Abstract
Background/Aim: Adrenal insufficiency is a recognized complication following adrenalectomy and, less commonly, nephrectomy due to the anatomical and functional relationship between the adrenal glands and kidneys. While unilateral adrenalectomy is typically well tolerated due to compensation by the contralateral adrenal gland, adrenal insufficiency may still occur, particularly in cases involving bilateral disease. Recognizing and managing this risk is critical in postoperative care to prevent life-threatening adrenal crises.
Case Report: We present a case of left renal cell carcinoma (RCC) with tumor thrombus (TT) level IV (extending into the right atrium). The surgery was completed exclusively through an abdominal approach without cardiopulmonary bypass (CPB). The surgical approach involved a left radical nephrectomy, left adrenalectomy, and removal of a large TT, which included a segment of the inferior vena cava (IVC) and the right adrenal vein. As a result, the right adrenal vein was sacrificed, and adrenal insufficiency was expected due to ligation of the right adrenal vein and removal of the left adrenal gland. However, one year after the procedure, adrenal insufficiency was not seen, perhaps due to venous collaterals draining the right adrenal gland.
Conclusion: This case highlights that in the case of complete obstruction of the IVC by the TT of an RCC, the remaining adrenal vein can be sacrificed without causing adrenal insufficiency, perhaps due to the presence of multiple venous collaterals that developed from chronic obstruction of the IVC.
Introduction
Adrenal insufficiency refers to the inadequate production of hormones from the adrenal glands (1). Driven by a decrease in serum cortisol and aldosterone, signs and symptoms of adrenal insufficiency include fatigue, fever, nausea, hypotension, and tachycardia (2). Primary adrenal insufficiency, also known as Addison’s disease when autoimmune in origin, results from intrinsic dysfunction of the adrenal glands (1).
Post-operative adrenal insufficiency can be challenging to diagnose and predict due to variabilities in surgical procedures and clinical presentation. The adrenal glands are situated superior to the kidneys, enveloped within the same perirenal fat capsule, creating a close anatomical relationship between the two structures (3). Due to this proximity, the adrenal gland is often removed during unilateral nephrectomy for renal cell carcinoma, particularly when there is concern for local invasion or metastasis (4). Despite this, adrenal insufficiency is uncommon following unilateral adrenalectomy, as the contralateral adrenal gland typically maintains adequate hormonal function. In contrast, adrenal insufficiency is expected if both adrenal glands are compromised or removed.
Despite the compensatory potential of the remaining adrenal gland, adrenal insufficiency can develop due to adrenal stress following unilateral nephrectomy in the post-operative period (4, 5). Notably, the existing literature has not addressed whether ligation of the contralateral adrenal vein, in combination with unilateral nephrectomy, contributes to adrenal insufficiency. This case report describes a patient with a large tumor thrombus (TT) extending from the left kidney into the inferior vena cava (IVC), reaching the right atrium. During a complex surgery involving the removal of the left kidney, left adrenal gland, and TT, a segment of the inferior vena cava containing the right adrenal vein was resected. Consequently, the right adrenal vein was ligated. Although adrenal insufficiency might have been anticipated, it did not occur, suggesting that ligation of the contralateral adrenal vein may be well tolerated in such procedures.
Case Report
A 49-year-old female with a past medical history of hypertension and type 1 diabetes was referred to cardiology after presenting with tachycardia. All workup was negative. She later presented to the hospital with symptoms of fatigue, bilateral pedal edema, leg pain, and palpitations. Laboratory values showed a creatinine of 2 mg/dl, and further workup with an ultrasound revealed a left renal mass. She denied any previous episodes of fever, hematuria, dysuria, or any other lower urinary tract symptoms. Abdominal magnetic resonace imaging (MRI) (Figure 1) confirmed the presence of a 6.5×5.5×4.7 cm left renal tumor with TT extending through the IVC into the right atrium (level IV). She was admitted to the hospital for further treatment. An abdominal and chest CT scan showed no distant metastases. The surgical team recommended a complete tumor excision via left radical nephrectomy with resection and reconstruction of the inferior vena cava. The patient was informed that the procedure may require cardiopulmonary bypass (CPB). The potential risks of CPB, including infection, pulmonary embolism, bleeding, blood transfusions, acute kidney injury of the surviving kidney, and low likelihood of complete tumor excision, were discussed. She understood and provided written informed consent for the procedure. This case presentation is in accordance with the University of Miami Institutional Review Board and the Helsinki Declaration (as revised in 2013).
Abdominal magnetic resonance imaging revealed a large tumor thrombus occupying the whole inferior vena cava, all the way to the right atrium.
Procedure in detail. The surgical team began the procedure with bilateral subcostal incisions. A modified Chevron incision was placed approximately two fingerbreadths below the left costal margin and extended out laterally to the mid-axillary line and medially towards the right costal margin. Once inside the abdomen, Thompson retractors were placed to elevate the costal margins and create an abdominal flap, reflecting the parietal peritoneum from the abdominal wall. The left kidney with the tumor was dissected on its lateral and posterior sides, and then mobilized medially. The renal artery was recognized, ligated, and divided using the posterior approach (6, 7).
