Robot-assisted Adrenalectomy

Clinical Management of Primary Aldosteronism: An Update

Despite carrying an excess risk of cardiovascular events, primary aldosteronism (PA) is a commonly overlooked secondary form of arterial hypertension. An increased awareness of its high prevalence and broader screening strategies are urgently needed to improve its detection rate and allow early diagnosis and targeted treatment. For patients with unilateral PA, these measures can correct hyperaldosteronism and ensure cure of hypertension, even when resistant to drug treatment, thus preventing adverse cardiovascular events. Among these, atrial fibrillation is the most common, but left ventricular hypertrophy, stroke, chronic kidney disease, and myocardial infarction also occur more often than in patients with hypertension and no PA. Young patients, who have higher chances of being cured long term, and high-risk patients, such as those with stage III or resistant hypertension, are those who will benefit most from an early diagnosis of PA. Therefore, the implementation of strategies to detect PA by a simplified diagnostic algorithm is necessary. In the patients who seek for surgical cure, adrenal vein sampling is key for the identification of unilateral PA and the achievement of optimal outcomes. Unfortunately, being technically demanding and poorly available, adrenal vein sampling represents the bottleneck in the workup of PA. Considering the novel knowledge generated in the past 5 years in many studies, particularly in the AVIS-2 study (Adrenal Vein Sampling International Study-2), based on 4 decades of experience at our center and on the last guidelines, we herein provide an update on the management of PA with recommendations for drug treatment and strategies to avoid adrenal vein sampling wherever it is poorly, or not, available.

Laparoscopic versus robotic lateral transabdominal adrenalectomy

BACKGROUND AND OBJECTIVES

Despite an increased adaptation of robotic adrenalectomy, its advantages over laparoscopic adrenalectomy (LA) have not been defined. The aim of the study was to compare perioperative outcomes of robotic versus laparoscopic lateral transabdominal adrenalectomy using a large single-center experience.

METHODS

This was a retrospective single center study. Within 22 years, patients who underwent laparoscopic and robotic transabdominal lateral adrenalectomy were identified from a prospective institutional review board-approved database. Clinical and perioperative outcomes were compared using Mann-Whitney U and χ2  tests.

RESULTS

There were 190 patients who underwent laparoscopic and 281 patients who underwent robotic transabdominal lateral adrenalectomy. The groups were comparable except for a higher percentage of female patients in the robotic group. For robotic versus LA, operative time and hospital stay were shorter, in addition to less blood loss, conversion to open and margin positivity, for pheochromocytoma and malignant tumors. Morbidity rates were similar between the two groups.

CONCLUSIONS

Despite the limitations of a retrospective design, this large study demonstrates significant advantages of robotic versus laparoscopic transabdominal lateral adrenalectomy in terms of perioperative outcomes and margin clearance.

Laparoscopic versus robotic adrenalectomy in pheochromocytoma patients

BACKGROUND AND OBJECTIVES

Pheochromocytoma is a challenging tumor type requiring resection with a clear margin and an intact capsule to prevent recurrences. Our aim was to compare perioperative outcomes of laparoscopic adrenalectomy (LA) versus robotic adrenalectomy (RA) for pheochromocytoma.

METHODS

In an institutional review board-approved retrospective study, clinical parameters of patients who underwent LA versus RA at a single center were compared using Mann-Whitney U, χ² , and survival analyses. Continuous data are expressed as median (interquartile range).

RESULTS

There was a total of 157 patients (RA: n = 87, LA: n = 70) analyzed. Estimated blood loss (36.3 [35.0] vs. 99.9 [65.0] cc, p = 0.020) and hospital stay (1.3 [0.0] vs. 2.2 [1.0] days, p = 0.010) were lower in robotic versus laparoscopic group, respectively. Disease-free and overall survival was similar between groups. The rate of conversion to open for tumors ≥5 cm was less in the robotic group (0% vs. 14%, respectively, p = 0.048).

CONCLUSION

In this study, long-term outcomes of LA and RA were similar, although adrenalectomies performed robotically were associated with less blood loss, shorter hospital stay, and a lower chance of conversion to open in the case of large tumors.

