Is Robotic Surgery Unnecessary for Adrenalectomy? Weighting the Pros and Cons of the Robotic Approach

Laparoscopicadrenalectomy(LA)wasfirstdescribedin1992byGagneretal.[1]and,sincethen,hasprogressivelyreplacedconventionalopenadrenalectomyasthegoldstandardprocedureforthetreatmentofbenignadrenaldisease[2].WhileLAmaybeconsideredbylaparoscopicsurgeonsforsmallorbenignadrenalmasses,incaseswithlargeormalignantlesions,LAmayrepresentanextremelychallengingsurgery.Thecurrentlimitationsofthelaparo-scopicapproach,mainlyconsistingofreducedmaneuver-abilityandlimitedergonomicdesignofinstruments,naturalhandfatigue,tremors,andcounterintuitivemove-ments,mayfurtherenhancethecomplexityofthisprocedure.Theseaspects,alongwiththerelativelylowincidenceofadrenallesions,havelimitedthediffusionofLAtofewhigh-volumetertiarycarecenters.Learningfromhistory,abetteralternativetoopenaccessshouldofferthesamecosmeticandpostoperativeadvantagesofLAbutshouldbefeasibleformanyurologistsand,consequently,availabletomanypatients.Theuseofaroboticplatformmayhelpachievethispurposebycombiningthebenefitsofashorterlearningcurvewithlowcomplicationrates.Thefirstexperiencewithrobot-assistedadrenalectomy(RA)wasreportedin1999byPiazzaetal,whoperformedarightadrenalectomyinapatientwithConn’ssyndromeusingtheZEUSAESOProbot(ComputerMotion,Inc.,SantaBarbara,CA,USA)[3].Conversely,thefirstRAperformedwiththedaVincirobot(IntuitiveSurgical,Sunnyvale,CA,USA)wasdescribedbyDesaietal.in2002[4].Fromthispreliminaryexperience,RAemergedasanextremelypromisingprocedure,capableofovercomingthetechnicaldifficultiesofLAandallowingbroaderdiffusionofminimallyinvasivesurgeryforthetreatmentofadrenalmasses.Specifically,thewell-knownadvantagesofthedaVincisystemallowsurgeonstoperformverypreciseadrenalectomyandeven,inselectedcases,adrenal-sparingsurgery,reducingthelearningcurve[5].Today,thewidespreaddiffusionofRAhasbeenlimitedonlybytheavailabilityofthedaVincirobotandbycost-effectivenessconsiderations.Inrecentyears,onlyafewpapershavecomparedtheperioperativeoutcomesofRArelativetoLAforsmalladrenalmasses[6].Thesestudiesdemonstratedthesurgicalfeasibilityofthisprocedurewithlowerbloodloss,shorterhospitalstay,andlowercompli-cationrates;however,theshort-andlong-termoncologicandbenignoutcomesofRAversusLAhavenotbeenadequatelyassessed.Consequently,theuseofRAshouldnotbeadvocatedforallpatients,accordingtotheavailableliterature;however,RAmayrepresenttheoptimaltreatmentchoiceforselectedpatientsforwhomLAmaybeextremelychallenging.Recently,Agcaogluetal.attemptedtodeterminewhetherRAwasappropriateforremovinglargeadrenaltumorsandshowedthatitcouldshortenoperatingtimeanddecreasetherateofconversiontoopenforadrenaltumors>5cm[7].Similarly,Brunaudetal.demonstratedthatinpatientswithabodymassindexof>30kg/m2andlargetumors(55mm),meanoperatingtimewaslongerintheLAgroupthanintheRAgroup[8].Conversely,conversionrate,morbidity,andhospitalstayweresimilarinbothgroups.Moreover,someparticularlychallengingprocedurescanbeperformedeasilywiththedaVincisystem.Alargeleftadrenalglandcoveredbythepancreasrequirestheuseofthefourthroboticarmtoreachthemasseasily,reducingtheriskofcomplication.Rightpheochromocytomawithretro-cavalveincontiguitycanberemovedsafelyusingthefourtharmtostablyretractthecavaveinandusingtheroboticclipdevicetosafelyreachtheadrenalvein.However,both Morinoetal.[9]andXiaoetal.[10]indicatedthatthetotalcostofRAwassignificantlyhigherthanthatforLA.Theincreasedexpensewasmainlyduetotheuseofonlytworoboticinstrumentsandthelongeroperativetimerelatedtodockingtime.Inconclusion,basedonthecurrentliterature,itisindeedtruethatRAmayrepresentaluxury,anditsadoptionmaynotbereasonableforallpatients.However,inselectedpatients,RAmayrepresentanappropriatesurgicaloption,combiningthebenefitsofminimallyinvasivesurgerywithashortlearningcurveandtheeaseofuseofrobotictechnology.Conflictsofinterest:Theauthorshavenothingtodisclose.References[1]GangerM,LacroixA,Bolte ́E.LaparoscopicadrenalectomyinCushing’ssyndromeandpheochromocytoma.NEnglJMed1992;327:1033.[2]GuazzoniG,MontorsiF,BocciardiA,etal.Transperitoneallaparo-scopicversusopenadrenalectomyforbenignhyperfunctioningadrenaltumors:acomparativestudy.JUrol1995;153:1597–600.[3]PiazzaL,CaraglianoP,ScardilliM,SgroiAV,MarinoG,GiannoneG.Laparoscopicrobot-assistedrightadrenalectomyandleftovariec-tomy(casereports).ChirItal1999;51:465–6.[4]DesaiMM,GillIS,KaoukJH,etal.Robotic-assistedlaparoscopicadrenalectomy.Urology2002;60:1104–7.[5]MannyTB,PompeoAS,HemalAK.Roboticpartialadrenalectomyusingindocyaninegreendyewithnear-infraredimaging:theinitialclinicalexperience.Urology2013;82:738–42.[6]BrandaoLF,AutorinoR,LaydnerH,etal.Roboticversuslaparoscop-icadrenalectomy:asystematicreviewandmeta-analysis.EurUrol2014;65:1154–61.[7]AgcaogluO,AliyevS,Karabulut,MitchellJ,SipersteinA,BerberE.Roboticversuslaparoscopicresectionoflargeadrenaltumors.AnnSurgOncol2012;19:2288–94.[8]BrunaudL,BreslerL,AyavA,etal.Robotic-assistedadrenalectomy:whatadvantagescomparedtolateraltransperitonealadrenalecto-my?AmJSurg2008;195:433–8.[9]MorinoM,Beninca`G,GiraudoG,DelGenioGM,RebecchiF,GarroneC.Robot-assistedvslaparoscopicadrenalectomy:aprospectiverandomizedcontrolledtrial.SurgEndosc2004;18:1742–6.[10]XiaoKF,YangJG,ChenT,FangJQ,YangJG.AcomparisonofZEUSrobotic-assistedlaparoscopicandconventionallaparoscopicadre-nalectomy[inChinese].ChinJEndourol2008;3:339–43