ELSEVIER
Contents lists available at ScienceDirect
International Journal of Surgery
journal homepage: www.journal-surgery.net
JOURNAL OF SURGERY
4
Review
Robotic assisted adrenalectomy: Surgical techniques, feasibility, indications, oncological outcome and safety
CrossMark
Eugenia Yiannakopoulou®
Faculty of Health and Caring Professions Technological Educational Institute of Athens, Greece
HIGHLIGHTS
. The majority of patients undergoing robotic assisted adrenalectomy are treated for benign disease.
. There are only a few case reports of robotic assisted adrenalectomy performed for malignant disease.
· Robotic assisted partial adrenalectomy seems especially promising for hereditary pheochromocytoma.
· Robotic assisted adrenalectomy could possibly elicit a mild surgical response instead of the well described surgical response.
ARTICLE INFO
Article history: Received 30 July 2015 Received in revised form 17 February 2016 Accepted 20 February 2016 Available online 27 February 2016
Keywords: Robotic assisted adrenalectomy Feasibility Indications Oncological outcome Safety
ABSTRACT
Nowadays robotic assisted adrenalectomy has become an alternative to conventional laparoscopic adrenalectomy. However, evidence on the possible advantages and drawbacks of robotic assisted adre- nalectomy remains still limited. This manuscript aimed to review evidence on robotic assisted adre- nalectomy in terms of surgical technique, feasibility, indications, oncological outcome and safety. Existing evidence, although limited, suggests that robotic assisted adrenalectomy is feasible and safe. However, the number of patients submitted to robotic assisted adrenalectomy is limited with the majority of them being operated for benign disease. There are only a few case reports of robotic assisted adrenalectomy performed for adrenocortical carcinoma, oncocytoma or metastasis. Partial adrenalectomy seems to be a promising application of robotic assisted adrenalectomy especially for the treatment of hereditary pheocromocytomas. Robotic assisted adrenalectomy overcoming the technical limitations of laparoscopic surgery could possibly elicit a mild surgical response instead of the well described surgical response. Surgical response affects surgical morbidity and mortality as well as oncological outcome of malignant disease. If this hypothesis is proved correct, robotic assisted adrenalectomy could be possibly indicated in the treatment of disease. In conclusion, robotic assisted adrenalectomy is feasible and safe. Further research is needed on the oncological outcome of this minimally invasive technique as well as on its effect on surgical stress response.
@ 2016 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
1. Introduction
Since its first description by Gagner et al., laparoscopic adre- nalectomy has become the standard of care for the management of functioning and non-functioning adrenal neoplasms with a benign appearance, ≤6 cm in diameter and weighing <100 g due to a lower morbidity rate, less postoperative pain, shorter hospital stay, and a more rapid recovery than “open” surgery, as well as increasing patient satisfaction and comfort [1-6]. Furthermore laparoscopic
adrenalectomy has been proposed even for tumors larger than 6 cm in diameter without signs of locoregional infiltration or malig- nancy. However, in that case, laparoscopic adrenalectomy may be associated with longer operative times, a greater blood loss, a higher conversion rate, and further complications. In addition, a higher risk of malignancy and of capsular disruption with seeding is advocated. Currently laparoscopic adrenalectomy remains still a mater of debate for adrenal lesions >6 cm. Adrenocortical cancer and malignant pheochromocytoma still remain relative contrain- dications for minimally invasive surgery [7-9]. In addition, lapa- roscopic adrenalectomy renders feasible the partial adrenalectomy, that has been accepted as an option in case of hereditary bilateral phaeochromocytomas. In unilateral adrenal tumors, partial
* Eleutheriou Benizelou 106, Kallithea, 17676, Athens, Greece. E-mail address: nyiannak@teiath.gr.
adrenalectomy has mainly been used in Conn’s syndrome [10-12].
However, laparoscopic adrenalectomy has some of the same limitations as other laparoscopic procedures, including the two- dimensional view, an unsteady camera, the lack of a good ergo- nomic setting and rigid instruments. In addition, taking into ac- count that the adrenals are small fragile organs situated in a narrow space and surrounded by large vessels, it is obvious that laparo- scopic surgery is especially demanding. Robotic assisted surgery seems to overcome the limitations of laparoscopic surgery due to three dimensional vision, wristed instruments with seven degrees of freedom, steady camera, ergonomic conditions. Nowadays ro- botic assisted adrenalectomy has become an alternative to con- ventional laparoscopic adrenalectomy. However, evidence on the possible advantages and drawbacks of robotic assisted adrenalec- tomy remains still limited. This systematic review aimed to syn- thesize evidence on robotic assisted adrenalectomy in terms of surgical technique, feasibility, indications, oncological outcome and safety.
