Comparison of Robotic Posterior Retroperitoneal Adrenalectomy over Laparoscopic Posterior Retroperitoneal Adrenalectomy: A Single Tertiary Center Experience

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.

Exploring the Benefits of a Reduced-Port Approach in Robotic Posterior Retroperitoneoscopic Adrenalectomy: A Comparative Study of the Two-Port and Three-Port Techniques

Background: Robotic adrenalectomy has become a surgical treatment option for benign and selected malignant adrenal diseases. We aimed to evaluate the eligibility of two-port robotic posterior retroperitoneoscopic adrenalectomy (PRA) as an alternative to the conventional three-port technique by comparing their surgical outcomes. Materials and Methods: This retrospective cohort study compared the clinicopathological factors and surgical outcomes among 197 patients who underwent two-port or three-port robotic adrenalectomy between 2016 and 2020 in a single tertiary center. For further evaluation, propensity score matching was performed to reduce the selection bias in population characteristics. Results: Patients were categorized by the number of ports (two-port group, 87; and three-port group, 110). The two-port group compared with the three-port group was significantly older (P = .006) and had a smaller mean tumor size (P = .003) and shorter mean operation time (P = .001). Upon comparing clinicopathologic characteristics according to adrenal disorders, for pheochromocytoma, the three-port group had a larger tumor size and a longer operation time. For Cushing's syndrome, the operation time was short and numeric rating scale pain score was significantly low in the two-port group. After propensity score matching, the two-port group had a short operation time and a significantly low postoperative pain score (P < .05). Predictive factors associated with prolonged operation time included male gender, an increased number of ports, and large tumor size. Conclusions: The two-port technique resulted in a shorter operation time and lower pain score compared with the three-port technique. The two-port technique may be a safe alternative to the conventional three-port technique for robotic PRA.

Robotic posterior retroperitoneal adrenalectomy versus laparoscopic posterior retroperitoneal adrenalectomy: outcomes from a pooled analysis

Background

The comparative advantages of robotic posterior retroperitoneal adrenalectomy (RPRA) over laparoscopic posterior retroperitoneal adrenalectomy (LPRA) remain a topic of ongoing debate within the medical community. This systematic literature review and meta-analysis aim to assess the safety and efficacy of RPRA compared to LPRA, with the ultimate goal of determining which procedure yields superior clinical outcomes.

Methods

A systematic search was conducted on databases including PubMed, Embase, Web of Science, and the Cochrane Library database to identify relevant studies, encompassing both randomized controlled trials (RCTs) and non-RCTs, that compare the outcomes of RPRA and LPRA. The primary focus of this study was to evaluate perioperative surgical outcomes and complications. Review Manager 5.4 was used for this analysis. The study was registered with PROSPERO (ID: CRD42023453816).

Results

A total of seven non-RCTs were identified and included in this study, encompassing a cohort of 675 patients. The findings indicate that RPRA exhibited superior performance compared to LPRA in terms of hospital stay (weighted mean difference [WMD] -0.78 days, 95% confidence interval [CI] -1.46 to -0.10; p = 0.02). However, there were no statistically significant differences observed between the two techniques in terms of operative time, blood loss, transfusion rates, conversion rates, major complications, and overall complications.

Conclusion

RPRA is associated with a significantly shorter hospital stay compared to LPRA, while demonstrating comparable operative time, blood loss, conversion rate, and complication rate. However, it is important to note that further research of a more comprehensive and rigorous nature is necessary to validate these findings.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=453816, identifier CRD42023453816.

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.

Comparison of robotic and laparoscopic lateral transperitoneal adrenalectomies

Purpose

This study aimed to compare the intraoperative and postoperative outcomes between robotic and laparoscopic transperitoneal adrenalectomies.

Methods

In this retrospective study, 93 patients underwent adrenalectomy using 2 surgical modalities: 45 patients underwent adrenalectomy using the da Vinci Xi system (robotic group), and 48 patients using laparoscopic devices (laparoscopic group). We compared the operation time, intraoperative bleeding, and hospital stay according to the surgical modality and tumor characteristics.

Results

There were no significant differences in the operative time (P = 0.827), hospital stay (P = 0.177), and intraoperative bleeding (P = 0.174) between the groups. However, the robotic group showed a lower coefficient of variation in total operative time than that of the laparoscopic group (100.6 ± 23.3 minutes vs. 101.9±32.7 minutes, 0.230 vs. 0.321). When divided into 2 subgroups based on the tumor size (<3 cm and ≥3 cm), the robotic group with a tumor sized >3 cm had a shorter operative time than that of the laparoscopic group (P = 0.032). The robotic group also had fewer cases of intraoperative bleeding (P = 0.034).

