Robot-assisted Laparoscopic Adrenalectomy Research Articles

Evolution of mineralocorticoid receptor antagonists, aldosterone synthase inhibitors, and alternative treatments for managing primary aldosteronism.

Primary aldosteronism (PA) is a prevalent and curable secondary hypertensive disorder that accounts for 5-13% of all hypertension cases. The prevalence of resistant hypertension, cerebral and cardiovascular diseases, and renal complications is higher in PA patients than in those with essential hypertension. Appropriate diagnosis and treatment at an early stage may suppress cerebral and cardiovascularevents. Lifestyle modifications recommended for essential hypertensive patients, including dietary salt restriction and appropriate calorie intake to avoid fat accumulation, play a crucial role in suppressing overactivation of the mineralocorticoid receptor (MR), which helps to control blood pressure and prevent end-organ damage. Esaxerenone is a safe mineralocorticoid receptor antagonist (MRA) with strong antihypertensive and anti-albuminuric effects. Aldosterone synthase inhibitors (ASIs) have been developed, which are antihypertensive agents with a new mechanism of action. The pharmacological mechanisms of MRAs and ASIs differ; MRAs block MR activity by preventingaldosterone and/or cortisol from bindingto the MR, while ASIs block aldosterone secretion from the adrenal gland. Other new treatments, such as robot-assisted laparoscopic adrenalectomy, percutaneous computed tomography radiofrequency ablation, transvenous radiofrequency catheter ablation, and super-selective adrenal arterial embolization have been developed. Further research will lead to better treatments for PA patients and reduce the frequency of cerebral and cardiovascularevents.

7206 Perioperative Management of Pheochromocytoma: The Mayo Clinic Florida Experience

Abstract Disclosure: A. Verma: None. F. Elli: None. S. Rao: None. M. Smith: None. A. Shapiro: None. C. Moshe: None. R. Chadha: None. Introduction: Pheochromocytomas are rare, neuroendocrine tumors derived from chromaffin cells of the neural crest, typically within the adrenal medulla. The pathophysiologic effect of primary concern is the uncontrolled release of catecholamines into the bloodstream, which carry risk for episodic hypertension, palpitations, and life-threatening crises. Preoperative preparation with drugs that block adrenergic receptors is utilized to improve hemodynamic oscillation force and surgical outcomes. Widely used premedication include alpha-blockers, beta-blockers, and calcium channel blockers. Despite adequate pretreatment, hemodynamic instability continues to evoke massive risk. The objective of this study was to assess the incidence of intraoperative hypertensive episodes in patients undergoing robotic assisted laparoscopic adrenalectomy. Methods: This study is an observational retrospective analysis of patients who underwent elective laparoscopic robotic-assisted adrenalectomies from February 2019 to April 2023. 17 patients total patients were included. Preoperative information included age, BMI, ASA physical classification, preoperative blockade regiment, and urine metanephrines. Intraoperative information included operation duration, tumor size, intraoperative anti-hypertensives, and hypertensive spikes defined as a SBP greater than 175 mmHg for 5 consecutive minutes. Data analysis was performed to obtain frequency counts (%), means (standard deviations), and median (range) as appropriate. Results: The mean age at the time of surgery was 57.12 ± 17.2 years. The majority of patients (76%) were ASA status class III. 7 of the 17 patients did not have active pheochromocytoma based on symptomatology, the incidental diagnoses being made by imaging and workup. The average tumor diameter was 3.90 ± 1.8, with a range of 2.0 - 8.0. Mean operative time was 153.76 ± 53.9 minutes. Preoperative urinary metanephrines were observed to have a mean of 1,248.44 ± 2,866.9 pg/mL. In terms of preoperative preparation, 65% of patients received Doxazosin, and 29% of patients received an alternative anti-hypertensive. Yet, 64.7% of patients were found to have at least 1 intraoperative hypertensive spike Conclusion: Despite premedication with anti-hypertensives, a significant percentage of patients experienced intraoperative hemodynamic instability. This emphasizes the importance of anesthesiologist preparation for intraoperative hypertension management to aggressively prevent hypertensive crises. In addition, it questions the routine use of alpha blockade for all cases preoperatively as has been suggested in certain studies, and whether or not it should be driven by other patient characteristics. Presentation: 6/1/2024