After renal artery ligation, the collateral circulation collapsed, allowing the remaining dissection to be easier to perform. The left kidney and adrenal gland were completely isolated, and the kidney was only attached to the IVC by the renal vein. Subsequently, the liver was mobilized using the Piggyback liver transplant technique (8) with ligation of the ligamentum teres, falciform ligament, and left triangular ligament. The liver was mobilized off the IVC, and small hepatic veins were ligated and divided to expose the infrahepatic, intrahepatic, and suprahepatic portions of the IVC (9). To have access to the intrapericardial IVC and right atrium, the central diaphragm tendon was dissected to the supra-diaphragmatic area. The right and left inferior phrenic veins were stapled during dissection. The posterior surface of the IVC was dissected, and lumbar veins were stapled to facilitate circumferential control of the IVC. The hepatic hilum was isolated to allow a Pringle maneuver when needed, and no replaced hepatic artery was identified. Dissection of the right renal and adrenal vein was also completed.
Under intra-operative transesophageal echocardiogram (TEE) monitoring, vascular clamps were placed in the infra-renal IVC, right adrenal vein, and right renal vein. TEE was used to monitor any intraoperative emboli (10). Then, the right renal and adrenal vein were clamped and a Pringle maneuver was performed to temporarily occlude blood inflow into the liver.
After clamping, the IVC was opened on the right side, and the left renal vein was removed along with the rest of the left kidney and left adrenal gland. The TT was mobilized and pulled down to the infrahepatic IVC. Then, the TT was extracted through the distal opening of the IVC. This allowed for the repositioning of the vascular clamp below the major hepatic veins. During this maneuver, blood outflow did not obscure the operative field due to complete IVC isolation and strategic placement of the vascular clamp at the IVC below the major hepatic veins. At this time, the Pringle maneuver was discontinued, and blood flow to the liver was re-established. The Pringle maneuver lasted six minutes. The TT was removed en bloc with the left kidney tumor (Figure 2), along with a segment of the IVC that included the right adrenal vein (Figure 3). As a result, the right adrenal vein had to be ligated and sacrificed. Afterwards, the IVC incision was closed using a continuous running suture with 4-0 polypropylene. A temporary IVC filter was placed below the right renal vein to prevent post-operative bland thrombus embolism.
Surgically resected specimens. The specimen on the left comprises a tumor thrombus (TT) and an associated blood thrombus (BT). The specimen on the right demonstrates the left kidney tumor (LKT), which was removed during the radical nephrectomy. The markings on the image of the right atrium (RA) and right renal vein (RRV) allow for visualization of where the tumor would have been before resection.
Detailed drawing of the surgical approach. The liver was mobilized using the Piggy-back liver transplant technique. The central tendon of the diaphragm was dissected to expose the supradiaphragmatic portion of the inferior vena cava (IVC). The hepatic hilum was isolated to enable a Pringle maneuver, allowing temporary occlusion of hepatic inflow if necessary. Vascular clamps were applied at the following locations: infra-renal IVC, right adrenal vein, right renal vein, IVC, and kidney resection margin. The IVC was opened on the right side. The left renal vein, left kidney, and left adrenal gland were removed en bloc. The tumor thrombus (TT) was mobilized and pulled down from the right atrium into the infrahepatic IVC. Then, the TT was extracted through the distal IVC opening and removed en bloc with the left renal tumor, including the involved segment of the IVC and the right adrenal vein. The IVC was closed primarily using 4-0 polypropylene suture.
At the end of the surgery, a final TEE was performed to ensure no pulmonary artery emboli or TT were present. Estimated blood loss was 3,000 cc, and the patient received 7 U of packed red blood cells (PRBCs). Pathology examination revealed 6.5 cm clear cell RCC Fuhrman grade 3, and lymph nodes were negative for carcinoma (pT3cN0Mn/a). The left adrenal gland was free of tumor. The patient did not develop adrenal insufficiency, and one month post-operative ACTH and cortisol levels (9 am) were 12.0 pg/ml and 9.8 μg/dl, respectively. The patient was discharged home on post-operative day seven. At her 12-month follow-up, the patient noted an uneventful recovery, showing a creatinine level of 0.76 mg/dl, and exhibited no signs and symptoms of adrenal insufficiency so no further workup was determined. Ongoing follow-up will be provided by both the surgery and oncology teams.
