Comparison of the effectiveness and safety of robotic-assisted and laparoscopic in adrenalectomy: A systematic review and meta-analysis

Retrospective analysis of robotic versus laparoscopic surgery in the treatment of giant pheochromocytoma and paraganglioma

To compare the safety and effectiveness of robot-assisted laparoscopic surgery and traditional laparoscopic surgery in the treatment of giant pheochromocytomas and paragangliomas (PPGL). A retrospective analysis was conducted using the data of patients who underwent surgery at our institution between January 2013 and November 2023 and whose postoperative pathological examination confirmed PPGL (n = 84). Patients were divided into the robot-assisted (n = 33) and laparoscopic (n = 51) groups. Baseline data and intraoperative and postoperative recovery conditions of the two groups were compared. There was no significant difference in the baseline data between the two groups. The time to resume food intake in the robot-assisted group was shorter than that in the laparoscopic group [2 (1-2) vs. 3 (2-3) days, p < 0.001], and the incidence of postoperative morbidity was also lower (15.2% vs. 43.1%, p = 0.009); however, operating room time was longer [265 (240-370) vs. 245 (205-297.5) min, p = 0.039], and overall hospitalization costs were higher [80336.38 (72,014.3-101,555.39) vs. 60,102.13 (43,059.205-88085.35) CNY, p = 0.003]. This study results indicate that robot-assisted laparoscopic surgery has a lower postoperative complication rate and faster postoperative gastrointestinal function recovery. However, the surgery is costlier and operating room time is longer than with traditional laparoscopic surgery. Robotic surgery can be considered for giant PPGL if the patient's financial condition permits.

A comparative study of retroperitoneal laparoscopic adrenalectomy via intra and extra perinephric fat approaches

OBJECTIVE

To investigate the safety and effectiveness of retroperitoneal adrenalectomy via extra and intra perinephric fat approaches to provide experience and basis for resection of adrenal tumors through the retroperitoneal cavity.

METHODS

The clinical data of 284 patients undergoing retroperitoneal adrenalectomy in our hospital from December 2017 to March 2023 were collected. The basic characteristics of the two groups of patients and the changes in perioperative indicators were retrospectively analyzed.

RESULTS

A total of 117 patients with intra perinephric fat approach (IPFA) were included,and 167 patients with extra perinephric fat approach (EPFA) were included. The estimated blood loss in the IPFA group (123.59 ± 50.76 ml) was higher than that in the EPFA group (99.10 ± 99.51 ml) (p = 0.015),and the operative time in the IPFA group(105.25 ± 42.25 min) was longer than that in the EPFA group(81.75 ± 30.45 min) (p < 0.001).The hospitalization expenses of IPFA patients (36,306.39 ± 7544.25RMB) were higher compared with patients receiving EPFA (32,122.77 ± 7284.00RMB) (p < 0.001).There were no significant differences between the two groups in terms of tumor size,blood transfusion times and postoperative hospitalization time.

CONCLUSION

Retroperitoneal laparoscopic adrenalectomy is a safe and effective procedure that can be performed via extra and intra perinephric fat approaches.IPFA is associated with higher estimated blood loss, and the operation time of EPFA is shorter than IPFA. The choice of surgical approach may depend primarily on the experience of the surgeon, the characteristics of adrenal tumor, and the nature of perirenal adipose tissue.

Single-Port Robotic Posterior Retroperitoneoscopic Adrenalectomy: Current Perspectives, Technical Considerations, and Future Directions

Single-port (SP) robotic posterior retroperitoneoscopic adrenalectomy (SP-PRA) represents a State-of-the-Art innovation in endocrine surgery, offering a minimally invasive approach for adrenal gland resection with significant improvements in surgical precision, cosmetic outcomes, and patient quality of life. The SP robotic system facilitates surgery through a single incision in the back, avoiding the transperitoneal cavity and enabling direct retroperitoneal access to the adrenal gland. This review explores the evolution, techniques, and clinical outcomes of SP-PRA, emphasizing its advantages over traditional multi-port and laparoscopic methods. Enhanced visualization and precise articulation of the SP robotic system minimize trauma to surrounding tissues, leading to fewer complications and faster recovery times. Initial studies suggest superior patient satisfaction due to hidden incisions and excellent postoperative outcomes. However, challenges such as a steep learning curve, high costs, and limited long-term data remain. This review highlights the need for continued research and innovation to optimize the adoption of SP-PRA and expand its indications.

