Robotic Enucleation of Adrenal Masses: Techniques and Outcomes - Beyond The Abstract

Adrenal mass is a common disease in urologic clinic. For big tumors or tumors with endocrine functions, surgery is still the standard of care. With the development of minimally invasive techniques, the surgical management of adrenal masses has been greatly simplified. Large incisions are replaced and exposure of the surgical field is improved significantly. As more and more patients with adrenal tumors undergoing surgical treatments, new problems arise. Some patients have bilateral tumors requiring surgical removal. Preservation of adrenal gland will prevent long-term hormone replacement therapy. Additionally, some patients hope to preserve as much adrenal gland as possible to improve quality of life. Therefore, the number of partial adrenalectomy has been on the rise. 

The robotic system has been widely used in urological field. However, it is underestimated in the field of adrenal diseases. In many centers, partial adrenalectomy cases are done laparoscopically since no complicated or delicate handling is needed. In fact, robotic system offers a novel approach. Adrenal tumors always present with a tumor capsule which is an excellent anatomic landmark for enucleation. In this series of patients, we mimicked the surgical procedure of partial nephrectomy. Blood vessels were temporarily clamped to provide a clear surgical field. The adrenal mass was resected closely to the capsule. A blood-free field is of great importance for the surgeon to observe tumor capsule clearly. Since the adrenal vascular pressure is relatively low, a simple and superficial suture would stop the bleeding. The average ischemic time was 12 minutes, much shorter than that in a nephron-sparing surgery. In this way, adrenal tissue is preserved to the greatest extent.

This technique also has its limitations. It is not suitable for large tumors. In these cases, the difficulty of operation is greatly increased. Besides, large tumors may have satellite lesions, and enucleation may lead to residual tumors. Also, it is not suitable for multiple tumors located on the same side. After multiple tumor enucleation and suture, less tissue could be preserved. More importantly, some small tumors are invisible to CT scan and naked eye.

In conclusion, robotic enucleation of adrenal masses is a feasible approach. It brings an alternative approach to surgeons as well as patients. 

Written by: Chao Zhang, MD, Yue Yang, MD, Elaine Yang Phd Candidate, MD, Department of Urology, Shanghai Changhai Hospital, the Second Military Medical University, Shanghai, China

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