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Robotic adrenalectomy: a comprehensive review of perioperative outcomes, comparative efficacy, and technological advancements
Danilo Coco1 · Silvana Leanza1
Received: 4 August 2025 / Accepted: 26 September 2025 / Published online: 3 October 2025 @ The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature 2025
Abstract
The adrenal glands are small but vital endocrine organs responsible for hormone production, which is essential for stress response, fluid balance, and blood pressure regulation. Adrenalectomy, the surgical removal of one or both adrenal glands, is indicated in various benign and malignant conditions such as pheochromocytomas, aldosterone-producing adenomas, and adrenocortical carcinoma. Historically performed via open surgery, adrenalectomy has evolved significantly with the introduction of laparoscopic adrenalectomy in the 1990s and more recently, robotic adrenalectomy. Robotic adrenalectomy enhances surgical precision through 3D visualization, articulated instruments, and improved ergonomics, thereby addressing the limitations inherent to laparoscopic adrenalectomy. This narrative review synthesises the findings from pivotal studies that compare the perioperative outcomes of robotic adrenalectomy and laparoscopic adrenalectomy. Robotic adrenalec- tomy demonstrates favourable outcomes in terms of operative precision, reduced estimated blood loss, and comparable or shorter hospital stay, especially in complex scenarios involving obesity, large tumours, or altered anatomy. Complication rates remain low, and R0 resection rates exceed 95% in well-selected malignancies, supporting the oncological adequacy of robotic adrenalectomies. While robotic adrenalectomy offers superior surgeon ergonomics and a relatively short learning curve, its high initial costs and lack of tactile feedback present notable limitations. Technological advancements, including high-definition 3D optics, fluorescence imaging, and artificial intelligence integration, have further refined the potential of robotic adrenalectomies. However, the evidence remains largely retrospective, with limited prospective randomised trials evaluating long-term outcomes and cost-effectiveness. Robotic adrenalectomy appears to be particularly advantageous in complex adrenal cases, offering a safe, minimally invasive option with the potential for improved recovery and surgical outcomes. Future research should focus on the long-term oncologic efficacy, patient-reported outcomes, and economic sus- tainability of robotic adrenalectomy in diverse clinical settings. Robotic adrenalectomy represents a significant milestone in adrenal surgery, with growing evidence supporting its selective use as a preferred approach in experienced centres and in appropriately chosen patients.
Keywords Robotic adrenalectomy · Laparoscopic adrenalectomy · Perioperative outcomes · Endocrine surgery
Introduction
The adrenal glands, which are small but critically important endocrine structures located atop each kidney, are essential regulators of homeostasis through the secretion of key hor- mones such as cortisol, aldosterone, and catecholamines. Their complex physiological functions include the modula- tion of the stress response, fluid and electrolyte balance, and
blood pressure regulation. Surgical intervention adrenalec- tomy is often necessitated by a range of adrenal patholo- gies, encompassing benign entities, such as aldosterone- producing adenomas and pheochromocytomas, as well as malignant conditions, such as adrenocortical carcinoma and metastatic lesions [1, 2]. The clinical significance of adrenal pathologies, particularly pheochromocytomas, lies in their potential for episodic or sustained hypersecretion of catecholamines such as adrenaline and noradrenaline. This biochemical instability can lead to life-threatening cardio- vascular complications, including paroxysmal hypertension, tachyarrhythmia, myocardial infarction, and cerebrovascular events. Intraoperative manipulation of these tumours further
☒ Danilo Coco webcostruction@msn.com
1 Department of General, Robotic, Oncologic Surgery, Giglio Hospital Foundation, Cefalù, Italy
increases the risk of sudden catecholamine surges, neces- sitating meticulous preoperative optimisation with alpha and beta blockade, as well as precise intraoperative moni- toring and anaesthetic management. These factors make surgical resection of pheochromocytomas among the most technically and physiologically challenging procedures in endocrine surgery [3, 4]. Historically, adrenalectomy has been used as an open surgical procedure with considerable morbidity, limited visualisation, and prolonged recovery. The advent of laparoscopic adrenalectomy (LA) in the early 1990s marked a transformative shift toward minimally invasive approaches, offering reduced operative trauma, shorter hospital stays, and faster convalescence [5]. Despite its advantages, LA poses challenges, including restricted instrument mobility and reliance on two-dimensional imag- ing. These limitations have catalysed the introduction and gradual adoption of robotic adrenalectomy (RA), which pro- vides enhanced three-dimensional visualisation, articulating instruments, tremor filtration, and improved ergonomics for the operating surgeon [6-8]. The robotic platform seeks to address the nuanced demands of adrenal surgery, particularly in complex cases involving obesity, large tumours, and chal- lenging retroperitoneal anatomies. As RA is widely adopted in urological and endocrine surgical practices, questions remain regarding its comparative efficacy, cost-effectiveness, learning curve, and long-term outcomes relative to LA. This narrative review aimed to comprehensively synthesise peri- operative outcomes from pivotal studies on RA, critically examine its efficacy in comparison to LA, and delineate the technological advancements that have shaped its evolution. Furthermore, this review offers a focused expert perspective on the current role of RA in adrenal surgery, highlighting both its promise and the ongoing need for high-quality pro- spective data to guide clinical decision-making.
