Comparative Efficacy of Laparoscopic Versus Robotic Adrenalectomy for Adrenal Malignancy - Beyond the Abstract

While robotic surgery has demonstrated benefits with complex renal procedures and hilar dissections, does it carry a similar benefit in adrenal surgery?  Furthermore, does it address the shortcomings of laparoscopic surgery which has led the European Society of Endocrine Surgeons (ESES) and European Network for the Study of Adrenal Tumors (ENSAT), published in 2017, to endorse for open adrenalectomy for masses demonstrating local invasion or concerning for ACC?

In a previous study, we demonstrated that open adrenalectomy is still the preferred and recommended approach for oncologic outcomes (i.e. positive surgical margin and tumor spillage) and lymph node dissection.  We found that masses larger than 10 cm should be approached with an open modality; however, smaller masses seem to have similar outcomes with an open or minimally invasive approach.  In the referenced study we grouped all laparoscopic adrenalectomies (LA) and robotic adrenalectomies (RA) together.  To build on the previous study, in our current study we aimed to determine whether there is a difference between outcomes between LA versus RA. 

Using the National Cancer Database, we identified patients who underwent LA or RA for non-metastatic primary adrenal malignancy from 2010-2013. Primary outcomes were needed for open conversion, surgical margin status, and performance of regional lymphadenectomy. Secondary outcomes were the length of stay, readmission, and perioperative mortality. 238 (82%) LA and 51 (18%) RA cases were identified. The LA and RA groups were similar in terms of patient age (p=.31), gender (p=.97), race (p=.19), Charlson score (p=.80), tumor laterality (p=18), size (p=.98), histology (p=.39), grade (p=.38), hospital type (p=.70), and case volume (p=.38). The rate of open conversion was 5.9% for RA vs. 17.2% for LA (p=.04). There were no significant differences in rates of positive margins, lymphadenectomy, inpatient stay, readmission, or mortality.

Overall, the only difference between the LA and RA groups was a decreased rate of conversion to open in the RA group.  Although the reasons for open conversion are not reported in the NCDB, the lower rate of conversion with the robot may be explained by improved dexterity, ergonomics, and optics afforded by the robotic platform.  But does this lower rate of conversion warrant the increased cost of robotic surgery?  Additionally, are these findings applicable on a global stage?  Similar to renal surgery, not all cases warrant the improved dexterity and optics for successful surgical outcomes.  In cases of complex dissection, RA may be warranted based on a case-by-case review.  Additionally, it is no secret that with the advent and incorporation of robotic surgery, laparoscopic skills amongst trainees and recent graduates has declined compared to trainees outside the United States; therefore, the findings from the study cannot be extrapolated on the global stage.  Overall, oncological adequacy of minimally invasive resection remains uncertain between LA versus RA.  In summary, RA and LA should be reserved for small masses that appear non-invasive.  Additionally, we acknowledge that adrenalectomies are uncommon cases and high-volume centers should be considered for these surgeries to optimize outcomes.  Given the volume-outcome relationship in surgery, we suspect that RA outcomes may be better in current practice and may differ from the results of this study due to the increased utilization of robotic surgery

Written by: Kirtishri Mishra1, Matthew J. Maurice2,. Laura Bukavina1, Robert Abouassaly3,4
1. Urology Institute, University Hospitals – Cleveland Medical Center, Cleveland, OH, USA
2. Canton Urology, Aultman Medical Group,  Canton, Ohio, USA
3. Glickman Urological and Kidney Institute, Cleveland Clinic,  Cleveland, Ohio, USA
4.Louis Stokes Veterans Affairs Medical Center, Cleveland Clinic,  Cleveland, Ohio, USA

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