tumors ◽

Perioperative Outcomes ◽

Robotic Partial Nephrectomy ◽

Cochrane Central Register ◽

Intraoperative Complication ◽

Estimated Blood Loss

Abstract BackgroundTo compare the perioperative outcomes of Robotic partial nephrectomy (RPN) versus laparoscopic partial nephrectomy (LPN). MethodsWe searched PubMed, EMBASE and the Cochrane Central Register for studies from 2000 to 2020 to evaluate the perioperative outcomes RPN and LPN in patients with a RENALnephrometry score≥7. We used RevMan 5.2 to pool the data. ResultsSeven studies were acquired in our study. No significant differences were found in the estimated blood loss (WMD: WMD: 34.49, 95% CI -75.16-144.14, p=0.54), hospital stay (WMD: -0.59 95% CI -1.24–0.06, p=0.07), operating time (WMD: -22.45, 95%CI: -35.06 to-9.85, ), postive surgical margin (OR: 0.85, 95% CI 0.65–1.11, p =0.23) and transfusion (OR: 0.72, 95% CI 0.48–1.08, p =0.11).between the two groups. RPN get better outcomes in postoperative renal function (WMD: 3.32, 95% CI 0.73–5.91, p=0.01), warm ischenia time (WMD: -6.96, 95% CI -7.30–-6.62, p <0.0001), conversion( OR: 0.34, 95%CI: 0.17 to 0.66, p=0.002) and intraoperative complication (OR: 0.52, 95% CI 0.28–0.97, p=0.04).ConclusionRPN could get better perioerative clinical outcomes than LPN for treatment of Complex Renal Tumors( with a RENALnephrometry score≥7).

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A comparison of surgical practice and operative outcomes between retroperitoneal and transperitoneal laparoscopic nephrectomies – 6 years of data from the BAUS Nephrectomy database

Journal of Clinical Urology ◽

10.1177/20514158211050008 ◽

2021 ◽

pp. 205141582110500

Author(s):

James Jenkins ◽

Christopher Foy ◽

Kim Davenport

Keyword(s):

Partial Nephrectomy ◽

Surgical Approach ◽

Intraoperative Complications ◽

Careful Consideration ◽

Perioperative Outcomes ◽

Transfusion Rate ◽

Volume Data ◽

Level Of Evidence ◽

Open Conversion ◽

The Impact

Objectives: While the choice of surgical approach for laparoscopic nephrectomy is broadly split between transperitoneal and retroperitoneal options, the evidence for the impact of this decision on perioperative outcomes is built on relatively small volume data, with often inconsistent findings and conclusions. We aimed to assess the impact of operative approach on perioperative outcomes for laparoscopic radical, partial and simple nephrectomy and nephroureterectomy through analysis of the British Association of Urological Surgeons (BAUS) Nephrectomy database. Patients and methods: All patients added to the BAUS Nephrectomy database with laparoscopic surgery between 2012 and 2017 inclusively were included and subdivided by operation and surgical approach. Preoperative patient and tumour characteristics, as well as intraoperative and post-operative short-term outcomes, were assessed. Results: Overall, 26,682 operations were documented over the review window (81.6% transperitoneal). Small increases in blood loss ( p = 0.001), transfusion rate ( p = 0.02) and operative length ( p = 0.01) were seen for transperitoneal radical nephrectomies and longer hospital stays seen for retroperitoneal procedures (radical nephrectomy p = 0.00l; partial nephrectomy p = 0.04). Retroperitoneal procedures were associated with increased rates of conversion for simple nephrectomy ( p = 0.02), nephroureterectomy ( p = 0.03) and most notably partial nephrectomy (10.5% versus 4.4%; p = 0.001). No further variation in intraoperative complications, post-operative complications, tumour margin positivity rates, unintended ITU admission, or likelihood of death was identified related to surgical approach. Conclusion: Observed variations in perioperative outcomes were generally modest in nature, and little ground is seen to support a change in operative technique for those committed to one approach. A caveat to this exists with open conversion for retroperitoneal partial nephrectomies and requires careful consideration of patient selection by the individual surgeon. Level of evidence: 4

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Comparison of Adrenal Tumor Size in Ultrasound Examinations with and without the Use of a Contrast Agent

Medicina ◽

10.3390/medicina55050165 ◽

2019 ◽

Vol 55 (5) ◽

pp. 165

Author(s):

Mateusz Winder ◽

Wojciech Spychałowicz ◽

Aleksander Owczarek ◽

Jerzy Chudek

Keyword(s):

Tumor Size ◽

Adrenal Tumor ◽

Three Dimensional ◽

Adrenal Tumors ◽

Tumor Vascularization ◽

Mri Scan ◽

Contrast Enhanced ◽

Median Volume ◽

Doppler Techniques ◽

Adrenal Volume

Background and objectives: Patients diagnosed with incidentally found adrenal tumors (incidentaloma) that do not meet the criteria for surgical treatment require follow-ups with repeated imaging. The aim of this study is to compare the accuracy of the measurements of the adrenal tumor size in ultrasound (US) with and without contrast in comparison to computed tomography (CT) or magnetic resonance (MRI). Further, this study attempts to answer the question of whether contrast-enhanced ultrasound (CEUS) can improve imaging accuracy and replace CT/MRI in the monitoring of patients with adrenal tumors. Materials and Methods: The retrospective analysis included 79 adult patients with adrenal incidentalomas not exceeding a dimension of 6 cm who underwent a CT or MRI scan, US, and CEUS with the use of SonoVue in two-dimensional (2D) and three-dimensional (3D) projections and Doppler techniques. Tumor vascularization in CEUS was classified as follows: peripheral, peripheral-central, central, or poor. Results: Of 79 adrenal tumors, 48.1% showed peripheral, 29.1% showed poor, 21.5% showed peripheral-central, and only 1.3% showed central vascularization. The median volume of tumors detected with CEUS (69.9 cm3) was significantly higher than with US (44.5 cm3) and CT or MRI (57.1 cm3). The relative error of the adrenal volume with CEUS compared with CT or MRI was significantly higher than with standard US, regardless of the type of tumor vascularization. Conclusions: CEUS does not improve the accuracy of adrenal tumor size assessment regardless of the type of vascularization.

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