Perioperative outcomes of robotic adrenalectomy: insights from leading studies
Surgical efficiency and operative metrics
RA has demonstrated varying degrees of surgical efficiency across studies, primarily influenced by tumour size, later- ality, surgeon experience, and robotic platform generation. Operative time (OT) is a commonly assessed metric, with the total time ranging from 80 to 230 min in most reports. Console time alone typically averages 90-120 min, while docking time remains under 15 min in experienced hands [9-12]. Factors such as tumor complexity, obesity, or the use of dual-console systems have been noted to prolong surgical duration, whereas procedural standardization and experience contribute to significant time reduction over the learning curve [13, 14]. Estimated blood loss (EBL) is consistently low across studies, with mean values ranging from 50 to
100 mL, and transfusion rates remain under 2% [15-17]. The precision and stability offered by robotic platforms are believed to reduce the risk of vascular injuries. Studies indi- cate conversion rates for laparoscopic adrenalectomy range from 2.7% to 3.6% across various techniques [17, 18].
Postoperative recovery profile
Length of hospital stay (LOS) is consistently favorable with RA, with median LOS ranging from 2 to 2.5 days [10, 16, 19]. Early discharge is often facilitated by minimal pain, early ambulation, and low rates of complications. Studies show that robotic surgery patients require fewer narcotic analgesics postoperatively and report lower pain scores, although precise data on pain scales vary among studies [20]. Functional recovery metrics, such as time to first oral intake and ambulation, are typically within 12-24 h post- surgery, underscoring the minimally invasive nature and ergonomic precision of robotic techniques [21].
Complication spectrum
Intraoperative complications during RA are uncommon but may include vascular injuries, particularly to the renal vein or vena cava, in right-sided tumours. These are usu- ally managed intraoperatively without conversion in most reported series [22]. Postoperative complications are gener- ally classified using the Clavien-Dindo system, with most studies reporting an overall complication rate below 10% [9]. Common postoperative issues include wound infections, ileus, and transient adrenal insufficiency, with serious events such as reoperation being rare. These favorable outcomes are largely attributed to improved surgical precision, stable instrumentation, and enhanced visualization afforded by robotic systems [23].
Oncological consideration
RA has shown promising oncological efficacy in malignant or potentially malignant adrenal tumours. R0 resection rates (clear surgical margins) exceeded 95% in most studies, con- firming the adequacy of oncologic dissection via robotic approaches [16, 24]. Although lymph node dissection is not routinely performed when indicated, robotic techniques enable adequate lymph node retrieval, which is often compa- rable to that of open or laparoscopic surgery. Long-term data on disease-free survival (DFS) and overall survival (OS) are limited but indicate no significant difference between RA and conventional techniques in well-selected cases, with recurrence rates remaining low in early-stage disease [25, 26].