Discussion
Surgical excision remains the primary option for patients with non-metastatic RCC with TT, offering a five-year disease-free survival rate of approximately 60% (11, 12). While studies (4, 13, 14) have noted the possibility of adrenal insufficiency following left radical nephrectomy for the resection of non-metastatic RCC, we present a case where the patient did not develop adrenal insufficiency postoperatively, even after ligation of the right adrenal vein. In this case, the patient underwent surgical resection of a left RCC with Level IV TT in May of 2024. Despite the complex and challenging nature of the surgery, it was done exclusively using the abdominal approach without requiring CBP. In surgeries requiring adrenal sparing, preservation of the vein in a partially resected adrenal gland has better outcomes than ligation of the vein (15). However, during the surgical resection of the left renal tumor and TT extension, a segment of the inferior vena cava required resection. Consequently, the right adrenal vein was sacrificed. Given the disruption of right adrenal venous drainage, postoperative adrenal insufficiency was expected. Remarkably, the patient did not develop clinical or biochemical signs suggestive of adrenal insufficiency throughout the postoperative period and at 12-month follow-up, and continues to be asymptomatic to date.
Conventionally, unilateral adrenalectomy is not expected to increase the risk of adrenal insufficiency due to the compensatory capacity of the contralateral adrenal gland (4). Bischoff et al. (16) conducted a prospective study of ten patients undergoing unilateral nephrectomy with adrenalectomy due to renal cell carcinoma (RCC) and found no evidence of adrenal insufficiency up to three days post-operatively. However, Yoshiji et al. (4) and Safir et al. (5) each highlight two cases of patients who developed adrenal insufficiency postoperatively following unilateral adrenalectomy for the resection of RCC. Yoshiji et al. describe a case of a 68-year-old man with RCC who underwent a unilateral nephron-adrenalectomy (4). The patient developed post-operative sepsis, which was successfully treated. However, one month after discharge, he returned with symptoms of adrenal insufficiency (4). In another case report, Van Laar et al. detailed the case of a patient who was diagnosed with adrenal insufficiency seven years after undergoing nephrectomy for RCC resection (13). As a result, monitoring and detecting subclinical adrenal insufficiency is important after nephroadrenalectomy, even years after surgery. In the present case, although the patient did not showed clinical or biochemical evidence of adrenal insufficiency following left adrenalectomy with concomitant right adrenal vein ligation, there is a potential risk for delayed onset, warranting long-term continued follow-up.
In the case of our 49-year-old female with RCC and TT, anatomic variations in venous drainage of the right adrenal gland are of particular importance. The right adrenal vein typically exits anteriorly near the apex of the adrenal gland and drains directly into the IVC posterolaterally, slightly above the right renal vein (17). In most cases, a single right adrenal vein drains into the IVC (17, 18). However, there are variations to the drainage of single adrenal veins noted in literature, including some that drain to the IVC via the hepatic vein, and some that directly drain to the IVC (17, 18). In rare cases, dual or triple drainage from the adrenal glands to the IVC has been observed (19).
According to Avisse et al., numerous accessory adrenal veins drain into the inferior phrenic vein and the renal vein, forming potential connections with the azygos system and the portal system through the gastric and esophageal plexuses (3, 17). In the setting of chronic IVC obstruction, such as a TT, these systemic-portal shunts can further develop to provide alternative drainage for the adrenal glands (3). In addition, these venous collaterals may have developed from chronic obstruction of the IVC. Thus, in this case, venous collaterals could have compensated for the ligation of the right adrenal vein.
Conclusion
In the present case, complete tumor resection required ligation of the right adrenal vein in addition to left nephrectomy and adrenalectomy. Adrenal insufficiency was anticipated; However, adrenal function remained intact post-operatively, with no indications of insufficiency from clinical and laboratory findings. Additionally, the patient has remained asymptomatic throughout the 12-month follow-up and continues to do well to date.
This unexpected finding highlights the limited literature addressing the consequences of sacrificing the adrenal vein of the remaining adrenal gland. Among the available reports, several case studies have described adrenal insufficiency following unilateral nephrectomy for RCC, particularly when linked to adrenal vascular compromise. However, each case is associated with other potential causative factors such as post-operative septicemia (4) and adrenal hemorrhage (14).
Furthermore, literature evidence on anatomic variations of adrenal venous drainage in the context of chronic IVC obstruction with TT is limited. This case underscores the importance of further research into the development of venous collaterals with TT and anatomic variations in adrenal venous drainage to systemic circulation.
Footnotes
Authors’ Contributions
D.D. drafted the manuscript. G.C. and A.A. performed the procedure described in this case report. G.C., A.A., and J.G. contributed to manuscript preparation. J.G. prepared Figure 3. All Authors reviewed and approved the final version of the manuscript.
Conflicts of Interest
The Authors declare that they have no conflicts of interest.
Artificial Intelligence (AI) Disclosure
During the preparation of this manuscript, a large language model (ChatGPT, OpenAI) was solely employed for stylistic improvements and minor language editing of select passages. No sections involving the generation, analysis, or interpretation of research data were produced by generative AI. All scientific content was created and verified by the authors. Furthermore, no figures or visual data were generated or modified using generative AI or machine learning–based image enhancement tools.
- Received September 24, 2025.
- Revision received October 23, 2025.
- Accepted November 6, 2025.
- Copyright © 2026 The Author(s). Published by the International Institute of Anticancer Research.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
References
In this issue
Jump to section
Related Articles
Cited By...
- No citing articles found.