Robot-assisted laparoscopic adrenalectomy: preliminary UK results

Robot-assisted adrenalectomy: state of the art

Currently, laparoscopic adrenalectomy is worldwide considered the gold standard technique. Both transperitoneal and retroperitoneal approaches have proved their efficacy with excellent outcomes. Since the introduction of da Vinci System (Intuitive Surgical, Sunnyvale, CA), robotic surgery has made many steps forward gaining progressively more diffusion in the field of general and endocrine surgery. The robotic technique offers advantages to overcome some laparoscopic shortcomings (rigid instruments, loss of 3D vision, unstable camera). Indeed, the robotic system is provided of stereoscopic 3D-magnified vision, additional degree of freedom, tremor-filtering technology and a stable camera. Recently, several case series have demonstrated the feasibility and the safety of robot-assisted adrenalectomy in high-volume centers with outcomes comparable to laparoscopic adrenalectomy. Notwithstanding, the technical advantages of the robotic system have not yet demonstrated significant improvements in terms of outcomes to undermine laparoscopic adrenalectomy. Moreover, robotic adrenalectomy harbor inherits drawbacks, such as longer operative time and elevated costs, that limit its use. In particular, the high cost associated with the use of the robotic system is primarily related to the purchase and the maintenance of the unit, the high instruments cost and the longer operative time. Notably, these aspects make robotic adrenalectomy up to 2.3 times more costly than laparoscopic adrenalectomy. This literature review summarizes the current available studies and provides an overview about the robotic scenario including applicability, technical details and surgical outcomes.

Robotic treatment of giant adrenal myelolipoma: A case report and review of the literature

Adrenal myelolipoma is a rare mesenchymal tumour with benign biological behaviour that is mainly composed of mature adipose and myeloid tissue. Both sexes are equally affected, most commonly between the fifth and seventh decades of life. The diagnosis of adrenal myelolipoma is mostly incidental. Although it may occasionally be associated with necrosis, rupture and haemorrhage, causing abdominal pain, this tumour is usually asymptomatic. Consequently, management is conservative, while surgical treatment is reserved for symptomatic cases, or for masses growing quickly or to a size >6 cm. Giant myelolipomas (sized >10 cm) are rare. Open radical adrenalectomy is the standard treatment for giant myelolipomas, while the minimally invasive approach has been used in only few cases. We herein report the case of a patient with a giant adrenal myelolipoma who underwent robotic partial adrenalectomy. To the best of our knowledge, this is the largest giant adrenal myelolipoma treated with robotic surgery reported in the literature to date. A 55-year-old male patient underwent an abdominal computed tomography scan during follow-up after radical prostatectomy for prostate cancer Gleason Score 6 (ISUP 1) due to biochemical recurrence. The examination revealed a right hypodense adrenal mass, sized 16×13 cm. Abdominal magnetic resonance imaging confirmed the presence of characteristics suggestive of a myelolipoma. The patient did not report any symptoms. Due to the benign characteristics of the mass, robotic partial adrenalectomy and enucleation of the mass were performed. The operative time and estimated blood loss were 205 min and 100 ml, respectively. No intra- or postoperative complications occurred. The patient was mobilized on the first postoperative day and the time to flatus was 36 h; the length of hospitalization was 4 days. Histological examination confirmed the diagnosis of adrenal myelolipoma, sized 18×11.5×6 cm. No tumour recurrence occurred over a follow-up period of 12 months. In conclusion, robotic surgery allows performing partial adrenalectomy with a lower risk of bleeding and with preservation of healthy adrenal tissue, which is of paramount importance for the patient as it reduces recovery time and the need for medical substitution therapy.

Robotic assisted adrenalectomy: Is it ready for prime time?

Adrenal surgery is undergoing continuous evolution and minimally invasive surgery is increasingly being used for the surgical management of adrenal masses. With robotic-assisted surgery being a widely accepted surgical treatment for many urological conditions such as prostate carcinoma and renal cell carcinoma, the use of the robot has been expanded to include robotic-assisted adrenalectomy, offering an alternative minimally invasive platform for adrenal surgery. We performed a literature review on robotic-assisted adrenalectomy, reviewing the current surgical techniques and perioperative outcomes.