Comparative efficacy: robotic vs. laparoscopic adrenalectomy
Comparative perioperative outcomes
Robotic adrenalectomy (RA) and laparoscopic adrenalec- tomy (LA) have been extensively compared, particularly in systematic reviews and meta-analyses. Operative time remains a frequently discussed metric, with most studies indicating slightly longer mean operative times for RA by 92.1-154 min largely due to docking and system setup [27, 28]. Blood loss is consistently lower in RA due to improved instrument precision and visualization, with EBL typically averaging 50-75 mL compared to 75-150 mL in LA cohorts, and transfusion requirements are marginally less frequent in RA groups [26]. Length of hospital stay (LOS) appears com- parable between the two approaches, generally ranging from 2 to 3 days, though a few studies report slightly shorter LOS with RA due to faster mobilization and pain recovery [29]. Regarding the overall complication rates, RA was associated with similar or slightly lower incidences of both major and minor complications. A meta-analysis by Du et al. found no statistically significant difference in major complication rates, though minor complications such as port-site issues were marginally less frequent in the robotic cohort [15].
Comparative oncological efficacy
In the treatment of malignant adrenal lesions, RA has dem- onstrated oncological outcomes that are comparable to those of LA. R0 resection rates are high in both techniques, with studies reporting rates above 95% for well-selected local- ized tumors [30]. Lymph node dissection, though not always indicated, lymph node dissection can be adequately per- formed robotically, with similar nodal yields reported across approaches when performed. Long-term oncological control,
including recurrence rates and overall survival, appears to be equivalent, based on limited but growing data.
Cost-effectiveness analysis
However, the cost profile of RA remains a subject of debate. The initial capital costs for robotic systems and the higher expenses for consumables and maintenance are substantially greater than those for LA. Additionally, longer operative times may increase intraoperative staffing and anesthesia costs [31]. However, proponents argue that these costs may be partially offset by lower complication rates, shorter LOS, and a quicker return to normal activity. Comprehensive eco- nomic evaluations show mixed results; some suggest that RA may approach cost neutrality in high-volume centers or when applied to complex cases. Still, LA is generally con- sidered more cost-effective in routine adrenalectomies [31].
Surgeon ergonomics and the learning curve
Surgeon ergonomics is a notable advantage of RA. Robotic systems significantly reduce physical strain, offering better posture, wrist articulation, and hand stability key benefits demonstrated in ergonomic surveys and studies [32]. The RA learning curve is also shorter than previously assumed, with proficiency typically defined as achieving consistent operative times, reduced complication rates, and minimal need for conversion often reached within 20-30 [33]. Morris et al. highlighted that even surgeons with extensive laparo- scopic experience required approximately 20 cases to over- come the initial robotic learning curve, particularly in terms of operative efficiency and safety [33]. Moreover, institu- tional and surgeon volumes correlate strongly with improved outcomes and reduced complications in RA, mirroring find- ings from high-volume centres where RA has become the standard for adrenal surgery (See Table 1).
| Year | Innovation | Description |
|---|---|---|
| 2000-2010 | da Vinci S/Si Systems | The da Vinci system debuted in 1999 and was FDA approved in 2000. The 2003 update added a fourth arm. The 2006 S model improved movement and setup, while the 2009 Si model added dual consoles and enhanced controls and vision [38] |
| 2013 | ICG Fluorescence Imaging | Real-time vascular mapping and adrenal perfusion assessment using indocyanine green. ICG has become available for minimally invasive surgery, with the development of more advanced laparoscopic and robotic platforms that can display ICG-enhanced images on the same screen [39] |
| 2014 | da Vinci Xi Platform | Xi System were introduced, offering improved multi-quadrant access, streamlined docking, and enhanced instrument reach for complex procedures [40, 41] |
| 2018 | da Vinci SP (Single-Port) | Food and Drug Administration (FDA) approved the SP system for sale in November 2018 [42] |
| 2021-Present | AR and Image-Guided Surgery | A more recent example of AR-guided surgery using VOSTARS took place in February 2020 [43, 44] |
| Ongoing | AI and ML in Robotic Surgery | Use of AI for decision support, image segmentation, and skill assessment in RA training and procedures |
Technological advancements shaping robotic adrenalectomy
