Robot-assisted vs open adrenalectomy: evaluation of cost-effectiveness and peri-operative outcome

[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.

Open versus Minimally Invasive Nephroureterectomy: Contemporary Analysis from a Wide National Population-Based Database

BACKGROUND

It is generally perceived that minimally invasive nephroureterectomy (MINU), especially in the form of robotic-assisted laparoscopy, is gaining an increasing role in many institutions.

OBJECTIVE

The aim of our study was to investigate contemporary trends in the adoption of MINU in the United States compared with open nephroureterectomy (ONU).

METHODS

Patients who underwent ONU or MINU between 2011 and 2021 were retrospectively analyzed using PearlDiver Mariner, an all-payer insurance claims database. International Classification of Diseases diagnosis and procedure codes were used to identify the type of surgical procedure, patients' characteristics, social determinants of health (SDOH), and perioperative complications. The primary objective assessed different trends and costs in NU adoption, while secondary objectives analyzed factors influencing the postoperative complications, including SDOH. Outcomes were compared using multivariable regression models.

RESULTS

Overall, 15,240 patients underwent ONU (n = 7675) and MINU (n = 7565). Utilization of ONU declined over the study period, whereas that of MINU increased from 29 to 72% (p = 0.01). The 60-day postoperative complication rate was 23% for ONU and 19% for MINU (p < 0.001). At multivariable analysis, ONU showed a significantly higher risk of postoperative complications (odds ratio 1.33, 95% CI 1.20-1.48). Approximately 5% and 9% of patients reported at least one SDOH at baseline for both ONU and MINU (p < 0.001).

CONCLUSIONS

Contemporary trend analysis of a large national dataset confirms that there has been a significant shift towards MINU, which is gradually replacing ONU. A minimally invasive approach is associated with lower risk of complications. SDOH are non-clinical factors that currently do not have an impact on the outcomes of nephroureterectomy.

Economic Evaluations of Robotic-Assisted Surgery: Methods, Challenges and Opportunities

BACKGROUND

The use of robotic-assisted surgery (RAS) is growing rapidly. However, economic evaluation of this technology is challenging. This study aims to identify and discuss the different economic evaluation methods which have been used to evaluate RAS.

METHOD

This scoping review systematically searched PubMed and Embase from 2015 to 2023. We included economic evaluation studies comparing RAS versus laparoscopic or open surgery. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was used to aid data extraction and was extended to cover additional features relevant to RAS, including learning curve, organisational impact, incremental innovation and dynamic pricing.

RESULTS

A total of 50 economic evaluations of RAS were included. Cost-utility analysis (46%) was the most commonly applied economic evaluation method, followed by cost-consequence analysis (32%). The studies focused on the specialties of urology (42%), hepato-pancreato-biliary (20%), colorectal (14%) and gynaecology (6%). Distinctive features related to the assessment of RAS were under-addressed in economic evaluations. Only 40% of the included studies considered learning curve and organisational impact and less than 12% of the included studies reflected on incremental innovation and dynamic pricing.

CONCLUSIONS

This review found that some studies have incorporated challenges specific to RAS in their evaluations. However, most studies still lack key aspects of importance. In particular, studies rarely considered the ability of RAS platforms to be shared across multiple specialities. Incorporating these distinctive features offers an opportunity for economic evaluation to provide decision-makers with a more realistic assessment of the cost-effectiveness of this technology and to ensure its optimal utilisation in clinical practice.

Last Resort from Nursing Shortage? Comparative Cost Analysis of Open vs. Robot-Assisted Partial Nephrectomies with a Focus on the Costs of Nursing Care

Despite perioperative advantages, robot-assisted surgery is associated with high costs. However, the lower morbidity of robotic surgery could lead to a lower nursing workload and cost savings. In this comparative cost analysis of open retroperitoneal versus robot-assisted transperitoneal partial nephrectomies (PN), these possible cost savings, including other cost factors, were quantified. Therefore, patient, tumor characteristics, and surgical results of all PN within two years at a tertiary referral center were retrospectively analyzed. The nursing effort was quantified by the local nursing staff regulation and INPULS^® intensive care and performance-recording system. Out of 259 procedures, 76.4% were performed robotically. After propensity score matching, the median total nursing time (2407.8 vs. 1126.8 min, p < 0.001) and daily nursing effort (245.7 vs. 222.6 min, p = 0.025) were significantly lower after robotic surgery. This resulted in mean savings of EUR 186.48 in nursing costs per robotic case, in addition to savings of EUR 61.76 due to less frequent administrations of erythrocyte concentrates. These savings did not amortize the higher material costs for the robotic system, causing additional expenses of EUR 1311.98 per case. To conclude, the nursing effort after a robotic partial nephrectomy was significantly lower compared to open surgery; however, this previously unnoticed savings mechanism alone could not amortize the overall increased costs.