1.1. Surgical technique
1.1.1. Right robotic assisted lateral transabdominal adrenalectomy
Preoperative preparation, positioning of the patient, and crea- tion of the port sites are the same as in the laparoscopic lateral transabdominal adrenalectomy. The patient is placed in the left lateral decubitus position. Four trocars are used. The first, 12-mm camera port, is placed midway between the umbilicus and the right costal margin. Two robotic instrument ports, both 8 mm, are placed along a line 2 fingerbreadths from the costal margin. A 10- mm liver retraction port is placed in the midline in the epigas- trium. An accessory 10/12 mm auxiliary port is occasionally placed near the umbilicus. The surgical steps reproduce those of the laparoscopic procedure including complete division of the hep- atocolic ligament, definition of the right adreno-caval junction, division of the right adrenal vein and dissection and removal of the adrenal gland circumferentially. Thus, after first laparoscopic exploration, the triangular ligament is divided via a robotic monopolar hook. The right lobe of the liver is retracted with a laparoscopic retractor and the inferior vena cava is exposed. The surgeon at the console uses the robotic hook for the precise dissection of the vena cava along its lateral edge between the inferior vena cava and the liver. Landmarks identified include laterally the superior pole of the right kidney and posteriorly the psoas muscle. The right adrenal vein is isolated and divided be- tween clips applied by the on-site assistant at the origin of the inferior cava vein. The dissection of the periadrenal space is completed using the robotic hook and bipolar forceps introduced from the auxiliary trocar. The specimen is delivered in a specimen retrieval bag.
1.1.2. Left robotic assisted lateral transabdominal adrenalectomy
Left robotic assisted lateral transabdominal adrenalectomy is performed with the patient in the right lateral decubitus position. Positioning is the mirror image of that for the right robotic assisted adrenalectomy as described above. Reproducing the operative steps of the laparoscopic technique, after the exposure of the abdominal cavity, the spleno-colic and freno-lienal ligaments are divided via the robotic hook diathermy, the splenic flexure of the colon is refracted downward, while the spleen and pancreas are rotated medially. Dissection continues into the periadrenal fat in order to identify the following landmarks: inferiorly, the left renal vein; laterally, the superior pole of the kidney; medially the tail of pancreas and the splenic vessels and posteriorly the psoas muscle. Hemostasis is achieved via alternation of the robotic monopolar hook and the laparoscopic bipolar forceps, introduced via the
auxiliary trocar. The left adrenal vein is divided between clips applied from the auxiliary trocar at the origin with the renal vein. After completion of the dissection of the adrenal space, the spec- imen is captured in a specimen retrieval bag and delivered through the auxiliary port site.
1.1.3. Robotic assisted posterior retroperitoneoscopic adrenalectomy
The patient is placed in a pronejack knife position. An optical trocar is introduced inferior to the 12th rib through an 1 cm inci- sion. Then the trocar is replaced with a dissecting balloon under direct view to generate a space. A 12 mm long trocar is placed in this space and carbon dioxide insufflation at 15 mmHg is main- tained. Carbon dioxide pressure can be increased at 20 mmHg, if there is a problem with exposure. Two 5 mm trocars are introduced medially and laterally, as far away as possible from each other, attempting to prevent instrument collision. Laparoscopic ultra- sound is used for the identification of the adrenal gland. Superior, lateral, and inferior dissections are performed. Then the medial aspect and the vascular pedicle are dissected. The adrenal vein is divided either with the Harmonic scalpel or with clips via the medial port. The specimen is removed in a specimen retrieval bag.
1.2. Feasibility
Horgan et al. [34] were the first who described a robot assisted bilateral transabdominal adrenalectomy [34]. Subsequent publica- tions have demonstrated the feasibility of robotic assisted adre- nalectomy. In a prospective study of 100 patients, Brunaud et al. [17] reported 4% conversion rate to conventional laparoscopic adrenalectomy and 1% conversion rare to open adrenalectomy [17]. In another series of 100 patients, Nordenstorm et al. [15] reported 7% conversion rate. D’Annibale et al. [14], in a series of 30 patients reported one conversion. Raman et al. [20] reported 4 conversions in a series of 39 patients. Winter et al. [18] in a series of 30 patients, Giullianotti et al. [16] in a series of 42 patients and Hanly et al. [19] in a series of 40 patients reported no conversion. Ludwig et al. [39] reported the first case of robotic assisted posterior retro- peritoneoscopic adrenalectomy. In total, five studies have pre- sented data on this technique reporting no conversion.