Robot-assisted laparoscopic adrenalectomy: Extended application in children

BackgroundMinimally invasive surgery for paediatric adrenal tumours has evolved, but robot-assisted laparoscopic adrenalectomy (RALA) in children remains poorly studied. The current prospective study aims to demonstrate the safety and efficacy of RALA in treating children with adrenal tumours. MethodsA prospective institutional analysis of children presenting with neuroblastic and endocrine tumours treated with RALA was undertaken over a six year-period. For each child, clinical parameters were collected relating to diagnosis, surgery and outcomes. ResultsA total 50 RALA were performed; 23 for unilateral neuroblastic tumours (87 % neuroblastomas) and 27 for endocrine tumours.Eight neuroblastic tumours (35 %) had image-defined risk factors (all due to tumour invading the renal pedicle). Median length of stay was two days. Resection margins were macroscopically clear in all cases. After median follow-up of 2.9 years (1.6–3.9), two children are under treatment for metastatic relapse (high-risk disease) and three died due to refractory disease.Sixteen children had endocrine tumours: pheochromocytoma (n = 13), or bilateral nodular adrenocortical hyperplasia with Cushing's syndrome (n = 14). One child required non-emergent conversion, and one complication occurred (grade IIIb) after median follow-up of 3.3 years (1.0–5.7). ConclusionsThe current study is the largest reported experience in the literature and confirms the safety and effectiveness of RALA in carefully selected children with adrenal tumours. Through an iterative process and in the setting of a dedicated paediatric robotic surgical team indications have been clarified and extended. The current study confirms RALA has particularly utility in patients with severe disease (IDRF + metastatic neuroblastomas) or genetic predisposition syndromes.

Comparison of clinical efficacy and safety between robotic-assisted and laparoscopic adrenalectomy for pheochromocytoma: a systematic review and meta-analysis.

To compare the clinical efficacy and safety of robot-assisted adrenalectomy (RA) and laparoscopic adrenalectomy (LA) for pheochromocytoma (PHEO). We conducted a comprehensive search of PubMed, the Cochrane Library, and Embase databases for studies comparing RA and LA treatment for PHEO, covering the period from database inception to January 1, 2024. Two researchers will independently screen literature and extract data, followed by meta-analysis using Review Manager 5.3 software. Six studies with 658 patients were included in the analysis. There were no significant differences in operation time [MD = -8.03, 95% CI (-25.68,9.62), P > 0.05], transfusion rate [OR = 1.10, 95% CI (0.55, 2.19) , P > 0.05], conversion rate [OR = 0.31, 95% CI (0.08, 1.12), P > 0.05], complication rate [OR = 0.93, 95% CI (0.52, 1.70), P > 0.05], Intraoperative max SBP [MD = -4.08, 95% CI (-10.13,1.97), P > 0.05], Intraoperative min SBP [MD = -2.71, 95% CI (-9.60,4.18), P > 0.05] among patients undergoing RA and LA. However, compared with patients who underwent LA, patients who underwent RA had less estimated blood loss [MD = -37.72, 95% CI (-64.11,-11.33), P < 0.05], a shorter length of hospital stay [MD = -0.43, 95% CI (-0.65,-0.21) P < 0.05]. RA has higher advantages in some aspects compared to LA. RA is a feasible, safe, and comparable treatment option for PHEO.

Comparison of perioperative outcomes between robot-assisted adrenalectomy and laparoscopic adrenalectomy: a propensity score matching analysis.

