Is ipsilateral adrenalectomy a necessary component of radical nephrectomy?

Due to the increased use of modern imaging systems during the last few years, kidney tumors are often diagnosed at an earlier and less advanced stage. This fact implies a reevaluation of the operative technique of radical nephrectomy that was recommended 30 years ago. The ipsilateral adrenal involvement during radical nephrectomy for renal cell carcinoma is assessed and the necessity of its extirpation is discussed. Between September 1987 and September 1993, we performed 299 radical nephrectomies for renal cell carcinoma and removed 285 ipsilateral adrenal glands. Eleven adrenal glands (3.8%) were involved with the kidney tumor and 274 (96.2%) were free of disease. In 7 of the adrenal gland involved cases (63.6%) the tumor invaded the gland by direct extension from the superior pole of the kidney. In the other 4 cases the ipsilateral adrenal gland was affected by a metastatic lesion. In all 11 adrenal gland involved cases the tumors were at an advanced stage (the lowest was stage pT3N1). Our results led us to recommend adrenalectomy during radical nephrectomy only when direct extension of the kidney tumor into the gland is suspected (upper pole or large tumors) or when the adrenal is the site of a single metastasis. Macroscopically normal adrenal glands at radical nephrectomy should not be routinely extirpated. Metastatic renal cell carcinoma (not by contiguity) in the ipsilateral adrenal gland should be regarded as a stage M+ (distant metastasis) tumor.