Robotic surgery in comparison to the open and laparoscopic approaches in the field of urology: a systematic review

To establish the feasibility of robotic surgical procedures in urology in terms of the applications, merits, and demerits as well as the postoperative and oncological outcomes while comparing it with the conventional approaches. A systematic search of electronic databases was performed to identify Randomized Controlled Trials and Cohort studies on Robot-Assisted urological surgical procedures in comparison with the conventional methods. The quality assessment of included studies was performed using the Newcastle-Ottawa Scale and the revised Cochrane "Risk of Bias" tool. A qualitative narrative synthesis of the data extracted from the studies was performed and presented in tabulated form. After screening, 39 studies were included in our review (7 Randomized Controlled Trials and 32 Cohort studies). Robot-Assisted Prostatectomy appears to be associated with lower estimated blood loss and shorter length of hospital stay. For Robot-Assisted Cystectomy, the results suggest longer operative time and fewer complications. Robot-Assisted Radical Nephrectomy was found to be associated with fewer perioperative complications and longer mean operative time while Robot-Assisted Partial Nephrectomy was associated with less positive surgical margins and reduced need for postoperative analgesia. The mean operative time was longer while the length of stay was shorter for the robotic approach in inguinal lymphadenectomy and ureteral reimplantation. The feasibility of Robot-Assisted surgery varied for different outcome measures as well as for different procedures. Some common advantages were a shorter length of stay, lesser blood loss, and fewer complications while the drawbacks included longer operative time.Study protocol PROSPERO database (Registration Number: CRD42021256623).

Robot-assisted and conventional urology surgical procedures: comparison of average length of stay, economic status, operative time and patient's expenditure in a tertiary care hospital of North India

Robot-assisted surgeries allows the surgeons to operate using remote-controlled robotic arms that are more effective in comparison to conventional (open/laparoscopic) surgeries. However, there is substantial lack of evidence on the effectiveness of robot-assisted surgeries in low to middle income countries (LMICs) like India. A study was conducted with an aim to evaluate the average length of stay (ALOS), Operative time, economic status (patient's) and cost borne by the patient (patient's expenditure) for undergoing robot-assisted surgeries and conventional surgeries. Grouping of the surgical procedures was done wherein patients who were treated with robot-assisted surgical procedures were placed in Group-01 whereas those treated with conventional surgical procedures were placed under Group-02. Comparative evaluation of the two surgical groups revealed that in robot-assisted surgical procedure, the ALOS was less (18.43 vs. 23.14 days, p = 0.06) whereas operative time (316.7 vs. 252.63 min, p = 0.05) and patient's expenditure were more (INR 70,654.29 vs. INR 41,314.73, p = 0.00). However, there was no significant difference between the economic statuses of patients in both groups. The study concluded that in this era of rapidly expanding health care scenario; targeted, regular, rigorous and repeated training programmes in future may shorten the learning curve thereby paving a way to reduce the cost as well as the operative time of robot-assisted surgeries in LMICs.

Feasibility, safety and effectiveness of robot-assisted retroperitoneal partial adrenalectomy with a new robotic surgical system: A prospective clinical study

Objectives

To evaluate the feasibility, safety and efficacy of the newly developed KD-SR-01® robotic system for retroperitoneal partial adrenalectomy.

Subjects and Methods

We prospectively enrolled patients with benign adrenal mass undergoing KD-SR-01® robot-assisted partial adrenalectomy in our institution from November 2020 to May 2022. Surgeries were performed via a retroperitoneal approach using the KD-SR-01® robotic system. The baseline, perioperative and short-term follow-up data were prospectively collected. A descriptive statistical analysis was performed.

Results

A total of 23 patients were enrolled, including nine (39.1%) patients with hormone-active tumors. All patients received partial adrenalectomy via the retroperitoneal approach without conversions to other procedures. The median operative time was 86.5 min [interquartile range (IQR), 60.0-112.5] and the median estimated blood loss was 50 ml (range, 20-400). Three (13.0%) patients developed Clavien-Dindo grade I-II postoperative complications. The median postoperative stay was 4.0 days (IQR, 3.0-5.0). All surgical margins were negative. The short-term follow-up demonstrated complete or partial clinical and biochemical success as well as absence of imaging recurrence in all patients with hormone-active tumors.

Conclusions

Initial results illustrate that the KD-SR-01® robotic system is safe, feasible and effective for the surgical management of benign adrenal tumors.

More work is needed on cost-utility analyses of robotic-assisted surgery

OBJECTIVE

To comprehensively analyze the cost-utility of robotic surgery in clinical practice and to investigate the reporting and methodological quality of the related evidence.

