Robot-assisted adrenalectomy: Step-by-step technique and surgical outcomes at a high-volume robotic center
Federico Piramideabc*(),Carlo Andrea Braviab,Marco Paciottiabd,Luca Sarchiabe,Luigi Noceraabf,Adele Piroabg,Maria Peraire Loresab,Eleonora Balestrazziabh,Angelo Mottaranabh,Rui Farinhab,Hubert Nicolasi,Pieter De Backerb,Frederiek D'hondta,Peter Schattemana,Ruben De Grootea,Geert De Naeyera,Alexandre Mottrieab
aDepartment of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium bORSI Academy, Ghent, Belgium cDepartment of Oncology, Division of Urology, University of Turin, San Luigi Gonzaga Hospital, Turin, Italy dDepartment of Urology, Humanitas Research Hospital- IRCCS, Rozzano, Italy eDepartment of Urology, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy fUnit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy gDepartment of Urology, Ospedale Policlinico e Nuovo Ospedale Civile S.Agostino Estense Modena, University of Modena and Reggio Emilia, Modena, Italy hDivision of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy iUrological Department, La Citadelle, Liège, Belgium
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.
. [J]. Asian Journal of Urology, 2023, 10(4): 475-481.
Federico Piramide, Carlo Andrea Bravi, Marco Paciotti, Luca Sarchi, Luigi Nocera, Adele Piro, Maria Peraire Lores, Eleonora Balestrazzi, Angelo Mottaran, Rui Farinha, Hubert Nicolas, Pieter De Backer, Frederiek D'hondt, Peter Schatteman, Ruben De Groote, Geert De Naeyer, Alexandre Mottrie. Robot-assisted adrenalectomy: Step-by-step technique and surgical outcomes at a high-volume robotic center. Asian Journal of Urology, 2023, 10(4): 475-481.
Gagner M, Lacroix A, Bolté E. Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl J Med 1992; 327:1033. https://doi.org/10.1056/NEJM199210013271417.
doi: 10.1056/NEJM199210013271417
[2]
Fassnacht M, Arlt W, Bancos I, Dralle H, Newell-Price J, Sahdev A, et al. Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice guideline in collaboration with the European network for the study of adrenal tumors. Eur J Endocrinol 2016; 175:G1-34. https: //doi.org/10.1530/EJE-16-0467.
doi: 10.1530/EJE-16-0467
[3]
Agrusa A, Romano G, Navarra G, Conzo G, Pantuso G, Di Buono G, et al. Innovation in endocrine surgery: robotic versus laparoscopic adrenalectomy. Meta-analysis and systematic literature review. Oncotarget 2017; 8:102392-400.
doi: 10.18632/oncotarget.v8i60
[4]
Conzo G, Tartaglia E, Gambardella C, Esposito D, Sciascia V, Mauriello C, et al. Minimally invasive approach for adrenal lesions: systematic review of laparoscopic versus retroperitoneoscopic adrenalectomy and assessment of risk factors for complications. Int J Surg 2016; 28(Suppl 1):S118-23. https://doi.org/10.1016/j.ijsu.2015.12.042.
doi: 10.1016/j.ijsu.2015.12.042
[5]
Araujo-Castro M, Garcia Centeno R, López-García MC, Lamas C, álvarez-Escolá C, Calatayud Gutiérrez M, et al. Risk factors for intraoperative complications in pheochromocytomas. Endocr Relat Cancer 2021;28:695-703.
[6]
Houenstein HA, Jing Z, Elsayed AS, Ramahi YO, St?ckle M, Wijburg C, et al. Analysis of complications after robot-assisted radical cystectomy between 2002-2021. Urology 2023; 171: 133-9.
doi: 10.1016/j.urology.2022.08.049
[7]
Porpiglia F, Checcucci E, Piramide F, Amparore D, Fiori C, Hemal A. Subtotal ureteral substitution with ileum for patients with multiple ureteral stenosis. Transl Androl Urol 2020; 9:971-6.
doi: 10.21037/tau.2019.12.32
pmid: 32420213
[8]
Bravi CA, Larcher A, Capitanio U, Mari A, Antonelli A, Artibani W, et al. Perioperative outcomes of open, laparoscopic, and robotic partial nephrectomy: a prospective multicenter observational study (the RECORd 2 project). Eur Urol Focus 2021; 7:390-6.
