Current state-of-the-art of adrenal surgery in Italy: the cancer risk in surgical adrenal lesions (CRISAL) survey

Adrenalectomies are growing worldwide because of the frequent diagnosis of incidentaloma and the use of minimally invasive surgery (MIS). The factors used to identify a malignant lesion and the best surgical technique are uncertain. In this context, the definition of high-volume center and expert surgeon is under debate. The Italian Society of Endoscopic Surgery and New Technologies (SICE) developed a nationwide survey to investigate the state-of-the-art of adrenal surgery in Italy. A web-based survey comprising 37 questions was developed and distributed to Italian surgeons involved in adrenal surgery. Two hundred forty-eight answers were analyzed. Consensus was reached among the survey participants regarding local infiltration (83%) and rapid growth of the lesion (81%) as markers of malignancy. Nearly 30% of the participants used MIS in case of malignant adrenal lesions. The lateral (50%) and anterior transperitoneal (44%) approaches were the most common among Italian surgeons. Approximately 40% of participants believe that 20–40 adrenalectomies/year are needed to define an expert surgeon and at least 20 procedures/year to define a high-volume center. Approximately half of participants performed < 10 adrenalectomies/year in centers with a median volume < 10 procedures/year. Based on participant feedback, this survey highlights local infiltration and rapid growth as the most significant markers of malignant adrenal lesions. While open adrenalectomy remains the gold standard for suspected malignant lesions, nearly 30% of the participants practice MIS even in these cases. The lateral and anterior transperitoneal approaches emerge as the most familiar for Italian surgeons. A substantial proportion of Italian patients with adrenal lesions undergo surgery performed by surgeons with an annual case volume < 10 procedures, at centers with a low annual volume of adrenalectomies. Moreover, there is a lack of standardized definitions for ‘expert surgeon’ and ‘high-volume center’ in this context.