Robot-assisted versus laparoscopic adrenalectomy: a systematic review and meta-analysis

BACKGROUND

More recently, robot-assisted adrenalectomy (RA) has emerged as an attractive alternative to laparoscopic adrenalectomy (LA), and many studies have shown the feasibility and safety of RA. However, the short- and long-term outcomes of RA versus LA have not been adequately assessed, and the advantage over the laparoscopic approach has not been demonstrated. The aim of this study was to compare the outcomes of RA versus LA by means of a systematic review and meta-analysis of the available literature in the early experience.

MATERIALS AND METHODS

A systematic search of PubMed, SCI/SSCI, CNKI, and the Cochrane Library was performed to identify prospective randomized controlled trials and retrospective observational studies that compared RA and LA and were published between January 2006 to the end of December 2012. Outcomes of interest included demographic and clinical characteristics, perioperative variables, and complications. The meta-analysis was prepared in accordance with the Quality of Reporting of Meta-analyses (QUOROM) statement.

RESULTS

Eight trials (232 cases and 297 controls) assessing RA versus LA were considered suitable for meta-analysis, including six prospective and two retrospective studies. There was a significant trend to choose patients for the performance of RA who were associated with a lower body mass index (weighted mean difference [WMD]=-2.78 kg/m(2); 95% confidence interval [CI], -3.00 to -2.55; P<.001) and higher incidence of previous surgery (odds ratio=1.59; 95% CI, 0.99-2.54; P=.05). There were no significant differences between the two groups in any other of the demographic parameters. With regard to perioperative variables, although there was a significant difference in the operating time in favor of LA (WMD=17.52 minutes; 95% CI, 3.48-31.56; P=.01), patients having RA might benefit from significantly less blood loss (WMD=-19.00 mL; 95% CI, -34.58 to -3.41; P=.02) and shorter length of hospital stay (WMD=-0.35 day; 95% CI, -0.51 to -0.19; P<.001). There were no significant differences between RA and LA with regard to conversion rates and overall complications. Sensitivity analysis performed by two methods both showed a positive reversal in the operating time with the statistical significance removed compared with the original analysis.

CONCLUSIONS

In the early experience, our data suggest that RA, compared with LA, may be a safe and feasible option associated with less blood loss and shorter hospital stay when performed by experienced surgeons in selected patients.

Adrenal cortex-sparing surgery for bilateral multiple pheochromocytomas in a patient with von hippel-lindau disease

Pheochromocytomas can be a part of familial neoplastic syndromes, in which case they tend to be multiple and involve both adrenal glands. Therefore, sparing adrenocortical function represents a major concern while dealing with these hereditary lesions. Herein, we describe the clinical characteristics and the management strategy of a patient with von Hippel-Lindau (VHL) disease who had multiple, bilateral pheochromocytomas as well as bilateral renal masses, pancreatic masses, and a paracaval mass. Only a portion of the left adrenal gland has remained in situ after two consecutive open surgeries and a percutaneous radiofrequency ablation which have been performed to treat the various components of this syndrome. No adrenal or extra-adrenal pheochromocytoma recurrences have been detected during a follow-up period of more than 2 years. Pancreatic and adrenal functions were normal throughout the postoperative period and never necessitated any replacement therapy. Adrenal cortex-sparing surgery is a valid option for VHL disease patients who present with synchronous bilateral adrenal pheochromocytomas.

Robotic-assisted minimally invasive surgery; a useful tool in resident training--the Peoria experience, 2002-2009

BACKGROUND

The purpose of this study was to review the use of robotic-assisted general surgery at our institution. We evaluated the 8 year experience of one minimally invasive surgery (MIS) fellowship-trained surgeon in Peoria, IL, performing 240 cases of foregut, colon, solid organ and biliary surgery using the da Vinci system, with resident assistance. Foregut and colon procedures are the fifth and sixth most commonly performed procedures of the senior author annually.

