Preoperative Evaluation of Adrenal Nodules Before Non-Adrenal Surgery

Initial Assessment and Hormonal Evaluation

A one-time hormonal evaluation is required for adrenal nodules, regardless of their benign appearance, as approximately 5% of radiologically benign incidentalomas have subclinical hormone production that requires treatment before any surgery, according to the American Urological Association 1, 3
The hormonal evaluation includes a 1 mg overnight dexamethasone suppression test to screen for autonomous cortisol secretion, plasma or 24-hour urinary metanephrines to exclude pheochromocytoma, and aldosterone-to-renin ratio only if the patient has hypertension and/or hypokalemia, as recommended by the American Urological Association 1, 2

A non-contrast CT should be obtained to measure Hounsfield units, and a 12 mm nodule with HU ≤10 on unenhanced CT is definitively benign and requires no further imaging, according to the American Urological Association 1
If the nodule is non-functional and benign-appearing (HU <10), cataract surgery can proceed without delay, and no further follow-up imaging or functional testing is required, as recommended by the American Urological Association 2, 3

Skipping the initial hormonal evaluation can lead to undiagnosed pheochromocytoma, which can cause life-threatening hypertensive crisis during any surgical procedure, including cataract surgery, according to the American Urological Association 1, 4
Adrenal biopsy is not indicated for adrenal incidentalomas and carries unnecessary risks, as stated by the American Urological Association 1, 2
Delaying cataract surgery for additional adrenal imaging is not necessary if the nodule is <40 mm, non-functional, and has benign imaging characteristics (HU <10), as recommended by the American Urological Association 2, 3