A commentary on 'Comparison of the effectiveness and safety of robotic-assisted and laparoscopic in adrenalectomy: a systematic review and meta-analysis' [Int J Surg (2022) 105:106853].

Highlights Robotic technology offers advantages in overcoming some laparoscopic defects. Robotic-assisted adrenalectomy is feasible in patients with large tumors. Retroperitoneal techniques have certain technical advantages for patients with obesity. The use of robotic-assisted adrenalectomy is constrained by costly prices and lengthy procedures. Dear Editor, Currently, laparoscopic adrenalectomy (LA) is widely regarded as the technique of choice. Since the introduction of the da Vinci System (Intuitive Surgical), robotic surgery has advanced significantly and is becoming increasingly popular in the field of urological surgery. The first robotic-assisted adrenalectomy (RA) was carried out by Piazza et al.1 in 1999 for a patient with a right adrenocortical adenoma. Since then, RA has received a great deal of attention, which has led to the addition of more surgical options. In recent years, several series of cases share experience in the application of RA in high-volume centers. Although there are still concerns about the economic costs and generalizability of the results as described in published publications, more and more evidence has brought us closer to those answers. Recently, Gan et al.2 performed a systematic review and meta-analysis to compare the safety and effectiveness of RA and LA. The findings suggest that RA is a better option than LA for adrenal tumors, especially in the areas of estimated blood loss, length of stay, and conversion to open surgery. For pheochromocytoma, robotics is still a better option. Robotic technology offers advantages in overcoming some laparoscopic defects (unstable camera, rigid instruments, loss of 3D vision). Indeed, the robotic system is equipped with stereoscopic vision magnified in 3D, an additional degree of freedom, shaking filtering technology, and a stable camera. The common routes for RA include transperitoneal and retroperitoneal approaches. Based on the patient’s body habitus and the surgeon’s experience, either the transperitoneal approach or the retroperitoneal route can be safely used to perform RA. Removing big adrenal tumors with minimally invasive surgery has sparked two significant concerns: first, the chance of a suspected malignant tumor’s capsular disruption or partial removal, which increases the chance of recurrence; and second, the technical difficulty of dissection given the large size of the lesion3. RA is feasible in patients with large tumors; the effective treatments obtained with the robotic approach may be attributable to the wrist-mounted articulated instruments and the 3D magnified vision, which enable a quicker and more accurate dissection3. Furthermore, the transperitoneal approach was advised since large lesions can make dissection difficult due to the limited retroperitoneal area. Retroperitoneal techniques greatly reduce the risk of problems associated with entering the abdominal cavity since they can approach the surgical location directly without the need for the mobilization of nearby structures. This presents some technical advantages for patients suffering from obesity and possible abdominal adhesions4. For bilateral adrenalectomy, the retroperitoneal route prevents repositioning of the patient and thus reduces surgery time, with results comparable to the transperitoneal approach5. On the other side, the constrained workspace served as a reminder of some constraints, which may collapse in the event of excessive suction, close positioning of the trocar, and reduced inclination of the rigid laparoscopic instrument. Additionally, the usage of RA is constrained by costly prices and lengthy procedures. The high expense of using the robotic system in particular is mostly connected to the purchase and maintenance of the unit, the high cost of instrumentation, and the longer operating time. Notably, these factors increase the cost of a RA compared to a LA by up to 2.3 times6. Further studies are needed to evaluate its impact on outcomes and to determine whether these qualities outweigh the cost burden. Ethical approval None. Sources of funding None. Authors’ contribution H.S.: writing. S.F. and J.W.: data collections and data analysis. H.W.: study design. Conflicts of interest disclosure The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) None. Guarantor Haifeng Wang.