Robotic Posterior Retroperitoneal Adrenalectomy: Patient Selection and Long-Term Outcomes

Augmenting Laparoscopic Surgery with Fluorescence Imaging

Minimally invasive endoscopic surgery is growing in veterinary medicine, in large part, due to the advantages associated with reduced pain, potential for decreased complications, and increased visualization of structures through magnification and illumination. With advancing technologies, we can now improve upon natural "white light" endoscopy with fluorescence-guided imaging. Near-infrared (NIR) cameras allow for real-time, high-definition visualization of vessels, anatomic structures, and perfusion. New uses of NIR technologies during laparoscopy are continuing to grow for vascular, lymphatic, and oncologic-related techniques. Limitations exist, and future efforts need to determine optimal dosing, tissue-specific fluorophores, and veterinary-specific techniques.

Safety and surgical outcomes of robotic adrenalectomy from a 15-year experience at a single institution

Robotic adrenalectomy (RA) has gained significant popularity in the management of adrenal gland diseases. We report our experience at a single tertiary institution and evaluate the safety and surgical outcomes of RA. The data of 122 consecutive patients who underwent RA from October 2009 to December 2022 at Korea University Anam Hospital (Seoul, Korea) were reviewed. There were no perioperative complications. Clinicopathological features and surgical outcomes were retrospectively analyzed through complete chart reviews. Noteworthy findings include the influence of sex, tumor size, and body mass index on operation time, with the female and small tumor groups exhibiting shorter operation times (P = 0.018 and P = 0.009, respectively). Pheochromocytoma was identified as a significant independent risk factor for a longer operation time in the multivariate analysis [odds ratio (OR), 3.709; 95% confidence interval (CI), 1.127-12.205; P = 0.031]. A temporal analysis revealed a decreasing trend in mean operation times across consecutive groups, reflecting a learning curve associated with RA adoption. RA is a safe and effective operative technique alternative to laparoscopic adrenalectomy that has favorable surgical outcomes and enhances the convenience of the operation.

A 1:1 matched comparison of posterior retroperitoneal and lateral transabdominal adrenalectomy using a robotic platform

BACKGROUND

Posterior retroperitoneal adrenalectomy is considered less invasive compared with lateral transperitoneal counterpart. There is controversy in the literature about how the two approaches compare regarding perioperative outcomes. Moreover, no studies have compared both approaches while incorporating the use of a robotic platform. The aim of this study was to compare the outcomes of robotic posterior retroperitoneal adrenalectomy and lateral transperitoneal adrenalectomy using a 1:1 matched propensity analysis.

METHODS

Patients who underwent robotic posterior retroperitoneal adrenalectomy were matched 1:1 to patients who underwent robotic lateral transperitoneal adrenalectomy between 2008 and 2022 at a single center. Matching factors included diagnosis, tumor size, Gerota's fascia-to-skin distance, and perinephric fat thickness. Perioperative outcomes were compared between groups using the χ2 analysis and Wilcoxon Rank Sum test.

RESULTS

A total of 511 robotic adrenalectomies were performed during the study period, of which 77 patients in each group were matched. There was no difference between posterior retroperitoneal adrenalectomy and lateral transperitoneal adrenalectomy groups, respectively, in terms of operative time (134 vs 128 min, P = .64), conversion to open (0% vs 0%, P = .99), pain level on a postoperative day 1 (visual analog scale 5 vs 6, P = .14), morphine milligram equivalents used (18 vs 20 morphine milligram equivalents /day, P = .72), length of stay (1 vs 1 day, P = .48), and 90-day complications (2.6% vs 3.9%, P = .65). Estimated blood loss for posterior retroperitoneal adrenalectomy was statistically lower (5 vs 10 mL, P = .001) but not considered to be clinically significant.

CONCLUSION

Perioperative outcomes of lateral transperitoneal adrenalectomy, including those related to recovery, were similar to those of posterior retroperitoneal adrenalectomy when matched for tumor and patient anthropometric parameters.