Pheochromocytomas and Paragangliomas-Current Management

Pheochromocytomas and paragangliomas (PPGLs) are infrequent neuroendocrine hypervascular neoplasms arising within different sites of the paraganglion system. They are divided into sympathetic (including pheochromocytomas and extraadrenal paragangliomas) and parasympathetic extraadrenal tumors. These tumors are usually not malignant and grow slowly; about 90% of them are found in the adrenal paraganglia (pheochromocytomas). Extraadrenal tumors are most frequently located in the abdominal cavity (85%), followed by the thoracic cavity (12%), and head and neck (3%). About 25% of PPGLs are related to germline mutations, which are risk factors for multifocal and metastatic disease. In PPGL diagnostics, laboratory, biochemical, and imaging (anatomical and functional) examinations are used. Surgery is the standard management choice for locoregional disease. For patients who are not candidates for surgery and who have stable, not-growing, or slow-growing tumors, active observation or other less invasive techniques (i.e., stereotactic surgery, hypofractionated stereotactic radiotherapy) are considered. In metastatic disease, systemic therapies (tyrosine kinase inhibitors [TKIs], mTORC1 inhibitor everolimus, immunotherapy, cold somatostatin analogs [biotherapy], and radioligand therapy) are used. The prognosis for PPGLs is quite good, and the 5-year survival rate is >90%. The goal of this paper is to review knowledge on the etiopathogenesis, current diagnostics, and therapy for PPGL patients. Our paper is particularly focused on the current management of PPGLs.

Robotic Adrenalectomy and Clevidipine: A New Frontier in Pheochromocytoma Management Preliminary Study

Background/Objectives: Adrenalectomy for pheochromocytoma presents a risk due to catecholamine discharge, leading to perioperative hemodynamic instability and potential fatality. Recommendations stress surgical caution and care in referral centers. Laparoscopic and robotic adrenalectomy advancements have decreased perioperative risks, with robotic access deemed advantageous for larger tumors. This study aimed to assess if surgical technique and a new clevidipine-based perioperative protocol could improve hemodynamic stability. Methods: All robotic adrenalectomies treated in recent years (50) were included (Group A). A control group of 50 laparoscopic adrenalectomies (Group B) was also included. Results: In Group A, 7 patients had a BMI > 30 (14%), and 20 patients (40%) had pheochromocytomas > 5 cm in size. During surgery, 22 patients (44%) had systolic blood pressure/SBP ≥ 160 mmHg, and 18 patients (36%) had heart rate/HR ≥ 110 bpm. A total of 44 patients (88%) were treated perioperatively with clevidipine, 32 (64%) required amines perioperatively, and 8 (16%) did not require transfer to intensive care. In Group B, 2 patients had BMI > 30 (4%), 12 (24%) had pheochromocytomas > 5 cm in size, 35 (70%) had SBP ≥ 160 mmHg, 16 patients (32%) had HR ≥ 110 bpm, 23 (46%) patients required amines perioperatively, and all were transferred to intensive care after surgery. In addition, 11 (22%) patients were treated with clevidipine. In both groups, MAP < 60 mmHg was equivalent (62% vs. 60%). Conclusions: The clevidipine-based protocol, combined with robotic adrenalectomy, notably for larger tumors, potentially improves perioperative hemodynamic stability, reducing postoperative intensive care needs. This combination could represent an advancement in managing those patients.

