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

Partial versus total adrenalectomy for pheochromocytoma: a population-based comparison of outcomes

PURPOSE

The literature assessing outcomes of partial adrenalectomy (PA) among patients with pheochromocytoma patients is largely limited to isolated, single-institution series. We aimed to perform a population-level comparison of outcomes between patients undergoing PA versus those undergoing total adrenalectomy (TA).

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database (1975-2016) was queried to identify adults with pheochromocytoma who underwent either PA or TA. Survival was assessed using multivariable Cox proportional hazards regression, Fine and Gray competing-risks regression, propensity score matching, Kaplan-Meier analysis, and cumulative incidence plots.

RESULTS

286 patients (PA: 101, TA: 185) were included in this study. As compared to those undergoing TA, patients undergoing PA had fewer tumors ≥ 8 cm in size (28.7% versus 42.7%, p = 0.048) and were more likely to have localized disease (61.4% versus 44.3%, p = 0.01). In multivariable analysis, patients undergoing PA demonstrated similar all-cause mortality (HR = 0.71, 95% CI 0.44-1.14, p = 0.16) and cancer-specific mortality (HR = 0.64, 95% CI 0.35-1.17, p = 0.15) compared to those who underwent TA. Following 1:1 propensity score matching, Kaplan-Meier analysis revealed no difference in overall survival between PA and TA groups (p = 0.26) nor was there a difference in the cumulative incidence of cancer-specific mortality (p = 0.29).

CONCLUSIONS

In this first population-level comparison of outcomes among patients with pheochromocytoma undergoing PA and those undergoing TA, we found no long-term differences in any survival metric between groups. PA circumvents the need for lifelong corticoid replacement therapy and remains a promising option for patients with bilateral or recurrent pheochromocytoma.

Robotic-Assisted Minimally Invasive Surgery in Children

Currently, minimally invasive surgery (MIS) includes conventional laparo-thoracoscopic surgery and robot-assisted surgery (RAS) or robotic surgery. Robotic surgery is performed with robotic devices, for example the Da Vinci system from Intuitive Surgical, which has a miniaturized camera capable of image magnification, a three-dimensional image of the surgical field, and the instruments are articulated with 7 degrees of freedom of movement, and the surgeon operates in a sitting position at a surgical console near the patient. Robotic surgery has gained an enormous surge in use on adults, but it has been slowly accepted for children, although it offers important advantages in complex surgeries. The areas of application of robotic surgery in the pediatric population include urological, general surgery, thoracic, oncological, and otorhinolaryngology, the largest application has been in urological surgery. There is evidence that robotic surgery in children is safe and it is important to offer its benefits. Intraoperative complications are rare, and the frequency of postoperative complications ranges from 0–15%. Recommendations for the implementation of a pediatric robotic surgery program are included. The future will be fascinating with upcoming advancements in robotic surgical systems, the use of artificial intelligence, and digital surgery.

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.

Single-incision robotic adrenalectomy (SIRA): the future of adrenal surgery?

In compliance with the trend toward less invasive techniques, single incision robotic surgeries have become more common and they have been increasingly used for several surgeries including adrenalectomy. Single incision robotic adrenalectomy (SIRA) aims to combine the merits of robotic surgery with previously defined single incision laparoscopic techniques. It has been shown to be safe and feasible, however, there are only few studies on this new technique. Due to scant data on SIRA in the current literature, it remains to be a current challenge in adrenal surgery. In this review, our goal is to present current literature on SIRA and discuss the data regarding perioperative outcomes, patient selection, learning curve, and its limitations.