doi: 10.1016/j.euf.2019.10.013
pmid: 31727523
[9]
Brandao LF, Autorino R, Laydner H, Haber GP, Ouzaid I, De Sio M, et al. Robotic versus laparoscopic adrenalectomy: a systematic review and meta-analysis. Eur Urol 2014; 65: 1154-61.
doi: 10.1016/j.eururo.2013.09.021
pmid: 24079955
[10]
Perivoliotis K, Baloyiannis I, Sarakatsianou C, Tzovaras G. Comparing the efficacy and safety of laparoscopic and robotic adrenalectomy: a meta-analysis and trial sequential analysis. Langenbeck’s Arch Surg 2020; 405:125-35.
doi: 10.1007/s00423-020-01860-9
[11]
Fassnacht M, Assie G, Baudin E, Eisenhofer G, de la Fouchardiere C, Haak HR, et al. Adrenocortical carcinomas and malignant phaeochromocytomas: ESMO-EURACAN Clinical Practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 2020; 31:1476-90.
doi: 10.1016/j.annonc.2020.08.2099
pmid: 32861807
[12]
García MIDO, PalasíR, Gómez RC, Marco JLP, Merino-Torres JF. Surgical and pharmacological management of functioning pheochromocytoma and paraganglioma. In: Mariani- Costantini R, editor. Paraganglioma: a multidisciplinary approach [internet]. Brisbane (AU): Codon Publications; 2019. Chapter 4. https://www.ncbi.nlm.nih.gov/books/NBK543229/.
[13]
Donatini G, Caiazzo R, Do Cao C, Aubert S, Zerrweck C, El- Kathib Z, et al. Long-term survival after adrenalectomy for stage I/II adrenocortical carcinoma (ACC): a retrospective comparative cohort study of laparoscopic versus open approach. Ann Surg Oncol 2014; 21:284-91.
doi: 10.1245/s10434-013-3164-6
pmid: 24046101
[14]
Porpiglia F, Fiori C, Daffara F, Zaggia B, Bollito E, Volante M, et al. Retrospective evaluation of the outcome of open versus laparoscopic adrenalectomy for stage I and II adrenocortical cancer. Eur Urol 2010; 57:873-8.
doi: 10.1016/j.eururo.2010.01.036
pmid: 20137850
[15]
Fiori C, Checcucci E, Amparore D, Cattaneo G, Manfredi M, Porpiglia F. Adrenal tumours: open surgery versus minimally invasive surgery. Curr Opin Oncol 2020; 32:27-34.
doi: 10.1097/CCO.0000000000000594
pmid: 31644473
[16]
Nomine-Criqui C, Moog S, Bresler L, Brunaud L. Operative technique: transperitoneal robotic adrenalectomy. J Vis Surg 2018; 155:50-8.
doi: 10.1016/j.jviscsurg.2017.11.001
[17]
Hassan T, de la Taille A, Ingels A. Right robot-assisted partial adrenalectomy for pheochromocytoma with video. J Vis Surg 2020; 157:259-60.
doi: 10.1016/j.jviscsurg.2020.02.008
[18]
Feng Z, Feng MP, Feng DP, Solórzano CC. Robotic-assisted adrenalectomy using da Vinci Xi vs. Si: are there differences? J Robot Surg 2020; 14:349-55.
doi: 10.1007/s11701-019-00995-2
pmid: 31273609
[19]
Brandao LF, Autorino R, Zargar H, Krishnan J, Laydner H, Akca O, et al. Robot-assisted laparoscopic adrenalectomy: step-by-step technique and comparative outcomes. Eur Urol 2014; 66:898-905.
doi: 10.1016/j.eururo.2014.04.003
pmid: 24830625
[20]
Sforza S, Minervini A, Tellini R, Ji C, Bergamini C, Giordano A, et al. Perioperative outcomes of robotic and laparoscopic adrenalectomy: a large international multicenter experience. Surg Endosc 2021; 35:1801-7.
doi: 10.1007/s00464-020-07578-5
[21]
Ma W, Mao Y, Zhuo R, Dai J, Fang C, Wang C, et al. Surgical outcomes of a randomized controlled trial compared robotic versus laparoscopic adrenalectomy for pheochromocytoma. Eur J Surg Oncol 2020; 46:1843-7.
