Robotic versus laparoscopic resection of large adrenal tumors

Adrenal Surgery: Open, Laparoscopic, and Robotic Approaches

Adrenal surgery is an established, critical tool in the management of various adrenal gland pathologies. Complete or partial adrenalectomy is employed to manage both benign lesions and malignant tumors. Beyond a technical understanding of surgical and anatomic principles, an understanding of adrenal endocrine function is essential for all surgeons who care for patients with adrenal pathologies. In this article, we provide an overview of adrenal surgery, discussing key anatomic and functional considerations, various surgical approaches, perioperative management strategies, and potential complications.

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.

Surgical outcomes from robotic-assisted adrenalectomy: a case series on experience in a large tertiary referral centre

BACKGROUND

Robotic-assisted surgery is gaining wider acceptance in most surgical specialties. However, in the United Kingdom, endocrine surgery has not fully adopted robotics. This paper aims to present the early experience and outcomes of patients who underwent robotic-assisted adrenalectomy at a tertiary referral endocrine surgery department. Outcomes were compared to national and international performance measures.

METHODS

Seventy-two elective robotic adrenalectomies were performed over a 24-month period. Data collected included patient demographics, co-morbidities, indication for surgery and tumour size. Outcomes assessed were console time, conversion rates, complications, length of stay and excision margin.

RESULTS

Seventy-two cases were included for analysis. Sixty-six percent (n = 48) of the patients were female with a median age of 60 years. Median BMI was 28. Functional tumours accounted for 76% (n = 55) of cases with the most common being phaeochromocytomas and cortisol producing adenomas. Median docking time was 5 min with a median intraoperative time on the console of 45.5 min. Tumour size ranged from 1 to 14 cm. Median length of stay postoperatively was 1 day. There was only one conversion to open procedure. Two patients reported post-op superficial surgical site infections and there were no mortalities.

CONCLUSION

This case series demonstrates robotic-assisted adrenalectomies performed in a tertiary care centre were safe and feasible in a selected cohort of patients with functional and non-functional tumours. Large randomised controlled trials with long-term follow-up are required to establish the benefits of robotic adrenal surgery over conventional laparoscopic adrenalectomy.

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.

[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.

Outcomes of Minimally Invasive Adrenalectomy for Large Adrenal Masses: A Multi-Centre Experience in Saudi Arabia

Introduction Advancements in radiological imaging technology have increased the discovery of adrenal incidentalomas. Large adrenal tumors (LATs) are not common, and the likelihood of malignancy increases with tumor size. LATs were defined as tumors larger than four centimeters (cm) with various pathologic diagnoses. Traditionally, open adrenalectomy was considered the gold standard for LATs, but with recent advancements in minimally invasive surgery (MIS), optimum perioperative and long-term outcomes are achievable by the MIS approach. The findings presented in this paper show that even large adrenal masses measuring up to 21 centimeters can be safely removed using a minimally invasive approach. Methodology After Institutional Review Board (IRB) approval, we reviewed medical records of adult patients who had adrenalectomies at two Saudi Arabian centers from January 2013 to February 2023. Inclusion criteria were laparoscopic or robotic adrenalectomy and adrenal lesions ≥5cm. Pediatric patients and those with open adrenalectomies were excluded. Pre-surgery, patients had imaging studies to assess mass characteristics. Pheochromocytoma patients received a 2-week adrenergic blocker treatment. Perioperative data including demographics, comorbidities, mass characteristics, surgery details, and follow-up were analyzed using SPSS-23. Patients provided informed consent and had follow-up appointments and imaging. Results Our experience involved 35 patients, 29 of whom received laparoscopic treatment and six of whom underwent robotic surgery. Of the 35 patients, more than half were females (57.1%), with a mean age of 41.7±14.9 years, the youngest and oldest participants being 16 and 73 years of age, respectively. The mean body mass index (BMI) of the participants was in the overweight range (26±6.0 kg/m2). The most common mode of presentation was incidental (42.9%), followed by hypertension (17.1%). Most patients had right-sided adrenal gland involvement (48.6%), with only four patients showing bilateral involvement. Most of the patients were classified as American Society of Anesthesiology score (ASA) 2 (40.0%) or ASA 3 (40.0%). Most of the patients were diagnosed with myelolipoma or adenoma (22.9% each) followed by pheochromocytoma (17.1%). The average estimated blood loss (EBL) was 189.3±354.6 ml for patients who underwent laparoscopic surgery and 80.0 ±34.6 ml for patients who underwent robotic surgery. The average operative room time (ORT) was 220.1±98.7 minutes (min) for laparoscopic surgery and 188.3±10.3 min for robotic surgery. One patient had to be converted from laparoscopic to open surgery due to aortic injury. The average length of stay (LOS) was 9.5±6.7 days for laparoscopic treatment and 5.5±1.9 days for robotic surgery. The mean tumor size in the greatest dimension was 8.0±4.4 cm. Only one patient who underwent unilateral laparoscopy experienced perioperative complications and converted to open surgery; nine patients who underwent unilateral laparoscopy required blood transfusion, and none of the patients who underwent robotic surgery required transfusion. None of the 35 patients experienced a recurrence of their adrenal disease during the mean follow-up period which lasted around 58 months. Conclusion MIS in Saudi Arabia is growing and is a safe method for LATs, with satisfactory surgical results compared to the traditional open surgery approach. It offers advantages in terms of EBL, complications, and disease recurrence.

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.

Robot-assisted adrenalectomy: Step-by-step technique and surgical outcomes at a high-volume robotic center

Objective

In the last years, robotic surgery was introduced in several different settings with good perioperative results. However, its role in the management of adrenal masses is still debated. In order to provide a contribution to this field, we described our step-by-step technique for robotic adrenalectomy (RA) and related modifications according to the type of adrenal mass treated.

Methods

We retrospectively analyzed 27 consecutive patients who underwent RA at Onze-Lieve-Vrouw hospital (Aalst, Belgium) between January 2009 and October 2022. Demographic, intra- and post-operative, and pathological data were retrieved from our prospectively maintained institutional database. Continuous variables are summarized as median and interquartile range (IQR). Categorical variables are reported as frequencies (percentages).

Results

Twenty-seven patients underwent RA were included in the study. Median age, body mass index, and Charlson's comorbidity index were 61 (IQR: 49-71) years, 26 (IQR: 24-29) kg/m2, and 2 (IQR: 0-3), respectively, and 16 (59.3%) patients were male. Median tumor size at computed tomography scan was 6.0 (IQR: 3.5-8.0) cm. Median operative time and blood loss were 105 (IQR: 82-120) min and 175 (IQR: 94-250) mL, respectively. No intraoperative complications were recorded. Overall postoperative complications rate was 11.1%, with a postoperative transfusion rate of 3.7%. A total of 10 (37.0%) patients harbored malignant adrenal masses. Among them, 3 (11.1%) had adrenocortical carcinoma, 6 (22.2%) secondary metastasis, and 1 (3.7%) malignant pheochromocytoma on final pathological exam. Only 1 (10.0%) patient had positive surgical margins.