Robotic Versus Laparoscopic Adrenalectomy for Adrenal Tumors: An Up-to-Date Meta-Analysis on Perioperative Outcomes

Background: Minimally invasive surgery (MIS) for adrenal glands is becoming increasingly developed worldwide and robotic surgery has advanced significantly. Although there are still concerns about the generalization of outcomes and the cost burden, the robotic platform shows several advantages in overcoming some laparoscopic shortcomings. Materials and Methods: A systematic review and meta-analysis were conducted using the PubMed, MEDLINE and Cochrane library databases of published articles comparing RA and LA up to January 2024. The evaluated endpoints were technical and post-operative outcomes. Dichotomous data were calculated using the odds ratio (OR), while continuous data were analyzed usingmean difference (MD) with a 95% confidence interval (95% CI). A random-effects model (REM) was applied. Results: By the inclusion of 28 studies, the meta-analysis revealed no statistically significant difference in the rates of intraoperative RBC transfusion, 30-day mortality, intraoperative and overall postoperative complications, re-admission, R1 resection margin and operating time in the RA group compared with the LA. However, the overall cost of hospitalization was significantly higher in the RA group than in the LA group, [MD USD 4101.32, (95% CI 3894.85, 4307.79) p < 0.00001]. With respect to the mean intraoperative blood loss, conversion to open surgery rate, time to first flatus and length of hospital stay, the RA group showed slightly statistically significant lower rates than the laparoscopic approach. Conclusions: To our knowledge, this is the largest and most recent meta-analysis that makes these comparisons. RA can be considered safe, feasible and comparable to LA in terms of the intraoperative and post-operative outcomes. In the near future, RA could represent a promising complementary approachto LA for benign and small malignant adrenal masses, particularly in high-volume referral centers specializing in robotic surgery. However, further studies are needed to confirm these findings.

Progress in surgical approaches and outcomes of patients with pheochromocytoma and paraganglioma

Significant advances have been made in the past few decades in surgical management and outcomes of patients with pheochromocytoma and paraganglioma. Improvements in preoperative hypertensive control with the implementation of alpha- and beta-adrenergic blockade has resulted in better intra-operative blood pressure control and less incidence of hypertensive crises, which had been a large source of morbidity in the past. Emphasis on anesthesia and surgical team communication has also assisted in minimizing intraoperative hypertensive events at critical points of the operation. Shifting away from open resection, the now standard-of-care laparoscopic and minimally invasive adrenalectomy offers less pain, shorter hospitalizations, and quicker recoveries. Patient underlying germline mutations can guide the timing, approach, and extent of surgery. Postoperative outcomes have significantly improved with recent advancements in perioperative care in addition to regimented biochemical and radiographic surveillance. Here, we highlight the recent advancements in surgical approaches and outcomes for patients with pheochromocytoma and paraganglioma.

Recent advances in algorithms predicting hemodynamic instability undergoing surgery for phaeochromocytoma and paraganglioma

Abdominal pheochromocytomas and paragangliomas (PPGLs) are characterized by the overproduction of catecholamines, which are associated with hemodynamic instability (HDI) during surgery. Therefore, perioperative management to prevent intraoperative HDI is imperative for the surgical treatment of PPGLs. Owing to the rarity and heterogeneous nature of these tumors, pre-surgical prediction of HDI is a clinical dilemma. The reported risk factors for HDI include perioperative preparation, genetic background, tumor conditions, body composition, catecholamine levels, and surgical approach. Additionally, several personalized algorithms or models including these factors have been developed. The first part of this review outlines the prediction models that include clinical features such as tumor size and location, body mass index (BMI), blood glucose level, catecholamine levels, and preoperative management with α-adrenoceptor blockade and crystal/colloid fluid. We then summarize recently reported models that consider additional factors such as genetic background, radiomics, robotic-assisted surgical approach, three-dimensional visualization, and machine-learning models. These findings suggest that a comprehensive model including risk factors is the most likely approach for achieving effective perioperative management.

[Robotic adrenalectomy-current evidence]

Laparoscopic adrenalectomy is worldwide currently considered the gold standard technique for patients suffering from benign lesions. There has been an increasing number of robotic-assisted adrenalectomies in the last decade due to the systematic further development of minimally invasive surgery resulting in the implementation of robot-assisted surgery. Interestingly, the available studies show some perioperative advantages for robotic surgery but overall the current evidence is weak and there are economic aspects that are not negligible. Therefore, further high-quality studies about robotic-assisted adrenalectomy are mandatory to strengthen the current evidence.