Conclusions

Compared to the laparoscopic transperitoneal adrenalectomy, the robotic one achieved a lower deviation in total operative time and showed less bleeding and a shorter operative time, especially for tumors sized >3 cm.

Comparative Analysis of Laparoscopic and Robotic Transperitoneal Adrenalectomy Performed at a Single Institution

Background and Objectives: Laparoscopic adrenalectomy (LA) is the standard surgical approach for adrenalectomy. At present, robotic adrenalectomy (RA) has been introduced at various hospitals. This study evaluated our initial experience with robotic adrenalectomy compared with conventional laparoscopic adrenalectomy. Materials and Methods: From October 2018 to March 2022, 56 adrenalectomies were performed by a single endocrine surgeon. Thirty-two patients underwent LA (LA group), and twenty-four patients underwent RA (RA group). Results: Patients in the RA group were significantly younger than those in the LA group (48.6 ± 9.7 years vs. 55.1 ± 11.4 years, p = 0.013). The RA group had a shorter operation time than the LA group (76.1 ± 28.2 min vs. 118.0 ± 54.3 min, p < 0.001). The length of hospital stay and postoperative pain level between the two groups were similar. There were no complications in the RA group. There was no significant difference in the pathologic diagnosis between the two groups. The cost of surgery was significantly higher in the RA group than in the LA group (5288.5 US dollars vs. 441.5 ± 136.8 US dollars, p < 0.001). Conclusions: In our initial experience, RA showed a shorter operation time than LA and no complications. RA could be a viable alternative surgical option for adrenalectomy, notwithstanding its higher cost.

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

OBJECTIVE

To compare the safety and effectiveness of robot-assisted adrenalectomy (RA) and laparoscopic adrenalectomy (LA).

METHODS

We performed a systematic review and cumulative meta-analysis of the primary outcomes of interest according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the Methodological Quality of Systematic Reviews) Guidelines. Five databases, including Medline, PubMed, Cochrane Library, Scopus, and Web of Science, were systematically searched. The search timeframe was set from the creation of the database to December 2021.

RESULTS

There were 26 studies including 2985 patients. Our study found that the robotic technique was superior to conventional laparoscopy for estimated blood loss (WMD = -18.25, 95% CI [-27.85, -8.65], P < 0.01), length of stay (WMD = -0.45, 95% CI [-0.57, -0.33], P < 0.01), and conversion to open (OR = 0.31, 95% CI [0.12, 0.78], P = 0.01), while complications and readmissions were comparable. Interestingly, there was no difference in operative time between the two surgical modalities, but subgroup analysis found that the retroperitoneal route robotic technique took longer (WMD = 14.64, 95% CI [0.04, 29.24], P < 0.05), whereas the study of the mixed surgical modality (RA versus LA with mixed transabdominal and retroperitoneal surgical routes) found that the robot required less time (WMD = -12.29, 95% CI [-22.86, -1.72], P < 0.05). For pheochromocytoma, RA was superior to LA in terms of length of stay (WMD = -0.49, 95% CI [-0.83, -0.15], P < 0.01), with no difference in other indicators.

CONCLUSION

robotic-assisted adrenalectomy is a superior technique to conventional laparoscopy in managing adrenal tumors, even in the case of a specific adrenal tumor - pheochromocytoma.

The association between the type of anesthesia and hemodynamic instability during pheochromocytoma surgery: a retrospective cohort study

BACKGROUND

Pheochromocytoma often carries a risk for perioperative hemodynamic instability (HDI). The aim of this study is to evaluate the risk factors of intraoperative HDI during minimally invasive posterior retroperitoneal adrenalectomy (PRA) for pheochromocytoma.

MATERIALS AND METHODS

This retrospective study analyzed the prospectively collected data of 172 patients who underwent laparoscopic PRA or robotic PRA for pheochromocytoma between January 2014 and December 2020 at a single tertiary center. The patients were divided into two groups according to the intraoperative hypertensive event of systolic blood pressure (> 160 mmHg). The clinical manifestations and perioperative hemodynamic conditions were analysed.

RESULTS

In the multivariate logistic regression analysis, the tumor size (> 3.4 cm) [OR 3.14, 95% confidence intervals (CI) (1.48-6.64), p = 0.003], type of preoperative alpha-blocker (selective type) [OR 3.9, 95% CI (1.52-10.02), p = 0.005], preoperative use of beta-blockers [OR 3.94, 95% CI (1.07-14.49), p = 0.039] and type of anesthesia [total intravenous anesthesia (TIVA) vs. balanced anesthesia (BA)] [OR 2.57, 95% CI (1.23-5.38), p = 0.012] were determined as independent risk factors of intraoperative hypertensive events during minimally invasive adrenalectomy.

