Adrenalectomy in selected cohorts of unilateral PA can result in complete biochemical success in 83–100%. How do these high rates of biochemical cure fit with the frequency of non-classical histopathologies in PA of the recent HISTALDO consensus? This poses questions on the nature of PA. Overall, the white elephant in the room is if true unilateral PA really exists, and whether unilateral adrenalectomy really has the potential to cure the patient from PA. In a worst-case scenario, it could be rather a debulking procedure, like surgical treatment of other forms of adrenal hyperplasia, for example primary bilateral macronodular hyperplasia (PBMAH). The much lower rate of major cardiovascular events and mortality in surgically treated patients, especially in those with long-term remission of hypertension, are highly suggestive of complete resection of the aldosterone-producing adrenal source. The data also demonstrate that case selection for unilateral adrenalectomy is paramount: patients with postoperative persistence or recurrence of hyperaldosteronism do not benefit similarly from surgery. Currently, we are lacking easy, cost-effective, and valid tools to identify those truly unilateral PA cases. Mineralocorticoid receptor antagonist enthusiasts advocating medical treatment in principle must face the reality that adrenalectomy is the better option for many patients.
