From the Division of Endocrine Surgery, Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, OH.The Cancer Journal (Impact Factor: 4.24). 03/2013; 19(2):162-6. DOI: 10.1097/PPO.0b013e31828ba0c7
Over the last 2 decades, laparoscopic adrenalectomy has become the standard for removal of adrenal tumors. Although accepted as a safe and efficient procedure, laparoscopy has certain disadvantages, such as the 2-dimensional view, unstable camera platform, and rigid instrumentation. Robotic surgery offers a solution for these drawbacks and has opened a new era of telemedicine, providing the surgeons with a sophisticated stable 3-dimensional platform, 7 degrees of freedom, and enhanced vision. In the recent years, robotic adrenal surgery has been adapted by many centers across the globe and become an alternative to laparoscopy. Herein, we provide a detailed review of the current literature and share our institutional experience on robotic adrenalectomy.
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ABSTRACT: CONTEXT: Centres worldwide have been performing partial nephrectomies laparoscopically for greater than a decade. With the increasing use of robotics, many centres have reported their early experiences using it for nephron-sparing surgery. OBJECTIVE: To review published literature comparing robotic partial nephrectomy (RPN) with laparoscopic partial nephrectomy (LPN). EVIDENCE ACQUISITION: An online systematic review of the literature according to Cochrane guidelines was conducted from 2000 to 2012 including studies comparing RPN and LPN. All studies comparing RPN with LPN were included. The outcome measures were the patient demographics, tumour size, operating time, warm ischaemic time, blood loss, transfusion rates, length of hospital stay, conversion rates, and complications. A meta-analysis of the results was conducted. For continuous data, a Mantel-Haenszel chi-square test was used; for dichotomous data, an inverse variance was used. Each was expressed as a risk ratio with a 95% confidence interval p<0.05 considered significant. EVIDENCE SYNTHESIS: A total of 717 patients were included, 313 patients in the robotic group and 404 patients in the laparoscopic group (seven studies). There was no significant difference between the two groups in any of the demographic parameters except for age (age: p=0.006; sex: p=0.54; laterality: p=0.05; tumour size: p=0.62, tumour location: p=57; or confirmed malignant final pathology: p=0.79). There was no difference between the two groups regarding operative times (p=0.58), estimated blood loss (p=0.76), or conversion rates (p=0.84). The RPN group had significantly less warm ischaemic time than the LPN group (p=0.0008). There was no difference regarding postoperative length of hospital stay (p=0.37), complications (p=0.86), or positive margins (p=0.93). CONCLUSIONS: In early experience, RPN appears to be a feasible and safe alternative to its laparoscopic counterpart with decreased warm ischaemia times noted.
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ABSTRACT: Recent evidence supports the use of robotic surgery for the minimally invasive surgical management of adrenal masses. To describe a contemporary step-by-step technique of robotic adrenalectomy (RA), to provide tips and tricks to help ensure a safe and effective implementation of the procedure, and to compare its outcomes with those of laparoscopic adrenalectomy (LA). We retrospectively reviewed the medical charts of consecutive patients who underwent RA performed by a single surgeon between April 2010 and October 2013. LA cases performed by the same surgeon between January 2004 and May 2010 were considered the control group. The main steps of our current surgical technique for RA are described in this video tutorial: patient positioning, port placement, and robot docking; exposure of the adrenal gland; identification and control of the adrenal vein; circumferential dissection of the adrenal gland; and specimen retrieval and closure. Demographic parameters and main surgical outcomes were assessed. A total of 76 cases (RA: 30; LA: 46) were included in the analysis. Median tumor size on computed tomography (CT) was significantly larger in the LA group (3cm [interquartile range (IQR): 3] vs 4cm [IQR: 3]; p=0.002). A significantly lower median estimated blood loss was recorded for the robotic group (50ml [IQR: 50] vs 100ml [IQR: 288]; p=0.02). The RA group presented five minor complications (16.7%) and one major (Clavien 3b) complication (3.3%), whereas four minor complications (8.7%) and one major (Clavien 3b) complication (2.3%) were observed in the LA group. No significant difference was noted between groups in terms of malignant histology (p=0.66) and positive margin rate (p=0.60). Distribution of pheochromocytomas in the LA group was significantly higher than in the RA group (43.5% vs 16.7%; p=0.02). The standardization of each surgical step optimizes the RA procedure. The robotic approach can be applied for a wide range of adrenal indications, recapitulating the safety and effectiveness of open surgery and potentially improving the outcomes of standard laparoscopy. In this report we detail our surgical technique for robotic removal of adrenal masses. This procedure has been standardized and can be offered to patients, with excellent outcomes.
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ABSTRACT: Context Over the last decade, robot-assisted adrenalectomy has been included in the surgical armamentarium for the management of adrenal masses. Objective To critically analyze the available evidence of studies comparing laparoscopic and robotic adrenalectomy. Evidence acquisition A systematic literature review was performed in August 2013 using PubMed, Scopus, and Web of Science electronic search engines. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria. Evidence synthesis Nine studies were selected for the analysis including 600 patients who underwent minimally invasive adrenalectomy (277 robot assisted and 323 laparoscopic). Only one of the studies was a randomized clinical trial (RCT) but of low quality according to the Jadad scale. However, the methodological quality of included nonrandomized studies was relatively high. Body mass index was higher for the laparoscopic group (weighted mean difference [WMD]: −2.37; 95% confidence interval [CI], − 3.01 to −1.74; p < 0.00001). A transperitoneal approach was mostly used for both techniques (72.5% of robotic cases and 75.5% of laparoscopic cases; p = 0.27). There was no significant difference between the two groups in terms of conversion rate (odds ratio [OR]: 0.82; 95% CI, 0.39–1.75; p = 0.61) and operative time (WMD: 5.88; 95% CI, −6.02 to 17.79; p = 0.33). There was a significantly longer hospital stay in the conventional laparoscopic group (WMD: −0.43; 95% CI, −0.56 to −0.30; p < 0.00001), as well as a higher estimated blood loss (WMD: −18.21; 95% CI, −29.11 to −7.32; p = 0.001). There was also no statistically significant difference in terms of postoperative complication rate (OR: 0.04; 95% CI, −0.07 to −0.00; p = 0.05) between groups. Most of the postoperative complications were minor (80% for the robotic group and 68% for the conventional laparoscopic group). Limitations of the present analysis are the limited sample size and including only one low-quality RCT. Conclusions Robot-assisted adrenalectomy can be performed safely and effectively with operative time and conversion rates similar to laparoscopic adrenalectomy. In addition, it can provide potential advantages of a shorter hospital stay, less blood loss, and lower occurrence of postoperative complications. These findings seem to support the use of robotics for the minimally invasive surgical management of adrenal masses.
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