This study aimed to evaluate and compare the perioperative outcomes of robot-assisted adrenalectomy (RAA) and laparoscopic adrenalectomy (LA) using propensity score matching. This retrospective study included 395 patients who underwent minimally invasive adrenalectomy: 354 who underwent LA and 41 who underwent RAA between February 2015 and March 2023. To mitigate potential confounding factors, 2:1 propensity score matching was conducted based on age, sex, body mass index, American Society of Anesthesiologists score, tumor laterality, and tumor size. Perioperative outcomes and complications were compared between the two groups, and prognostic factors for complications were analyzed. Propensity score matching analysis identified 123 patients, with 82 and 41 in the LA and RAA groups, respectively. Operative time (81.4 ± 26.6min vs. 83.5 ± 25.9min, P = 0.675), estimated blood loss (77.7 ± 68.3mL vs. 83.2 ± 73.9mL, P = 0.683), and post-operative stay (3.8 ± 1.0days vs. 4.0 ± 0.9days, P = 0.211) showed no significant differences between two groups. Intraoperative complications occurred in 8 patients (9.8%) in the LA group, while no patients (0%) experienced intraoperative complications in the RAA group (P = 0.051). In both groups, post-operative complications occurred in 2.4% (P = 1). The only factor contributing to complications after adrenalectomy was tumor size (OR 1.026, 95% CI 1.001-1.051, P = 0.042). RAA exhibited comparable perioperative outcomes and presented an improved intraoperative complication rate compared with LA. Tumor size was the only factor that contributed to complications after adrenalectomy.

Patient satisfaction analysis of robot-assisted minimally invasive adrenalectomy: a single-center retrospective study.

The objective of this study is to compare the satisfaction of patients undergoing robot-assisted retroperitoneal laparoscopy adrenalectomy under the ambulatory mode and conventional mode. Basic information and clinical data of patients who underwent robotic-assisted posterior laparoscopic adrenalectomy between June 2020 and June 2023 were queried from our case system. The Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems Survey (OAS CAHPS®) was used to investigate patient satisfaction with preoperative preparation, discharge counseling, postoperative instructions, postoperative pain, and satisfaction with nursing work. The stats R package was used to select the appropriate statistic for the statistics based on the characteristics of the data. A total of 311 patients who underwent robot-assisted posterior laparoscopic adrenalectomy were enrolled in our case system. There were no statistical differences between the two groups in gender, age, body mass index, ASA classification, laterality, maximum tumor diameter, type of resection, hormonal activity, disease type, pathological classification, duration of surgery, estimated intraoperative bleeding, postoperative complications and follow-up period that were compared between the two groups of patients. There were no significant differences in preoperative preparation score, discharge counseling score, postoperative guidance score and nursing care satisfaction score (P > 0.05). Postoperative hospitalization, peristalsis time, defecation time, time to first postoperative mobilization, duration of indwelling drain and hospitalization costs in patients in the ambulatory model group were significantly less than patients in the conventional model group (P < 0.001). Patients in the ambulatory model group had significantly higher postoperative pain relief scores than patients in the conventional model group. In conclusion, our data suggest that patient satisfaction is equal between the conventional and ambulatory mode of performing robotic-assisted adrenalectomy. Patient satisfaction was probably associated with shorter hospitalization days, adequate preoperative preparation and standardized, high-quality post-discharge information and guidance.

Effectiveness of continuity of care after robot-assisted laparoscopic adrenalectomy under ambulatory mode: a single-center intervention study.

