Robot-Assisted Laparoscopic Partial Adrenalectomy for Pheochromocytoma: The National Cancer Institute Technique

doi:10.1016/j.eururo.2011.03.046

European Urology

Volume 60, Issue 1, July 2011, Pages 118-124

https://doi.org/10.1016/j.eururo.2011.03.046 Get rights and content

Abstract

Background

Partial adrenalectomy has recently been advocated to preserve unaffected adrenal tissue during resection of pheochromocytoma.

Objective

To describe a robot-assisted laparoscopic partial adrenalectomy (RALPA) technique and to report on early functional and oncologic outcomes.

Design, setting, and participants

From 2007 to 2010, 15 RALPA were performed on 12 consecutive patients with pheochromocytoma. Follow-up data of >1 yr are available on 11 procedures. Median follow-up for the entire cohort was 17.3 mo (range: 6–45).

Surgical procedure

Positioning and port placement is designed for adequate reach and visualization of the upper retroperitoneum. The plane between the adrenal cortex and pheochromocytoma pseudocapsule is identified visually and with laparoscopic ultrasound. The tumor is dissected away from normal adrenal cortex, preserving normal adrenal tissue.

Measurements

Preoperative, perioperative, pathologic, and functional outcomes data were analyzed.

Results and limitations

Fourteen of 15 cases were completed robotically. Among 15 procedures, 4 were performed on a solitary adrenal gland. Four cases required resection of multiple tumors (up to six) with two performed in a solitary gland. The mean age of the patients was 30 yr, and the mean body mass index was 27. The mean operative time was 163 min, the median estimated blood loss was 161 ml, and the median tumor size was 2.7 cm (range: 1.3–5.5). There was one conversion to an open procedure in a patient requiring reoperation on a solitary adrenal gland. One patient who underwent RALPA on a solitary adrenal gland required postoperative steroid supplementation at last follow-up. At a median follow-up of 17.3 mo (range: 6–45), there were no recurrences or metastatic events. Study limitations include small sample size and short follow-up.

Conclusions

RALPA for the treatment of pheochromocytoma is feasible and safe and provides encouraging functional and oncologic outcomes, even in patients with a solitary adrenal lesion or multiple ipsilateral lesions.

Introduction

Pheochromocytoma is an uncommon tumor with an incidence of approximately one or two per 100 000 adults per year but is much more common in familial cancer syndromes, including von Hippel-Lindau (VHL), multiple endocrine neoplasia (MEN) type 2, and neurofibromatosis type I. Among VHL patients who develop pheochromocytomas, up to 47% will develop bilateral lesions [1]. Traditional surgical treatment for pheochromocytoma has been total adrenalectomy. Recent reports have described adrenal-sparing surgery as a surgical option for patients with hereditary cancer syndromes [2], [3], [4], [5], [6], [7]. In addition, adrenal-sparing surgery has also been described for sporadic adrenal masses, since, even in sporadic cases, other pathologic processes may affect the remaining solitary adrenal gland [8], [9], [10], [11].

Laparoscopic approaches have become widely used for adrenal lesions [12], [13], [14], including several reports describing laparoscopic adrenal-sparing surgery utilizing both the transperitoneal and retroperitoneal approaches [15], [16], [17].

At our referral center, the majority of patients have hereditary conditions and may develop bilateral, multifocal adrenal lesions. Additionally, many patients have had prior adrenal surgery and some have multiple adrenal lesions. These patients afforded us a unique opportunity to evaluate robot-assisted, laparoscopic, partial adrenalectomy (RALPA) for pheochromocytoma. Here we describe our surgical technique and report early functional and oncologic outcomes.

Section snippets

Patients and methods

We performed 15 RALPA procedures in 12 consecutive patients presenting with pheochromocytoma to the National Cancer Institute, US National Institutes of Health, from June 2007 through August 2010. All patients gave written consent regarding the surgical risks of the procedure and the risk for postoperative steroid replacement. The study protocol was approved by the institutional review board.

Results

A total of 15 RALPAs were performed in 12 patients. Patient characteristics are listed in Table 1. Ten of 12 patients had VHL disease, one patient had neurofibromatosis type 1, and the other had bilateral pheochromocytomas without a known genetic disorder. Median follow-up for the entire cohort was 17.3 mo (range: 6–45), and 11 procedures had >1 yr follow-up. Mean tumor size for the cohort was 2.7 cm.