1.3. Indications
Robotic assisted adrenalectomy has been mainly performed for the treatment of benign adrenal disease including non functioning adrenal adenoma, benign pheochromocytoma, aldosteronoma, Cushing syndrome, myelolipoma. Yet, robotic assisted adrenalec- tomy has been described in special populations, including pregnant patients and children. Thus, an uneventful robotic left trans- abdominal adrenalectomy for a right-sided pheochromocytoma has been described in a pregnant patient during second trimester of pregnancy [24]. However, there are also case reports of robotic assisted adrenalectomy for adrenal carcinoma, oncocytoma and adrenal metastasis [21,27].
1.4. Oncological outcome
D’Annibale et al. [14] in their series of 30 patients reported three patients treated with robotic assisted adrenalectomy for metastasis, one from lung cancer and two from colorectal carcinoma. There was one cancer related death 37 months after the operation, while the other patients were alive with systematic disease at 8 and 29 months after the operation [14]. However, in the majority of the studies the duration of the follow up was not reported or was too limited.
1.5. Safety
Reported data show that robotic assisted adrenalectomy is safe [Table 1]. Brunaud et al. [17], in their series of 100 patients have reported three Clavien grade I complications including two wound infections, one case of facial edema and seven grade II complica- tions including three patients presenting with pneumonia, two patients presenting with urinary tract infection, one case of post- operative anemia and one case of hematoma [17]. In another series of 100 patients, Nordenstrom et al. [15] reported that thirteen pa- tients had at least one perioperative complication Clavien grade II [15]. Giullianotti et al. [16] in their series of 40 patients reported one case of capsular disruption in a patient with a 6 cm pheochromo- cytoma and one case of Clostridium difficile diarrhea. There was also a death due to myocardial infarction in a patient treated for pheochromocytoma [16]. D’Annibale et al. [14] in a series of 30 patients have reported two intraoperative complications, one capsular distortion of a large right adrenal mass and marked arte- rial instability in patient with left pheochromocytoma. In addition, the authors have reported three postoperative complications, one case of abdominal hematoma, one case of pneumonia and one case of myocardial infarction [14].
1.6. Robotic assisted partial adrenalectomy
The first robot-assisted partial adrenalectomy has been reported by Julien et al. [44] in a patient with von Hippel-Lindau (VHL) disease suffering from pheochromocytoma. Asher et al. [41] have published a series of 12 patients undergoing 15 cases of robotic partial adrenalectomy procedures for pheochromocytoma. Ten of
the patients had VHL disease, one patient had neurofibromatosis type 1, and the other had bilateral pheochromocytomas without a known genetic disorder. There was one conversion to open partial adrenalectomy due to severe adhesions to the liver and repeated vena cava injuries. There was one Clavien grade 3 complication, one bile leak that required a temporary drain for 5 days. During a follow-up of 17.5 months, there were no recurrences and one pa- tient required steroid supplementation [41]. Mannie et al. [40]. have reported a case series of three patients treated with robotic partial adrenalectomy for pheochromocytoma, lipoadenoma and follicular lymphoid hyperplasia [40]. In addition one case report of a pediatric patient with VHL treated with robotic partial adrenal- ectomy for pheochromocytoma has been published [43]. Kumar et al. [42] have published a case of robotic partial adrenalectomy for renal cell carcinoma adrenal metastasis in a patient previously treated with contralateral adrenalectomy for metastasis [42].