To investigate the effectiveness of continuity of care after robot-assisted adrenal tumor resection under ambulatory mode. Patients who underwent robot-assisted laparoscopic adrenalectomy (RALA) in the ambulatory surgery department and urology department of our hospital from January 2022 to January 2023 were selected as study subjects. Among them, 50 patients in the Department of Urology as the control group were given routine care. The 50 patients in the ambulatory surgery department as the observation group were given continuity of care on the basis of routine care. Observation indexes include: wound healing, blood pressure, blood potassium, renal function impairment, self-care ability in daily life, medication compliance, follow-up rate, and patient satisfaction. There were no remarkable discrepancies between the two groups in terms of demographic data and basic preoperative conditions of the patients. Compared with the control group, the observation group significantly improved the patients' wound healing, postoperative blood pressure and blood potassium and kidney function (P value all < 0.05). Compared with the control group, the observation group significantly improved postoperative patients' ADL scores, follow-up rates within three months after surgery, and patient satisfaction scores (P value all < 0.05). For patients receiving ambulatory mode robot-assisted laparoscopic adrenalectomy, continuity of care can effectively reduce postoperative complications, improve patients' postoperative self-care ability in daily life, medication compliance and follow-up rate, and improve patient satisfaction, which is worthy of promotion and application by nursing workers.

Robotic-assisted laparoscopic adrenalectomy (RARLA): What advantages and disadvantages compared to retroperitoneal laparoscopic adrenalectomy (RLA)?

To explore the advantages and disadvantages of robot-assisted laparoscopic adrenalectomy compared with retroperitoneal laparoscopic adrenalectomy. A total of 101 patients with adrenal tumors who received retroperitoneal laparoscopic adrenalectomy (RLA) (n=75) or robot-assisted laparoscopic adrenalectomy (RARLA) (n=26) in our hospital from January 2021 to December 2021 were retrospectively collected. Patients' demographics, tumor characteristics, and perioperative indicators were compared. Statistical analysis was performed using t-test for continuous variables and Pearson chi-square test or Fisher's exact test for categorical variables. We found that blood loss in the RARLA group was significantly less than that in the RLA group (66.9 ± 35.5ml vs 91.5 ± 66.1ml, p = 0.020). Gastrointestinal function recovery time in RARLA group was significantly less than that in RLA group (19.9 ± 6.9 hours vs 32.0 ± 9.0 hours, p < 0.001). However, the operation time, drainage tube placement time, post-operative hospital stay in the RARLA group were significantly longer compared with the RLA group (149.6 ± 53.4 mins vs 118.7 ± 41.2 mins, p = 0.003; 4.9 ± 2.0 days vs 3.6 ± 1.1 days, p = 0.004; 6.4 ± 1.8 days vs 4.6 ± 1.6 days, p < 0.001). The hospitalization expense in the RARLA group is significantly higher than that in the RLA group (59284 ± 8724 RMB¥ vs 39785 ± 10126 RMB¥, p < 0.001). We found that there was no significant difference in the incidence of postoperative complications between the two groups. However, the pathological types of the two groups were significantly different. Patients in the RLA group had a higher proportion of adrenocortical adenoma, while patients in the RARLA group had a higher proportion of pheochromocytoma. Compared with traditional laparoscopic adrenalectomy, robot-assisted laparoscopic adrenalectomy can significantly reduce intraoperative blood loss and accelerate postoperative gastrointestinal recovery. It is committed to studying how to reduce the hospitalization time and hospitalization cost of RARLA, which can make RARLA more widely used.

Hypokalemia-Induced Rhabdomyolysis Caused by Adrenal Tumor-Related Primary Aldosteronism: A Report of 2 Cases