Four patients underwent RALPA with resection of multiple ipsilateral pheochromocytomas, ranging

Discussion

Pheochromocytoma has traditionally been surgically managed by total adrenalectomy. In this report we describe our technique of RALPA in detail. We have found this technique effective for the management of pheochromocytoma, even with multiple lesions or in the setting of a solitary adrenal gland, with promising functional and oncologic outcomes.

Several technical considerations are important to successfully perform this procedure (Table 3). First, the patient must be positioned in an exaggerated

Conclusions

RALPA for pheochromocytoma is a safe, technically feasible procedure that provides excellent short-term functional and oncologic outcomes. Our technique for RALPA may be used for patients with adrenal pheochromocytoma, including multifocal lesions, and is especially well suited to those with a solitary adrenal gland. The procedure may be applicable for other type of adrenal lesions. Longer follow-up is needed to assess long-term functional and oncologic outcomes.

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Cited by (56)

Robot-assisted versus conventional laparoscopic adrenalectomy: Results from the EUROCRINE Surgical Registry
2022, Surgery (United States)
Citation Excerpt :
On the other hand, there might be a selection bias: inexperienced surgeons may have preferred smaller tumors to operate. There is lack of data when specifically addressing robotic surgery in the pheochromocytoma patient.31,35-38 In a multi-institutional case-control study, Fang et al demonstrated that both laparoscopic and robotic adrenalectomy offer similar perioperative outcomes.38
Adrenalectomy is routinely performed via the minimally invasive approach. Safety of adrenalectomy using the robot-assisted technique has been widely demonstrated by several series, but the literature is scarce regarding the comparison of conventional laparoscopic versus robot-assisted approach. We decided to carry out a multicenter study to compare clinical and surgical outcomes between laparoscopic and robotic adrenalectomy.
This is a retrospective case-control study, including data from centers affiliated to the Surgical Registry EUROCRINE. Patients undergoing laparoscopic surgery for adrenal tumors and registered between 2015 and 2018 were included. Robot-assisted versus laparoscopic adrenalectomy was compared. All comparisons were carried out in terms of complication rate, conversion rate and duration of stay.
A total of 1,005 patients from 46 clinics underwent robotic or conventional laparoscopic adrenalectomy. Median age was 55 (interquartile range: 45−65) years. Robotic adrenalectomy was performed in 189 (18.8%) patients. According to Clavien-Dindo classification, complication rate was lower in the robotic surgery group (1.6% vs 16.5%, P < .001). Laparoscopic surgery and active hormonal status were significantly correlated with complications, both in univariate and multivariate analysis. There was no significant difference between laparoscopic and robotic surgery groups, in terms of conversion rate (2.1% vs 0.5%, respectively, P = .147). Duration of stay was shorter in the robotic adrenalectomy group (82.1% vs 28.8%, P < .001).
Analysis of the EUROCRINE database supports that robotic adrenalectomy resulted in a lower complication rate and shorter duration of stay, compared with laparoscopic adrenalectomy. Granular data to support this is warranted.
Data set for the reporting of pheochromocytoma and paraganglioma: explanations and recommendations of the guidelines from the International Collaboration on Cancer Reporting
2021, Human Pathology
The International Collaboration on Cancer Reporting (ICCR) is a not-for-profit to develop evidence-based, internationally agreed-upon standardized data sets for each anatomic site, to be used throughout the world. Providing global standardization of pathology tumor classification, staging, and other reporting elements will lead to improved patient management and enhanced epidemiological research.
Pheochromocytoma and paraganglioma are uncommon and are frequently overlooked in registry data sets. Malignant criteria have previously been defined only when there was metastatic disease.
With recent recognition of a significant inheritance association and the development of risk stratification tools, this data set was created in order to obtain more meaningful outcomes and management data, using similar criteria across the global pathology community. Issues related to key core and non-core elements, especially clinical hormonal status, familial history, tumor focality, proliferative fraction, adverse or risk stratification features, and ancillary techniques, are discussed in the context of daily application to these types of specimens.
The ICCR data set, developed by an international panel of endocrine organ specialists, establishes a pathology-standardized reporting guide for pheochromocytoma and paraganglioma.
Robotic renal and adrenal oncologic surgery: A contemporary review
2021, Asian Journal of Urology