Robotic and Laparoscopic Adrenalectomy for Pheochromocytoma: An International Multicenter Study

BACKGROUND AND OBJECTIVE

Robotic adrenalectomy (RA) has attracted interest as an alternative to laparoscopic adrenalectomy (LA) for patients with pheochromocytoma, although its beneficial effects are uncertain. Our aim was to compare RA and LA outcomes for these patients.

METHODS

Data for patients who underwent RA or LA for pheochromocytoma in 46 international centers between 2012 and 2022 were reviewed. We analyzed baseline characteristics and postoperative complications at discharge, 90 d, and 1 yr. We conducted propensity score matching (PSM; 1:1 ratio) and multivariable analyses to evaluate outcomes and risk factors for the occurrence of complications and higher Comprehensive Complication Index (CCI).

KEY FINDINGS AND LIMITATIONS

Of 1755 patients, 1613 (91.9%) underwent LA and 142 (8.1%) underwent RA. Estimated blood loss, conversion rate, complication rate, and CCI at discharge, 90 d, and 1 yr were similar between the groups. However, RA was associated with a longer operative time in comparison to LA (100 vs 123 min; p < 0.001), but not after PSM (p = 0.120). Multivariable analysis revealed that Charlson comorbidity index (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.07-1.29; p = 0.001), and tumor size per 1-cm increment (OR 1.13, 95% CI 1.07-1.21; p < 0.001) were independently associated with the incidence of complications, but there was no significant difference in complication rates between the LA and RA groups (OR 1.09, 95% CI 0.63-1.87; p = 0.767). After PSM, RA was associated with a lower rate of severe (grade ≥3a) complications in comparison to LA (p = 0.023).

CONCLUSIONS AND CLINICAL IMPLICATIONS

RA is a safe alternative to LA and yields similar outcomes for patients with pheochromocytoma. RA may be associated with a lower likelihood of severe complications. Further studies are warranted to determine the role of robotic surgery in pheochromocytoma.

PATIENT SUMMARY

Pheochromocytoma is a rare tumor in the adrenal gland and the gold-standard treatment is surgical removal. We assessed patient outcomes after robot-assisted surgery compared with laparoscopic surgery and found that outcomes are similar, but the rate of severe complications may be lower if a surgical robot is used.

The effect of mass functionality on laparoscopic adrenalectomy outcomes

PURPOSE

This study aimed to determine the effect of adrenal mass functionality and different hormone subtypes synthesized by the adrenal masses on laparoscopic adrenalectomy (LA) outcomes.

MATERIALS AND METHODS

The study included 298 patients, 154 of whom were diagnosed with nonfunctional masses. In the functional group, 33, 62, and 59 patients had Conn syndrome, Cushing's syndrome, and pheochromocytoma, respectively. The variables were analyzed between the functional and nonfunctional groups and then compared among functional masses through subgroup analysis.

RESULTS

The incidence of diabetes mellitus, hypertension, and obesity, blood loss, and length of hospital stay (LOH) were significantly higher in the functional group than in the nonfunctional group. In the subgroup analysis, patients with pheochromocytoma had significantly lower body mass index but significantly higher mass size, blood loss, and LOH than the other two groups. A positive correlation was found between mass size and blood loss in patients with pheochromocytoma (p ≤ 0.001, r = 0.761). However, no significant difference in complications was found among the groups.

CONCLUSIONS

In this study, patients with functional adrenal masses had higher comorbidity rates and American Society of Anesthesiologists scores. Moreover, blood loss and LOH were longer on patients with functional adrenal masses who underwent LA. Mass size, blood loss, and LOH in patients with pheochromocytoma were significantly longer than those in patients with other functional adrenal masses. Thus, mass functionality did not increase the complications.

