Ep. 333 Evaluating Adrenal Incidentalomas: A Urologist's Guide with Dr. Chris Anderson and Dr. Ben Ristau

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. --- Get the BackTable app https://www.backtable.com/app --- This podcast was developed in collaboration with Society of Academic Urologists https://sauweb.org/ --- Timestamps 00:00 - Introduction 03:42 - Imaging Criteria for Adrenal Adenoma 08:15 - Framework for Hormonal Workup 12:48 - Mild Autonomous Cortisol Secretion 16:20 - Adrenal Venous Sampling 21:12 - Genetic Syndromes and Pheochromocytoma 25:40 - Suspected Pheochromocytoma Case 31:19 - Alpha Blockade Before Surgery 35:36 - Intraoperative Hemodynamic Swings 40:50 - Adrenocortical Carcinoma Case 45:00 - Managing Adrenal Vein Avulsion 48:00 - Closing Remarks --- 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. --- 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 Incidentalomas https://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 Urologists https://sauweb.org/ --- BackTable Urology is the go-to podcast for urologists, urologic oncologists, and urogynecologists. Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty. ► https://www.backtable.com/app