Conclusion

We described our step-by-step technique for RA, which can be safely performed even in case of high challenging settings as malignant tumors, pheochromocytoma, and large masses. The standardization of perioperative protocol should be encouraged to maximize the outcomes of this complex surgical procedure.

Perioperative, functional, and oncologic outcomes in patients undergoing robot-assisted radical prostatectomy previous transurethral resection of prostate: a systematic review and meta-analysis of comparative trials

The influence of robot-assisted radical prostatectomy (RARP) on patients who have previously undergone transurethral resection of the prostate (TURP) versus TURP-naive patients is still debatable. The present study aimed to compare perioperative, functional, and oncologic outcomes of RARP between TURP and Non-TURP groups. We systematically searched the databases such as Science, PubMed, Embase, Web of Science, and the Cochrane Library database to identify relevant studies published in English up to August 2022. Review Manager was used to compare various parameters. The study was registered with PROSPERO (CRD42022378126). Eight comparative trials with a total of 4186 participants were conducted. The TURP group had a longer operative time (WMD 22.22 min, 95% CI 8.48, 35.95; p = 0.002), a longer catheterization time (WMD 1.32 day, 95% CI 0.37, 2.26; p = 0.006), a higher estimated blood loss (WMD 23.86 mL, 95% CI 2.81, 44.90; p = 0.03), and higher bladder neck reconstruction rate (OR 8.02, 95% CI 3.07, 20.93; p < 0.0001). Moreover, the positive surgical margin (PSM) was higher in the TURP group (OR 1.49, 95% CI 1.12, 1.98 p = 0.007). However, there was no difference between the two groups regarding the length of hospital stay, transfusion rates, nerve-sparing status, complication rates, long-term continence, potency rates and biochemical recurrence (BCR). Performing RARP on patients who have previously undergone TURP is a safe procedure. Furthermore, the current findings demonstrated that the TURP group had comparable oncologic and long-term functional outcomes to the Non-TURP group.

Minimally invasive versus open adrenalectomy for adrenocortical carcinoma: the keys surgical factors influencing the outcomes-a collective overview

PURPOSE

Adrenocortical carcinoma (A.C.C.) is a rare tumour, often discovered at an advanced stage and associated with a poor prognosis. Surgery is the treatment of choice. We aimed to review the different surgical approaches trying to compare their outcome.

METHODS

This comprehensive review has been carried out according to the PRISMA statement. The literature search was performed in PubMed, Scopus, the Cochrane Library and Google Scholar.

RESULTS

Among all studies identified, 18 were selected for the review. A total of 14,600 patients were included in the studies, of whom 4421 were treated by mini-invasive surgery (M.I.S.). Ten studies reported 531 conversions from M.I.S. to an open approach (OA) (12%). Differences were reported for operative times as well as for postoperative complications more often in favour of OA, whereas differences for hospitalization time in favour of M.I.S. Some studies showed an R0 resection rate from 77 to 89% for A.C.C. treated by OA and 67 to 85% for tumours treated by M.I.S. The overall recurrence rate ranged from 24 to 29% for A.C.C. treated by OA and from 26 to 36% for tumours treated by M.I.S.

CONCLUSIONS

OA should still be considered the standard surgical management of A.C.C. Laparoscopic adrenalectomy has shown shorter hospital stays and faster recovery compared to open surgery. However, the laparoscopic approach resulted in the worst recurrence rate, time to recurrence and cancer-specific mortality in stages I-III ACC. The robotic approach had similar complications rate and hospital stays, but there are still scarce results about oncologic follow-up.

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.

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.

A case of robot‐assisted adrenalectomy performed for an adrenal tumor (anastomosing hemangioma) exceeding 7 cm

Introduction

Anastomosing hemangioma in the adrenal area is extremely rare. We report a large anastomosing hemangioma in the adrenal area that underwent robot‐assisted adrenalectomy.

Case presentation

A 49‐year‐old man with left back pain underwent magnetic resonance imaging (MRI) that revealed a tumor in the left adrenal area; it was diagnosed as nonfunctional endocrinologically. However, the major axis of the tumor increased from 64 to 72 mm during the 4‐month period. Robot‐assisted left adrenalectomy was performed. Although the large tumor adhered to the surrounding tissues, it was safely resected by the effective use of an extra robotic arm. An anastomosing hemangioma was diagnosed since there were no malignant findings.

Conclusion

Robotic surgical systems may serve as an effective treatment option for large adrenal tumors, and our report is the first robot‐assisted adrenalectomy performed on an anastomosing hemangioma.

Robot assisted laparoscopic adrenalectomy: Should this be the new standard?

Introduction:

Minimal invasive surgeries (MIS) for large size adrenal tumors are still debatable. The objective is to evaluate the contemporary peri- and post-operative outcomes of patients undergoing (open = OA, laparoscopic = LA, and robotic = RA) adrenalectomies in three institutions.

Materials and methods:

Retrospectively gathered peri- and post-operative data of 235 patients, underwent adrenalectomy at three Institutions over a 7-year period (2013–2020) were analyzed. All patients underwent thorough radiological and endocrine workup.

Results:

Two hundred and thirty five patients who underwent adrenalectomy (OA ( n = 29), LA ( n = 146), and RA ( n = 60)) were assessed. OA ( n = 29) versus Minimally invasive surgery ( n = 206) showed significant differences (median, p value) in larger tumour size, cm (9.4 vs 5, ( p = 0.0001)), longer operative time, mins (240 vs 100, ( p = 0.0001)), longer hospital stay, days (8 vs 3,( p = .0001)), Higher readmission rates (14% vs 1.9%), higher blood loss, ml (400 vs 100, ( p = 0.0001)) requiring blood transfusion (14% vs 4.3%) ( p = 0.03), higher intraoperative complication (21% vs 6%) ( p = 0.0004), and post op complications (17% vs 5.3%) ( p = 0.01). Amongst the MIS (RA vs LA), RA appeared be have better outcomes in terms of shorter operative time, less blood loss and less intra operative complications with a p value <0.05. These results were consistent for the assessment of patients who had ⩾6 cm tumor size. The postoperative complication rates were lowest with RA (3.3%) compared to OA (17%) and LA (6.1%).

Conclusions:

Contemporary practice of adrenalectomy shows that robotic adrenalectomy is safe and effective irrespective of the tumor size.