Safety and surgical outcomes of robotic adrenalectomy from a 15-year experience at a single institution

Robotic adrenalectomy (RA) has gained significant popularity in the management of adrenal gland diseases. We report our experience at a single tertiary institution and evaluate the safety and surgical outcomes of RA. The data of 122 consecutive patients who underwent RA from October 2009 to December 2022 at Korea University Anam Hospital (Seoul, Korea) were reviewed. There were no perioperative complications. Clinicopathological features and surgical outcomes were retrospectively analyzed through complete chart reviews. Noteworthy findings include the influence of sex, tumor size, and body mass index on operation time, with the female and small tumor groups exhibiting shorter operation times (P = 0.018 and P = 0.009, respectively). Pheochromocytoma was identified as a significant independent risk factor for a longer operation time in the multivariate analysis [odds ratio (OR), 3.709; 95% confidence interval (CI), 1.127-12.205; P = 0.031]. A temporal analysis revealed a decreasing trend in mean operation times across consecutive groups, reflecting a learning curve associated with RA adoption. RA is a safe and effective operative technique alternative to laparoscopic adrenalectomy that has favorable surgical outcomes and enhances the convenience of the operation.

Comparison of perioperative outcomes between robot-assisted adrenalectomy and laparoscopic adrenalectomy: a propensity score matching analysis

This study aimed to evaluate and compare the perioperative outcomes of robot-assisted adrenalectomy (RAA) and laparoscopic adrenalectomy (LA) using propensity score matching. This retrospective study included 395 patients who underwent minimally invasive adrenalectomy: 354 who underwent LA and 41 who underwent RAA between February 2015 and March 2023. To mitigate potential confounding factors, 2:1 propensity score matching was conducted based on age, sex, body mass index, American Society of Anesthesiologists score, tumor laterality, and tumor size. Perioperative outcomes and complications were compared between the two groups, and prognostic factors for complications were analyzed. Propensity score matching analysis identified 123 patients, with 82 and 41 in the LA and RAA groups, respectively. Operative time (81.4 ± 26.6 min vs. 83.5 ± 25.9 min, P = 0.675), estimated blood loss (77.7 ± 68.3 mL vs. 83.2 ± 73.9 mL, P = 0.683), and post-operative stay (3.8 ± 1.0 days vs. 4.0 ± 0.9 days, P = 0.211) showed no significant differences between two groups. Intraoperative complications occurred in 8 patients (9.8%) in the LA group, while no patients (0%) experienced intraoperative complications in the RAA group (P = 0.051). In both groups, post-operative complications occurred in 2.4% (P = 1). The only factor contributing to complications after adrenalectomy was tumor size (OR 1.026, 95% CI 1.001-1.051, P = 0.042). RAA exhibited comparable perioperative outcomes and presented an improved intraoperative complication rate compared with LA. Tumor size was the only factor that contributed to complications after adrenalectomy.

Robot-assisted versus laparoscopic pheochromocytoma resection and construction of a nomogram to predict perioperative hemodynamic instability

BACKGROUND

Despite recent improvements in perioperative outcomes after pheochromocytoma resection, hemodynamic instability (HI) remained of high concern. The emergence of robot-assisted surgery may bring different results to pheochromocytoma surgery. The purposes of this study were to investigate whether robot-assisted retroperitoneal pheochromocytoma resection promotes hemodynamic instability compared with laparoscopic retroperitoneal pheochromocytoma resection and construct a nomogram to predict perioperative hemodynamic instability.

METHODS

The clinical data of 221 patients who underwent pheochromocytoma resection were analyzed retrospectively. The patients were divided into two groups according to the mode of operation. Stepwise logistic regression was used to determine the independent risk factors of perioperative hemodynamic instability and to construct a visual prediction model. The final model was visualized via a nomogram.

RESULTS

124 (56.1 %) out of 221 patients experienced HI. The variables that were eventually included in the model were tumor size (OR1.363(1.143-1.646), P < 0.001), abnormal blood glucose (OR3.381(1.534-7.903), P = 0.003), preoperative SBP(OR1.04(1.014-1.067),P = 0.002), robot-assisted surgery(OR0.241(0.108-0.513),P < 0.001), and catecholamines(OR4.567(2.424-8.834),P < 0.001). The receiver operating characteristic curve showed the area under curve was 0.816(95 %CI 0.761-0.871).