Case seriesPatients: Male, 53-year-old • Male, 46-year-oldFinal Diagnosis: Primary aldosteronismSymptoms: Myalgia • weaknessMedication: —Clinical Procedure: AdrenalectomySpecialty: Endocrinology and Metabolic • UrologyObjective:Unusual clinical courseBackground:Primary aldosteronism, also known as Conn’s syndrome, is a clinical condition caused by excessive production of aldosterone. The classic presenting signs of primary aldosteronism are hypertension and hypokalemia. However, rhabdomyolysis induced by severe hypokalemia is a rare manifestation of primary aldosteronism. There were only a few cases presented in the English literature over the last 4 decades.Case Report:We present 2 cases, a 53-year-old man and a 46-year-old man, with severe hypokalemia-induced rhabdomyolysis caused by adrenal tumor-related primary aldosteronism. Both of these patients were under medical treatment with oral anti-hypertension drug for hypertension, but were poorly controlled. They both presented to the Emergency Department with muscle weakness and pain. Laboratory testing showed elevated creatinine phosphokinase (CPK) and low serum potassium levels. Hypokalemia-induced rhabdomyolysis was suspected. A further endocrine survey showed low PRA (plasma renin activity) and high aldosterone levels, finding which are compatible with primary aldosteronism. Computed tomography (CT) was arranged for further evaluation, and adrenal tumors were found in both cases. Both patients underwent robotic-assisted laparoscopic adrenal-ectomy. In both cases, there was no recurrence of hypokalemia without potassium supplementation, and their hypertension was under better control at further follow-up visits.Conclusions:Hypokalemic rhabdomyolysis is a rare manifestation of primary aldosteronism. It might be difficult to making a diagnosis when rhabdomyolysis and severe hypokalemia are the first manifestations in patients with primary aldosteronism. The use of diuretics for hypertension treatment might be a risk factor for extremely low potassium levels, which can induce rhabdomyolysis in patients with primary aldosteronism.

Is robot-assisted retroperitoneal adrenalectomy safe? An investigation of perioperative hypertensive crisis among hypertensive and normotensive patients.

Objective: We examined the incidence of perioperative hypertensive crisis in robot-assisted retroperitoneal laparoscopic adrenalectomy. A consecutive series of 120 patients with adrenal tumours undergoing robot-assisted retroperitoneal laparoscopic adrenalectomy were included. Patients were divided into two groups: group A (hypertension group, 58 cases, mean age 43.59 years) and group B (normotension group, 62 cases, mean age 48.01 years). General anaesthesia was applied using endotracheal intubation and haemodynamic changes were closely monitored. A total of nine (7.5%) hypertensive crisis cases were observed. After intravenous infusion of sodium nitroprusside, seven cases of them were quickly controlled and two cases experienced transient severe hypertension. The incidence of hypertensive crisis was 13.7% and 1.6% in groups A and B, respectively (p<0.05). These findings highlight the importance of strengthening the monitoring of anaesthesia and taking various measures to effectively control the blood pressure in robot-assisted retroperitoneal laparoscopic adrenalectomy, especially among hypertensive patients.

Comparison of robot-assisted retroperitoneal laparoscopic adrenalectomy versus retroperitoneal laparoscopic adrenalectomy for large pheochromocytoma: a single-centre retrospective study

BackgroundTo evaluate the feasibility and safety of robot-assisted retroperitoneal laparoscopic adrenalectomy (RARLA) for large pheochromocytomas (PHEOs; size≥6 cm) compared with retroperitoneal laparoscopic adrenalectomy (RLA).MethodsFifty-one patients who underwent adrenalectomy for large PHEOs between March 2016 and January 2019 were enrolled and divided into two groups, including 32 RLA cases and 19 RARLA cases. We compared the perioperative efficacy and long-term follow-up results between the two groups.ResultsPreoperative data, including demographics, comorbidities and tumour characteristics, were similar between the groups. Intraoperatively, the RARLA group had a lower incidence of haemodynamic instability (26.3% vs. 56.2%, P = 0.038) and less intraoperative blood loss (100 ml vs. Two hundred milliliter, P = 0.042) than the RLA group. The groups showed no significant differences in operative time or transfusion rates. Postoperatively, the time to diet resumption, time to ambulation, time to drainage removal and postoperative hospital stay were shorter in the RARLA group than in the RLA group (1 d vs. 2 d, P = 0.027; 1 d vs. 2 d, P = 0.034; 3 d vs. 5 d, P = 0.002; 5 d vs. 6 d, P = 0.02, respectively). The groups exhibited no significant differences in the duration of anaesthetic use, complications, or long-term follow-up results for the blood pressure (BP) improvement rate.ConclusionsCompared with RLA, RARLA is a safe, feasible and even optimized procedure for large PHEOs.