Detection of near-infrared autofluorescence from adrenal neoplasms: An initial experience

BACKGROUND AND OBJECTIVES

Fluorescence from adrenal tumors can be detected with near-infrared imaging after injection with indocyanine green. However, it is unknown if adrenal tumors exhibit autofluorescence. The aim of this study was to determine whether adrenal tumors emit near-infrared autofluorescence (NIRAF).

METHODS

This was a prospective study of patients who underwent minimally invasive adrenalectomy at a tertiary center. Intraoperative images were analyzed to detect NIRAF with a 750 nm camera. Descriptive and comparative statistical analyses were performed.

RESULTS

Twenty-five adrenalectomies were examined. Only 11 tumors (44%), that originated from the cortex exhibited autofluorescence. A contrast distinction between the tumor and retroperitoneum was observed in 23 patients, whereas a contrast distinction between the tumor and normal adrenocortical tissue was seen in 12 patients. The overall fluorescence intensity of adrenal tumors was found to be variable and ranging between 0.3 and 5.6 times that of the background tissue. Pheochromocytoma, malignancy and adrenal cyst did not demonstrate NIRAF.

CONCLUSION

This is the first study to show that adrenocortical tissue can demonstrate NIRAF. The pattern of fluorescence was similar to that observed after indocyanine green injection in our historical experience. NIRAF has a potential to be used as an intraoperative optical adjunct during adrenalectomy.

A Descriptive Comparative Analysis of the Surgical Management of Adrenal Tumors: The Open, Robotic, and Laparoscopic Approaches

Background

Currently, adrenalectomies are trending toward minimally invasive approach including robotic and laparoscopic surgery. We aimed to describe the clinical presentation and outcomes associated with the 3 different surgical approaches in patients who underwent adrenalectomy for adrenal mass at a single tertiary center.

Methods

A retrospective descriptive observational study was conducted to include all patients who underwent surgical interventions for adrenal gland mass between 2004 and 2019. Patients were categorized into three groups according to the interventional approach (open, robotic vs. laparoscopic adrenalectomy) and data were analyzed and compared.

Results

A total of 124 patients underwent adrenalectomies (61.3% robotic, 22.6% open, and 16.1% laparoscopic approach). Incidentally discovered adrenal mass was reported in 67% of patients, and hypertension was the most prevalent comorbidity (53%). The tendency for malignancy increased with increasing tumor size while the functioning tumors were more in the smaller tumor size. Larger tumors were more common in younger patients. The robotic approach showed shorter surgical intensive care and hospital length of stay. Patients in the open adrenalectomy group frequently presented with abdominal pain (p = 0.001), had more nonfunctional adrenal mass (p = 0.04), larger mean tumor size (p = 0.001), and were frequently operated on the right side (p = 0.03). There was no post-operative mortality; however, during follow-up, 8 patients died (3 open, 3 laparoscopic and, 2 robotic approach). The median follow-up was 746 days (range 7–5,840).

Conclusions

The study explored the three surgical adrenalectomy approaches in a dedicated center for patients with adrenal pathology. It showed that robotic adrenalectomy could be safe and effective surgical approach for patients with benign functioning adrenal tumors of a diameter &lt;6 cm. However, the choice of a surgical approach varies according to the adrenal mass presentation, patient fitness for surgery, type and sizes of the tumor, surgeon's experience, and hospital resources. Open surgery is considered the first choice for larger, ruptured adrenal tumor or malignancy. However, the recent restructuring of the surgical department resulted in selection bias in favor of the robotic surgery. Further studies are required to address the risk factors, selection criteria for appropriate management, cost, and quality of life.

Robot-assisted versus conventional laparoscopic adrenalectomy: Results from the EUROCRINE Surgical Registry

BACKGROUND

Adrenalectomy is routinely performed via the minimally invasive approach. Safety of adrenalectomy using the robot-assisted technique has been widely demonstrated by several series, but the literature is scarce regarding the comparison of conventional laparoscopic versus robot-assisted approach. We decided to carry out a multicenter study to compare clinical and surgical outcomes between laparoscopic and robotic adrenalectomy.

METHODS

This is a retrospective case-control study, including data from centers affiliated to the Surgical Registry EUROCRINE. Patients undergoing laparoscopic surgery for adrenal tumors and registered between 2015 and 2018 were included. Robot-assisted versus laparoscopic adrenalectomy was compared. All comparisons were carried out in terms of complication rate, conversion rate and duration of stay.

RESULTS

A total of 1,005 patients from 46 clinics underwent robotic or conventional laparoscopic adrenalectomy. Median age was 55 (interquartile range: 45-65) years. Robotic adrenalectomy was performed in 189 (18.8%) patients. According to Clavien-Dindo classification, complication rate was lower in the robotic surgery group (1.6% vs 16.5%, P < .001). Laparoscopic surgery and active hormonal status were significantly correlated with complications, both in univariate and multivariate analysis. There was no significant difference between laparoscopic and robotic surgery groups, in terms of conversion rate (2.1% vs 0.5%, respectively, P = .147). Duration of stay was shorter in the robotic adrenalectomy group (82.1% vs 28.8%, P < .001).

CONCLUSION

Analysis of the EUROCRINE database supports that robotic adrenalectomy resulted in a lower complication rate and shorter duration of stay, compared with laparoscopic adrenalectomy. Granular data to support this is warranted.

The ADRENAL score: A comprehensive scoring system for standardized evaluation of adrenal tumor

OBJECTIVES

To propose an original and standardized scoring system to quantify the functional and anatomical characteristics of adrenal tumor.

MATERIALS AND METHODS

Four groups of consecutive adrenalectomies (n = 458) with heterogeneity in tumor characteristics and surgical approaches, including 212 laparoscopic cases (Group 1) and 105 robotic cases (Group 2) from The First Affiliated Hospital of Nanchang University, 28 robotic cases from Temple University Hospital (Group 3) and 113 laparoscopic cases from The First Affiliated Hospital of Guangxi Medical University (Group 4). All patients were followed up for 4.5 to 5.5 years. Six parameters including functional status or suspicion of malignancy, tumor size, relationship to adjacent organs, intratumoral enhancement on CT, nearness of the tumor to major vessels and body mass index were assessed and scored on a 0, 1 and 2 points scale. Correlation between the sum of the 6 scores and tumor laterality (ADRENAL score) verse operative time (OT), estimated blood loss (EBL), perioperative complications, transfusion, conversion and length of hospital stay was analyzed.

RESULTS

ADRENAL score was a strong predictor of both OT and EBL in all four groups (p < 0.05 for all tests). In Group 2 and 4, higher ADRENAL score seemed to correlate with longer hospital stay. No statistically significant correlation between ADRENAL score and complication, transfusion or conversion was noted yet.

CONCLUSIONS

ADRENAL score appears to be a valid predictor of surgical outcomes. It may provide a common reference for adrenal surgery training program, preoperative risk assessment and stratified comparative analysis of adrenal surgeries via different techniques and approaches.