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

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

Exploring the Applications of Indocyanine Green in Robot-Assisted Urological Surgery: A Comprehensive Review of Fluorescence-Guided Techniques

This comprehensive review aims to explore the applications of indocyanine green (ICG) in robot-assisted urological surgery through a detailed examination of fluorescence-guided techniques. An extensive literature search was conducted in PubMed/MEDLINE, EMBASE and Scopus, using keywords such as "indocyanine green," "ICG", "NIRF", "Near Infrared Fluorescence", "robot-assisted", and "urology". Additional suitable articles were collected by manually cross-referencing the bibliography of previously selected papers. The integration of the Firefly^® technology in the Da Vinci^® robotic system has opened new avenues for the advancement and exploration of different urological procedures. ICG is a fluorophore widely used in near-infrared fluorescence-guided techniques. The synergistic combination of intraoperative support, safety profiles and widespread availability comprises an additional asset that empowers ICG-guided robotic surgery. This overview of the current state of the art illustrates the potential advantages and broad applications of combining ICG-fluorescence guidance with robotic-assisted urological surgery.

Surgical approaches to the adrenal gland

PURPOSE OF REVIEW

Review the literature on the surgical management of adrenal diseases, highlighting the various surgical approaches and their respective pros and cons.

RECENT FINDINGS

Minimally invasive adrenalectomy is commonly used for small and benign adrenal tumors, whereas open adrenalectomy is preferred for larger tumors and primary adrenal malignancy. Although minimally invasive adrenalectomy results in shorter recovery and fewer complications compared with open, the latter offers better oncologic outcomes in the setting of primary adrenal malignancy. Adrenalectomy is performed transabdominally or retroperitoneoscopically, both yielding equivalent results and recovery. Traditional laparoscopic or robotic equipment can be utilized for either minimally invasive approach. Subtotal adrenalectomy may be appropriate for patients with genetically associated pheochromocytoma to preserve cortical function and reduce the risk of adrenal insufficiency. However, the potential benefits of sparing adrenal function must be weighed against the risk of recurrence.

SUMMARY

Adrenalectomy is becoming increasingly common worldwide. For benign and small adrenal tumors, minimally invasive adrenalectomy is generally considered the standard approach, while open adrenalectomy is preferred for primary adrenal malignancy and larger tumors. Subtotal adrenalectomy may be appropriate for patients with bilateral adrenal pheochromocytoma, as it can reduce the need for lifelong glucocorticoid dependency.

Laparoscopic versus robotic adrenalectomy in severely obese patients

BACKGROUND

Over the last 20 years, the prevalence of severe obesity (body mass index ≥ 35 kg/m²) has almost doubled. This condition increases the challenge of laparoscopic adrenalectomy (LA) by creating problems with instrument reach, adequate exposure, and visualization. The aim was to compare perioperative outcomes of laparoscopic versus robotic adrenalectomy (RA) in severely obese patients.

METHODS

This was an institutional review board-approved retrospective study. Prospectively collected clinical parameters of patients who underwent LA versus RA between 2000 and 2021 at a single center were compared using Mann-Whitney U, ANOVA, Chi-square, and multivariate regression analysis. Continuous data are expressed as median (interquartile range).

RESULTS

For lateral transabdominal (LT) adrenalectomies, skin-to-skin operative time (OT) [164.5 (71.0) vs 198.8 (117.0) minutes, p = 0.006] and estimated blood loss [26.2 (15.0) vs 72.6 (50.0) ml, p = 0.010] were less in RA versus LA group, respectively. Positive margin rate, hospital stay and 90-day morbidity were similar between the groups (p = NS). For posterior retroperitoneal (PR) approach, operative time and perioperative outcomes were similar between LA and RA groups. Multivariate analysis demonstrated robotic versus laparoscopic technique (p = 0.006) to be an independent predictor of a shorter OT.

CONCLUSION

There was a benefit of robotic over the laparoscopic LT adrenalectomy regarding OT and estimated blood loss. Although limited by the small sample size, there was no difference regarding perioperative outcomes between RA and LA performed through a PR approach.

Operative approach and case volume are associated with negative resection margins for adrenocortical carcinoma

BACKGROUND

Surgical resection with negative margins is the treatment of choice for adrenocortical carcinoma (ACC). This study was undertaken to determine factors associated with negative resection margins.

