Adrenal lesions now turn up on four to ten percent of cross-sectional scans, and every urologist needs a reliable way to sort out the harmless ones from the dangerous ones. On this episode of BackTable Urology, co-hosts Dr. Gina Badalato and Dr. Chris Anderson speak with Dr. Ben Ristau to share a practical, case-based framework for evaluating adrenal lesions. They walk through imaging criteria, the essential hormonal workup, size thresholds for surgery, the rare but crucial role of biopsy, and the operative planning that separates a smooth adrenalectomy from a crisis.
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Society of Academic Urologistshttps://sauweb.org/
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Timestamps
00:00 - Introduction03:42 - Imaging Criteria for Adrenal Adenoma08:15 - Framework for Hormonal Workup12:48 - Mild Autonomous Cortisol Secretion16:20 - Adrenal Venous Sampling21:12 - Genetic Syndromes and Pheochromocytoma25:40 - Suspected Pheochromocytoma Case31:19 - Alpha Blockade Before Surgery35:36 - Intraoperative Hemodynamic Swings40:50 - Adrenocortical Carcinoma Case45:00 - Managing Adrenal Vein Avulsion48:00 - Closing Remarks
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More about this episode
The discussion opens with a 3.4 centimeter lipid-rich adenoma and the two questions that drive every evaluation, whether the lesion is malignant and whether it is functional. Dr. Ristau walks through the overnight 1 mg dexamethasone suppression test, the aldosterone to renin ratio, plasma free metanephrines and adrenal venous sampling, then explains why mild autonomous cortisol secretion is the most commonly missed diagnosis. Later cases cover preoperative alpha blockade for pheochromocytoma, the blood pressure swing that follows adrenal vein ligation, and open resection for suspected adrenocortical carcinoma. They close with pearls on surgical judgment, resident teaching, and the importance of systematic protocols in adrenal mass evaluation.
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Resources
CUA guideline: Diagnosis, management, and follow-up of the incidentally discovered adrenal mass (endorsed by the AUA, Rowe et al., CUAJ 2023)https://cuaj.ca/index.php/journal/article/view/8248 European Society of Endocrinology clinical practice guidelines on the management of adrenal incidentalomas, with ENSAT (Fassnacht et al., Eur J Endocrinol 2023)https://doi.org/10.1093/ejendo/lvad066 AACE / AAES Medical Guidelines for the Management of Adrenal Incidentalomashttps://pro.aace.com/disease-state-resources/pituitary-and-neuroendocrine/clinical-practice-guidelines/american Discrepancies in the Recommended Management of Adrenal Incidentalomas by Various Guidelines (Journal of Urology)https://www.auajournals.org/doi/10.1097/JU.0000000000001342 Society of Academic Urologistshttps://sauweb.org/
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