Surgical Management of Adrenocortical Carcinoma: Current Highlights

INTRODUCTION

Adrenocortical carcinoma (ACC) is a rare tumor, often discovered at an advanced stage and associated with poor prognosis. Treatment is guided by staging according to the European Network for the Study of Adrenal Tumors (ENSAT) classification. Surgery is the treatment of choice for ACC. The aim of this review is to provide a complete overview on surgical approaches and management of adrenocortical carcinoma.

METHODS

This comprehensive review has been carried out according to the PRISMA statement. The literature sources were the databases PubMed, Scopus and Cochrane Library. The search thread was: ((surgery) OR (adrenalectomy)) AND (adrenocortical carcinoma).

RESULTS

Among all studies identified, 17 were selected for the review. All of them were retrospective. A total of 2498 patients were included in the studies, of whom 734 were treated by mini-invasive approaches and 1764 patients were treated by open surgery.

CONCLUSIONS

Surgery is the treatment of choice for ACC. Open adrenalectomy (OA) is defined as the gold standard. In recent years laparoscopic adrenalectomy (LA) has gained more popularity. No significant differences were reported for overall recurrence rate, time to recurrence, and cancer-specific mortality between LA and OA, in particular for Stage I-II. Robotic adrenalectomy (RA) has several advantages compared to LA, but there is still a lack of specific documentation on RA use in ACC.

Perioperative outcomes of robotic and laparoscopic adrenalectomy: a large international multicenter experience

BACKGROUND

The aim of the study was to describe the surgical outcomes of a retrospective series of consecutive patients treated with laparoscopic and robotic approach for adrenal masses in two tertiary referral centers.

METHODS

We retrospectively gathered data of 477 patients submitted to adrenalectomy performed at two Institutions from March 2008 to February 2018 by six highly experienced surgeons. We excluded from the analysis 43 patients that had an open approach for tumors or for anesthetic contraindications to minimally invasive surgery (MIS). Patients were selected for surgery after a radiologic and an endocrinology work up. Preoperative, perioperative and postoperative data were recorded.

RESULTS

Overall, 477 patients were included in the study. The robotic and the laparoscopic group included 110 and 367 patients, respectively. The preoperative characteristics were similar in both groups except for ASA score with a median (IQR) of 3 and 2 in the robotic and in the laparoscopic group, respectively (p = 0.03). Tumor size of adrenal tumors treated robotically (4, IQR 2.6-6 cm) was significantly larger than those treated laparoscopically (3, IQR 2.3-4.1 cm) (p = 0.01). The intraoperative complication rates were similar between robotic and laparoscopic groups (6.3% and 6%, respectively). The postoperative complication rate was 5.4% for robotic group and similarly 3.5% for laparoscopic adrenalectomy strategy. We analyzed the tumor ≥ 6 cm, with 29 patients in the robotic group and 43 in the laparoscopic one, with an overall complication rate of 19.5%. At multivariable analyses tumor size (OR 1.287; CI 1.128-1.468; p < 0.001) was the only independent predictor of overall complication.

CONCLUSION

Adrenal tumors can be safely treated either by robotic or laparoscopic strategy. MIS seems to be feasible also in larger adrenal masses (≥ 6 cm). Tumor size represents the only predictive factors for overall complication.

A visual quantification of tissue distinction in robotic transabdominal lateral adrenalectomy: comparison of indocyanine green and conventional views

BACKGROUND

Recent studies have reported the feasibility of indocyanine green fluorescence imaging of adrenal tumors to guide dissection. Although the adrenal has been reported to concentrate the dye more than surrounding tissues, the amount of tissue distinction and how this compares with conventional vision has not been quantified before. The aim of this study is to quantify this distinction using color analysis.

METHODS

This was an institutional review board-approved retrospective study. By excluding adrenal cortical carcinoma, metastasis and pheochromocytoma, video recordings of 50 patients who underwent robotic transabdominal lateral adrenalectomy with indocyanine green (ICG) imaging for adrenocortical tumors between August 2015 and May 2018 were reviewed. Using a color analysis software, the pixel intensity of adrenal tumors versus adjacent retroperitoneal tissues was calculated for conventional red, green and blue, as well as indocyanine green (ICG) scales. Statistical analysis was performed using ANOVA.

RESULTS

A total of 50 patients underwent unilateral robotic transabdominal lateral adrenalectomy. All procedures were completed robotically without a conversion to laparoscopy or open. Morbidity was 4%. Measured pixel intensity of adrenal tumors was higher than adjacent retroperitoneal tissues for all conventional color and ICG modes (p < 0.0001), with the gradient being more pronounced for ICG green versus conventional red, green and blue modes.

CONCLUSIONS

To our knowledge this is the first study attempting to encode tissue planes in robotic adrenalectomy. The results show that the visual contrast distinction observed between adrenal and adjacent retroperitoneal tissues can be quantified using pixel intensity. ICG enabled the distinction of tissue planes with a wider gradient compared to conventional RGB view, quantifying its subjective benefits reported in prior studies.

Robotic Versus Laparoscopic Adrenalectomy: Pluriannual Experience in a High-Volume Center Evaluating Indications and Results

Background: Robotic adrenalectomy offers several clinical benefits if compared with laparoscopic adrenalectomy; however, its superiority is still under debate. The aim of this study was the investigation of differences between the two techniques, and a comparison when approaching right or left side adrenal lesions was further conducted. Materials and Methods: All patients undergoing laparoscopic and robotic unilateral adrenalectomy at our institution from January 2006 to December 2019 were collected and retrospectively analyzed. Statistical analysis was conducted; differences between the two cohorts were reported. Results: A total of 160 cases were included (84 patients in laparoscopic adrenalectomy-group [LA-g] 76 cases in robotic adrenalectomy-group [RA-g]). The groups were homogeneous for demographic data. No intraoperative complications were reported; mean amount of intraoperative blood loss was comparable. No cases of conversion to open surgery were required. RA-g presented a longer operative time than LA-g for right adrenalectomy (P = .05), no differences were noted for left side (P = .187). Overall morbidity was 21% for LA-g and 10.5% for RA-g (P = .087), with an inferior rate of surgical complications for RA-g (P = .024), and for robotic left adrenalectomy than robotic right procedure (P = .03). Length of hospital stay was shorter for RA-g (P = .005). Conclusions: Robotic adrenalectomy presents similar outcomes as laparoscopic approach with some benefits for selected cases. Left adrenal lesions seem to receive greater advantages from robotic technique. Large randomized controlled trials are required to determine the role of robotic adrenal surgery and if the indication can be standardized based on the laterality of adrenal procedure.