2. Concluding remarks
Currently, laparoscopic adrenalectomy has been recognized as standard treatment for benign adrenal pathology. Robotic assisted adrenalectomy is another minimally invasive option. Existing evi- dence, although limited, suggests that robotic assisted adrenalec- tomy is feasible and safe. However, the number of patients submitted to robotic assisted adrenalectomy is limited with the majority of them being operated for benign disease. There are only a few case reports of robotic assisted adrenalectomy performed for adrenocortical carcinoma, oncocytoma or metastasis. Partial adre- nalectomy seems to be a promising application of robotic assisted adrenalectomy especially for the treatment of benign
| Author | Number of cases | Complications |
|---|---|---|
| Treiyer et al., 2013 D'Annibale et al., 2012 | N = 18 | Five patients had perioperative complications, of these one had major complication (Clavien III) |
| N = 30 | Two intraoperative complications: (1) capsular disruption of a large right adrenal mass treated with temporary hemostasis by sponges; (2) marked arterial blood instability in a patient affected by a left pheochromocytoma, which required postoperative subintensive care. | |
| Three Postoperative complications: a hematoma of the abdominal wall due to bleeding of a trocar site in a right robotic adrenalectomy, which required blood transfusions but not re-intervention; pneumonia after left robotic adrenalectomy in an ASA IV patient with severe COPD and myocardial infarction during permanence in the intensive care unit. | ||
| Nordenstorm et al., 2011 | N = 100 | Thirteen patients (13%) had at least 1 perioperative complication (bleeding 4, tachycardia 2, postoperative adrenal insufficiency 2, emphysema 1, confusion 1, hypotension 1, urinary catheter 1, and fever 1). |
| Giullianotti et al., 2011 | N = 42, with one being submitted to bilateral adrenalectomy | one |
| intra-operative complication, minimal capsule tear in a patient with a relatively large tumor (a phaeochromocytoma of 6 cm). One postoperative complication, Clostridium difficile diarrhea. One death due to myocardial infarction in a patient treated for pheochromocytoma | ||
| Brunaud et al., 2008 | N = 100 | 3 grade I (wound infection 2, facial edema 1) and 7 grade II (pneumonia 3, urinary tract infection 2, postoperative anemia 1, hematoma 1) surgical complications according to the Clavien classification |
| Winter et al., 2006 | N = 30 | No intraoperative complications. One patient had a prolonged postoperative ileus; another patient suffered a brief episode of hypoxemia that was likely due to a combination of bronchitis and atelectasis. |
| Hanly et al., 2004 | N = 30 | Not reported |
| Raman et al., 2012 | N = 39 submitted in 40 adrenalectomies | 4 |
pheocromocytomas. Undoubtedly, further research is needed. Large randomized controlled trials comparing robotic assisted adrenalectomy with conventional laparoscopic adrenalectomy are needed. A number of studies comparing robotic assisted adrenal- ectomy with conventional laparoscopy have already been pub- lished, but these studies include a limited number of patients [45-50]. In what aspect could robotic assisted adrenalectomy be superior than conventional laparoscopic adrenalectomy? Robotic assisted adrenalectomy overcoming the technical limitations of laparoscopic surgery could possibly elicit a mild surgical response instead of the well described surgical response. Surgical response affects surgical morbidity and mortality as well as oncological outcome of malignant disease. If this hypothesis is proved correct, robotic assisted adrenalectomy could be possibly indicated in ma- lignant disease.
Undoubtedly, the cost of robotic assisted surgery is a drawback. However, if robotic assisted adrenalectomy could reduce morbidity and mortality, then it would also be cost effective.
In conclusion, robotic assisted adrenalectomy is feasible and safe. Further research is needed on the oncological outcome of this minimally invasive technique as well as on its effect on surgical stress response.
Financial disclosure
None to declare.
Author contribution
Eugenia Yiannakopoulou has contributed to study design, data collections, data analysis and writing.
Conflict of interest
Author Eugenia Yiannakopoulou has nothing to disclose.
Guarantor
Eugenia Yiannakopoulou.
References
[1] G. Conzo, M. Musella, F. Corcione, M. De Palma, N. Avenia, M. Milone, C. Della Pietra, A. Palazzo, D. Parmeggiani, D. Pasquali, A.A. Sinisi, L. Santini, Laparo- scopic treatment of pheochromocytomas smaller or larger than 6 cm A clinical retrospective study on 44 patients. Laparoscopic adrenalectomy for pheo- chromocytoma, Ann. Ital. Chir. 13 (2012) 417-422.
[2] A. Toniato, I.M. Boschin, G. Opocher, A. Guolo, M. Pelizzo, F. Mantero, Is the laparoscopic adrenalectomy for pheochromocytoma the best treatment? Surgery 13 (2007) 723-727.
[3] W.T. Shen, R. Grogan, M. Vriens, O.H. Clark, Q.Y. Duh, One hundred two pa- tients with pheochromocytoma treated at a single institution since the introduction of laparoscopic adrenalectomy, Arch. Surg. 13 (2010) 893-897.
