Adrenocortical carcinoma is a rare and aggressive malignancy. Patients usually present early with manifestation of abnormal hormone secretion. However, adrenocortical carcinoma can also be nonfunctioning, and such patients present late with a mass effect or distant metastases. We herein report a case of a 30-year-old Sri-Lankan woman who presented with a 3-month history of left flank pain associated with nausea, vomiting, and weight loss. Imaging revealed a large left upper quadrant mass with a 1.8-cm left lung nodule. The differential diagnoses included a left adrenal mass, left upper pole renal mass, and retroperitoneal sarcoma. A functional adrenal work-up revealed no abnormal findings. Surgical excision of the mass was uneventful with no postoperative complications. Pathological analysis revealed a nonfunctioning adrenocortical carcinoma measuring 16 × 14 × 10 cm. To our knowledge, a mass of this size is among the largest nonfunctioning adrenocortical carcinomas reported in the published literature. The investigations and approach to treatment were consistent with those in the published literature. Large nonfunctioning adrenocortical carcinomas pose a diagnostic and therapeutic challenge, and most are diagnosed at a late stage. Appropriate imaging and functional work-up of the mass are vital before treatment. Surgical excision is safe, even for large adrenocortical carcinomas; excision in patients with advanced disease has been shown to have the best outcomes.

To compare the outcomes of using prophylactic direct oral anti-coagulants (DOAC) and low-molecular-weight heparin (LMWH) after major urologic surgery. Systematic literature searches of MEDLINE, Embase, Web of Science, and Cochrane CENTRAL were performed up to 9 November 2023, and protocols were registered on PROSPERO (CRD42024494424). The primary outcomes were post-operative incidence of VTE and bleeding. The secondary outcomes included re-admissions and transfusions needed, post-operative complications and exploring the radical cystectomy sub-group. Outcomes were reported in 30 and 90 days where feasible with sub-group analysis. Searches yielded four studies that included 856 patients and the outcomes were reported within 30 and 90 days, with sub-analysis performed for each time-interval. We found no statistically significant differences between DOAC and LWMH within neither primary nor secondary outcomes; VTE events (RR 0.36; p = 0.06); bleeding events (RR 0.64; p = 0.45); re-admissions (RR 1.14; p = 0.39); transfusions (RR 0.42; p = 0.05) within 0-90 days and post-operative complications within 30 days (RR 0.76; p = 0.17). Similar results were found when exploring radical cystectomy sub-group: VTE risk (RR 0.42, p = 0.15), bleeding risk (RR 1.09; p = 0.90), and re-admissions to hospital (RR 1.18, p = 0.35). Limitations include small sample size, and difficult generalization to all urological surgery as most of the analyzed cohort underwent radical cystectomy. DOACs may be a safe and possibly cost-effective alternative to LMWH as post-operative thromboprophylaxis. However, these findings should be interpreted with caution due to limitations; therefore, more randomized studies are needed to ascertain our findings.