Robotic versus Traditional Laparoscopic Approach for Posterior Retroperitoneal Adrenalectomy: A Critical Appraisal and Balance Between Perioperative Outcomes and Costs

With the introduction of minimally invasive approaches to retroperitoneal space, adrenalectomy has shown better perioperative and cosmetic results and has become perhaps faster and easier if checked against traditional open technique, without renouncing to comparable surgical and oncological effectiveness [1].

From an anatomical point of view, posterior approach to the retroperitoneal cavity allows to directly access the adrenal gland, but actually becomes more and more challenging in case of laparoscopic or robot-assisted techniques adoption, because of limited working space and bothersome instruments collisions [2], and perhaps requires a longer learning curve to reach proficient perioperative results. For this reason, the posterior retroperitoneal minimally invasive approach is being less adopted over time if compared to lateral access to adrenals.

In this particular scenario, robotic assistance with DaVinci® platform might overcome the technical challenges of traditional laparoscopy, giving the higher degrees of freedom of wristed instruments, better surgeon’s comfort and enhanced 3 D vision, thus potentially becoming the ideal competitor of open surgery, as previously reported for renal surgery [3,4].

However, the current scientific knowledge about the potential advantages offered by robotic over traditional laparoscopic approach in posterior retroperitoneal adrenalectomy is quite limited so far, since the adoption of DaVinci® technology has been only more recently reported in this context [2].

With their propensity-score matched series [5], Wenming Ma and colleagues offered an insightful contribution in this field. In their original research, a quite large retrospective cohort has been extracted in less than 6 years, underlining the remarkably high Institutional volume and surgeons’ experience. Wenming Ma and colleagues should be commended for this interesting study.

By considering all the comprehensive analyses, the main finding sounds clearly: traditional laparoscopic and robot-assisted approach should actually be considered equivalent for the vast majority of perioperative end-points, even considering a subgroup analysis of patients treated for pheochromocytomas [5]. For sure, these are outstanding results, but at dramatically higher hospitalization costs for robotics. Indeed, it was found to roughly be twofold expensive than laparoscopy.

So said, is not easy to say if these costs could actually be justified by shorter observed median length of stay – only one day less for patients receiving robot-assisted surgery – lower, but not significant, transfusions rate or maybe less analgesics adoption.

On the other hand, it must be acknowledged that the robotic series included in this study was more recent, and perhaps the surgeon was not so far from the completion of his learning curve. For this reason, a longer experience with higher robotic surgical volume might have mitigated the economic disadvantages of DaVinci® technology over traditional laparoscopy.

Taken together and basing on the current evidences, robotics and laparoscopy are equivalently effective and safe, even for posterior retroperitoneal adrenalectomy. The divergent costs, a not-negligible aspect for most of the hospital administrations, should be balanced between expected benefits and surgeons’ experience and confidence.

We do believe that these considerations could perhaps be the real key messages of the study, the conclusion that we might keep in mind when facing and choosing the most appropriate minimally invasive approach to posterior retroperitoneal adrenalectomy in our daily clinical practice.

Disclosure statement

No potential conflict of interest was reported by the author(s).