Robotic renal and adrenal oncologic surgery: A contemporary review

Robot-assisted surgery has evolved over time. Radical nephrectomy with inferior vena cava thrombectomy is feasible and safe for level I, II and III thrombus in high volume centers. Though it is feasible for level IV thrombus, this procedure needs a multi-departmental co-operation. However, the safety of robot-assisted procedures in this subset is still unknown. Robot-assisted partial nephrectomy has been universally approved and found oncologically safe. Robotic adrenalectomy has been increasingly utilized for select cases, especially in bilateral tumors and for retroperitoneal adrenalectomy.

An intra-operative video comparison of laparoscopic versus robotic transabdominal lateral adrenalectomy

BACKGROUND

The aim was to compare intraoperative conduct of adrenalectomy between laparoscopic and robotic approaches.

METHODS

Intraoperative video-recordings of patients who underwent robotic (n = 30) and laparoscopic adrenalectomy (n = 30) were analysed using Mann-Whitney U, chi-square and multivariate regression analyses.

RESULTS

Demographics, indications and outcomes were similar between groups. For all tumour sizes, camera was more engaged to surgical task and exhibited less vision problems in robotic versus laparoscopic group. There was less instrument exchange and restriction of exposure with robotic approach. For dissection, robotic approach allowed for a wider range of instrument reach around adrenal. Robotically, there was an increased ability to do fine dissection, rather than en bloc division with rigid laparoscopic vessel sealers. Bleeding problems were less robotically.

CONCLUSION

Despite similarities in post-operative morbidity and hospital stay, there was a superiority in quality of procedure performed with robotic versus laparoscopic adrenalectomy for both small and large adrenal tumours.

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.

Robot Assisted Laparoscopic Adrenalectomy: Does Size Matter?

Objective: Open adrenalectomy (OA) is considered to be the standard care for large adrenal tumors. Minimally invasive surgery (MIS) using laparoscopic technique is considered for many patients in the modern era. Robot assisted laparoscopic adrenalectomy (RALA) can be an extremely useful tool which will negate the disadvantage of laparoscopic method. The aim of the present study is to determine whether adrenal tumor size and laterality have an impact on patients undergoing RALA with respect to perioperative and postoperative outcomes.

 Methods: During the study period, 38 patients who underwent RALA in a tertiary care center were considered for retrospectively analysis. The study populations were subdivided into distinctive groups based on the tumor size (<5 cm and ≥5 cm, <8 cm and ≥8 cm), and side (right and left side). For all the subgroups, perioperative and postoperative outcomes were analyzed. Perioperative and postoperative outcomes were assessed between patient groups, group a) <5 cm and ≥5 cm tumor, group b) <8 cm and ≥8 cm, and group c) laterality (right vs left).

Results: None of the patients showed any differences. In the current study, the conversion rate, readmission, and mortality were not observed. No major complications were noted.

Conclusion: RALA appears to be an extremely viable alternative to MIS using laparoscopic technique. The operative time, console time, blood loss, complication rates, and stay were extremely minimal irrespective of the size or laterality of the adrenal tumor.

Use, Cost, Complications, and Mortality of Robotic versus Nonrobotic General Surgery Procedures Based on a Nationwide Database

Since its introduction in 1997, robotic surgery has overcome many limitations, including setup costs and surgeon training. The use of robotics in general surgery remains unknown. This study evaluates robotic-assisted procedures in general surgery by comparing characteristics with its nonrobotic (laparoscopic and open) counterparts. Weighted Healthcare Cost and Utilization Project Nationwide Inpatient Sample data (2008, 2009) were used to identify the top 12 procedures for robotic general surgery. Robotic cases were identified by Current Procedural Terminology codes 17.41 and 17.42. Procedures were grouped: esophagogastric, colorectal, adrenalectomy, lysis of adhesion, and cholecystectomy. Analyses were descriptive, t tests, χ2s, and logistic regression. Charges and length of stay were adjusted for gender, age, race, payer, hospital bed size, hospital location, hospital region, median household income, Charlson score, and procedure type. There were 1,389,235 (97.4%) nonrobotic and 37,270 (2.6%) robotic cases. Robotic cases increased from 0.8 per cent (2008) to 4.3 per cent (2009, P < 0.001). In all subgroups, robotic surgery had significantly shorter lengths of stay (4.9 days) than open surgery (6.1 days) and lower charges (median $30,540) than laparoscopic ($34,537) and open ($46,704) surgery. Fewer complications were seen in robotic-assisted colorectal, adrenalectomy and lysis of adhesion; however, robotic cholecystectomy and esophagogastric procedures had higher complications than nonrobotic surgery ( P < 0.05). Overall robotic surgery had a lower mortality rate (0.097%) than nonrobotic surgeries per 10,000 procedures (laparoscopic 0.48%, open 0.92%; P < 0.001). The cost of robotic surgery is generally considered a prohibitive factor. In the present study, when overall cost was considered, including length of stay, robotic surgery appeared to be cost-effective and as safe as nonrobotic surgery except in cholecystectomy and esophagogastric procedures. Further study is needed to fully understand the long-term implications of this new technology.

Retrospective comparison of three minimally invasive approaches for adrenal tumors: perioperative outcomes of transperitoneal laparoscopic, retroperitoneal laparoscopic and robot-assisted laparoscopic adrenalectomy

Background

To compare the perioperative outcomes of transperitoneal laparoscopic (TLA), retroperitoneal laparoscopic (RLA), and robot-assisted transperitoneal laparoscopic (RATLA) adrenalectomy for adrenal tumors in our center.

Methods

Between April 2012 and February 2018, 241 minimally invasive adrenalectomies were performed. Cases were categorized based on the minimally invasive adrenalectomy technique. Demographic characteristics, perioperative information and pathological data were retrospectively collected and analyzed.

Results

This study included 37 TLA, 117 RLA, and 87 RATLA procedures. Any two groups had comparable age, ASA score, Charlson Comorbidity Index, and preoperative hemoglobin. The tumor size for RLA patients was 2.7 ± 1.1 cm, which was significantly smaller compared to patients who underwent TLA/RATLA (p = 0.000/0.000). Operative time was similar in any two groups, while estimated blood loss was lower for RATLA group (75.6 ± 95.6 ml) compared with the TLA group (131.1 ± 204.5 ml) (p = 0.041). Conversion to an open procedure occurred in only one (2.7%) patient in the TLA group for significant adhesion and hemorrhage. There were no significant differences between groups in terms of transfusion rate and complication rate. Length of stay was shorter for the RATLA group versus the TLA/RLA group (p = 0.000/0.029). In all groups, adrenocortical adenoma and pheochromocytoma were the most frequent histotypes.

Conclusions

Minimally invasive adrenalectomy is associated with expected excellent outcomes. In our study, the RATLA approach appears to provide the benefits of decreased estimated blood loss and length of stay. Robotic adrenalectomy appears to be a safe and effective alternative to conventional laparoscopic adrenalectomy.

