Radical removal of the adrenal gland

What is the evidence base for this information?

This leaflet includes advice from consensus panels, the British Association of Urological Surgeons, the Department of Health and evidence based sources; it is, therefore, a reflection of best practice in the UK. It is intended to supplement any advice you may already have been given by your Urologist or Nurse Specialist as well as the Surgical team at Addenbrooke’s. Alternative treatments are outlined below and can be discussed in more detail with your Urologist or Nurse Specialist.

Key Points

• The aim of this operation is to remove your adrenal gland
• You have two adrenal glands in the body, one sitting above each kidney
• Reasons for removing the adrenal gland include benign tumours that produce hormones and suspected (or confirmed) adrenal cancer

What does the procedure involve?

This involves removal of the adrenal gland and surrounding fat for suspected cancer of the adrenal.

What are the alternatives to this procedure?

• Observation – this may be an option when your tumour is very small and the risk of progression is felt to be low
• Partial adrenalectomy– this involves removal of the tumour only and preserving the rest of the adrenal gland; it is an experimental technique and is not widely available
• Laparoscopic (keyhole) surgery– this involves removal of your adrenal gland through several small incisions. It may not be suitable for all tumours or in patients who have had previous abdominal surgery

What should I expect before the procedure?

You will usually be admitted on the same day as your surgery. You will normally undergo pre-assessment on the day of your clinic or an appointment for pre-assessment will be made from clinic, to assess your general fitness, to screen for the carriage of MRSA and to perform some baseline investigations. After admission, you will be seen by members of the medical team which may include the consultant, junior urology doctors and your named nurse.

You will be asked not to eat or drink for six hours before surgery and, immediately before the operation, you may be given a pre-medication by the anaesthetist which will make you dry-mouthed and pleasantly sleepy.

You will need to wear anti-thrombosis stockings during your hospital stay; these help prevent blood clots forming in the veins of your legs during and after surgery.

Please be sure to inform your Urologist in advance of your surgery if you have any of the following:

• an artificial heart valve
• a coronary artery stent
• a heart pacemaker or defibrillator
• an artificial joint
• an artificial blood vessel graft
• a neurosurgical shunt
• any other implanted foreign body
• a prescription for warfarin, aspirin, rivaroxaban, dabigatran, apixaban, edoxaban or clopidogrel, ticagrelor or blood thinning medication
• a previous or current MRSA infection
• high risk of variant CJD (if you have received a corneal transplant, a neurosurgical dural transplant or previous injections of human derived growth hormone)

What happens during the procedure?

Normally, a full general anaesthetic will be used and you will be asleep throughout the procedure. In some patients, the anaesthetist may also use an epidural anaesthetic which improves or minimises pain post-operatively.

The operation is usually performed through an incision in your loin (side). On occasion, the incision is made in the front of the abdomen or extended into the chest area. Absorbable sutures are used which do not require removal. A temporary bladder catheter will be inserted to measure urine output. A wound drain is sometimes inserted. These are normally removed after two to three days.

What happens immediately after the procedure?

You will be given fluids to drink from an early stage after the operation and you will be encouraged to mobilise early to prevent blood clots in the veins of your legs.

The average hospital stay is 3-5 days.

Are there any side effects?

Most procedures have a potential for side effects. You should be reassured that, although all these complications are well recognised, the majority of patients do not suffer any problems after a urological procedure.

Please use the check boxes to tick off individual items when you are happy that they have been discussed to your satisfaction:

Common (greater than one in 10)

☐ Temporary insertion of a bladder catheter and wound drain

☐ Bulging of the wound due to damage to the nerves serving the abdominal wall muscles

☐ Temporary abdominal bloating

Occasional (between one in 10 and one in 50)

☐ Bleeding requiring further surgery or transfusions

☐ Entry into the lung cavity requiring insertion of a temporary drainage tube

☐ Need for further treatment if the adrenal contains cancer

☐ Infection, pain or bulging of the incision site requiring further treatment

☐ Problems with blood pressure requiring treatment

☐ Hormone replacement may be required of the opposite adrenal is not functioning adequately

Rare (less than one in 50)

☐ Anaesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack and death)

☐ Involvement or injury to nearby local structures (blood vessels, spleen liver, lung, pancreas and bowel) requiring more extensive surgery

☐ The histological abnormality in the adrenal may subsequently be shown not to be cancer

Hospital-acquired infection (overall risk for Addenbrooke’s)

☐ Colonisation with MRSA (0.02%, 1 in 5,000)

☐ Clostridium difficile bowel infection (0.04%; 1 in 2,500)

☐ MRSA bloodstream infection (0.01%; 1 in 10,000)

(These rates may be greater in high-risk patients e.g. with long-term drainage tubes, after removal of the bladder for cancer, after previous infections, after prolonged hospitalisation or after multiple admissions)

What should I expect when I get home?