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.

Retrospective comparison of three minimally invasive approaches for adrenal tumors: perioperative outcomes of transperitoneal laparoscopic, retroperitoneal laparoscopic and robot-assisted laparoscopic adrenalectomy

BackgroundTo compare the perioperative outcomes of transperitoneal laparoscopic (TLA), retroperitoneal laparoscopic (RLA), and robot-assisted transperitoneal laparoscopic (RATLA) adrenalectomy for adrenal tumors in our center.MethodsBetween 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.ResultsThis 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.ConclusionsMinimally 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.

Surgical outcomes of a randomized controlled trial compared robotic versus laparoscopic adrenalectomy for pheochromocytoma

BackgroundRobotic adrenalectomy for pheochromocytoma is increasingly popular because of the advantage that have been proved by some researchers recently. However, prospective randomized clinical trials comparing robotic assisted laparoscopic adrenalectomy (RA) with traditional laparoscopic adrenalectomy (LA) for pheochromocytoma are rare. The aim of this study is to compare perioperative outcomes of RA versus LA for pheochromocytoma prospectively. MethodsFrom March 2016 to April 2019, all patients with pheochromocytoma suitable for laparoscopic adrenalectomy were assigned randomly to RA or LA. The primary endpoint was the operative (exclude docking time) time. Secondary endpoints were estimated blood loss and postoperative recovery. Demographics and perioperative data were prospectively collected. ResultsA total of 140 (RA 70, LA 70) patients were enrolled in this prospective research. The following significant differences were identified in favor of RA: shorter median operative (exclude docking time) time (92.5 vs 122.5 min, P = 0.007), however, RA group has higher total hospitalization cost (8869.9 vs 4721.8 $, P < 0.001). Demographics and other perioperative outcomes were similar in both groups. The RA group showed a significant lower blood loss and operative (exclude docking time) time compared with LA group (P < 0.05) for patients with high Nor-Metanephrine (NMN). ConclusionsBoth RA and LA for pheochromocytoma are safe and effective. Patients with high NMN can benefit from less blood loss and operative time when a robotic surgery system was used, but RA has a significant higher cost.

Surgical Indications and Techniques for Adrenalectomy.

Indications for adrenalectomy are malignancy suspicion or malignant tumors, non-functional tumors with the risk of malignancy and functional adrenal tumors. Regardless of the size of functional tumors, they have surgical indications. The hormone-secreting adrenal tumors in which adrenalectomy is indicated are as follows: Cushing’s syndrome, arises from hypersecretion of glucocorticoids produced in fasciculata adrenal cortex, Conn’s syndrome, arises from an hypersecretion of aldosterone produced by glomerulosa adrenal cortex, and Pheochromocytomas that arise from adrenal medulla and produce catecholamines. Sometimes, bilateral adrenalectomy may be required in Cushing’s disease due to pituitary or ectopic ACTH secretion. Adenomas arise from the reticularis layer of the adrenal cortex, which rarely releases too much adrenal androgen and estrogen, may also develop and have an indication for adrenalectomy. Adrenal surgery can be performed by laparoscopic or open technique. Today, laparoscopic adrenalectomy is the gold standard treatment in selected patients. Laparoscopic adrenalectomy can be performed transperitoneally or retroperitoneoscopically. Both approaches have their advantages and disadvantages. In the selection of the surgery type, the experience and habits of the surgeon are also important, along with the patient’s characteristics. The most common type of surgery performed in the world is laparoscopic transabdominal lateral adrenalectomy, which most surgeons are more familiar with. The laparoscopic anterior transperitoneal approach is the least preferred laparoscopic method in adrenalectomy. Retroperitoneal laparoscopic adrenalectomy can be performed with a posterior or lateral approach. In addition to conventional laparoscopy, laparoscopic surgery is robot-assisted, which can be administered by transperitoneal or retroperitoneal approach. In addition, conventional or robot-assisted laparoscopic adrenalectomy can be performed transabdominally or retroperitoneally using the single-port method. Today, partial adrenalectomy can be performed using laparoscopic techniques in bilateral adrenal masses, hereditary diseases with the risk of developing multiple adrenal tumors, and solitary masses of the adrenal gland. Open surgery is indicated in the case of malignancy or suspected malignancy and large tumors when laparoscopic surgery is contraindicated. The risk of conversion to open surgery is low (approximately 5%). The open transperitoneal anterior approach is the most common open intervention, especially in large tumors with malignancy or suspected malignancy. This procedure can be performed using a midline incision, bilateral or unilateral subcostal incision, Makuuchi or modified Makuuchi incision. Thoracoabdominal incision may be required, especially in the removal of large malignant lesions as a block. The open retroperitoneal approach can be applied posteriorly or laterally.