METHODS

Data on cost-utility analyses (CUAs) of robotic surgery were collected in seven electronic databases from the inception to July 2021. The quality of the included studies was assessed using the CHEERs and QHES checklists. A systematic review was performed with the incremental cost-effectiveness ratio as the outcome of interest.

RESULTS

Thirty-one CUAs of robotic surgery were eligible. Overall, the identified CUAs were fair to high quality, and 63% of the CUAs ranked the cost-utility of robotic surgery as "favored," 32% categorized as "reject," and the remaining 5% ranked as "unclear." Although a high heterogeneity was present in terms of the study design among the included CUAs, most studies (81.25%) consistently found that robotic surgery was more cost-utility than open surgery for prostatectomy (ICER: $6905.31/QALY to $26240.75/QALY; time horizon: 10 years or lifetime), colectomy (dominated by robotic surgery; time horizon: 1 year), knee arthroplasty (ICER: $1134.22/QALY to $1232.27/QALY; time horizon: lifetime), gastrectomy (dominated by robotic surgery; time horizon: 1 year), spine surgery (ICER: $17707.27/QALY; time horizon: 1 year), and cystectomy (ICER: $3154.46/QALY; time horizon: 3 months). However, inconsistent evidence was found for the cost-utility of robotic surgery versus laparoscopic surgery and (chemo)radiotherapy.

CONCLUSIONS

Fair or high-quality evidence indicated that robotic surgery is more cost-utility than open surgery, while it remains inconclusive whether robotic surgery is more cost-utility than laparoscopic surgery and (chemo)radiotherapy. Thus, an additional evaluation is required.

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.

Initial Experience of Robot-Assisted Adrenalectomy in Japan: What is the Optimal Selection of Robotic Forceps for Adrenalectomy?

Minimally invasive adrenalectomy is the preferred technique for managing adrenal tumors. Laparoscopic adrenalectomy is widely performed and covered by insurance in Japan, but robot-assisted adrenalectomy is not. To investigate the best forceps combinations for performing robot-assisted adrenalectomy safely, we performed robot-assisted adrenalectomy for two left and two right adrenal adenomas using different robotic forceps combinations (bipolar forceps, monopolar curved scissors, Vessel Sealer Extend, and SynchroSeal) for each case. Although we evaluated a small number of RAs, lower blood loss was observed in patients where the vessel sealing devices were used. The extent of dissection is small for adrenalectomy, and robotic bipolar vessel sealing tools may not be necessary, especially for the small adrenal tumors. However, considering the risk benefits, the combination of forceps with Vessel Sealer Extend (by the left arm) and monopolar curved scissors (by the right arm) will become one of the best forceps combinations for performing robot-assisted adrenalectomy safely.

Factors associated with postoperative complications and costs for adrenalectomy in benign adrenal disorders

BACKGROUND

The incidence of adrenal incidentaloma has been increasing, and indications of and approaches to adrenalectomy are diverse. Drivers of complications and costs are not well identified.

METHODS

The 2016 National Inpatient Sample data were used to identify patients who underwent adrenalectomy for benign adrenal disorders, such as Cushing syndrome, primary hyperaldosteronism, pheochromocytoma, and other benign neoplasms defined using the 10th Revision of the International Classification of Diseases. The primary outcome was determining the factors associated with clinical outcomes, perioperative complications, and hospitalization costs.

RESULTS

Using weighted estimates of the national sample data, 5,140 patients were identified. The mean age was 55 years. The majority of adrenalectomies were performed laparoscopically (48.5%) followed by a robotic approach (32.7%). The postoperative complication rate was 7.6%. In adjusted multivariable analyses, independent risk factors for perioperative complications included Hispanic race (odds ratio, 2.5; P = .01), and perioperative comorbid heart failure (odds ratio, 6.3; P < .001) and respiratory failure (odds ratio, 9.9; P < .001). The mean cost was $18,122. Independent risk factors associated with decrease of cost were female sex and primary hyperaldosteronism; factors associated with increased cost were pheochromocytoma, intraoperative complications, perioperative underlying comorbid respiratory failure and heart failure, and postoperative complications (P < .001).

CONCLUSION

Among patients undergoing adrenalectomy for benign adrenal disorders, underlying comorbidities, including heart and respiratory failure, should be considered when recommending adrenalectomy, as these may increase the postoperative complication rates and hospitalization costs.

Robot-assisted adrenalectomy: state of the art

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

Robotic and Laparoscopic Approaches for Adrenal Surgery in Obese Patients

OBJECTIVE

Minimally invasive adrenalectomy is a challenging procedure in obese patients. Few recent studies have advocated against robot-assisted adrenalectomy, particularly in obese patients. This study aims to compare operative outcomes between the robotic and laparoscopic adrenalectomy, particularly in obese patients.