Robotic adrenalectomy: evaluation of cost-effectiveness

Laparoscopic adrenalectomy (LA) is the preferred treatment option for adrenal lesions, considering the improved patients outcomes, due to the reduced postoperative morbidity and postoperative pain, the faster recovery and the shorter length of hospital stay. The widespread diffusion of robotic technology led to the development and standardization of robot-assisted approach to adrenalectomy. However, to date, no clear benefit from the use of the robot-assisted approach has been found. The higher costs remain an important drawback and limit the implementation of robot-assisted adrenalectomy (RA) programs. This review summarizes the current available data regarding RA including its operative outcomes, advantages and drawbacks in comparison with conventional LA, evaluating its cost-effectiveness.

Comparing the efficacy and safety of laparoscopic and robotic adrenalectomy: a meta-analysis and trial sequential analysis

PURPOSE

A systematic literature review and a meta-analysis were designed and conducted, in order to provide an up-to-date comparison of the robotic (RA) and laparoscopic (LA) adrenalectomy in terms of perioperative efficacy and safety.

METHODS

The present meta-analysis was completed in accordance with the guidelines provided by the PRISMA study group and the Cochrane Handbook for Systematic Reviews of Interventions. The electronic scholar databases (Medline, Web of Science, Scopus) were screened. For the reduction of type I errors, a trial sequential analysis (TSA) was performed.

RESULTS

Overall, 21 studies and 2997 patients were included in this study. RA was associated with a significantly lower open conversion rate (OR: 1.79; 95%CI: 1.10, 2.92) and length of hospitalization (LOS WMD: 0.52; 95%CI: 0.2, 0.84). Marginal results regarding blood loss were recorded (WMD: 2.02; 95%CI: 0.0, 4.03). TSA could not validate the superiority of RA in open conversion rate and blood loss. LA and RA were similar in terms of operative duration (P = 0.18) and positive margin (P = 0.81), complications (P = 0.94) and mortality rate (P = 0.45).

CONCLUSIONS

Even though RA and LA were equivalent regarding perioperative safety, RA was associated with a favorable LOS.

Perioperative outcomes of laparoscopic, robotic, and open approaches to pheochromocytoma

While multiple studies have demonstrated that minimally invasive surgical (MIS) techniques are a safe and efficacious approach to adrenalectomy for pheochromocytomas (PC), these studies have only been small comparative studies. The aim of this multi-institutional study is to compare perioperative outcomes between open and MIS, stratified by robotic and conventional laparoscopic, techniques in the surgical management of PC. We retrospectively evaluated patients who underwent adrenalectomy for PCs from 2000 to 2017 at three different institutions. Clinical, perioperative, and pathologic parameters were analyzed using t test, Chi square, and Fisher exact statistical measures. Of the 156 adrenalectomy cases performed, 26 (16.7%) were with an open approach and 130 (83.3%) using MIS techniques. Of the MIS procedures, 41 (31.5%) were performed robotically and 89 (68.5%) performed laparoscopically without robotic assistance. Demographic and clinical parameters were similar between the open and MIS groups. Patients, who underwent MIS procedure had a lower complication rate (p = 0.04), shorter hospitalization (p = 0.02), shorter operative time (p < 0.001), and less blood loss (p = 0.002) than those who underwent open surgical resection. Conventional laparoscopic and robotic operative approaches resulted in similar complication rates, length of hospitalization, and blood loss. Our study is one of the largest cohorts comparing the perioperative outcomes between conventional laparoscopic and robotic adrenalectomies in patients with PC. Our results support that MIS techniques have potentially lower morbidity compared to open techniques, while laparoscopic and robotic approaches have similar perioperative outcomes.

Robotic adrenalectomy: when and how?

Currently, laparoscopic adrenalectomy is considered as the preferred technique to manage adrenal tumors. However, there are no prospective randomized studies evaluating this strategy. With the recent advances in surgical equipment and the widespread of robotic technology, a robotic approach is considered as an interesting option in some medical centers. This approach seems to be feasible and safe but high-level evidence of its benefits is still lacking. This review summarizes indications, advantages and drawbacks of robotic adrenalectomy and describes its surgical technique.

Clinical analysis of adrenal lesions larger than 5 cm in diameter (an analysis of 251 cases)

Background

To describe the pathological distribution, imaging manifestations, and surgical managements and prognosis of large adrenal tumors (LATs) ≥ 5 cm

Methods

A total of 251 patients with LATs were analyzed on the basis of pathological or clinical diagnosis. Regarding surgery, open adrenalectomy was performed on 89 patients, and laparoscopic adrenalectomy was performed on 89 patients. Thirty-two patients with bilateral tumors were analyzed in terms of clinical characteristics. The survival rate was determined for 43 patients with adrenal metastases and 29 patients with primary adrenal malignancies. The CT characteristics including tumor diameter, shape, edge, heterogeneity, necrosis, calcification, pre-contrast attenuation, and contrast attenuation were analyzed for 117 patients.

Results

The majority of LATs were still benign, but they had a higher probability to be malignant. Benign LATs made up 68.13% of all cases, mainly adrenal cysts (19.52%), pheochromocytoma (18.73%), benign adenoma (16.73%), and myelolipoma (7.17%). Malignant LATs accounted for 28.69% of cases, mainly including adrenocortical carcinoma (8.76%) and metastases (17.13%). Laparoscopic surgery was found to involve less trauma than open surgery. It was also safer and postoperative recovery was faster, but it had drawbacks and could not completely replace open surgery. CT features had obvious specificity for the diagnosis of benign and malignant tumors. For example, benign adenomas had a smaller pre-contrast (< 10 Hu) whereas malignant adrenal tumors had, on the contrary, higher attenuation. Regarding adrenal malignant carcinoma, adrenal primary malignant tumors showed a better prognosis than adrenal metastases (mean survival of 19.17 months vs 9.49 months). Primary adrenal cortical carcinoma without metastasis had a better prognosis than primary adrenal cortical carcinoma metastasis (mean survival of 23.71 months vs 12.75 months), and adrenal solitary metastasis had a better prognosis than general multiple metastatic carcinoma (mean survival of 14.95 months vs 5.17 months).

Conclusion

LATs were more likely to be benign; however, they still had a high probability of being a malignant tumor. Understanding the clinicopathological characteristics of LATs can facilitate selection of more effective clinical treatment options.

Volume-outcome correlation in adrenal surgery-an ESES consensus statement

BACKGROUND

Published data in the last decade showed that a majority of adrenal operations are done by surgeons performing only one such case per year and based on the distribution of personal workloads 'high-volume' surgeons are defined as those doing 4 or more cases/year.

PURPOSE

This paper summarises literature data identified by a working group established by the European Society of Endocrine Surgeons (ESES). The findings were discussed during ESES-2019 conference and members agreed on a consensus statement.