V30 - Robot-assisted laparoscopic adrenalectomy – utility and feasibility in a tertiary setup

V30 - Robot-assisted laparoscopic adrenalectomy – utility and feasibility in a tertiary setup

Retrospective analysis of variant venous anatomy in 303 laparoscopic adrenalectomies and its clinical implications.

To clarify the correlation of variant venous anatomy with adrenal tumor phenotype and surgical outcomes. This retrospective study included 303 consecutive minimally invasive adrenalectomies from 301 patients. All adrenal veins were identified. We compared the preoperative, intraoperative, and postoperative data between patients with and without variant adrenal venous anatomy. We also explored the factors associated with venous variants. We found variant venous anatomy in 62 of 303 adrenalectomies (20.5%). Compared with patients with normal anatomy, those with variant anatomy were associated with larger tumor size, larger adrenal veins, more adrenal medullary tumors, longer operation time, more estimated intraoperative blood loss, longer length of hospitalization, and more transfusion. Computed tomography (CT) images may improve the identification of venous anatomy. Tumor size and diagnosis of pheochromocytoma were independently related to variant venous anatomy, whereas sex, tumor size, and venous variant influenced hemorrhage. For pheochromocytoma with variant venous anatomy operated on by a single surgeon, robot-assisted laparoscopic adrenalectomy was associated with shorter postoperative hospitalization. Adrenal vein variants are associated with worse outcomes in adrenal tumors and an optimized surgery strategy should be applied to this group of patients.

Robotic-assisted radical adrenalectomy for large adrenocortical carcinoma

Adrenocortical carcinoma (ACC) is a rare and highly aggressive malignancy with poor prognosis. Laparoscopic adrenalectomy has been a favorite surgical approach for the treatment of adrenal masses. The use of robotic-assisted surgery is the latest development for minimally invasive surgical management of adrenal masses. Here, we describe a rare case of ACC in a 51-year-old male patient who presented with pain in the lumbar region, and robot-assisted laparoscopic radical adrenalectomy was successfully performed transperitoneally with the assistance of the da Vinci robotic system. We also discuss the summary of clinical features of ACC. Robot-assisted laparoscopic adrenalectomy is safe, is easier with lesser blood loss, and is comfortable to the patient due to its low complication rates. The patient improved after tumor removal.