The evolution of RA has been closely tied to continual inno- vations in surgical robotics and supporting technologies, particularly those associated with da Vinci platforms. Early systems, such as the da Vinci S and Si, provided founda- tional robotic capabilities, including 3D vision and instru- ment articulation, but were limited in arm configuration and docking complexity. The subsequent da Vinci Xi sys- tem introduced significant upgrades such as overhead boom architecture, slimmer arms, and improved multi-quadrant access, features that particularly benefit adrenalectomy by enabling better reach and angulation in the retroperitoneal space [34]. The da Vinci SP (single-port) platform, though less widely adopted for adrenal surgery, offers a minimally invasive approach with a single incision and enhanced cos- metic outcomes [35]. Enhanced visualization technologies are pivotal for RA. High-definition 3D optics dramatically improve depth perception and anatomical resolution, con- tributing to more precise dissection and reduced complica- tions. Additionally, fluorescence imaging with indocyanine green (ICG) has emerged as a valuable tool for vascular mapping, adrenal gland perfusion assessment, and lym- phatic structure identification, especially during oncologic procedures [36]. Advancements in robotic instrumentation, particularly EndoWrist technology, provide unparalleled dexterity through seven degrees of freedom, mimicking the human wrist and enhancing the surgeon’s ability to navi- gate confined spaces, such as the adrenal bed. Coupled with integrated energy devices, such as robotic vessel sealers and advanced bipolar instruments, these tools support meticu- lous tissue handling and haemostasis. While traditional lapa- roscopy lacks tactile feedback, the robotic community has explored force-feedback systems to address this limitation. Though full haptic integration remains under development, promising prototypes and sensor technologies suggest a future where robotic surgery may incorporate real-time force perception [37]. Augmented reality (AR) and surgical navi- gation systems are also entering the RA, with preliminary studies demonstrating the utility of integrating preoperative CT/MRI into the surgical field for enhanced anatomical orientation.
These tools allow for intraoperative guidance, support safe resection margins, and minimise injury to the adjacent structures. Artificial intelligence (AI) and machine learn- ing (ML) are increasingly being discussed in robotic sur- gery literature. Applications include predictive analytics for surgical planning, AI-driven image segmentation for tumour identification, and real-time intraoperative decision support. Moreover, ML algorithms are being integrated into surgical training simulators to assess performance and guide skill development [45]. Collectively, these innovations
underscore the paradigm shift in adrenal surgery, transition- ing from manual laparoscopy to a technology-enhanced pre- cision-driven robotic model that continually evolves to meet the demands of complex endocrine procedures.
Discussion
Robotic adrenalectomy (RA) has emerged as a transforma- tive advancement in endocrine surgery, with consistently reported advantages in the literature. Studies have empha- sized RA’s technical superiority in terms of enhanced pre- cision, increased dexterity, and superior 3D high-definition visualization, particularly beneficial in the confined and complex retroperitoneal space [45]. The introduction of wristed instruments allows for finer dissection and more natural movements than traditional laparoscopic instru- ments, particularly during delicate manoeuvres near major vascular structures. Additionally, RA offers significant ergo- nomic benefits to the operating surgeon, reducing fatigue and musculoskeletal strain due to its seated console position and intuitive control system [46]. Despite these advantages, RA has several limitations. One of the most cited concerns is cost, both in terms of the initial capital investment and recurring expenses for maintenance and disposable instru- ments. Furthermore, the learning curve, though reportedly shorter than for laparoscopic adrenalectomy in some series, still presents a barrier in centers with low case volumes [47]. Another ongoing limitation is the absence of tactile (haptic) feedback, which, while partially compensated by enhanced visualization, remains an area of active technological devel- opment [48]. A consensus across the literature defines the RA niche as the most beneficial niche in complex adrenal cases. These include patients with obesity, large or poste- riorly located tumors, hormonally active lesions like pheo- chromocytomas, and re-do surgeries where altered anatomy or adhesions present technical challenges [49-51]. In such scenarios, the strengths of the robotic platform can translate into measurable clinical benefits, including lower estimated blood loss, reduced conversion rates, and safer dissection.
Factors influencing outcomes and patient selection
Patient selection remains critical for the optimisation of RA outcomes. Tumour size, location, functionality, and laterality influence intraoperative complexity. For example, right-sided adrenal tumors often present greater techni- cal challenges due to proximity to the inferior vena cava, which may be better managed with the improved control provided by the robotic system [46]. Obese patients, who often have increased intra-abdominal fat and limited working space, also appear to benefit from RA, as the robotic arms offer better reach and articulation in restricted fields [51].
