Case Reports in Medicine Figure 4: Abdominal MRI following two sessions of open surgery and radiofrequency ablation for a left-sided recurrent solid mass. There is no sign of recurrent or residual solid tumor in the kidneys. Remnant adrenal tissue on the left side was free of any recurrent lesion and was measuring 24.62 × 9.48 mm in diameter. Multiple cysts are visible in the right kidney. malignancy are regarded as surgical indications [2]. The probability of discovering a pheochromocytoma during evaluation and treatment process for adrenal incidentalomas is around 5% [3]. Pheochromocytoma can develop in association with familial neoplastic syndromes, which typically have auto- somal-dominant patterns of inheritance (multiple endocrine neoplasia, VHL disease). VHL disease is an autosomal dominant syndrome manifested by cerebellar and retinal hemangioblastomas; cysts of the pancreas, kidney, and epididymis; epididymal cystadenoma; pheochromocytoma; clear cell RCC. Incidence ranges from 1 in 30,000 to 1 in 50,000 individuals. It has over 95% penetrance by the age of 65 years in aﬀected individuals [4]. The mean age at presentation is 35 to 40 years [5]. Pheochromocytoma occurs in 10% to 17% of aﬀected persons and appears to be conﬁned to speciﬁc families [6, 7]. Pheochromocytomas are particularly troublesome entities in the context of VHL disease because of the rapid and unanticipated release of catecholamines. In VHL disease, the incidence of bilateral pheochromo- cytomas ranges from 40% to 80%; however, there is con- siderable variability regarding the presence of synchronous disease [8, 9]. The treatment of synchronous heredi- tary pheochromocytoma is highly controversial. Treatment strategies range from routine bilateral adrenalectomy to surveillance of nonfunctioning tumors [10, 11]. Authorities that advocate bilateral adrenalectomy argue that there is a small but real risk of malignancy [12]. Moreover, bilateral adrenalectomy will prevent the occurrence of catastrophic complications from undetected functioning pheochromocy- tomas. Conversely, Walther et al. advocate a more conserva- tive approach to the management of pheochromocytoma in families with VHL disease [10]. In their series of 64 patients with VHL disease and pheochromocytoma, 12 patients with newly diagnosed pheochromocytomas, but no signs or symptoms, were followed for a median period of 34.5 months with no related morbidity. The authors concluded that nonfunctioning or subclinical disease can be safely 3 followed, especially if quality of life issues mitigate against surgery [10]. In an attempt to preserve adrenal cortical functions and avoid life-long steroid replacement therapy, some cen- ters prefer subtotal adrenalectomy, which requires a small segment of well-vascularized cortical tissue to be left in situ after tumor excision [13–16]. Proponents justify ortho- topic adrenal cortex preservation by predictable occurrence of bilateral disease and low incidence of malignancy in hereditary pheochromocytomas. Furthermore, patients with VHL disease often require multiple operations for associated pathologic conditions, which may be more diﬃcult to treat after bilateral adrenalectomy. Moreover, the risk of experiencing at least 1 acute Addisonian crisis approaches 20% after bilateral adrenalectomy [12]. When considering subtotal cortical-sparing adrenalectomy, the avoidance of permanent steroid dependency and potential Addisonian crises must be weighed against the risk of recurrence, which was reported to be in the range of 21–60% [14]. Once subtotal adrenalectomy has been performed, life-long clinical and biochemical surveillance is warranted to detect recurrent disease as early as possible. The ﬁrst report of the preservation of adrenocortical function during surgery for bilateral pheochromocytoma was in 1982 [17]. Since then various reports, documenting the feasibility of such conservation, have been published [18– 20]. Beside open surgery, partial adrenalectomy can also be performed by laparoscopic and robot-assisted laparoscopic approaches. Janetschek et al. were the ﬁrst to document the feasibility of laparoscopic partial adrenal resection for pheochromocytoma [21]. Sasagawa et al. replicated the safety and eﬃcacy of this procedure via the retroperitoneoscopic route [22]. In a recent article, Wang et al. presented their data composed of retroperitoneoscopic partial adrenalectomies performed for small (≤1 cm) adrenal tumours. In their series, there were no long-term complications or recurrence of adrenal tumours during a followup of 2–41 months [23]. Recently, Boris et al. reported the results of 10 patients undergoing robot-assisted laparoscopic partial adrenalec- tomy for removal of 19 adrenal tumors. Of the 19 tumors removed, 17 were pheochromocytoma and 2 were adrenal- cortical hyperplasia. They denied any local recurrence after a median followup of 16.2 months [24]. In a comprehensive literature review, Kaye et al. analyzed the results of 22 partial adrenalectomy series counting for a total of 417 patients. According to their results, 76% of the cases were performed laparoscopically with less than 1% requiring conversion to an open procedure. Moreover, only 3% of the cases developed a recurrent lesion after a mean follow-up duration of 56 months. Considering the results of the studies that reported data on postoperative steroid replacement, only 5.3% (n = 7/133) required corticosteroid supplementation on the long term [25]. It has been reported that 20% of well-perfused adrenal cortical tissue from a single gland is suﬃcient to maintain an adequate stress response for the individual [15]. Partial adrenalectomy with orthotopic adrenal cortex preservation may speciﬁcally be recommended for patients with single adrenal gland, bilateral adrenal tumors, or hereditary adrenal