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Point of Focus Debate: For

Robotic Surgery Is Unnecessary for Adrenalectomy

By: Mesut Remzi

EU Focus, Volume 1 Issue 3, February 2016, Pages 261-262

Published online: 01 February 2016

Abstract Full Text Full Text PDF (150 KB)

The word unnecessary is provocative. To begin, we have to define necessity.

If one argues the other way around—a robot is necessary for adrenalectomy—it implies that everybody in world who does not use a robot for this indication in wrong. In contrast, the given title, including the small word unnecessary, implies that everybody who uses a robot for this indication is somehow extravagant.

What is the truth?

Brandao et al [1] recently published a systematic review and meta-analysis on this topic. The conclusion remained unclear. That robotic adrenalectomy is safe and feasible is without doubt and is not very surprising, but the potential advantages of shorter hospital stay and lower blood loss are not so clear. A shorter hospital stay for reasons other than “we know better today” can be explained only by less trauma and pain with one approach. Robotic adrenalectomy is just another form of laparoscopic approach (as used in this paper, laparoscopic approach includes the retroperitoneoscopic approach), so it is not logical that the robotic procedure should cause less trauma for the patient. This is different from the open approach, which has largely been replaced by laparoscopy as the standard of care for the vast majority of adrenal surgery, given demonstrated advantages such as less postoperative pain, minor blood loss, and better cosmetic appearance [1]. Less blood loss with one technique versus the other is important only if it is clinically meaningful. A difference of 50 ml (50 vs 100 ml) is most probably not clinically meaningful. As surgeons with broad laparoscopic experience, adrenalectomy is an “easy” indication in urologic surgery; it is performed for rather small masses and is usually bloodless or has only minor bleeding!

The authors [1] also reported no significant differences between groups in terms of clinically meaningful outcomes like intraoperative complication rate (p = 0.23), intraoperative transfusion rate (p = 0.64), postoperative complication rate (p = 0.32), and postoperative transfusion rate (p = 0.64). The robotic group had five minor complications (16.7%) and one major (Clavien 3b) complication (3.3%), whereas the laparoscopic group reported four minor complications (8.7%) and one major (Clavien 3b) complication (2.3%). This evidence shows six versus five complications, and we try to use it as evidence-based medicine and bring it to conclusion. This should not lower the quality of the hard work done by the authors, but a systematic review and meta-analysis depends on the quality and quantity of studies available. Only nine studies were included in the analysis. In general, another problem in systematic reviews comparing newer and older technologies is that the quality of the papers increases over time, thus many studies published years ago would not have been accepted today; for example, for partial nephrectomy, quality criteria did not improve over time [2]. The only way to improve the quality of the surgical scientific literature and to allow sound comparisons among different approaches, especially with the lack of randomized trials, is the use of more rigorous methodology (eg, for complication reporting [3]) than that recently proposed to report outcomes and complications [4]. The chance of being published is higher with new techniques.

The question of whether a robot is necessary cannot be answered by evidence-based medicine today. Consequently, in many discussions, emotions will influence arguments. One could argue that it is sometimes like buying cars: If you measure the outcome driving from point A to point B, the probability that the outcome is the same for most common trips is high independent of the horsepower of the car. If you have special circumstances (eg, large masses, tumor thrombus), “horsepower” can make a difference. The chance that robotic use in adrenalectomy will broaden the indication for what can be done to avoid open surgery is higher than for laparoscopic surgery, but in the vast majority of cases, the approach will not make the difference. Alternatively, is there any reason, aside from economic reasons, not to use the robot for adrenalectomy? If the robot use is standard for radical prostatectomy and/or partial nephrectomy, only minor or even no arguments can be made not to use the robot for adrenalectomy, especially if one has switched from open to robotic surgery or is trained primarily in the robotic approach. It also clear and fair to extrapolate the results of laparoscopic adrenalectomy, compared with open surgery, to robotic surgery. Again, the advantages for endoscopic surgery are clear and demonstrated by evidence.

After all, the patient will follow the arguments of the doctor in most cases if adrenalectomy is needed. The most important factor for the patient is the surgical experience of the surgeon performing the operation. If the surgeon is well trained in laparoscopy or robotic surgery, this will provide potential advantages for the surgery. If the patient will be operated during the learning curve of one or the other technique, the probability of complications increases [5] in nearly all indications. Why not also for adrenalectomy? If only open surgery can be offered, patients should be informed that there are other methods with potential advantages for patient outcome.

Conflicts of interest

The author has nothing to disclose.

References

  • [1] L.F. Brandao, R. Autorino, H. Zargar, et al. Robot-assisted laparoscopic adrenalectomy: step-by-step technique and comparative outcomes. Eur Urol. 2014;66:898-905 Crossref
  • [2] D. Mitropoulos, W. Artibani, C.S. Biyani, et al. Quality assessment of partial nephrectomy complications reporting using EAU standardised quality criteria. Eur Urol. 2014;66:522-526 Crossref
  • [3] D. Mitropoulos, W. Artibani, M. Graefen, M. Remzi, M. Rouprêt, M. Truss. European Association of Urology Guidelines Panel. Reporting and grading of complications after urologic surgical procedures: an ad hoc EAU guidelines panel assessment and recommendations. Eur Urol. 2012;61:341-349 Crossref
  • [4] A.S. Merseburger, T.R. Herrmann, S.F. Shariat, et al., European Association of Urology. EAU guidelines on robotic and single-site surgery in urology. Eur Urol. 2013;64:277-291 Crossref
  • [5] F. Porpiglia, R. Bertolo, D. Amparore, C. Fiori. Margins, ischaemia and complications rate after laparoscopic partial nephrectomy: impact of learning curve and tumour anatomical characteristics. BJU Int. 2013;112:1125-1132 Crossref

Footnotes

Department of Urology, LKH Korneuburg, Wiener Ring 3-5, Korneuburg, 2100, Austria

Tel. +43 676 3261972; Fax: +43 1 40400 2615.

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