Laparoscopic adrenalectomy (LA) was first described in 1992 by Gagner et al.  and, since then, has progressively replaced conventional open adrenalectomy as the gold standard procedure for the treatment of benign adrenal disease . While LA may be considered by laparoscopic surgeons for small or benign adrenal masses, in cases with large or malignant lesions, LA may represent an extremely challenging surgery. The current limitations of the laparoscopic approach, mainly consisting of reduced maneuverability and limited ergonomic design of instruments, natural hand fatigue, tremors, and counterintuitive movements, may further enhance the complexity of this procedure.
These aspects, along with the relatively low incidence of adrenal lesions, have limited the diffusion of LA to few high-volume tertiary care centers. Learning from history, a better alternative to open access should offer the same cosmetic and postoperative advantages of LA but should be feasible for many urologists and, consequently, available to many patients. The use of a robotic platform may help achieve this purpose by combining the benefits of a shorter learning curve with low complication rates.
The first experience with robot-assisted adrenalectomy (RA) was reported in 1999 by Piazza et al, who performed a right adrenalectomy in a patient with Conn's syndrome using the ZEUS AESOP robot (Computer Motion, Inc., Santa Barbara, CA, USA) . Conversely, the first RA performed with the da Vinci robot (Intuitive Surgical, Sunnyvale, CA, USA) was described by Desai et al. in 2002 . From this preliminary experience, RA emerged as an extremely promising procedure, capable of overcoming the technical difficulties of LA and allowing broader diffusion of minimally invasive surgery for the treatment of adrenal masses. Specifically, the well-known advantages of the da Vinci system allow surgeons to perform very precise adrenalectomy and even, in selected cases, adrenal-sparing surgery, reducing the learning curve .
Today, the widespread diffusion of RA has been limited only by the availability of the da Vinci robot and by cost-effectiveness considerations. In recent years, only a few papers have compared the perioperative outcomes of RA relative to LA for small adrenal masses . These studies demonstrated the surgical feasibility of this procedure with lower blood loss, shorter hospital stay, and lower complication rates; however, the short- and long-term oncologic and benign outcomes of RA versus LA have not been adequately assessed.
Consequently, the use of RA should not be advocated for all patients, according to the available literature; however, RA may represent the optimal treatment choice for selected patients for whom LA may be extremely challenging. Recently, Agcaoglu et al. attempted to determine whether RA was appropriate for removing large adrenal tumors and showed that it could shorten operating time and decrease the rate of conversion to open for adrenal tumors >5 cm . Similarly, Brunaud et al. demonstrated that in patients with a body mass index of >30 kg/m2 and large tumors (≥55 mm), mean operating time was longer in the LA group than in the RA group . Conversely, conversion rate, morbidity, and hospital stay were similar in both groups.
Moreover, some particularly challenging procedures can be performed easily with the da Vinci system. A large left adrenal gland covered by the pancreas requires the use of the fourth robotic arm to reach the mass easily, reducing the risk of complication. Right pheochromocytoma with retrocaval vein contiguity can be removed safely using the fourth arm to stably retract the cava vein and using the robotic clip device to safely reach the adrenal vein. However, both Morino et al.  and Xiao et al.  indicated that the total cost of RA was significantly higher than that for LA. The increased expense was mainly due to the use of only two robotic instruments and the longer operative time related to docking time.
In conclusion, based on the current literature, it is indeed true that RA may represent a luxury, and its adoption may not be reasonable for all patients. However, in selected patients, RA may represent an appropriate surgical option, combining the benefits of minimally invasive surgery with a short learning curve and the ease of use of robotic technology.
Conflicts of interest
The authors have nothing to disclose.
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Department of Urology, Humanitas Clinical and Research Center, Humanitas University, Milan, Italy
Corresponding author. Department of Urology, Humanitas Clinical and Research Center, via Alessandro Manzoni, 56, Rozzano, Milan, 20089, Italy.
© 2015 European Association of Urology, Published by Elsevier B.V.