Recently laparoscopic adrenalectomy has been the standard surgical procedure for adrenal tumors gradually [16]. Except the acknowledged benefits of laparoscopic surgery, surgeons need to overcome some specific disadvantages, including hand fatigue, the inferior ergonomic instruments, and a two-dimensional surgical view. The robotic system can provide three-dimensional imaging, more precise operation with fewer complications, the elimination of hand tremor, and reduction of surgeon’s fatigue, leading to quick recovery of patient while providing feasible oncological and perioperative outcomes [17]. Moreover, robotic adrenalectomy may benefit from a shorter learning curve and intracorporeal sewing compared with laparoscopic approach [18]. In addition, robotic surgery may offer a better selection for obese patients or those with large tumors [19].
In the present study, we compared the perioperative outcomes of three minimally invasive adrenalectomy approaches, including RATLA, TLA, and RLA in a high-volume center. Only a few previous studies exist that compare the results for all these three widely used techniques for minimally invasive adrenalectomy [20, 21]. Although the potential advantages to the surgeon have been shown in robotic adrenalectomy, most studies have demonstrated that the robotic approach has non-inferior oncologic results and perioperative outcomes, when compared with the laparoscopic approach [22]. In the present study, the results suggested that RATLA is as safe and effective as laparoscopic approach, and robotic approach was superior to laparoscopic approach in regard to blood loss and length of hospital stay. Robotic adrenalectomy may also help with partial adrenalectomy by providing clearer visualization and maneuverability to preserving the normal adrenal cortex and venous drainage. Another aspect of disadvantage with robotic approach was the higher cost compared with conventional laparoscopic and open adrenalectomy [8].
Conversion to an open procedure occurred in only 1 patient in the TLA group for significant adhesion and hemorrhage. No Conversion occurred in the RLA/RATLA group. Regarding the complications, most studies have shown that the risk of perioperative complications in robotic surgery is similar to or lower than that of conventional laparoscopic surgery [6]. In this study, minimally invasive adrenalectomy was performed with excellent perioperative outcomes, regardless of the approach. Most complications were mild, mostly consisted of nausea, pneumonia, hypokalemia, hematoma, and blood transfusion. Only 1 patient in the RLA group experienced grade 3 complication of retroperitoneal hematoma requiring reoperation.
Tumor size in patients undergoing RLA was significantly smaller compared to patients who underwent TLA/RATLA. This difference reflected the influence of selection bias, that is, the patients with smaller tumors were more likely to accept retroperitoneal approach, which may explain the shorter length of stay for the RLA group compared with the TLA group. In any two groups the operative time was similar, while the previous study demonstrated longer operative time in the robotic group compared with the laparoscopic group [22]. During follow-up, no imaging recurrence was observed in all patients probably for the benign characteristics of adrenal tumors.
The management of adrenocortical carcinoma is still controversial [23,24,25]. In this study, adrenocortical carcinoma was resected to clear margins in 2 patients of laparoscopic approach and in 1 patient of robotic approach. Of the 3 patients, one has developed local recurrence at the adrenalectomy bed during follow up.
Most patients with adrenal tumors often showed an abnormal and complex endocrinological presentation. All patients in our study received a preoperative consultation of endocrinology to determine functional tumors. We always think that an multidisciplinary model of preoperative preparation, operation, and long-term follow-up is necessary [26], and we strongly suggest a sufficient discussion between urologists and endocrinologists to ensure the patient’s safety. Although perioperative blood pressure control and monitoring is strictly enforced, the results show that endocrinological events, such as hypotension and hypokalemia, account for the majority of intraoperative complications.
The limitations of this study include the retrospective nature of the analysis, the selection bias of patients, and the confounding influences of the inherent bias in surgical approach selection. Other important outcomes variables, including patient satisfaction, postoperative pain, and cost, were not evaluated in the current study. Finally, the study lacks a long-term follow-up.
