Efficacy and Safety of Non-surgical Versus Surgical Management of Primary Hyperaldosteronism: A Systematic Review and Meta-Analysis

Primary aldosteronism (PA) is an increasingly recognised cause of treatment-resistant secondary hypertension. However, rates of diagnosis and awareness remain low due to under-screening and the challenges of lateralising aldosterone secretion. Adrenal venous sampling (AVS), the gold standard for subtype differentiation, is technically demanding and not widely available, contributing to delayed or suboptimal management. Laparoscopic adrenalectomy (LA) is the current gold-standard treatment for unilateral aldosterone-producing adenomas, but many patients are unfit for or decline surgery. Minimally invasive techniques such as radiofrequency ablation (RFA) and adrenal artery embolisation have emerged as potential alternatives, offering shorter recovery and lower complication risk. This systematic review and meta-analysis evaluated the efficacy and safety of ablative and embolisation therapies compared with LA in the management of PA. PubMed, MEDLINE, Embase, SCOPUS, and Web of Science were systematically searched with no language or year restrictions. Eligible studies directly compared LA with ablation or embolisation in patients with unilateral PA. Data were extracted on clinical and biochemical success (using the Primary Aldosteronism Surgical Outcome (PASO) criteria), complications, operative time, hospital stay, blood loss, hypertensive crises, and antihypertensive medication use. Continuous variables were analysed as mean differences (MD) and categorical outcomes as odds ratios (OR) with 95% confidence intervals (CI) using a Mantel-Haenszel random-effects model. Medians and ranges were converted to means and standard deviations using the Luo/Wan method. Heterogeneity was assessed using I², with sensitivity analyses performed via leave-one-out testing. Eight studies (one prospective, seven retrospective), including 448 patients (193 non-surgical, 255 surgical), were analysed. Clinical success rates were comparable between LA and non-surgical management (90.1% vs. 85.9%; OR: 0.63; 95% CI: 0.40, 1.00; p = 0.05). Biochemical success was also similar (94.7% vs. 95.2%; RR: 0.99; 95% CI: 0.95, 1.04; p = 0.61). Minor complication rates did not differ significantly (OR: 0.73; 95% CI: 0.22, 2.45; p = 0.61), and no major complications were reported in non-surgical cohorts. The mean operative time was significantly shorter in the non-surgical group (MD: -75.28: 95% CI: -126.67, -23.90; p = 0.01). Length of stay, blood loss, and post-procedure serum potassium did not differ significantly between groups. Non-surgical management was associated with a slightly higher number of antihypertensive medications post-procedure (MD: 0.13; 95% CI: 0.01, 0.25; p = 0.04) and a higher, but non-significant, rate of intraoperative hypertensive crises (OR: 1.77; 95% CI: 0.30, 10.46; p = 0.38). Minimally invasive interventions such as ablation and embolisation demonstrate comparable clinical and biochemical efficacy to LA in treating PA, with fewer major complications and reduced operative time. However, they may carry a greater risk of intraoperative hypertensive crises and continued reliance on antihypertensive medication. As global populations age and surgical risk profiles increase, these approaches may offer valuable alternatives, particularly where surgical expertise or AVS capability is limited. Ongoing randomised controlled trials will be crucial in defining their long-term efficacy, safety, and cost-effectiveness.