Function‐Driven Versus Size‐Driven Decision‐Making: Real‐World Evaluation of the European Society of Endocrinology Criteria in Adrenal Surgery

ABSTRACT Background The increasing detection of adrenal incidentalomas has intensified the need for clearly defined surgical indications. The 2023 European Society of Endocrinology (ESE) guidelines introduced a paradigm shift from size‐based to function‐based criteria for adrenalectomy. Methods A retrospective cohort study was conducted including consecutive patients who underwent adrenal surgery between 2012 and 2023. Patients were reevaluated according to the ESE 2023 recommendations to determine whether historical surgical indications aligned with contemporary guideline‐defined criteria. Patients were classified as ESE‐positive (ESE YES) or ESE‐negative (ESE NO) based on hormonal activity and histopathological findings. Results The study included 797 consecutive patients who underwent adrenalectomy for adrenal masses. According to the ESE 2023 criteria, 541 (67.9%) patients were classified as ESE‐positive. Hormonal hypersecretion was present in 458 (57.8%) patients. Patients with clinically significant adrenal pathology were significantly more likely to have hormonally active tumors (81.7% vs. 4.3%, χ 2 = 474.1, df = 1, p < 0.001). Median tumor diameter did not differ significantly between groups (4.5 cm [IQR 4.0–6.0] in the ESE‐positive group and 4.5 cm [IQR 3.5–6.0] in the ESE‐negative group ( p = 0.118). Median age was similar between the ESE‐positive and ESE‐negative groups (55 years [IQR 44.5–63.0] vs. 56 years [IQR 41.0–62.0], p = 0.292). Conclusion Hormonal activity is strongly associated with clinically significant adrenal pathology according to the ESE 2023 criteria, whereas tumor size alone does not appear to reliably discriminate between patients who do and do not fulfill guideline‐defined indications for surgery. These findings provide real‐world evidence supporting function‐driven decision‐making and reinforce the contemporary paradigm shift away from size‐based surgical indications.