[4] J.G.I.V. Bittner, V.M. Gershuni, B.D. Matthews, J.F. Moley, L.M. Brunt, Risk factors affecting operative approach, conversion, and morbidity for adrenal- ectomy: a single-institution series of 402 patients, Surg. Endosc. 13 (2013) 2342-2350.
[5] R. Sharma, A. Ganpule, M. Veeramani, R.B. Sabnis, M. Desai, Laparoscopic management of adrenal lesions larger than 5 cm in diameter, Urol. J. 13 (2009) 254-259.
[6] G. Conzo, D. Pasquali, C. Della Pietra, S. Napolitano, D. Esposito, S. Iorio, A. De Bellis, G. Docimo, F. Ferraro, L. Santini, A. Sinisi, Laparoscopic adrenal surgery: ten-year experience in a single institution, BMC Surg. 13 (Suppl. 2) (2013) S5, http://dx.doi.org/10.1186/1471-2482-13-S2-S5.
[7] G. Prager, G. Heinz-Peer, C. Passler, K. Kaczirek, C. Scheuba, B. Niederle, Applicability of laparoscopic adrenalectomy in a prospective study in 150 consecutive patients, Arch. Surg. 13 (2004) 46-49.
[8] C.P. Lombardi, M. Raffaelli, C. De Crea, M. Boniardi, G. De Toma, L.A. Marzano, P. Miccoli, F. Minni, M. Morino, M.R. Pelizzo, A. Pietrabissa, A. Renda, A. Valeri, R. Bellantone, Open versus endoscopic adrenalectomy in the treatment of localized (stage I/II) adrenocortical carcinoma: results of a multiinstitutional
Italian survey, Surgery 13 (6) (2012) 1158-1164.
[9] C.P. Lombardi, M. Raffaelli, M. Boniardi, G. De Toma, L.A. Marzano, P. Miccoli, F. Minni, M. Morino, M.R. Pelizzo, A. Pietrabissa, A. Renda, A. Valeri, C. De Crea, R. Bellantone, Adrenocortical carcinoma: effect of hospital volume on patient outcome, Langenbecks Arch. Surg. 13 (2) (2012) 201-207.
[10] G. Pedullà, D. Crocetti, A. Paliotta, M.R. Tarallo, A. De Gori, G. Cavallaro, G. De Toma, Surgical treatment of pheochromocytoma in MEN 2, Ann. Ital. Chir. 85 (2014) pii: S0003469X14021721.
[11] M.M. Walther, J. Herring, P.L. Choyke, W.M. Linehan, Laparoscopic partial adrenalectomy in patients with hereditary forms of pheochromocytoma, J. Urol. 164 (2000) 14-17.
[12] M.K. Walz, Adrenalectomy for preservation of adrenocortical function, Indic. Results Chir. 80 (2009) 99-104.
[14] A. D’Annibale, G. Lucandri, I. Monsellato, M. De Angelis, G. Pernazza, G. Alfano, P. Mazzocchi, V. Pende, Robotic adrenalectomy: technical aspects, early re- sults and learning curve, Int. J. Med. Robot. 8 (2012) 483-490.
[15] E. Nordenström, J. Westerdahl, P. Hallgrimsson, A. Bergenfelz, A prospective study of 100 robotically assisted laparoscopic adrenalectomies, J. Robot. Surg. 5 (2011) 127-131.
[16] P.C. Guillianotti, N.C. Buchs, P. Addeo, F.M. Bianco, S.M. Ayloo, G. Caravaglios, A. Coratti, Robot assisted adrenalectomy: a technical option for the surgeon? Int. J. Med. Robot. Comput. Assist. Surg. 7 (2011) 27-32.
[17] L. Brunaud, A. Ayav, R. Zarnegar, A. Rouers, M. Klein, P. Boissel, L. Bresler, Prospective evaluation of 100 robotic-assisted unilateral adrenalectomies, Surgery 144 (2008) 995-1001.
[18] J.M. Winter, M.A. Talamini, C.L. Stanfield, D.C. Chang, J.D. Hundt, A.P. Dackiw, K.A. Campbell, R.D. Schulick, Thirty robotic adrenalectomies: a single in- stitution’s experience, Surg. Endosc. 20 (2006) 119-124.
[19] E.J. Hanly, M.A. Talamini, Robotic abdominal surgery, Am. J. Surg. 188 (4A Suppl.) (2004) 19S-26S.