METHODS

An IRB-approved retrospective review of prospectively collected data representing 124 foregut and 102 colon operations was performed. Data analysed were procedure performed and indications for surgery, gender, age, body mass index (BMI), estimated blood loss (EBL), port set-up time (PST), robot operating time (ROT), total case time (TCT), length of stay (LOS), complications, conversions and resident involvement were recorded. Fourteen cases were excluded from the data review. Statistical analysis using the ANOVA test was applied. A specific review of resident participation was performed.

RESULTS

Times for 226 foregut and colon cases were: PST 31.2 ± 9.4 (range 10-64) min, ROT 119.3 ± 41.5 (range 12-306) min, and TCT 194.8 ± 50.3 (range 50-380) min. The EBL was 48.6 ± 55.0 (range 5-500) ml, BMI 28.5 ± 4.7 (range 15.4-46.8) kg/m(2) , and median LOS 2.0 (range 0-27) days. The overall complication rate was 13.3%. No deaths occurred. Over the 8 year study period the number of cases participated in by residents was 0, 16, 22, 15, 29, 26, 28 and 10 (as of June 2009), respectively.

CONCLUSION

This series demonstrates the technical feasibility and safety of robotic surgery for the foregut and colon in a clinical setting where the surgeon does far more of other types of MIS. This series compares favorably with the literature. Incorporation of robotic training in the curriculum has allowed residents to learn robotic techniques in an effective manner.

Current trends in pediatric minimally invasive urologic surgery

Over the past two decades, laparoscopic and robotic surgery in children has been described as a viable minimally invasive alternative to open surgery for many pediatric urologic conditions. With the goal of reducing the morbidity associated with open surgery, minimally invasive surgery in children is increasingly being performed as laparoscopic and robotic patients appear to be experiencing shorter hospital stays, decreased pain medication requirements, and the potential for improved cosmesis. This article provides an overview of the existing literature in laparoscopic and robotic-assisted laparoscopic urologic surgery in children. Laparoscopic and robotic-assisted laparoscopic surgery appears to be safe and effective in children for a wide range of ablative and reconstructive procedures. Conventional laparoscopic surgery is effective for ablative procedures, while robotic surgery may be ideally suited for reconstructive cases requiring advanced suturing and dissection. Overall, more prospective studies are needed to study the long-term outcomes of minimally invasive surgery in pediatric patients, and the appropriate use of the available technology.

Robot-assisted laparoscopic adrenalectomy for adrenocortical carcinoma: initial report and review of the literature

We report the first robot-assisted laparoscopic adrenalectomy for adrenocortical carcinoma. This patient was referred to our center for extirpation of an incidentally discovered 8-cm adrenal mass. The patient underwent robot-assisted laparoscopic adrenalectomy. Surgical margins were negative for malignancy, and the patient was discharged home on the first postoperative day. We review the literature regarding robot-assisted laparoscopic adrenalectomy and discuss the potential benefits of this technique as compared with standard laparoscopy in the management of adrenocortical carcinoma.

Robotics and surgery: a long-term relationship?

This article introduces robotic surgical systems by explaining the shortcomings of traditional laparoscopic surgery, and how these new systems have been developed to address them. This is followed by a descriptive section of robotic systems past and present and their use in different surgical specialities. Finally, we discuss advances that are planned for the development of current systems and the future role of robotics in surgery.

Robotic-assisted adrenalectomy: what advantages compared to lateral transperitoneal laparoscopic adrenalectomy?

BACKGROUND

This study evaluates the perioperative outcomes of robotic-assisted adrenalectomy (RA) compared with lateral transperitoneal laparoscopic adrenalectomy (LA).

METHODS

Prospective evaluation of 50 patients who underwent unilateral RA versus 59 patients who underwent unilateral LA.

