Robotic adrenalectomy in the pediatric population: initial experience case series from a tertiary center

A 2-year-old female had previously undergone a robot-assisted adrenal-sparing left upper pole partial nephrectomy at 14 months of age for recurrent febrile urinary tract infections and a poorly functioning renal moiety with ectopic ureter. Postoperative ultrasound showed a new 2.5 cm right adrenal mass, which was confirmed on MRI. Metabolic activity was confirmed by MIBG study (Fig. 1a, b). 24-h urine metanephrines, homovanillate and vanillylmandelate, and corresponding plasma chemistry levels were within normal limits.

Under general anesthesia, the patient was positioned in left lateral decubitus. An 8 mm robotic camera port was introduced at the umbilicus using the Hasson technique [8]. Following low-pressure insufflation, the camera was introduced and visceral injuries were ruled out. Three additional 8 mm robotic ports and a 5 mm assistant port were then placed (Fig. 1c). After docking the da Vinci Xi robot, the hepatic flexure of the right colon was minimally mobilized to aid in visualization of the right adrenal gland. After identifying the right suprarenal vein and adrenal gland, dissection was carried cephalad under the liver. Combination of monopolar and bipolar cautery was used to obtain hemostasis. A tough dissection plane between the medial aspect of the adrenal gland and the inferior vena cava resulted in creation of a small inadvertent cavotomy that was rapidly repaired primarily with figure-of-eight 4–0 polypropylene suture (Fig. 1d). The right adrenal gland was mobilized (Fig. 1e). The adrenal vein was suture-ligated with 4–0 polypropylene suture before transection. Hemostasis was confirmed and the kidney was well perfused throughout. Specimen was delivered intact through the umbilical port incision using an EndoCatch specimen pouch (Covidien, Minneapolis, MN). Estimated blood loss was 175 ml; 125 ml packed red blood cells, 1000 ml crystalloids and 60 ml colloids were transfused intraoperatively. Operative time was 244 min.

Patient had an uneventful hospital course with good in-house pain control and was discharged on post-operative day two. Final pathological evaluation of the 7.1 gm specimen revealed nodular ganglioneuroblastoma that was negative for c-Myc by immunohistochemistry. FISH did not show MYCN amplification (Fig. 1e). Surgical margins were negative. No lymphovascular invasion was noted. Patient is being followed with serial MRI, MIBG scan, and urine catecholamines. She remains disease-free at 30 months of post-operative follow-up.

A 13-year-old male was noted to be intermittently tachycardic and hypertensive during hospitalization for a pneumonia episode, and found to have a 6 cm right adrenal mass on MRI (Fig. 2). Patient’s father has von Hippel-Lindau disease and had undergone bilateral adrenalectomy for pheochromocytoma and bilateral nephrectomy for renal cell carcinoma. A pathogenic VHL mutation (c.583C > T, p.Q195X) was found in the patient, which was same as the father. 24-h urine norepinephrine level was elevated.

Patient’s postoperative stay was prolonged due to a generalized morbilliform eruption attributed to a previously unknown allergy to clindamycin. This gradually resolved after administration of systemic corticosteroids and stopping the offending drug, and he was discharged on post-operative day six. Pathological evaluation of the 48.5 gm specimen was consistent with pheochromocytoma. No capsular or vascular invasion was seen. Surgical margins were negative. Patient is being monitored with serial ultrasound and MRI. He remains disease-free at 19 months of post-operative follow-up.

Renal ultrasound for workup of microscopic hematuria in a 4-year-old male showed an incidental mass in the area of the right kidney. A subsequent CT scan showed a 6.4 cm heterogeneous mass replacing the right adrenal gland, which was MIBG-avid (Fig. 3a–c). CT chest and bone scan were negative for metastatic disease. 24-h urine homovanillate and vanillylmandelate were elevated.

Patient had an uneventful hospital course and was discharged on post-operative day one. Pathological diagnosis of the 57 gm specimen was intermixed type, Schwannian stroma-rich ganglioneuroblastoma with negative surgical margins. Immunohistochemistry was negative for c-Myc and n-Myc. FISH did not show MYCN amplification (Fig. 3d). No malignancy was identified in the resected lymph node. Patient is being followed with serial MRI, MIBG scan, and urine catecholamines. He remains disease-free at 12 months of post-operative follow-up.