[20] S.R. Raman, E. Shakov, N. Carnevale, A. Yiengpruksawan, Robotic adrenalec- tomy by an open surgeon: are outcomes different? J. Robot. Surg. 6 (2012) 207-212.
[21] Z. Alguraan, O. Agcaoglu, S. Aliyev, E. Berber, A rare case of merkel cell car- cinoma metastasis to the adrenal resected robotically, Surg. Laparosc. Endosc. Percutan Tech. 23 (2013 Feb) e35-e37.
[24] E.R. Podolsky, L. Feo, A.D. Brooks, A. Castellanos, Robotic resection of pheo- chromocytoma in the second trimester of pregnancy, JSLS 14 (2010) 303-308.
[27] S.S. Zafar, R. Abaza, Robot-assisted laparoscopic adrenalectomy for adreno- cortical carcinoma: initial report and review of the literature, J. Endourol. 22 (2008) 985-989.
[34] S. Horgan, D. Vanuno, Robots in laparoscopic surgery, J. Laparoendosc. Adv. Surg. Tech. A 11 (2001) 415-419.
[39] A.T. Ludwig, K.R. Wagner, P.S. Lowry, H.T. Papaconstantinou, T.C. Lairmore, Robot-assisted posterior retroperitoneoscopic adrenalectomy, J. Endourol. 24 (2010) 1307-1314.
[40] T.B. Manny, A.S. Pompeo, A.K. Hemal, Robotic partial adrenalectomy using indocyanine green dye with near-infrared imaging: the initial clinical expe- rience, Urology 82 (2013) 738-742.
[41] K.P. Asher, G.N. Gupta, R.S. Boris, P.A. Pinto, W.M. Linehan, G. Bratslavsky, Robot-assisted laparoscopic partial adrenalectomy for pheochromocytoma: the National Cancer Institute technique, Eur. Urol. 60 (2011) 118-124.
[42] A. Kumar, E.S. Hyams, M.D. Stifelman, Robot-assisted partial adrenalectomy for isolated adrenal metastasis, J. Endourol. 23 (2009) 651-654.
[43] C.G. Rogers, A.M. Blatt, G.E. Miles, W.M. Linehan, P.A. Pinto, Concurrent robotic partial adrenalectomy and extra-adrenal pheochromocytoma resection in a pediatric patient with von Hippel-Lindau disease, J. Endourol. 22 (2008) 1501-1503.
[44] J. St Julien, D. Ball, R. Schulick, Robot-assisted cortical-sparing adrenalectomy in a patient with Von Hippel-Lindau disease and bilateral pheochromocy- tomas separated by 9 years, J. Laparoendosc. Adv. Surg. Tech. A 16 (2006) 473-477.
[45] J.Y. You, H.Y. Lee, G.S. Son, J.B. Lee, J.W. Bae, H.Y. Kim, Comparison of robotic adrenalectomy with traditional laparoscopic adrenalectomy with a lateral transperitoneal approach: a single-surgeon experience, Int. J. Med. Robot. 9 (2013) 345-350.
[46] J.C. Wu, H.S. Wu, M.S. Lin, D.A. Chou, M.H. Huang, Comparison of robot- assisted laparoscopic adrenalectomy with traditional laparoscopic adrenal- ectomy - 1 year follow-up, Surg. Endosc. 22 (2008) 463-466.
[47] M. Morino, G. Benincà, G. Giraudo, G.M. Del Genio, F. Rebecchi, C. Garrone, Robot-assisted vs laparoscopic adrenalectomy: a prospective randomized controlled trial, Surg. Endosc. 18 (2004) 1742-1746.
[48] K. Karabulut, O. Agcaoglu, S. Aliyev, A. Siperstein, E. Berber, Comparison of intraoperative time use and perioperative outcomes for robotic versus lapa- roscopic adrenalectomy, Surgery 151 (2012) 537-542.
[49] O. Agcaoglu, S. Aliyev, K. Karabulut, A. Siperstein, E. Berber, Robotic vs lapa- roscopic posterior retroperitoneal adrenalectomy, Arch. Surg. 147 (2012) 272-275.
[50] M. Raffaelli, L. Brunaud, C. De Crea, G. Hoche, L. Oragano, L. Bresler, R. Bellantone, C.P. Lombardi, Synchronous bilateral adrenalectomy for Cush- ing’s syndrome: laparoscopic versus posterior retroperitoneoscopic versus robotic approach, World J. Surg. 38 (2014) 709-715.