Robotic Adrenalectomy: A 10-Year Clinical Experience at a Tertiary Medical Center

Background and Objective:

Laparoscopic adrenalectomy is now the preferred approach for most adrenal tumors. As minimally invasive surgery departments gain familiarity with the robotic platform, the safety profiles and efficacy of robotic adrenalectomy has been an area of continued discussion. The objective of this study is to outline our experience with transitioning to the robotic platform and determining the effectiveness and safety of transperitoneal robotic adrenalectomy.

Methods:

We performed a single-center, retrospective review of 37 patients who underwent transperitoneal robotic adrenalectomy between August 1, 2010 and August 31, 2020. Outcomes included patient morbidity, hospital length of stay, operative time, estimated blood loss, gland volume, pathology, and postoperative complications.

Results:

Sixty-five percent of the total robotic adrenalectomies were of the left adrenal gland. The average operating room time was 213 minutes. The average gland volume was 71 cm³, estimated blood loss was 74 mL and length of stay was 1.4 days. There were no significant differences in outcomes between the right and left total robotic adrenalectomies. Approximately one-third of our cohort had an adrenal cortical adenoma, while only one patient had adrenal cortical carcinoma. Four patients experienced postoperative complications that resulted in unplanned hospital readmissions and there was one mortality.

Conclusions:

Although the standard of care for most adrenal tumors is laparoscopic resection, our 10-year experience has shown that robotic adrenalectomy is highly effective and can be a valuable tool in the community and academic setting.

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 approach for partial adrenalectomy

Although safe and feasible, partial adrenalectomy is not a widespread procedure. Endorsement of robotic technologies and fluorescence techniques in adrenal surgery might help develop partial adrenalectomy and could avoid unnecessary total adrenalectomies. When performed in selected cases, partial adrenalectomy is associated with good postoperative outcomes comparable with those reported after total adrenalectomy. It has been hypothesized that one of the advantages of the robotic approach in adrenal-sparing surgery is to reduce manipulation of the gland allowing preservation of the vascularization of the residual adrenal, overcoming some limits when performing a laparoscopic conventional approach. A major drawback of the robotic surgery is its cost, but the overcost due to the use of the robotic system could be balanced by the execution of a high number of partial adrenalectomies leading to fewer life-long replacement steroid treatment. Partial adrenalectomy could become the recommended management for small benign and hormonal active adrenal tumors. Indocyanine green fluorescence (IGF) also seems to be a useful technique to help surgeons identify the adrenal gland and to locate small tumors from the normal adrenal tissue in difficult patients. It is likely that the use of a robotic approach associated with IGF may extend indications of partial adrenalectomy in the years to come.

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.

Primary Aldosteronism: JACC State-of-the-Art Review

Primary aldosteronism (PA) is a common, but frequently overlooked, cause of arterial hypertension and excess cardiovascular events, particularly atrial fibrillation. As timely diagnosis and treatment can provide a cure of hyperaldosteronism and hypertension, even when the latter is resistant to drug treatment, strategies to screen patients for PA early with a simplified diagnostic algorithm are justified. They can be particularly beneficial in some subgroups of hypertensive patients, as those who are at highest cardiovascular risk. However, identification of the surgically curable cases of PA and achievement of optimal results require subtyping with adrenal vein sampling, which, as it is technically challenging and currently performed only in tertiary referral centers, represents the bottleneck in the work-up of PA. Measures aimed at improving the clinical use of adrenal vein sampling and at developing alternative techniques for subtyping, alongside recommendations for drug treatment, including new development in the field, and for follow-up are discussed.

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.

Adrenalectomy for Cushing's syndrome: do's and don'ts

Aim. To present specific aspects of adrenalectomy for Cushing’s syndrome (CS) by introducing well established aspects (“do’s”) and less known aspects (“don’ts”).

Material and Method. This is a narrative review.

