Surgical Management of Adrenocortical Carcinoma: Current Highlights

Introduction: Adrenocortical carcinoma (ACC) is a rare tumor, often discovered at an advanced stage and associated with poor prognosis. Treatment is guided by staging according to the European Network for the Study of Adrenal Tumors (ENSAT) classification. Surgery is the treatment of choice for ACC. The aim of this review is to provide a complete overview on surgical approaches and management of adrenocortical carcinoma. Methods: This comprehensive review has been carried out according to the PRISMA statement. The literature sources were the databases PubMed, Scopus and Cochrane Library. The search thread was: ((surgery) OR (adrenalectomy)) AND (adrenocortical carcinoma). Results: Among all studies identified, 17 were selected for the review. All of them were retrospective. A total of 2498 patients were included in the studies, of whom 734 were treated by mini-invasive approaches and 1764 patients were treated by open surgery. Conclusions: Surgery is the treatment of choice for ACC. Open adrenalectomy (OA) is defined as the gold standard. In recent years laparoscopic adrenalectomy (LA) has gained more popularity. No significant differences were reported for overall recurrence rate, time to recurrence, and cancer-specific mortality between LA and OA, in particular for Stage I-II. Robotic adrenalectomy (RA) has several advantages compared to LA, but there is still a lack of specific documentation on RA use in ACC.

Robotic Versus Laparoscopic Adrenalectomy: Systemic Review

Background: Minimal invasive surgery has become the standard for most surgical procedures now. Many studies have tried to compare robotic versus laparoscopic to adrenalectomy. Objectives: The aim of this study is to review most of the available studies comparing robotic to laparoscopic adrenalectomy to evaluate which procedure provides the superior clinical outcomes. Methods: A systematic literature search of ScienceDirect and PubMed databases. The perioperative clinical outcomes were collected by two independent reviewers. We used Random-effects (DerSimonian-Laird) models to get the pooled effect estimates. Results: 18 studies were eligible in our study. 10 of them were prospective and 8 were retrospective. A total of 1376 patients underwent adrenalectomy, 592 (43.02%) were treated with RA and 784 (56.9%) with the LA technique. There were no significant differences between both groups regarding the conversion rate (Odds ratio: 0.70, 95% CI 0.31-1.57, P= 0.65), intraoperative complications (OR: 2.18, 95% CI 0.49- 9.71, P= 0.28), post-operative complications (OR: 0.83, 95% CI: 0.55-1.24, P= 0.49), and mortality (OR: 0.42, 95% CI: 0.07-2.72, P= 0.98). However, robotic adrenalectomy was associated with longer operative times (MD: 9.89 min, 95% CI: -2.79 to 22.58), shorter hospital stay (MD: -0.33, 95% CI: -0.46 to -0.21) with less blood loss (MD: -25.34, 95% CI: -36.77 to -13.91). Conclusions: We proved that robotic adrenalectomy has equal safety and feasibility with similar clinical outcomes when compared with laparoscopic approach. However, better well-designed studies are required to determine the role and cost-effectiveness of robotic adrenal surgery.

Robot-assisted adrenalectomy: state of the art

Currently, laparoscopic adrenalectomy is worldwide considered the gold standard technique. Both transperitoneal and retroperitoneal approaches have proved their efficacy with excellent outcomes. Since the introduction of da Vinci System (Intuitive Surgical, Sunnyvale, CA), robotic surgery has made many steps forward gaining progressively more diffusion in the field of general and endocrine surgery. The robotic technique offers advantages to overcome some laparoscopic shortcomings (rigid instruments, loss of 3D vision, unstable camera). Indeed, the robotic system is provided of stereoscopic 3D-magnified vision, additional degree of freedom, tremor-filtering technology and a stable camera. Recently, several case series have demonstrated the feasibility and the safety of robot-assisted adrenalectomy in high-volume centers with outcomes comparable to laparoscopic adrenalectomy. Notwithstanding, the technical advantages of the robotic system have not yet demonstrated significant improvements in terms of outcomes to undermine laparoscopic adrenalectomy. Moreover, robotic adrenalectomy harbor inherits drawbacks, such as longer operative time and elevated costs, that limit its use. In particular, the high cost associated with the use of the robotic system is primarily related to the purchase and the maintenance of the unit, the high instruments cost and the longer operative time. Notably, these aspects make robotic adrenalectomy up to 2.3 times more costly than laparoscopic adrenalectomy. This literature review summarizes the current available studies and provides an overview about the robotic scenario including applicability, technical details and surgical outcomes.