RESULTS

The annual of adrenal operations performed yearly in individual countries was reported to be 800/year in UK and over 1600/year in France. The learning curve of an individual surgeon undertaking laparoscopic, retroperitoneoscopic or robotic adrenalectomy is estimated to be 20-40 cases. Preoperative morbidity and length of stay are more favourable in high-volume centres.

CONCLUSION

The main recommendations are that adrenal surgery should continue only in centres performing at least 6 cases per year, surgery for adrenocortical cancer should be restricted to centres performing at least 12 adrenal operations per year, and an integrated multidisciplinary team should be established in all such centres. Clinical information regarding adrenalectomies should be recorded prospectively and contribution to the established EUROCRINE and ENSAT databases is strongly encouraged. Surgeons wishing to develop expertise in this field should seek mentorship and further training from established adrenal surgeons.

Robotic adrenalectomy

With the recent advances in equipment and surgical techniques, robot-assisted surgery has become accepted and efficient in the surgical field. It is an emerging technology that can safely be applied for a broad spectrum of surgical procedures. As a result of increased ergonomics, three-dimensional view of the operative area and improved moving capacity of the robotic arms with multi-articulation, robotic technology also has found place in adrenal surgery. Recently, robot-assisted adrenal surgery has been adopted widely in many high-volume tertiary centers. Although there are expected theoretical benefits to this approach, the literature is lacking regarding high level evidence. In this review, we will discuss implementation of robotic adrenalectomy as well as perioperative and postoperative measures that helped improved outcomes, offer a comparison of outcomes between conventional laparoscopic adrenalectomy and robotic adrenalectomy and summarize recent developments that may offer evidence for or against a paradigm shift in this specific field of endocrine surgery.

The Impact of Body Mass Index on Perioperative Outcomes of Robotic Adrenalectomy: An Update

Background. Robotic surgery has gained increasing popularity over the past 2 decades. However, factors including patient comorbidities and tumor characteristics are still crucial factors for outcomes of surgery. In this study, we evaluated the impact of body mass index (BMI) on perioperative outcomes in patients who underwent robotic adrenal surgery. Methods. Between May 2012 and November 2017, 66 consecutive patients who underwent robotic adrenalectomy were included in this study. Patients were divided into 2 groups based on their BMI: nonobese (<30 kg/m²) and obese (≥30 kg/m²). Additionally, patient demographics, tumor size, total operative time, docking time, console time, estimated blood loss, conversion to open, complications, additional analgesia requirement, length of hospital stay, and rough costs were evaluated. Results. Of the 66 patients, a total of 26 patients were obese (30%). Between study groups, the median BMI was calculated as 26 (18-29) and 33 (30-57). The groups were similar in terms of age, gender, American Society of Anesthesiologists scores, and previous history of abdominal surgery. Likewise, there were no significant differences between groups regarding total operative time (P = .085), docking time (P = .196), console time (P = .211), estimated blood loss (P = .180), complications (P = .991), length of hospital stay (P = .598), and rough costs (P = .468). Five cases were converted to open surgery. Nonobese cases required additional analgesia (P = .007). We had no unexpected hospitalizations in either group. Conclusion. Guidelines express the advantages of robotic surgery in obese patients. No statistically significant differences were detected between the 2 groups except for the additional analgesia required in nonobese patients.

Robotic versus open resection of benign nonadrenal retroperitoneal tumors: A propensity score-matched study

BACKGROUND

Robotic resection of benign nonadrenal retroperitoneal tumors (BNRTs) is considered safety and feasibility. However, whether robotic BNRT resection (RBR) is superior to open BNRT resection (OBR) has not been reported. The comparative study was designed to analyze the short outcomes of RBR versus OBR on patients with BNRTs.

METHODS

Demographics and perioperative outcomes among patients who underwent RBR (n = 30) versus OBR (n = 30) for BNRTs between January 2015 and September 2018 were reviewed. A 1:1 propensity score matched analysis was performed between both groups.

RESULTS

There were no significant differences in the operative time, blood transfusion rate, and morbidity rate between the RBR and OBR groups. No patients underwent RBR required conversion to laparotomy. Robotic approach reduced estimated blood loss (EBL) (50 vs. 100 ml, p = 0.00) and postoperative hospital stay (PHS) significantly (4.6 vs. 7.9 d, p = 0.00) when compared with OBR. In patients with tumors adherent to major vessels, RBR also reduced EBL and PHS significantly (50 vs. 250 ml, p = 0.02; 4.4 vs. 9.3 d, p = 0.00), which were similar to the results of the patients with tumors larger than 5 cm (50 vs. 200 ml, p = 0.00; 4.9 vs. 7.5 d, p = 0.01).

CONCLUSIONS

When compared with OBR, RBR was associated with less EBL, and shorter PHS in selected patients even for tumors which are large or adherent to major vessels.

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.

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

BACKGROUND

The aim of this study is to compare the clinical outcomes of laparoscopic posterior retroperitoneal adrenalectomy (LPRA) and robotic posterior retroperitoneal adrenalectomy (RPRA) and determine the differences that could affect the outcomes.

METHODS

We retrospectively analyzed 230 adrenalectomy cases from 2014 to 2017. There were 169 LPRA and 61 RPRA cases, and their clinicopathological features and surgical outcomes were compared.

RESULTS

In LPRA, there was a positive relationship between operation time and male gender, early period of experience, adrenal tumor size, and pheochromocytoma. In RPRA, adrenal tumor size and pheochromocytoma were the factors affecting the operation time. When the adrenal tumor size was ≤5.5 cm, the operation time of LPRA was shorter than that of RPRA (p=0.001). When the tumor size was >5.5 cm, there was no significant difference in the operation times of LPRA and RPRA (p=0.102).

CONCLUSIONS

RPRA is a feasible and technically safe approach for benign adrenal diseases. The use of RPRA could benefit patients and provide comfort by overcoming the factors contributing to a longer operation time in the laparoscopic technique, such as male gender and high BMI.

A Comparison of Robotic Versus Laparoscopic Adrenalectomy in Patients With Primary Hyperaldosteronism

BACKGROUND

Over the last decade, robotic approaches have been described for removing adrenal tumors. Although there are reports comparing robotic and laparoscopic techniques in general, there are limited data on outcomes in patients with primary hyperaldosteronism (PHA). The aim of this study is to compare the safety and efficacy of robotic adrenalectomy (RA) versus laparoscopic adrenalectomy (LA) for PHA.

MATERIALS AND METHODS

The records of 20 patients who underwent RA for PHA were compared with 16 patients who underwent LA between 2000 and 2014. Data were retrospectively reviewed from a prospectively maintained, IRB-approved adrenal database. Statistical analysis was performed using t test and the Fisher exact analysis. Continuous variables are reported as mean±SEM.