Robot-assisted surgery has evolved over time. Radical nephrectomy with inferior vena cava thrombectomy is feasible and safe for level I, II and III thrombus in high volume centers. Though it is feasible for level IV thrombus, this procedure needs a multi-departmental co-operation. However, the safety of robot-assisted procedures in this subset is still unknown. Robot-assisted partial nephrectomy has been universally approved and found oncologically safe. Robotic adrenalectomy has been increasingly utilized for select cases, especially in bilateral tumors and for retroperitoneal adrenalectomy.
Long-term Functional and Oncologic Outcomes of Partial Adrenalectomy for Pheochromocytoma
2020, Urology
To evaluate the recurrence and functional outcomes in a primarily hereditary cohort of patients undergoing partial adrenalectomy for pheochromocytoma.
A retrospective review from a prospectively managed database of patients undergoing partial adrenalectomy from 1995 to 2018 at the National Cancer Institute was performed. Local recurrence was defined as imaging evidence of a recurrent or de novo lesion on the operative side. Steroid dependency was defined as requiring daily steroid replacement at time of last follow-up.
One hundred and twenty-four partial adrenalectomies, removing 162 tumors, were performed in 107 patients. Most patients had a known hereditary predisposition to develop bilateral, multifocal, and recurrent pheochromocytoma. Median tumor size was 2 cm (interquartile range (IQR) 1.5-2.8). Median follow-up was 60 months (IQR 13-131). Local recurrence occurred in 17 patients (15.8%) and were managed with active surveillance or surgery. A single patient (1/106, 0.9%) developed metastatic spread of pheochromocytoma approximately 14 years after his first of 2 partial adrenalectomies and remains alive under active surveillance. Median time to recurrence was 71 months (IQR 26-127) with 10 patients (9.3%) requiring daily steroid replacement at time of last follow-up.
Partial adrenalectomy offers excellent oncologic and functional outcomes, sparing most patients from lifelong steroid replacement therapy. Recurrences can be easily managed with repeat surgery or active surveillance via functional work-up and imaging. Partial adrenalectomy remains the recommended surgical management for patients pre-disposed to development of bilateral, multifocal and recurrent pheochromocytoma.
Ultrasound guidance in minimally invasive robotic procedures
2019, Medical Image Analysis
In the past decade, medical robotics has gained significant traction within the surgical field. While the introduction of fully autonomous robotic systems for surgical procedures still remains a challenge, robotic assisted interventions have become increasingly more interesting for the scientific and clinical community. This happens especially when difficulties associated with complex surgical manoeuvres under reduced field of view are involved, as encountered in minimally invasive surgeries. Various imaging modalities can be used to support these procedures, by re-creating a virtual, enhanced view of the intervention site. Among them, ultrasound imaging showed several advantages, such as cost effectiveness, non-invasiveness and real-time volumetric imaging. In this review we comprehensively report about the interventional applications where ultrasound imaging has been used to provide guidance for the intervention tools, allowing the surgeon to visualize intra-operatively the soft tissue configuration in real-time and to compensate for possible anatomical changes. Future directions are also discussed, in particular how the recent developments in 3D/4D ultrasound imaging and the introduction of advanced imaging capabilities (such as elastography) in commercially available systems may fulfil the unmet needs towards fully autonomous robotic interventions.
Robotic Versus Laparoscopic Retroperitoneal Resection of Large Adrenal Tumors: A Propensity Score-Matched Cohort Analysis
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Published by Elsevier B.V.

Surgery in MotionRobot-Assisted Laparoscopic Partial Adrenalectomy for Pheochromocytoma: The National Cancer Institute Technique

Abstract

Background

Objective

Design, setting, and participants

Surgical procedure

Measurements

Results and limitations

Conclusions

Introduction

Section snippets

Patients and methods

Results

Discussion

Conclusions

J Urol

J Urol

Urology

Eur Urol

Best Pract Res Clin Endocrinol Metab

Urology

J Urol

Urology

Pathophysiology, evaluation, and medical management of adrenal disorders

Laparoscopic partial adrenalectomy for recurrent pheochromocytoma after open partial adrenalectomy in von Hippel-Lindau disease

J Endourol

Pheochromocytomas and paragangliomas in von Hippel-Lindau disease: a role for laparoscopic and cortical-sparing surgery

Arch Surg

Preserved adrenocortical function after laparoscopic bilateral adrenal sparing surgery for hereditary pheochromocytoma

J Clin Endocrinol Metab

Surgery in Motion
Robot-Assisted Laparoscopic Partial Adrenalectomy for Pheochromocytoma: The National Cancer Institute Technique