V7-05 ROBOTIC ASSISTED LAPAROSCOPIC ADRENALECTOMY IN THE SETTING OF AN INCIDENTAL ADRENAL MASS

You have accessJournal of UrologyPediatrics1 Apr 2017V7-05 ROBOTIC ASSISTED LAPAROSCOPIC ADRENALECTOMY IN THE SETTING OF AN INCIDENTAL ADRENAL MASS Eli Thompson, Evalynn Vasquez, Paul Kokorowski, and Andy Chang Eli ThompsonEli Thompson More articles by this author , Evalynn VasquezEvalynn Vasquez More articles by this author , Paul KokorowskiPaul Kokorowski More articles by this author , and Andy ChangAndy Chang More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1923AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Since Rudolf Virchow first described abdominal “glioma” tumors in children, neuroblastoma has come to be recognized as the most common malignancy in infants and the most common solid malignancy in children. Resection in neuroblastomas that are classified as low risk is often curative. Traditionally the standard operative management has been open surgical resection. More recently however, a shift towards minimally invasive approaches has been described. Here we report a case of neuroblastoma managed with robotic assisted laparoscopic adrenalectomy. This is the first robotic adrenalectomy performed at our institution and, to the best of our knowledge, the first performed on a Da Vinci Xi robot. METHODS A single case was reviewed and reported. RESULTS A 2-year-old female with a history of a febrile urinary tract infection found to have a poorly functioning left upper pole moiety with ectopic ureter initially underwent a successful robotic assisted left upper pole partial nephrectomy. On her postoperative renal ultrasound, she was found to have a new right sided adrenal mass. This was confirmed with MRI and MIBG scan. Metanephrinies, homovanillic acid, and vanillylmandelic acid levels were obtained to evaluate for pheochromocytoma and were within normal limits. Robotic assisted laparoscopic right adrenalectomy was then performed. Intraoperatively, a small iatrogenic cavotomy was made and repaired. There were no further complications and the patient tolerated the procedure well. She had an uneventful recovery and was discharged home on post-operative day two. CONCLUSIONS Robotic assisted laparoscopic adrenalectomy represents a viable option for surgical excision of adrenal tumors and can be accomplished with rapid recovery time, decreased surgical morbidity, and comparable oncologic outcomes. Injury to surrounding vessels presents a known complication to adrenalectomy. Our case demonstrates the advantage of a Da Vinci Xi surgical system for laparoscopic vascular repair and tumor excision. In our experience, while adhering to sound oncologic surgical principles, a robotic assisted laparoscopic approach can be considered as an alternative to traditional open adrenalectomy for select children with neuroblastoma. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e824 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Eli Thompson More articles by this author Evalynn Vasquez More articles by this author Paul Kokorowski More articles by this author Andy Chang More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V11-12 ROBOTIC ADRENALECTOMY FOR METASTATIC MELANOMA

You have accessJournal of UrologyAdrenal/Single Port Surgery/LESS/NOTES1 Apr 2016V11-12 ROBOTIC ADRENALECTOMY FOR METASTATIC MELANOMA Michael Jennings and Wesley White Michael JenningsMichael Jennings More articles by this author and Wesley WhiteWesley White More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1829AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Due to the delicacy of some particular pathologies, there are some disease states that urologist can provide a service in non urologic malignancies. A minimally invasive adrenalectomy for metastatic melanoma with hemorrhage is a procedure not commonly performed. However, adrenal metastasis is present in 50% of Stage IV melanoma. The robotics trained urologists can provide minimally invasive procedure for Stage IV melanoma. Our goal is to provide a methodical and reproducible template for performing a minimally invasive, adrenalectomy and metastatectomy for a suspected melanoma metastasis. METHODS We present a robot-assisted laparoscopic left adrenalectomy, highlighting the key steps to performing the procedure safely and efficiently. We provide narration and bulleted slides to present the case. RESULTS We perform the procedure without intraoperative or postoperative complication. The final pathology revealed necrotic melanoma involving the adrenal. The procedure was completed in three and a half hours. The patient was discharged on postoperative day two, and had resolution of preoperative nausea caused from gastric compression by the mass. CONCLUSIONS Robotic adrenalectomy for melanoma metastasis is a procedure a urologist can provide as part of a multidisciplinary team for both oncologic and palliative purposes, given the correct preoperative findings. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1006 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Michael Jennings More articles by this author Wesley White More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...