Adrenal myelolipomas are benign, nonfunctioning and mostly asymptomatic tumors, with increasing detection rate through the development of imaging technology. Posterior retroperitoneoscopic adrenalectomy (PRA) to these tumors may be a reliable option.

We report a clinical case and step-by-step procedure through a surgical video of a patient submitted to PRA for an adrenal myelolipoma.

A 62-years-old male patient performed a thoracic computed tomography (CT) showing a 5cm nodular lesion in the dependence of the left adrenal gland (incidentaloma). The imaging study by abdominal CT and magnetic resonance confirmed a lesion composed predominantly by fat material, consistent with adrenal myelolipoma. The functional study was negative. Given the lesion dimensions, surgical treatment was proposed - PRA. The patient was placed in prone position, with lower limbs flexed to 90º. Three trocars were used. The retroperitoneum was opened and pneumoretroperitoneum created. Advanced bipolar energy was used to dissect the superior kidney pole, by a lateral-to-medial approach, and the adrenal gland was isolated from the kidney on its antero-medial surface. The left adrenal vein was then ligated and cutted. The adrenal gland was finally fully isolated and extracted. The surgery time was 115 minutes. There were no surgical complications and the patient was discharged on the second day. The histologic examination confirmed the myelolipoma diagnosis.

Surgery is indicated for patients with adrenal myelolipomas and associated symptoms, large size or uncertain diagnosis. A retroperitoneoscopic approach may be a reliable option in selected patients, with benefits of non-invasion of peritoneal cavity and a faster recovery.