Smith's General Urology

Emil A. Tanagho
Jack W.McAninch

Adrenocortical Tumors
Adrenocortical tumors producing anclrogens are most frequently carcinomas;
however, a Few benign adenomas have been reported. Most of the carcinomas also
hypersecrete other hormones (ie, cortisol or l1-deoxycorticosterone), and thus the
clinical presentation is variable.
Female patients present with androgen excess, which may be severe enough to
cause virilization; many of these patients also have Cushing syndrome and
mineralocorticoid excess (hypertension and hypokalemia). In adult males excess
androgens may cause no clinical manifestations, and diagnosis in these patients
may be delayed until there is abdominal pain or an abdominal mass. These patients
may also present with Cushing syndrome and mineralocorticoid excess.
The tumor can be located by CT scan, which is also used to dene the extent of
tumor spread. Local invasion and distant spread to the liver and lungs are common
at the time of diagnosis. The primary therapy is surgical resection of the adrenal
tumor, as discussed above; however, surgical cure is rare. These patients are
subsequently treated with mitotane and other adrenal inhibitors, as discussed in the
section on Cushing syndrome.

Urology Second Edition

John Blandy
Christoper Fowler
Anatomy
Embryology
The cortex of the adrenal gland arises from the genitourinary ridge near the
developing gonads and kidneys: tiny rests of adrenal cortical tissue are common in
the renal cortex, retroperitoneum, and testis as well as the broad ligament near the
ovary (Fig. 40.1). The adrenal cortex shares many of the enzymes of gonads notably those for the synthesis of steroids - so that some inbom errors of
metabolism affect them both. In the seventh week of fetal life neuroblasts from the
neural crest invade the developing adrenal cortex to form the medulla. After a week
they differentiate into sympathicoblasts and pheochromocytes containing the
intracellular catecholamines, adrenalin and noradrenalin. ln fetal life, the adrenals
are larger than the kidneys and are still about one-third of their size at birth [1,2].
Topographical anatomy

The adrenal has two distinct parts: (a) the cortex, a busy endocrine gland
subordinate to the pituilary; and (b) the medulla, a specialized part of the
sympathetic nervous system [3].
Each adrenal gland is shaped like a cocked hat. Its cross-section resembles a triple
sandwich: the outermost layer is the yellow zona glomerulosa, next the zona
fasciculata, and third, the brown zona reticularis. Finally, there is a vascular lling
the medulla. (Fig. 40.2). The triple layer of cortex is only a few millimetres thick
hence the term suprarenal capsule.
Each of the three layers of the cortex has a different function. The foamy cells of the
outermost zona glomerulosa form aldosterone (Fig. 40.3). The zona fasciculata so
called because its cells are lined up in orderly bundles produces glucocorticoids,
mainly cortisol. The zona reticularis produces androgens.The medulla is made of
pheochromoqvtes surrounded by spongy vascular spaces, rich in
sympathetic ganglion cells. The pheochromocytes make the catecholamines
adrenalin and noradrenalin. Because these turn brown when oxidized, this is called
the chromafn reaction

Surgical relations
Above each adrenal (Fig. 40.4) lies the diaphragm; medially arc the aorta or the
vena cava; laterally is the abdominal wall; infcriorly is the kidney to which the
adrenal is so rmly attached that pulling down the kidney is a useful way of bringing
the adrenal into a surgical incision. In front are the duodenum and colon: behind the
diaphragm, 12th rib and the pleural retess.

Arterial supply
The adrenal is supplied by small branches of the phrenic, renal and lumbar arteries.
Blood leaves the hilum through a single vein which ows into the renal vein on the
left side, and the inferior vena cava on the right. These adrenal veins areeasily
torn: On the right such a tear may lead to daunting, haemorrhage from the vena
cava.
Nerve supply
A rich plexus of sympathetic nerves enters the adrenal medulla.

Physiology
Adrenal cortex
The cells of the zona glomerulosa make aldosterone - the 18-aldehyde of
corticosterone which is released under the action of angiotensin ll, and by retaining
water and salt in the distal tubules
helps to sustain a rise in blood pressure by increasing blood volume.
The zonae fasciculata and reticularis are controlled by adrenocorticotrophic
hormone (ACTH) from the anterior pituitary, which in turn responds to ACT Hreleasing hormone of the hypothalamus (Fig. 40.5).
The zona fasciculata forms the glucocorticoids cortisol and corticosterone, and the
mineralocorticoid cleoxycorticosterone. The glucocorticoids -all 17hydroxycorticosteroids - can be measured
in the urine. Cortisol can be measured in the plasma where it rises and falls
according to the time of day, usually being lowest in the morning and highest in the
evening.

Glucocorticoids are so named because they increase the production of glucose.

Many synthetic glucccorticoicls are available, e.g prednison, prednisolone,
betamethasone and dexamethasone,
which all vary in the relative strength of their effects on inammation and sodium
retention.
The zona reticularis fomis a little testosterone, and more of the androgen precursors
dihydroepiandrosterone and androstenedione, which are converted into
testosterone in tissue. The metabolic end product of all these androgens appears in
the urine as the 17-ketosteroids. The androgens stimulate growth and the
appearance of male secondary sexual hair.

Adrenal medulla
The medulla secretes the catecholamines dopamine, noradrenalin and adrenalin
which are in turn metabolized to nonnetanephrin and metanephrin. Their common
metabolic end-result in the urine is vanillyl mandelic add (VMA) (Fig.
40.6).
Noradrenalin raises the blood pressure by increasing peripheral resistance without
changing the cardiac output. Adrenalin increases cardiac output by raising pulse
rate and systolic pressure, without increasing peripheral vascular resistance.

Congenital disorders of the adrenals

Hemorrhagc into the adrenals on one or both sides may follow a difficult labour or
childbirth asphyxia.