Episode # 3 • 17 Jan 2025
Evaluating Adrenal Incidentalomas: A Urologist's Guide
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.
This podcast was developed in collaboration with Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU).
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
Resources
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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.
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