Surgeon experience and institutional volume have consist- ently been identified as the major determinants of success- ful RA outcomes. High-volume centres demonstrate lower operative times, reduced complication rates, and shorter hos- pital stays, suggesting a volume-outcome relationship that is particularly relevant in technically complex procedures such as adrenalectomy. Proposed selection criteria for RA candidates, based on a synthesis of current literature, include patients with tumors up to 6-8 cm in diameter, localized dis- ease, absence of extensive vascular involvement, and those in whom minimally invasive approaches are preferred due to comorbid conditions [52]. These criteria help to ensure safety while maximising the procedural advantages offered by robotic platforms.
Robotic adrenalectomy in specific clinical scenarios
Several challenging clinical scenarios have demonstrated the utility of RA. A study reported that, even in tumours previously deemed complex for laparoscopic management, RA enabled successful minimally invasive excision with low conversion rates. Pheochromocytomas characterized by hemodynamic instability require meticulous dissection and minimal manipulation, which RA facilitates through tremor filtration and finer movement control [15]. RA also plays a key role in patients with prior abdominal surgery, where adhesions may obscure anatomy. The enhanced visu- alisation and precision of RA allow for careful adhesiolysis and identification of the adrenal gland without resorting to open conversion. Similarly, in morbidly obese patients, the robotic platform’s superior reach and stable camera control reduce the technical difficulties often associated with thick abdominal walls and deep operative fields [53].
Limitations of the current body of evidence and remaining questions
Although numerous comparative studies and retrospec- tive cohorts have demonstrated the advantages of RA, the overall strength of the evidence is limited by several fac- tors. Most data are derived from retrospective case series or non-randomised comparisons, with very few large pro- spective randomised controlled trials (RCTs) available. This limitation limits the generalisability and conclusiveness of our findings. Heterogeneity in surgical technique, patient population, tumour types, and outcome definitions further complicates the data synthesis. For example, operative time definitions vary across studies, and few studies have reported standardised pain scores or long-term quality of life metrics. Moreover, while short-term oncological outcomes such as R0 resection rates appear equivalent between RA and LA, long-term data on recurrence and survival, espe- cially in malignant disease, remain sparse and inconclusive.
Cost-effectiveness continues to be a subject of debate. While some studies suggest that reduced complication rates and shorter hospital stays may offset robotic costs in high-vol- ume centres, others argue that these benefits do not justify the added financial burden in routine cases. Comprehensive economic analyses that account for all direct and indirect costs are required to resolve this debate.
Conclusion
Robotic adrenalectomy offers distinct perioperative advan- tages, particularly in terms of surgical precision, reduced blood loss, favourable recovery profiles, and applicability in complex scenarios. Technological innovations, including enhanced visualisation, articulating instruments, and ergo- nomics, continue to increase RA’s clinical utility. Despite these strengths, limitations such as cost, learning curve, and lack of tactile feedback remain barriers to its widespread adoption. RA is now a well-established surgical modality, particularly in high-volume centres with trained surgeons and access to a robotic infrastructure. It has become the preferred approach in selected patients and complex adre- nal cases, where its advantages are the most evident. To strengthen the evidence base, more prospective, multicen- tre, randomised trials comparing RA and LA are required. Long-term oncological follow-up, particularly in malignant cases, will help to establish RA’s role of RA in endocrine oncology. Furthermore, continued integration of advanced technologies, such as haptic feedback, augmented reality, and AI-based decision support, will shape the next genera- tion of robotic adrenal surgery. RA should be considered in patients in whom its technical benefits are likely to improve outcomes, such as in those with obesity, large or functional tumours, and prior surgeries. However, its use must be indi- vidualised based on the surgeon’s expertise, institutional capabilities, and economic feasibility. Importantly, shared decision-making with patients regarding risks, benefits, and alternatives remains central to ethical and patient-centred care.
Author contributions SL. and C.D. wrote the main manuscript text. All authors reviewed the manuscript.
Funding The authors declare that this research received no specific funding from any public, commercial, or not-for-profit organization.
Data availability No datasets were generated or analysed during the current study.
Declarations
Conflict of interest The authors declare no competing interests.
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