Robotic-Assisted Retroperitoneoscopic Adrenalectomy: Making a Good Procedure Even Better

Posterior retroperitoneoscopic adrenalectomy (PRA) is a minimally invasive procedure offering several advantages over a transabdominal laparoscopic operation. The three-dimensional optics and articulating instrumentation offered by current robotic surgical technology potentially improve this procedure. Robotic-assisted PRA (RA-PRA) was performed in patients meeting standard criteria for minimally invasive adrenalectomy. We prospectively collected demographic, clinical, perioperative, and pathologic data on patients undergoing RA-PRA. Thirty consecutive RA-PRAs were performed in 28 patients (26 unilateral and 2 bilateral). Indications for adrenalectomy included pheochromocytoma (8), hyperaldosteronism (3), hypercortisolism (8), oligometastases (5), and nonfunctional tumors (6). Mean tumor size was 3.8 ± 1.6 cm. Mean body mass index was 30.7 ± 6.5 kg/m2. Mean operative time was 154 ± 43 minutes for unilateral total adrenalectomy. Four patients with multiple endocrine neoplasia Type 2A-associated pheochromocytomas underwent cortical-preserving procedures. Three patients experienced perioperative complications (one pneumothorax, one urinary retention, one required postoperative blood transfusion). No patient required conversion to an open procedure. Robotic surgical technology is an excellent complement to retroperitoneoscopic adrenalectomy. The three-dimensional view and ergonomic advantages of a robotic procedure promote better visualization and a more flexible approach to dissection. We believe these features may optimize the ability to maintain a vascularized remnant during minimally invasive cortical-sparing adrenalectomy.

Robotic enucleation of adrenal masses: technique and outcomes

OBJECTIVES

To evaluate the feasibility and safety of the application of robotic enucleation of adrenal masses (REAM).

METHODS

Thirteen patients at Shanghai Changhai Hospital who underwent robotic enucleation of adrenal mass from February 2017 to March 2018 were reviewed. After mobilizing the adrenal gland and clamping the feeding blood vessels, the tumor was enucleated and reconstruction was performed. Relevant clinical data were recorded including baseline patient and tumor characteristics, and perioperative outcomes (operating time, ischemic time, estimated blood loss, complications, and so on).

RESULTS

All cases were successfully completed without conversion to total adrenalectomy or open surgery. The mean operative time was 75 min (range 60-95), with a mean warm ischemia time of 12 min (range 8-17). The estimated blood loss was 20 mL (range 10-50). No intraoperative complications were observed, and no steroid replacement was given post-operatively. After a median follow-up period of 12 months (range 9-15), no evidence of disease recurrence was detected.

CONCLUSIONS

Robotic enucleation of adrenal masses is a safe and feasible procedure with excellent short-term functional and oncologic outcomes. Steroid supplementation is not necessary and recurrence is not usual with limited follow-up. Long-term follow-up and larger studies should be conducted to further evaluate outcomes of this robotic adrenal-sparing approach.

Is there any role for minimally invasive surgery in NET?

Neuroendocrine tumors (NET) represent the variability of almost benign lesions either secreting hormones occurring as a single lesion up to malignant lesions with metastatic potential. Treatment of NET is usually performed by surgical resection. Due to the rarity of NET, surgical treatment is mainly based on the experience and recommendations of experts and less on the basis of prospective randomized studies. In addition, the development and establishment of new surgical procedures is made more difficult by their rarity. The development of laparoscopic-assisted surgery has significantly improved the treatment of many diseases. Due to the well-known advantages of laparoscopic surgery, this method has also been increasingly used to treat NET. However, due to limited comparative data, the assumed superiority of laparoscopic surgery in the area NET remains often unclear or not yet proven. This review focuses on the present usage of laparoscopic techniques in the area of NET. Relating to the current literature, this review presents the evidence of various laparoscopic procedures for treatment of adrenal, pancreatic and intestine NET as well as extraadrenal pheochromocytoma and neuroendocrine liver metastases. Further, this review focuses on recent new developments of minimally invasive surgery in the area of NET. Here, robotic-assisted surgery and single-port surgery are promising approaches.

Revisiting robotic approaches to endocrine neoplasia: do the data support their continued use?

PURPOSE OF REVIEW

Although the advent of the robot has revolutionized the modern treatment of endocrine neoplasia, substantial controversies exist on its applicability, safety and benefits over the conventional laparoscopic operations. The present review aims to review the recent literature on various robotic approaches in treating thyroid, parathyroid, adrenal and pancreatic endocrine neoplasia and see whether its continued use should be supported.