CONCLUSION

We developed a nomogram for successful prediction of perioperative hemodynamics based on five independent risk factors. Clinicians can leverage this easy-to-use nomogram to perform personalized risk predictions for HI and develop preventive interventions to improve patient safety and surgical outcomes.

[Personalized treatment of pheochromocytoma]

BACKGROUND

Pheochromocytoma is a rare but severe disease of the adrenal glands. The aim of this study is to present and discuss recent developments in the diagnosis and treatment of pheochromocytoma.

MATERIAL AND METHODS

A narrative review article based on the most recent literature is presented.

RESULTS AND DISCUSSION

The proportion of pheochromocytomas as tumors of adrenal origin is about 5% of incidentally discovered adrenal tumors. The classical symptomatic triad of headaches, sweating, and palpitations occurs in only about 20% of patients, while almost all patients show at least 1 of these symptoms. To diagnose pheochromocytoma, levels of free plasma metanephrines or alternatively, fractionated metanephrines in a 24‑h urine collection is required in a first step. In the second step an imaging procedure, computed tomography (CT) or magnetic resonance imaging (MRI), is performed to localize the adrenal tumor. Functional imaging is also recommended to preoperatively detect potential metastases. Genetic testing should always be offered during the course of treatment as 30-40% of pheochromocytomas are associated with genetic mutations. The dogma of preoperative alpha blockade is increasingly being questioned and has been controversially discussed in recent years. Minimally invasive removal of the adrenal tumor is the standard surgical procedure to cure patients with pheochromocytoma. The transabdominal and retroperitoneal laparoscopic approaches are considered equivalent. The choice of the minimally invasive procedure depends on the expertise and experience of the surgeon and should be tailored accordingly. Individualized and regular follow-up care is important after surgery.

Patient satisfaction analysis of robot-assisted minimally invasive adrenalectomy: a single-center retrospective study

The objective of this study is to compare the satisfaction of patients undergoing robot-assisted retroperitoneal laparoscopy adrenalectomy under the ambulatory mode and conventional mode. Basic information and clinical data of patients who underwent robotic-assisted posterior laparoscopic adrenalectomy between June 2020 and June 2023 were queried from our case system. The Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems Survey (OAS CAHPS®) was used to investigate patient satisfaction with preoperative preparation, discharge counseling, postoperative instructions, postoperative pain, and satisfaction with nursing work. The stats R package was used to select the appropriate statistic for the statistics based on the characteristics of the data. A total of 311 patients who underwent robot-assisted posterior laparoscopic adrenalectomy were enrolled in our case system. There were no statistical differences between the two groups in gender, age, body mass index, ASA classification, laterality, maximum tumor diameter, type of resection, hormonal activity, disease type, pathological classification, duration of surgery, estimated intraoperative bleeding, postoperative complications and follow-up period that were compared between the two groups of patients. There were no significant differences in preoperative preparation score, discharge counseling score, postoperative guidance score and nursing care satisfaction score (P > 0.05). Postoperative hospitalization, peristalsis time, defecation time, time to first postoperative mobilization, duration of indwelling drain and hospitalization costs in patients in the ambulatory model group were significantly less than patients in the conventional model group (P < 0.001). Patients in the ambulatory model group had significantly higher postoperative pain relief scores than patients in the conventional model group. In conclusion, our data suggest that patient satisfaction is equal between the conventional and ambulatory mode of performing robotic-assisted adrenalectomy. Patient satisfaction was probably associated with shorter hospitalization days, adequate preoperative preparation and standardized, high-quality post-discharge information and guidance.

Comparison of Perioperative Outcomes Between Laparoscopic and Robot-Assisted Adrenalectomy for Large Pheochromocytoma (≥ 5cm): A Retrospective Study

Purpose

The objective of this study was to compare perioperative outcomes in patients with large (≥5cm) pheochromocytomas who underwent adrenalectomy.