MATERIALS AND METHODS

A retrospective analysis was performed on all consecutive patients undergoing adrenalectomy for benign disease by a single surgeon using either a laparoscopic or robotic approach. Adrenal surgeries for adrenal cancer were excluded. Demographics, operative time, length of hospital stays, estimated blood loss (EBL), and intraoperative and postoperative complications were evaluated. Patients were divided into 2 groups; obese and nonobese. A sub-analysis was performed comparing robotic and laparoscopic approaches in obese and nonobese patients.

RESULTS

Out of 120, 55 (45.83%) were obese (body mass index ≥ 30 kg/m²). 14 (25.45%) of the obese patients underwent a laparoscopic approach, and 41 (74.55%) underwent a robotic approach. Operative times were longer in the obese vs. nonobese groups (173.30 ± 72.90 minutes and 148.20 ± 61.68 minutes, P = .04) and were associated with less EBL (53.77 ± 82.48 vs. 101.30 ± 122, P = .01). The robotic approach required a longer operative time when compared to the laparoscopic approach (187 ± 72.42 minutes vs. 126.60 ± 54.55 minutes, P = .0102) in the obese but was associated with less blood loss (29.02 ± 51.05 mL vs. 138.30 ± 112.20 mL, P < .01) and shorter hospital stay (1.73 ± 1.23 days vs. 3.17 ± 1.27 days, P < .001).

CONCLUSION

Robot-assisted adrenal surgery is safe in obese patients and appears to be longer; however, it provides improvements in postoperative outcomes, including EBL and shorter hospital stay.

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.

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.

Surgical Approach to Endocrine Hypertension in Patients with Adrenal Disorders

Increased hormonal secretion of aldosterone, cortisol, or catecholamines from an adrenal gland can produce a variety of undesirable symptoms, including hypertension, which may be the initial presenting symptom. Consequences of secondary hypertension can result in potential cardiovascular and cerebrovascular complications at higher rates than in those with essential hypertension. Once a biochemical diagnosis is confirmed, targeted pharmacotherapy can be initiated to improve hypertension and may be corrected with surgical intervention. Adrenalectomy can be curative and can reverse the risk of cardiovascular sequelae once blood pressure control is achieved. This article discusses perioperative and operative considerations of adrenal causes of hypertension.

A short review of primary aldosteronism in a question and answer fashion

OBJECTIVES

The aim of this study was to present up to date information concerning the diagnosis and treatment of primary aldosteronism (PA). PA is the most common cause of endocrine hypertension. It has been reported up to 24% of selective referred hypertensive patients.

METHODS

We did a search in Pub-Med and Google Scholar using the terms: PA, hyperaldosteronism, idiopathic adrenal hyperplasia, diagnosis of PA, mineralocorticoid receptor antagonists, adrenalectomy, and surgery. We also did cross-referencing search with the above terms. We had divided our study into five sections: Introduction, Diagnosis, Genetics, Treatment, and Conclusions. We present our results in a question and answer fashion in order to make reading more interesting.

RESULTS

PA should be searched in all high-risk populations. The gold standard for diagnosis PA is the plasma aldosterone/plasma renin ratio (ARR). If this test is positive, then we proceed with one of the four confirmatory tests. If positive, then we proceed with a localizing technique like adrenal vein sampling (AVS) and CT scan. If the lesion is unilateral, after proper preoperative preparation, we proceed, in adrenalectomy. If the lesion is bilateral or the patient refuses or is not fit for surgery, we treat them with mineralocorticoid receptor antagonists, usually spironolactone.

CONCLUSIONS

Primary aldosteronism is the most common and a treatable case of secondary hypertension. Only patients with unilateral adrenal diseases are eligible for surgery, while patients with bilateral and non-surgically correctable PA are usually treated by mineralocorticoid receptor antagonist (MRA). Thus, the distinction between unilateral and bilateral aldosterone hypersecretion is crucial.

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.

Frontiers in robot-assisted retroperitoneal oncological surgery

Robot assistance has been rapidly adopted by urological surgeons and has become particularly popular for oncological procedures involving the retroperitoneal space. The wide dissemination of robot assistance probably reflects the limited amount of operating space available within the retroperitoneum and the advantages provided by robot-assisted approaches, including 3D imaging, wristed instrumentation and the shorter learning curve compared with that associated with the equivalent laparoscopic techniques. Surgical procedures that have traditionally been performed using an open or laparoscopic approach, such as partial nephrectomy, radical nephrectomy, retroperitoneal lymph node dissection, nephroureterectomy and adrenalectomy, are now often being performed using robot assistance. The frontiers of robot-assisted retroperitoneal oncological surgery are constantly expanding, with an emphasis on maintaining oncological and functional outcomes, while minimizing the level of surgical invasiveness.

Robotic assisted adrenalectomy: Is it ready for prime time?

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