When you leave hospital, you will be given a discharge summary of your admission. This holds important information about your inpatient stay and your operation. If, in the first few weeks after your discharge, you need to call your GP for any reason or to attend another hospital, please take this summary with you to allow the doctors to see details of your treatment. This is particularly important if you need to consult another doctor within a few days of your discharge.

It will be at least six weeks before healing of the wound occurs but it may take up to two months before you feel fully recovered from the surgery. You may return to work when you are comfortable enough and your GP is satisfied with your progress.

Many patients have persistent twinges of discomfort in the loin wound, which can go on for several months.

After surgery through the loin, the wall of the abdomen around the scar will bulge due to nerve damage. This is not a hernia, but can be helped by strengthening up the muscles of the abdominal wall by exercises.

What else should I look out for?

If you develop a temperature, increased redness, throbbing or drainage at the site of the operation, increasing abdominal pain or dizziness, please contact your GP or the Urology ward (Ward M5, 01223 254850). Any other post-operative problems should also be reported to your GP, especially if they involve chest symptoms.

Are there any other important points?

It will be at least 14 to 21 days before the pathology results on the tissue removed are available. It is normal practice for the results of all biopsies to be discussed in detail at a multidisciplinary meeting before any further treatment decisions are made. You and your GP will be informed of the results after this discussion.

Your remaining adrenal gland will serve the full function originally carried out by the pair of glands. It is sometimes necessary, however, to take medications to help the remaining gland recover (usually in patients with Cushing’s syndrome). If both glands have to be removed (this is very rare), medications will need to be taken to replace their function.

Driving after surgery

It is your responsibility to ensure that you are fit to drive following your surgery.

You do not normally need to notify the DVLA unless you have a medical condition that will last for longer than three months after your surgery and may affect your ability to drive. You should, however, check with your insurance company before returning to driving. Your doctors will be happy to provide you with advice on request.

Privacy & dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high tech equipment and/or specialist one to one care is required.

Hair removal before an operation

For most operations, you do not need to have the hair around the site of the operation removed. However, sometimes the healthcare team need to see or reach your skin and if this is necessary they will use an electric hair clipper with a single-use disposable head, on the day of the surgery. Please do not shave the hair yourself or use a razor to remove hair, as this can increase the risk of infection. Your healthcare team will be happy to discuss this with you.

References

NICE clinical guideline No 74: Surgical site infection (October 2008); Department of Health: High Impact Intervention No 4: Care bundle to preventing surgical site infection (August 2007)

Is there any research being carried out in this field at Addenbrooke’s Hospital?

Yes. As part of your operation, various specimens of tissue will be sent to the Pathology department so that we can find out details of the disease, and whether it has affected other areas. This information sheet has already described to you what tissue will be removed.

We would also like your agreement to carry out research on that tissue which will be left over when the pathologist has finished making a full diagnosis. Normally, this tissue is disposed of or simply stored. What we would like to do is to store samples of the tissue, both frozen and after it has been processed. Please note that we are not asking you to provide any tissue apart from that which would normally be removed during the operation.

We are carrying out a series of research projects which involve studying the genes and proteins produced by normal and diseased tissues. The reason for doing this is to try to discover differences between diseased and normal tissue to help develop new tests or treatments that might benefit future generations.

This research is being carried out here in Cambridge but we sometimes work with other universities or with industry to move our research forwards more quickly than it would if we did everything here.

The consent form you will sign from the hospital allows you to indicate whether you are prepared to provide this tissue. If you would like any further information, please ask the ward to contact your consultant.

Who can I contact for more help or information?

Oncology nurses

Uro-oncology nurse specialist
01223 586748

Bladder cancer nurse practitioner (haematuria, chemotherapy and BCG)
01223 274608

Prostate cancer nurse practitioner
01223 274608 or 01223 216897

Surgical care practitioner
01223 348590 or 01223 256157

Non-oncology nurses

Urology nurse practitioner (incontinence, urodynamics, catheter patients)
01223 274608

Urology nurse practitioner (stoma care)
01223 349800

Urology nurse practitioner (stone disease)
07860 781828

Patient advice and liaison service (PALS)

Telephone: 01223 216756
PatientLine: *801 (from patient bedside telephones only)
Email PALS

Mail: PALS, Box No 53
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

Chaplaincy and multi faith community

Telephone: 01223 217769
Email the chaplaincy

Mail: The Chaplaincy, Box No 105
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

MINICOM System ("type" system for the hard of hearing)

Telephone: 01223 217589

Access office (travel, parking and security information)

Telephone: 01223 596060

What should I do with this leaflet?

Thank you for taking the trouble to read this patient information leaflet. If you wish to sign it and retain a copy for your own records, please do so below.

If you would like a copy of this leaflet to be filed in your hospital records for future reference, please let your urologist or specialist nurse know. If you do, however, decide to proceed with the scheduled procedure, you will be asked to sign a separate consent form which will be filed in your hospital notes and you will, in addition, be provided with a copy of the form if you wish.

I have read this patient information leaflet and I accept the information it provides.

Signature……………………………….……………Date…………….………………….