Patients and Methods

We retrospectively reviewed patients who underwent laparoscopic adrenalectomy (LA) and robot-assisted adrenalectomy (RA) for large pheochromocytoma (≥ 5cm) at our center between January 2015 to February 2023. We compared the perioperative outcomes between the two groups and investigated impact of high Nor-Metanephrine (NMN) levels on perioperative outcomes by analyzing this subgroup.

Results

A total of 115 patients were included in the study, with 48 patients in the robotic group and 67 patients in the laparoscopic group. The following significant difference were identified in favor of RA: shorter operative (excluding docking time) time (190.0 vs 220.0 min, p=0.002), lower estimated blood loss (50.0 vs 120.0 mL, p=0.013), however, RA group has higher surgical expenses (37933.0 vs 7936.0 CNY, p< 0.001). This finding remained consistent when analyzing patients with high NMN levels.

Conclusion

Patients with large pheochromocytoma may experience reduced blood loss and shorter operative time when undergoing robot-assisted adrenalectomy. However, it is important to note that the RA approach is associated with significantly higher costs.

Systematic review: robot-assisted versus conventional laparoscopic multiport cholecystectomy

Laparoscopic cholecystectomy has become the standard of care for the treatment of symptomatic gallstone disease. In the context of the increasing uptake of robotic surgery, robotic cholecystectomy has seen a substantial growth over the past decades. Despite this, a formal assessment of the evidence for this practice remains elusive and a randomised controlled trial is yet to be performed. This paper reviews the evidence to date for robotic multiport cholecystectomy compared to conventional multiport cholecystectomy. This systematic review was performed conducted using the Medline, Embase and Cochrane databases; in line with the PRISMA guideline. All articles that compared robotic and conventional laparoscopic cholecystectomy were included. The studies were assessed with regards to operative outcomes, postoperative recovery and complications. Fourteen studies were included, describing a total of 3002 patients. There was no difference in operative blood loss, complication rates, incidence of bile duct injury or length of hospital stay between the robotic and laparoscopic groups. The operative time for robotic cholecystectomy was longer, whereas the risk of conversion to open surgery was lower. There was marked variation in definitions of measured outcomes, and most studies lacked data on training and quality assessment, leading to substantial heterogeneity of the data. Available evidence on multiport robotic cholecystectomy compared to conventional laparoscopic cholecystectomy is scarce and the quality of the available studies is generally poor. Results suggest longer operating time for robotic cholecystectomy, although many studies included the learning curve period. Postoperative recovery and complications were similar in both groups.

Surgical approaches to the adrenal gland

PURPOSE OF REVIEW

Review the literature on the surgical management of adrenal diseases, highlighting the various surgical approaches and their respective pros and cons.

RECENT FINDINGS

Minimally invasive adrenalectomy is commonly used for small and benign adrenal tumors, whereas open adrenalectomy is preferred for larger tumors and primary adrenal malignancy. Although minimally invasive adrenalectomy results in shorter recovery and fewer complications compared with open, the latter offers better oncologic outcomes in the setting of primary adrenal malignancy. Adrenalectomy is performed transabdominally or retroperitoneoscopically, both yielding equivalent results and recovery. Traditional laparoscopic or robotic equipment can be utilized for either minimally invasive approach. Subtotal adrenalectomy may be appropriate for patients with genetically associated pheochromocytoma to preserve cortical function and reduce the risk of adrenal insufficiency. However, the potential benefits of sparing adrenal function must be weighed against the risk of recurrence.

SUMMARY

Adrenalectomy is becoming increasingly common worldwide. For benign and small adrenal tumors, minimally invasive adrenalectomy is generally considered the standard approach, while open adrenalectomy is preferred for primary adrenal malignancy and larger tumors. Subtotal adrenalectomy may be appropriate for patients with bilateral adrenal pheochromocytoma, as it can reduce the need for lifelong glucocorticoid dependency.