RESULTS

Demographic and clinical parameters were similar between the groups. There were no conversions to open in either group. Estimated blood loss, length of stay, and complication rates were comparable. Operative time was shorter in the robotic versus laparoscopic group (130±8.94 vs. 159±11.1 min, P=0.0487). In follow-up, the improvement in patients' blood pressure after adrenalectomy, as assessed by the reduction in the number of antihypertensive medications, was similar between the 2 groups. However, 1 patient in the RA and 1 patient in the LA group were not cured, as determined by postoperative aldosterone:renin levels. The biochemical cure rate between the groups was similar (P=0.529).

CONCLUSIONS

To our knowledge, this is the first study comparing robotic versus laparoscopic resection of PHA. Our results show that the robotic approach was similar to laparoscopic regarding safety and efficacy. Operative time was shorter with the robotic approach, which could be related to more efficient dissection with wristed instrumentation.

Evaluation of Open and Minimally Invasive Adrenalectomy: A Systematic Review and Network Meta-analysis

BACKGROUND

Adrenalectomy can be performed via open and various minimally invasive approaches. The aim of this systematic review was to summarize the current evidence on surgical techniques of adrenalectomy.

METHODS

Systematic literature searches (MEDLINE, EMBASE, Web of Science, Cochrane Library) were conducted to identify randomized controlled trials (RCTs) and controlled clinical trials (CCTs) comparing at least two surgical procedures for adrenalectomy. Statistical analyses were performed, and meta-analyses were conducted. Furthermore, an indirect comparison of RCTs and a network meta-analysis of CCTs were carried out for each outcome.

RESULTS

Twenty-six trials (1710 patients) were included. Postoperative complication rates did not show differences for open and minimally invasive techniques. Operation time was significantly shorter for open adrenalectomy than for the robotic approach (p < 0.001). No differences were found between laparoscopic and robotic approaches. Network meta-analysis showed open adrenalectomy to be the fastest technique. Blood loss was significantly reduced in the robotic arm compared with open and laparoscopic adrenalectomy (p = 0.01). Length of hospital stay (LOS) was significantly lower after conventional laparoscopy than open adrenalectomy in CCTs (p < 0.001). Furthermore, both retroperitoneoscopic (p < 0.001) and robotic access (p < 0.001) led to another significant reduction of LOS compared with conventional laparoscopy. This difference was not consistent in RCTs. Network meta-analysis revealed the lowest LOS after retroperitoneoscopic adrenalectomy.

CONCLUSION

Minimally invasive adrenalectomy is safe and should be preferred over open adrenalectomy due to shorter LOS, lower blood loss, and equivalent complication rates. The retroperitoneoscopic access features the shortest LOS and operating time. Further high-quality RCTs are warranted, especially to compare the posterior retroperitoneoscopic and the transperitoneal robotic approach.

Laparoscopic versus robotic adrenalectomy: a review of the national inpatient sample

BACKGROUND

Laparoscopic adrenalectomy (LA) has become the standard treatment of adrenal lesions. Recently, robotic-assisted adrenalectomy (RA) has become an option, however, short-term outcomes for RA have not been well studied and benefits over LA are debatable. The aim of this study was to explore differences in short-term outcomes between LA and RA using the national inpatient sample (NIS) database.

METHODS

Patient data were collected from the NIS. All patients undergoing LA or RA from January 2009 to December 2012 were included. Univariate analysis and propensity matching were performed to look for differences between the groups.

RESULTS

A total of 1006 patients (66.4% in LA group and 33.6% in RA group) were identified. Patient age group, gender, race, risk of mortality, severity of illness or indication for adrenalectomy did not differ significantly between the LA or RA cohorts. Insurance type predicted procedure type (45% of medicare patients underwent RA versus 29% of patients with private insurance, p < 0.0001). Patients living in the highest income areas were more likely to receive the laparoscopic approach (31.7 versus 17.4%, p < 0.0001). Hospital volume, bed size and teaching status of the hospital were not significant factors in the decision of RA versus LA. There was no difference in complication and conversion rates between RA versus LA. The mean length of stay was shorter in the RA group (2.2 versus 1.9 days, p = 0.03). Total charges were higher in the RA group ($42,659 versus $33,748, p < 0.0001). There was a significant trend towards more adrenalectomies being performed robotic assisted by year. Only 22% of adrenalectomies were performed robotic-assisted in 2009 compared with 48% in 2012.

CONCLUSIONS

The overall benefit for RA remains small and higher total charges for RA may currently outweigh the benefits. These findings may change as more cases are performed robotically assisted and robotic technology improves.

Current status of robotic surgery in urology

As a result of ergonomics, optimal magnification of the operative field, surgeon dexterity, and precision of surgical manipulation, robotic technology has been shown to overcome many difficulties associated with pure laparoscopy. With the recent expansion of robot-assisted surgery in the field of urology and following the success of robot-assisted prostatectomy and robot-assisted partial nephrectomy, robot-assisted surgery is being applied to treat many other genitourinary diseases, such as bladder cancer and ureteropelvic junction obstruction. The aim of the present review is to discuss the role of robotic surgery in urology and summarize recent developments in the field of urologic robotic surgery.

Innovation in endocrine surgery: robotic versus laparoscopic adrenalectomy. Meta-analysis and systematic literature review

Several studies in the last years demonstrated the better surgical outcome of laparoscopic approach to adrenal gland. Laparoscopic surgery is more difficult to learn and requires different psychomotor skills than open surgery, especially with regard to complex maneuvers requiring precision and dexterity. The development of robotic platform with three-dimensional vision and increased degrees of freedom of the surgical instruments has the aim to overcome these problems. We performed a systematic literature review with meta-analysis to evaluate preoperative data and surgical outcomes of robotic adrenalectomy compared with laparoscopic technique. In September 2016 we performed a systematic literature review using the Pubmed, Scopus and ISI web of knowledge database with search term “robotic adrenalectomy”. We identified 13 studies with eligible criteria that compared surgical outcomes. This present systematic review with meta-analysis includes 798 patients: 379 underwent to robotic adrenalectomy (cases group) and 419 to laparoscopic adrenalectomy (controls group). There were no significant differences between the two groups of patients respect to age, gender, laterality and tumor size. BMI instead was significant lower in the robotic group. In this group we found also patients with higher incidence of previous abdominal surgery. The results from operative time demonstrated lower operative time for laparoscopic group but there were no significant differences with robotic group. Robotic adrenalectomy showed a significant lower blood loss. Robotic adrenalectomy is a safe and feasible technique with reduced blood loss and shorter hospital stay than laparoscopic adrenalectomy. Laparoscopic approach seems to be a more rapid technique when comparing to robotic technique, although recent studies demonstrate a significant operative time reduction in robotic group with the learning curve improvement and the development of new surgical technology.