METHODS

National Cancer Database was queried from 2010 to 2016 to identify patients with AJCC/ENSAT Stage I-III ACC who underwent adrenalectomy. Patient, tumor, facility, and operative characteristics were compared by margin status (positive-PM or negative-NM) and operative approach (open-OA, laparoscopic-LA, or robotic-RA). Multivariable logistic regression was used to identify factors associated with PM.

RESULTS

Eight hundred and eighty-one patients were identified, of which 18.4% had PM and 81.6% had NM. Patients with advanced pathologic T stage and pathologic N1 stage were more likely to have PM (vs. NM) (T3, 49.7% vs. 24.8%, p < 0.01; T4, 26.2% vs. 10.0%, p < 0.01; N1, 6.7% vs. 3.5%, p < 0.01). Patients undergoing OA (vs. LA and RA) were more likely to have advanced clinical T stage (T4, 16.6% vs. 5.7% vs. 7.8%, p < 0.01) and larger tumors (> 6 cm, 84.6% vs. 64.1% vs. 62.3%, p < 0.01). High-volume centers (≥ 5 cases) were more likely to utilize OA. Patients undergoing LA (vs. RA) were more likely to require conversion to open (20.3% vs. 7.8%, p = 0.011). On multivariable analysis, factors associated with higher odds of PM included T3 disease (OR 7.02, 95% CI 2.66-18.55), T4 disease (OR 10.22, 95% CI 3.66-28.53), and LA (OR 1.99, 95% CI 1.28-3.09). High-volume centers were associated with lower odds of PM (OR 0.67, 95% CI 0.45-0.98). There was no significant difference in margin status between OA and RA (OR 1.44, 95% CI 0.71-2.90).

CONCLUSION

Centers with higher ACC case volumes have lower odds of PM and utilize OA more often. LA is associated with higher odds of PM, whereas RA is not. These factors should be considered when planning the operative approach for ACC.

Robot-assisted tumorectomy for an unusual pelvic retroperitoneal leiomyoma: A case report

RATIONALE

Extrauterine leiomyoma occasionally occurs in rare locations with unusual growth patterns, especially pelvic retroperitoneal leiomyoma, which brings great challenges for surgeons to make a diagnosis. It is essential to distinguish benign from malignant retroperitoneal neoplasms according to the imaging manifestations. Laparotomy and laparoscopy are the common options for pelvic retroperitoneal neoplasms, while they may cause side effects during operation such as secondary damage. Appropriate surgical techniques should be adopted to ensure the complete excision of neoplasms meanwhile preserve the urination, defecation, and sexual function.

PATIENT CONCERNS

A 30-year-old woman was referred to our hospital because of dull pain in the perianal region for 1 month. Laboratory results including tumor markers were all within normal limits. The digital rectal examination revealed a huge and tough mass with smooth mucosa protruding into the rectal cavity from the rear area of rectum.

DIAGNOSIS

Imaging examinations were performed. Contrasted computed tomography (CT) of pelvis showed an enhanced retroperitoneal solid mass in the space between sacrum and rectum, and very close to the levator ani muscle. The mass was about 11.0*8.0 cm in size. Computerized tomography angiography (CTA) showed the distal branches of bilateral internal iliac artery went into the mass. Endoscopic ultrasonography (US) showed the mass compressed the rectum, as well as a clear boundary to the rectal wall. A histopathologic examination confirmed the mass was a pelvic retroperitoneal leiomyoma.

INTERVENTIONS

The patient underwent an operative resection with da Vinci Si surgical system after routine preoperative preparation. Anorectal motility was weekly monitored postoperation. No additional adjuvant therapy was performed.

OUTCOMES

The patient could walk after 1 day and defecate normally on the third day after operation. She was discharged on the seventh postoperative day. No adverse events including pelvic floor hernia or defecation dysfunction occurred in the follow-up period. At 4 weeks follow-up, the patient was pain-free and recovered well.

LESSONS

Although imaging examinations were crucial for retroperitoneal neoplasms, histopathological examination remains the "gold standard" for making a definite diagnosis. This case highlights the possibility of retroperitoneal leiomyoma occurring in a woman of reproductive age and the advantages of robotic surgical system in pelvic retroperitoneal surgeries.

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.