Robotic-assisted laparoscopic adrenalectomy (RARLA): What advantages and disadvantages compared to retroperitoneal laparoscopic adrenalectomy (RLA)?

OBJECTIVE

To explore the advantages and disadvantages of robot-assisted laparoscopic adrenalectomy compared with retroperitoneal laparoscopic adrenalectomy.

METHODS

A total of 101 patients with adrenal tumors who received retroperitoneal laparoscopic adrenalectomy (RLA) (n=75) or robot-assisted laparoscopic adrenalectomy (RARLA) (n=26) in our hospital from January 2021 to December 2021 were retrospectively collected. Patients' demographics, tumor characteristics, and perioperative indicators were compared. Statistical analysis was performed using t-test for continuous variables and Pearson chi-square test or Fisher's exact test for categorical variables.

RESULTS

We found that blood loss in the RARLA group was significantly less than that in the RLA group (66.9 ± 35.5 ml vs 91.5 ± 66.1 ml, p = 0.020). Gastrointestinal function recovery time in RARLA group was significantly less than that in RLA group (19.9 ± 6.9 hours vs 32.0 ± 9.0 hours, p < 0.001). However, the operation time, drainage tube placement time, post-operative hospital stay in the RARLA group were significantly longer compared with the RLA group (149.6 ± 53.4 mins vs 118.7 ± 41.2 mins, p = 0.003; 4.9 ± 2.0 days vs 3.6 ± 1.1 days, p = 0.004; 6.4 ± 1.8 days vs 4.6 ± 1.6 days, p < 0.001). The hospitalization expense in the RARLA group is significantly higher than that in the RLA group (59284 ± 8724 RMB¥ vs 39785 ± 10126 RMB¥, p < 0.001). We found that there was no significant difference in the incidence of postoperative complications between the two groups. However, the pathological types of the two groups were significantly different. Patients in the RLA group had a higher proportion of adrenocortical adenoma, while patients in the RARLA group had a higher proportion of pheochromocytoma.

CONCLUSION

Compared with traditional laparoscopic adrenalectomy, robot-assisted laparoscopic adrenalectomy can significantly reduce intraoperative blood loss and accelerate postoperative gastrointestinal recovery. It is committed to studying how to reduce the hospitalization time and hospitalization cost of RARLA, which can make RARLA more widely used.

Effects of epidural anesthesia in pheochromocytoma and paraganglioma surgeries: A protocol for systematic review and meta-analysis

OBJECTIVE

Anesthetic management is a great challenge during the surgical resection of pheochromocytomas and paragangliomas (PPGLs) due to potential hemodynamic fluctuations and/or postoperative complications. Although combined epidural-general anesthesia is commonly used in PPGLs surgeries, there is still no consensus whether combined epidural-general anesthesia was superior than general anesthesia alone for these populations. For the first time, we conducted this systematic review and meta-analysis to summarize the effects of combined epidural-general anesthesia versus general anesthesia alone on hemodynamic fluctuations as well as postoperative complications in patients undergone PPGLs surgeries.

METHODS

This systematic review and meta-analysis was performed according to the preferred reporting items for systematic reviews and meta-analyses statement. The primary outcome were hemodynamic fluctuations, including intraoperative hypotension, postoperative hypotension, and hypertensive crisis. Secondary outcome was the incidence of postoperative complications during hospital stay.

RESULTS

Finally, three retrospective cohort studies involving 347 patients met the inclusion criteria. A meta-analysis was not performed since outcomes from included studies were not available to be pooled. On the basis of the findings of non-randomized controlled trials (RCTs) literature, 2 studies suggested that combined epidural-general anesthesia was associated with intraoperative and postoperative hypotension, although one study reported that epidural anesthesia use reduced the incidence of postoperative complications in patients undergone surgical resection of PPGLs.

CONCLUSIONS

Currently, no published RCTs have yet assessed clinically relevant outcomes with respect to the application of epidural anesthesia during PPGLs surgeries. Well-designed RCTs should nonetheless be encouraged to properly assess the efficacy and safety of epidural anesthesia for PPGLs surgeries.