CONCLUSIONS

The type of anesthesia was independently associated with intraoperative HDI along with larger tumor size, type of preoperative alpha-blocker and the use of preoperative beta-blockers. TIVA increased the risk of intraoperative hypertensive events compared with BA. Thus, the consideration of the type of anesthesia prior to adrenal surgery for pheochromocytoma along with the use of preoperative non-selective alpha-blockers may be beneficial in minimizing the risk of intraoperative HDI.

Application of retroperitoneal laparoscopy and robotic surgery in complex adrenal tumors

As a surgical method for the treatment of adrenal surgical diseases, laparoscopy has the advantages of small trauma, short operation time, less bleeding, and fast postoperative recovery. It is considered as the gold standard for the treatment of adrenal surgical diseases. Retroperitoneal laparoscopy is widely used because it does not pass through the abdominal cavity, does not interfere with internal organs, and has little effect on gastrointestinal function. However, complex adrenal tumors have the characteristics of large volume, compression of adjacent tissues, and invasion of surrounding tissues, so they are rarely treated by retroperitoneal laparoscopy. In recent years, with the development of laparoscopic technology and the progress of surgical technology, robotic surgery has been gradually applied to the surgical treatment of complex adrenal tumors. This paper reviews the clinical application of retroperitoneal laparoscopic surgery and robotic surgery in the treatment of complex adrenal tumors.

Comparison of robot-assisted retroperitoneal laparoscopic adrenalectomy versus retroperitoneal laparoscopic adrenalectomy for large pheochromocytoma: a single-centre retrospective study

BACKGROUND

To evaluate the feasibility and safety of robot-assisted retroperitoneal laparoscopic adrenalectomy (RARLA) for large pheochromocytomas (PHEOs; size≥6 cm) compared with retroperitoneal laparoscopic adrenalectomy (RLA).

METHODS

Fifty-one patients who underwent adrenalectomy for large PHEOs between March 2016 and January 2019 were enrolled and divided into two groups, including 32 RLA cases and 19 RARLA cases. We compared the perioperative efficacy and long-term follow-up results between the two groups.

RESULTS

Preoperative data, including demographics, comorbidities and tumour characteristics, were similar between the groups. Intraoperatively, the RARLA group had a lower incidence of haemodynamic instability (26.3% vs. 56.2%, P = 0.038) and less intraoperative blood loss (100 ml vs. Two hundred milliliter, P = 0.042) than the RLA group. The groups showed no significant differences in operative time or transfusion rates. Postoperatively, the time to diet resumption, time to ambulation, time to drainage removal and postoperative hospital stay were shorter in the RARLA group than in the RLA group (1 d vs. 2 d, P = 0.027; 1 d vs. 2 d, P = 0.034; 3 d vs. 5 d, P = 0.002; 5 d vs. 6 d, P = 0.02, respectively). The groups exhibited no significant differences in the duration of anaesthetic use, complications, or long-term follow-up results for the blood pressure (BP) improvement rate.

CONCLUSIONS

Compared with RLA, RARLA is a safe, feasible and even optimized procedure for large PHEOs.

Minimally Invasive Surgery of Primary Retroperitoneal Tumors from the Perspective of General Surgeons: 6 Years of Experience at a Single Institution

Objective: This retrospective study aimed to present our surgical experience in patients with primary retroperitoneal tumors (PRTs) who underwent laparoscopic surgery and to compare the results with those of patients who underwent an open operation. Materials and Methods: We analyzed the medical data of patients who underwent retroperitoneal tumor resection through laparoscopic surgery or open operation between February 2014 and November 2019. Results: In total, 77 patients were enrolled. In total, 37 patients underwent open surgery and 40 patients underwent laparoscopic surgery. The tumor size in the open surgery group (10.2 ± 5.4 cm) was more significant than that in the laparoscopic surgery group (6.5 ± 3.1 cm) (P < .001). No difference was observed in operative time, blood loss, and transfusion between the two groups. Postoperative hospitalization in the open group (8.43 ± 2.77 days) was longer than that in the laparoscopic group (5.63 ± 2.16 days) (P < .001). The patients with PRTs in the IV area had minimal bleeding (16.67 ± 40.82 mL) and minimum postoperative hospitalization (3.83 ± 1.60 days). Conclusions: Laparoscopic resection of PRT is feasible in the selection of appropriate cases. The advantages are small trauma, light pain, quick recovery, and short hospital stay. It is especially suitable for benign PRTs with small size and cystic or small adhesion with vital organs or great vessels.