RECENT FINDINGS

In summary, the role of robotic thyroidectomy has been clearly established and should be continued by experienced surgeons on selected patients. Because of the limited availability of evidence, the feasibility of robotic parathyroidectomy has yet to be elucidated. With proven favorable perioperative outcomes, robotic adrenalectomy and pancreatectomy should be continued as potential alternatives to conventional surgery.

SUMMARY

Robotic endocrine procedures still play a pivotal role in minimally invasive endocrine surgery with demonstrable safety and effectiveness. Future research should embark on prospective randomized-controlled trials on robotic endocrine procedures to collect higher level of evidence and long-term survival data.

Robotic renal surgery: The future or a passing curiosity?

The development, advancement and clinical integration of robotic technology in surgery continue at a staggering pace. In no other discipline has this rapid evolution occurred to a greater degree than in urology. Although radical prostatectomy has grown to become the prototypical application for the robot, the role of the robot in renal surgery remains controversial. Herein we review the literature on robotic renal surgery. A comprehensive PubMed literature search was performed to identify all published reports relating to robotic renal surgery. All clinically related articles involving human participants were critically appraised in this review. Fifty-one clinical articles were included, encompassing robot-assisted pyeloplasty, nephrectomy, nephroureterectomy, living-donor nephrectomy and partial nephrectomy. Feasibility has been shown for each of these procedures. Robot-assisted techniques have been described for almost all renal-related procedures. However, the intersect between feasibility and necessity as it pertains to robotic renal surgery has yet to be defined. Also, the high cost of surgical robotic technology mandates critical appraisal before adoption, especially in a publicly funded health care system, such as the one present in Canada.

Robotic endocrine surgery: technical details and review of the literature

Over the last decade, robotic technology has been used in multiple general surgical procedures. Endocrine surgeons have embraced this technology and subsequently transformed neck operations into more cosmetically acceptable procedures and improved ergonomics. Technical details of various robotic endocrine surgical procedures have recently been described. The aim of this review is to illustrate these technical details and analyze the current data to propose an evidence-based approach to robotic endocrine surgery.

The emerging role of robotics in adrenal surgery

Robotic surgery is being performed more frequently for a variety of urologic procedures. Since the first robotic adrenalectomy less than a decade ago, this modality has gained increased acceptance in the urologic community and has been employed with increased frequency in minimally invasive centers. This review evaluates the current literature on robotic adrenalectomy, its indications, as well as its advantages and limitations compared with other forms of surgical management of adrenal pathology.

Concurrent robotic partial adrenalectomy and extra-adrenal pheochromocytoma resection in a pediatric patient with von Hippel-Lindau disease

Laparoscopic partial adrenalectomy is a surgical option for select patients with hereditary pheochromocytoma. We present a case of a pediatric patient with von Hippel-Lindau disease (VHL) and both an adrenal pheochromocytoma and an extra-adrenal pheochromocytoma, who underwent concurrent partial adrenalectomy and extra-adrenal pheochromocytoma resection utilizing robotic assistance. To the best of our knowledge, this is the first report of partial adrenalectomy with concurrent extra-adrenal pheochromocytoma resection.

Adrenal-preserving minimally invasive surgery: update on the current status of laparoscopic partial adrenalectomy

Adrenalectomy is the standard of care for hormonally active adrenal masses. In recent years, minimally invasive laparoscopic excision has become a preferred management option. As with advances in parenchymal-sparing renal surgery, investigators have begun to examine adrenal-sparing procedures to preserve functional adrenal tissue. This article reviews the recent literature and reports on intermediate results with laparoscopic partial adrenalectomy (LPA).

Robotic adrenalectomy

The use of robotics in surgery is an emerging field. Robot-assisted laparoscopic adrenalectomy has been performed in small numbers worldwide. Advantages of robotic assistance over conventional laparoscopy are not acknowledged. Improvement in robotic technology, including addition of tactile feedback, miniaturization of end-effectors, reduced cost, and advances in remote surgery telecommunication technology are awaited.