Results. The “do’s” for laparoscopic adrenalectomy (LA) are the following: it represents the “gold standard” for secretor and non-secretor adrenal tumors and the first line therapy for CS with an improvement of cardio-metabolic co-morbidities; the success rate depending on the adequate patients’ selection and the surgeon’s skills. The “don’ts” are large (>6-8 centimeters), locally invasive, malignant tumors requiring open adrenalectomy (OA). Robotic adrenalectomy is a new alternative for LA, with similar safety and conversion rate and lower pain drugs use. The “don’ts” are the following: lack of randomized controlled studies including oncologic outcome, different availability at surgical centers. Related to the sub-types of CS, the “do’s” are the following: adrenal adenomas which are cured by LA, while adrenocortical carcinoma (ACC) requires adrenalectomy as first line therapy and adjuvant mitotane therapy; synchronous bilateral adrenalectomy (SBA) is useful for Cushing’s disease (only cases refractory to pituitary targeted therapy), for ectopic Cushing’s syndrome (cases with unknown or inoperable primary site), and for bilateral cortisol producing adenomas. The less established aspects are the following: criteria of skilled surgeon to approach ACC; the timing of surgery in subclinical CS; the need for adrenal vein catheterization (which is not available in many centers) to avoid unnecessary SBA.

Conclusion. Adrenalectomy for CS is a dynamic domain; LA overstepped the former OA area. The future will improve the knowledge related to RA while the cutting edge is represented by a specific frame of intervention in SCS, children and pregnant women.

Abbreviations: ACC = adrenocortical carcinoma, ACTH = Adrenocorticotropic Hormone, CD = Cushing’s disease, CS = Cushing’s syndrome, ECS = Ectopic Cushing’s syndrome, LA = laparoscopic adrenalectomy, OA = open adrenalectomy, PA = partial adrenalectomy, RA = robotic adrenalectomy, SCS = subclinical Cushing’ syndrome

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Synchronous bilateral adrenalectomy for Cushing's syndrome: laparoscopic versus posterior retroperitoneoscopic versus robotic approach

BACKGROUND

Synchronous endoscopic bilateral adrenalectomy (BilA) can effectively provide definitive cure of hypercortisolism in ACTH-dependent Cushing's syndrome and in primary adrenal bilateral disease. We compared three different approaches for BilA: transabdominal laparoscopic BilA (TL-BilA), simultaneous posterior retroperitoneoscopic BilA (PR-BilA), and robot-assisted BilA (RA-BilA).

METHODS

All patients who underwent BilA between January 1999 and December 2012 at two referral centers (one performing TL-BilA and PR-BilA and one performing RA-BilA) were included. A comparative analysis was performed.

RESULTS

Twenty-nine patients were included: 5 underwent TL-BilA, 11 underwent PR-BilA, and 13 underwent RA-BilA. No significant difference was found concerning age, gender, diagnosis, and previous abdominal surgery. No conversion to open approach was registered. Operative time was significantly shorter for the PR-BilA group than for the TL-BilA and RA-BilA groups (157.4 ± 54.6 vs 256.0 ± 43.4 vs 221.5 ± 42.2 min, respectively) (P < 0.001). No significant difference was found concerning intraoperative and postoperative complications rate and time to first flatus. Drains were used routinely after PR-BilA and TL-BilA and electively in four RA-BilA patients (P < 0.001). Hospital stay was longer in the TL-BilA and PR-BilA groups than in the RA-BilA group (12.0 ± 5.7 vs 10.8 ± 3.7 vs 4.4 ± 1.7 days, respectively) (P < 0.001). No recurrence or disease-related death was registered.

CONCLUSIONS

Operative time was significantly shorter in the PR-BilA group, because it eliminates the need to reposition the patient. The number of drains and the length of hospital stay were reduced after RA-BilA, but this was likely related to different management protocols in different settings. Because no significant difference was found in terms of postoperative outcome, none of the three operative approaches can be considered the preferable one.

The early results of our initial experience with robotic adrenalectomy

OBJECTIVE

Robotic adrenalectomy is one of the minimally invasive surgical methods gaining wide acceptance due to the three-dimensional imaging system and ergonomics of the equipment. We aimed to present the early data on patients who underwent robotic adrenalectomy due to adrenal masses in our hospital.

