Beyond Tumor Size: Hormonal Risk Stratification, Preoperative Imaging, and Precision Surgical Decision-Making in Adrenal Incidentalomas

Adrenal incidentalomas represent an increasingly prevalent diagnostic challenge associated with the widespread use of cross-sectional imaging and the growing complexity of endocrine and surgical decision-making. Although most incidentally detected adrenal masses are benign, a clinically relevant proportion exhibit autonomous hormonal secretion or radiological characteristics requiring further investigation. This narrative review aimed to analyze and integrate current international evidence regarding hormonal assessment, preoperative imaging characterization, and the selection of minimally invasive adrenalectomy, incorporating relevant contributions from Latin American investigations. A structured thematic synthesis of 20 scientific publications, including international clinical guidelines, randomized controlled trials, observational studies, systematic reviews, and meta-analyses, was developed to examine diagnostic criteria, therapeutic indications, and perioperative outcomes. The reviewed evidence identified the importance of systematic cortisol assessment, selective screening for primary aldosteronism, and biochemical exclusion of pheochromocytoma in appropriate clinical settings. Radiological characterization using unenhanced computed tomography attenuation, lesion homogeneity, tumor dimensions, and complementary magnetic resonance imaging emerged as a central component of malignancy risk stratification. Randomized evidence indicated that adrenalectomy may improve selected cardiometabolic outcomes in patients with mild autonomous cortisol secretion, although treatment benefits were not uniform across studies. Comparative surgical investigations demonstrated favorable perioperative outcomes with laparoscopic and robotic-assisted adrenalectomy, with certain meta-analyses reporting lower blood loss, shorter hospitalization, and fewer complications with robotic techniques. Nevertheless, operative selection remains dependent on anatomical complexity, oncological safety, institutional expertise, and healthcare resources. Latin American investigations contributed evidence regarding metabolic characteristics and surgical management, highlighting the importance of adapting international recommendations to different clinical environments. Overall, optimal management of adrenal incidentalomas requires integrating endocrine functionality, radiological findings, and patient-specific risk factors to support individualized surveillance or surgical intervention. Further prospective multicenter research is necessary to establish long-term outcomes, refine surgical selection criteria, and strengthen evidence applicable to Latin American healthcare systems.