RESULTS

RA was associated with lower blood loss (49 mL) but longer operative times (104 minutes) (P < .001). However, the difference in operative time was not significant after the learning curve of 20 cases. In patients with body mass index (BMI) > or = 30 kg/m(2), mean operative time was longer in the LA group (90 vs 78 minutes, P = .03) but not in the RA group. In patients with large tumors (> or = 55 mm), mean operative time was longer in the LA group (100 vs 80 minutes, P = .009) but not in the RA group. Conversion rate, morbidity, and hospital stay were similar in both groups.

CONCLUSIONS

After a learning curve of 20 cases, RA has similar perioperative outcomes compared to lateral transperitoneal LA. Several criteria (previous laparoscopic expertise, first assistant's skill and tumor side) remain determinative on RA operative time.

Robotic urology in the United Kingdom: experience and overview of robotic-assisted cystectomy

In this article we look at the evolution of robotic technology in operative urology and the significant early contribution of Mr John Wickham. We explore the ergonomics of robotic technology and discuss financial issues from a British perspective. We share our clinical experience, describe the authors’ robotic-assisted cystectomy technique, and conclude by exploring the patients’ perception of this new treatment modality.

Robot-Assisted Cortical-Sparing Adrenalectomy in a Patient with Von Hippel-Lindau Disease and Bilateral Pheochromocytomas Separated by 9 Years

Von Hippel-Lindau disease is a heritable syndrome that confers an increased risk of developing various benign and malignant tumors to those with a germline mutation of the tumor suppressor gene. We present a case of a male patient who initially presented at age 9 with headaches, fevers, and fatigue. He was found to have a left pheochromocytoma which was successfully managed with open total adrenalectomy. He presented again at age 18 with a second pheochromocytoma in the right adrenal gland. DNA analysis revealed a de novo Val84Leu mutation in the Von Hippel-Lindau gene, not seen in either parent. The challenge presented was that of balancing the obvious benefits of cortical- sparing adrenalectomy with the risk of tumor recurrence in spared tissue. Ultimately, management consisted of a robot-assisted laparoscopic partial right adrenalectomy with successful preservation of adrenocortical function.

Thirty robotic adrenalectomies

BACKGROUND

Robotic adrenalectomy is a minimally invasive alternative to traditional laparoscopic adrenalectomy. To date, only case reports and small series of robotic adrenalectomies have been reported. This study presents a single institution's series of 30 robotic adrenalectomies, and evaluates the procedure's safety, efficacy, and cost.

METHODS

Thirty patients underwent robotic adrenalectomy at the Johns Hopkins Hospital between April 2001 and January 2004. Patient morbidity, hospital length of stay, operative time, and conversion rate to traditional laparoscopic or open surgery are presented. Improvement in operative time with surgeon experience is evaluated. Hospital charges are compared to charges for traditional laparoscopic and open adrenalectomies performed during the same time period.

RESULTS

Median operative time was 185 min. Patient morbidity was 7%. There were no conversions to traditional laparoscopic or open surgery. The median hospital stay was 2 days. Operative time improved significantly by 3 min with each operation. Hospital charges for robotic adrenalectomy (12,977 dollars) were not significantly different than charges for traditional laparoscopic (11,599 dollars) or open adrenalectomy (14,600 dollars).

CONCLUSIONS

Robotic adrenalectomy is a safe and effective alternative to traditional laparoscopic adrenalectomy.

Nerve-sparing axillary dissection using the da Vinci Surgical System

This is an initial report of a new method of axillary dissection via a periareolar incision and an 8 mm incision in the axilla with the da Vinci Surgical System. The 10x magnification and three-dimensional image, together with the versatility and precision of the robotic telemanipulators, has enabled us to perform nerve-sparing axillary dissection in four patients with invasive ductal carcinoma of the breast undergoing segmental (conservative) excision and level II axillary dissection. The time for the robotic axillary dissection ranged from 30 to 105 minutes (average 70.5 minutes). The average number of lymph nodes retrieved was 13 (11, 11, 13, and 17, respectively). Postoperatively all four patients recovered well and were discharged the next day. The robotic system can enhance the surgeon's ability by providing a high-definition, magnified, three-dimensional view of the operative field, intuitively controlled articulating instruments, and elimination of tremors; and it has potential benefits for the patient.