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CUA GUIDELINE

priOr TO puBLiCATiON, ThiS guidELiNE uNdErwENT rEviEw By ThE CuA guidELiNES COmmiTTEE, TOpiC ExpErTS, ANd ThE CuA ExECuTivE BOArd
Canadian Urological Association guideline:

Diagnosis, management, and followup of

the incidentally discovered adrenal mass

April 2021, McInnes et al suggested an important revi-
Neal E. Rowe , Ravi M. Kumar , Nicola Schieda , Ferhan Siddiqi , sion to the current CUA guideline.
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Thomas McGregor , Kristen McAlpine , Philippe D. Violette ,
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Varun Bathini , Michael Eng , Jason Izard The purpose of this guideline is to provide an
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updated approach to the diagnosis, management, and
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1 Division of Urology, University of Ottawa, Ottawa, ON, Canada; Division of Urology, University followup of adrenal incidentalomas, with a special focus
of Toronto, Toronto, ON, Canada; Department of Radiology, University of Ottawa, Ottawa, ON, on the areas of discrepancy/controversy existing among
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Canada; Department of Endocrinology, Dalhousie University, Halifax, NS, Canada; Department
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of Urology, Queen’s University, Kingston, ON, Canada; Urology, Credit Valley, Mississauga, ON, the published guidelines from other associations.
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Canada; Divison of Urology, McMaster University, Hamilton, ON, Canada; Division of Urology,
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University of Saskatchewan, Saskatoon, SK, Canada; Department of Urologic Sciences, University of
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British Columbia, Vancouver, BC, Canada METHODS
This guideline was developed by a working group com-
* Joint first author
prised of urologists, endocrinologists, and radiologists
REVIEWERS: across Canada. The working group met virtually on mul-
Kunal Jana, Division of Urology, University of Saskatchewan, Saskatoon, SK, Canada tiple occasions to discuss the priorities for the guideline
Alexander Kutikov, Division of Urology and Urologic Oncology, Fox Chase Cancer Center,
Philadelphia, PA, United States and to review the manuscript and recommendations.
Wesley Mayer, Department of Urology Baylor College of Medicine, Houston, TX, United States
The recommendations and the evidence used to inform
Cite as: Rowe NE, Kumar RM, Schieda N, et al. Canadian Urological Association guideline: each recommendation were reviewed and agreed upon
Diagnosis, management, and followup of the incidentally discovered adrenal mass. Can Urol Assoc J by the working group. When required, consensus was
2023;17(2):12-24. http://dx.doi.org/10.5489/cuaj.8248
reached by discussion among group members. The tar-
get audience of this guideline is healthcare providers
who manage patients with adrenal incidentalomas (e.g.,
INTRODUCTION family physicians, endocrinologists, internists, urologists,
Adrenal incidentalomas are adrenal masses greater endocrine surgeons, etc.), as well as patients with adre-
than 1 cm in size that are detected on cross-sectional nal incidentalomas.
imaging performed for an unrelated indication. These The Grading of Recommendations Assessment,
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lesions are common, estimated to be present in 4% of Development and Evaluation (GRADE) framework
patients on imaging series, and up to 10% of the elderly was used as a methodological basis for this guideline.
population. Most of these lesions are benign non- Our evidence synthesis was completed using PubMed,
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functioning adrenocortical adenomas, with a minority Medline, and Cochrane Library databases.
being hormonally active or malignant. The first step was defining clinical questions. A list of
The evaluation and management of adrenal inciden- 12 clinical questions were compiled and are displayed
talomas is a multidisciplinary process, relying on the in Table 1. Next, a systematic literature search was
expertise of family physicians, urologists, endocrinolo- conducted to address each question. For questions
gists, and radiologists. In 2011, the Canadian Urological where there was a recent high-quality guideline analy-
Association (CUA) released a guideline on the manage- sis and recommendation, focus was given towards any
ment of the incidentally discovered adrenal mass. Since subsequent peer-reviewed publications and adapting
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then, there have been several clinical practice guidelines the recommendation to a Canadian context. Special
published by various endocrine, radiological, and surgi- attention was paid to areas of controversy/discrepancy
cal societies. A review by Maas et al compared these between the currently published guidelines. For each
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guidelines and found many points of discrepancy and recommendation, the strength of recommendation was
controversy. Furthermore, in a letter to the editor from reported as weak or strong, and the quality of evidence
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12 CUAJ • FEBRUARY 2023 • VOLUME 17, ISSUE 2 © 2023 CANADIAN UROLOGICAL ASSOCIATION