MATERIAL AND METHODS

The records of eight cases, in which a unilateral robotic trans-peritoneal adrenalectomy was conducted due to an adrenal mass between 2011 and 2013, have been evaluated. Demographic characteristics of cases, body mass index (BMI), American Society of Anesthesiologists (ASA) score, preoperative diagnosis, diameter and localization of the adrenal mass, operative time, blood loss, conversion rate to open surgery, morbidity and mortality rates, length of hospital stay, total hospital charges and postoperative pathologic results were considered.

RESULTS

The female to male ratio was 6:2, the median age was 49.5 (26-71) and the median BMI was 29.7 (21.7-38.5). An adrenalectomy was performed in six cases for a right adrenal mass and in two cases for a left adrenal mass. The mean tumor diameter was 53.6 mm (20-90). The average surgical time (including docking) was 98 min. (55-175 min.) and the average blood loss was 50 mL. The only complication was a diaphragm injury which was repaired robotically. There were no conversions to traditional laparoscopic or open surgery and there have not been any mortality in the series. The median length of hospital stay was 4.1 days (range 2-11) and the average cost was 3617.12 TL ($1808.56).

CONCLUSION

Robotic adrenalectomy is an effective and safe surgical alternative to laparoscopic adrenalectomy. However its high cost has emerged as its main disadvantage.

Robotic versus laparoscopic adrenalectomy: what is the best?

Evaluation of: Karabulut K, Agcaoglu O, Aliyev S et al. Comparison of intraoperative time use and perioperative outcomes for robotic versus laparoscopic adrenalectomy. Surgery 151(4), 537-542 (2012) Currently, laparoscopic adrenalectomy is regarded as the preferred surgical approach for the management of most adrenal surgical disorders. Despite the benefits of laparoscopic adrenalectomy over open approaches, the procedure has shortcomings such as the absence of 3D perception, reduced dexterity and poor ergonomics for the surgeon. Recently, robotic technology has been introduced and could theoretically improve the laparoscopic adrenalectomy procedure and lead to improved perioperative and postoperative outcomes. A recent study by Karabulut et al. provides a comparison of intraoperative time analysis and perioperative outcomes for robotic adrenalectomy versus laparoscopic adrenalectomy. These data suggest that the use of a robotic system could improve perioperative outcomes when performing an adrenalectomy.

Robotic versus laparoscopic adrenalectomy in obese patients

BACKGROUND

Recently, we demonstrated better perioperative outcomes with robotic versus laparoscopic adrenalectomy (LA) with the posterior retroperitoneal approach in general, and for removal of large adrenal tumors. It is unknown if robotic adrenalectomy (RA) is equivalent to LA in obese patients. The aim of this study is to compare perioperative outcomes of RA versus LA in obese patients.

METHODS

Between 2003 and 2012, 99 obese (BMI ≥ 30 kg/m(2)) patients underwent adrenalectomy at a tertiary academic center. Of these, 42 patients had RA and 57 had LA. The perioperative outcomes of these patients were compared between the RA and LA groups. Data were collected from a prospectively maintained, institutional review board approved database. Clinical and perioperative parameters were analyzed using Student t and χ(2) tests. All data are expressed as mean ± standard error of the mean.

RESULTS

The groups were similar in terms of age, gender, and tumor side. Body mass index was lower in the robotic versus laparoscopic group (35.4 ± 1.0 vs. 38.8 ± 0.8 kg/m(2), respectively, p = 0.01). Tumor size (4.0 ± 0.4 vs. 4.3 ± 0.3 cm, respectively, p = 0.56), skin-to-skin operative time (186.1 ± 12.1 vs. 187.3 ± 11 min, respectively, p = 0.94), estimated blood loss (50.3 ± 24.3 vs. 76.6 ± 21.3 ml, respectively, p = 0.42), and hospital stay (1.3 ± 0.1 vs. 1.6 ± 0.1 days, respectively, p = 0.06) were similar in both groups. The conversion to open rate was zero in the robotic and 5.2 % in the laparoscopic group (p = 0.06). The 30-day morbidity was 4.8 % in the robotic and 7 % in the laparoscopic group (p = 0.63).

CONCLUSIONS

Our study did not show any difference in perioperative outcomes between RA and LA in obese patients. These results suggest that the difficulties in maintaining exposure and dissection in obese patients nullify the advantages of robotic articulating versus rigid laparoscopic instruments in adrenal surgery.