doi: S0748-7983(20)30395-4
pmid: 32723609
[22]
Niglio A, Grasso M, Costigliola L, Zenone P, De Palma M. Laparoscopic and robot-assisted transperitoneal lateral adrenalectomy: a large clinical series from a single center. Updates Surg 2020; 72:193-8.
doi: 10.1007/s13304-019-00675-8
pmid: 31473921
[23]
Piccoli M, Pecchini F, Serra F, Nigro C, Colli G, Gozzo D, et al. Robotic versus laparoscopic adrenalectomy: pluriannual experience in a high-volume center evaluating indications and results. J Laparoendosc Adv Surg Tech 2021; 31:375-81.
doi: 10.1089/lap.2020.0839
[24]
Vatansever S, Nordenstr?m E, Raffaelli M, Brunaud L, Makay ?; Eurocrine Council. Robot-assisted versus conventional laparoscopic adrenalectomy: results from the EUROCRINE Surgical Registry. Surgery 2022; 171:1224-30.
doi: 10.1016/j.surg.2021.12.003
[25]
Bihain F, Klein M, Nomine-Criqui C, Brunaud L. Robotic adrenalectomy in patients with pheochromocytoma: a systematic review. Gland Surg 2020; 9:844-8.
doi: 10.21037/gs-2019-ra-05
pmid: 32775278
[26]
Agcaoglu O, Aliyev S, Karabulut K, Mitchell J, Siperstein A, Berber E. Robotic versus laparoscopic resection of large adrenal tumors. Ann Surg Oncol 2012; 19:2288-94.
doi: 10.1245/s10434-012-2296-4
pmid: 22396002
[27]
Fu SQ, Zhuang CS, Yang XR, Xie WJ, Gong BB, Liu YF, et al. Comparison of robot-assisted retroperitoneal laparoscopic adrenalectomy versus retroperitoneal laparoscopic adrenalectomy for large pheochromocytoma: a single-centre retrospective study. BMC Surg 2020; 20:227. https://doi.org/10.1186/s12893-020-00895-5.
doi: 10.1186/s12893-020-00895-5
[28]
Aksoy E, Taskin HE, Aliyev S, Mitchell J, Siperstein A, Berber E. Robotic versus laparoscopic adrenalectomy in obese patients. Surg Endosc 2013; 27:1233-6.
doi: 10.1007/s00464-012-2580-1
pmid: 23073684
[29]
Hue JJ, Ahorukomeye P, Bingmer K, Drapalik L, Ammori JB, Wilhelm SM, et al. A comparison of robotic and laparoscopic minimally invasive adrenalectomy for adrenal malignancies. Surg Endosc 2022; 36:5374-81.
doi: 10.1007/s00464-021-08827-x
[30]
Isiktas G, Nazli Avci S, Ergun O, Krishnamurthy V, Jin J, Siperstein A, et al. Laparoscopic versus robotic adrenalectomy in pheochromocytoma patients. J Surg Oncol 2022; 126: 460-4.
doi: 10.1002/jso.26918
pmid: 35567781
[31]
Isiktas G, Avci SN, Erten O, Ergun O, Krishnamurthy V, Shin J, et al. Laparoscopic versus robotic adrenalectomy in severely obese patients. Surg Endosc 2023; 37:1107-13.
doi: 10.1007/s00464-022-09594-z
[32]
Piramide F, Turri F, Dell’oglio P, Rocco B, Larcher A; Junior ERUS/YAU Working Group on Robot-assisted Surgery of the European Association of Urology. Are we ready for single overnight stay after robot-assisted partial nephrectomy? Minerva Urol Nephrol 2021; 73:858-60.
doi: 10.23736/S2724-6051.21.04812-6
pmid: 35144371
[33]
Bravi CA, Paciotti M, Sarchi L, Mottaran A, Nocera L, Farinha R, et al. Robot-assisted radical prostatectomy with the novel Hugo robotic system: initial experience and optimal surgical set-up at a tertiary referral robotic center. Eur Urol 2022; 82:233-7.
doi: 10.1016/j.eururo.2022.04.029
pmid: 35568597
[34]
Raffaelli M, Gallucci P, Voloudakis N, Pennestr?` F, De Cicco R, Arcuri G, et al. The new robotic platform HugoTM RAS for lateral transabdominal adrenalectomy: a first world report of a series of five cases. Updates Surg 2023; 75:217-25.
