Robotic Versus Laparoscopic Adrenalectomy for Adrenal Tumors: An Up-to-Date Meta-Analysis on Perioperative Outcomes

Abstract

Background: Minimally invasive surgery (MIS) for adrenal glands is becoming increasingly developed worldwide and robotic surgery has advanced significantly. Although there are still concerns about the generalization of outcomes and the cost burden, the robotic platform shows several advantages in overcoming some laparoscopic shortcomings. Materials and Methods: A systematic review and meta-analysis were conducted using the PubMed, MEDLINE and Cochrane library databases of published articles comparing RA and LA up to January 2024. The evaluated endpoints were technical and post-operative outcomes. Dichotomous data were calculated using the odds ratio (OR), while continuous data were analyzed usingmean difference (MD) with a 95% confidence interval (95% CI). A random-effects model (REM) was applied. Results: By the inclusion of 28 studies, the meta-analysis revealed no statistically significant difference in the rates of intraoperative RBC transfusion, 30-day mortality, intraoperative and overall postoperative complications, re-admission, R1 resection margin and operating time in the RA group compared with the LA. However, the overall cost of hospitalization was significantly higher in the RA group than in the LA group, [MD USD 4101.32, (95% CI 3894.85, 4307.79) p < 0.00001]. With respect to the mean intraoperative blood loss, conversion to open surgery rate, time to first flatus and length of hospital stay, the RA group showed slightly statistically significant lower rates than the laparoscopic approach. Conclusions: To our knowledge, this is the largest and most recent meta-analysis that makes these comparisons. RA can be considered safe, feasible and comparable to LA in terms of the intraoperative and post-operative outcomes. In the near future, RA could represent a promising complementary approachto LA for benign and small malignant adrenal masses, particularly in high-volume referral centers specializing in robotic surgery. However, further studies are needed to confirm these findings.

Keywords: adrenal gland surgery; adrenalectomy; laparoscopic adrenalectomy; robotic adrenalectomy; robotic surgery.

Figure 1

PRISMA flow diagram.

Figure 2

Operating time (min) [5,7,9,13,16,25,27,28,29,30,31,32,33,35,36,37,38,39,40,41,43,45,46,47,48,49].

Figure 3

Intraoperative blood loss (mL) [5,7,9,13,27,28,29,30,31,32,33,35,37,41,45,46,47,49].

Figure 4

Intraoperative Red Blood Cell (RBC) transfusion rate [7,35,37,38,41,46,47,49].

Figure 5

Conversion to open surgery rate [5,7,9,13,16,25,27,28,29,30,31,32,33,35,36,37,38,39,41,42,43,45,48,49].

Figure 6

Intraoperative complication rate [7,13,16,33,35,36,37,38,47,48].

Figure 7

Time to first flatus [7,38].

Figure 8

Overall complication rate [5,7,9,13,16,25,27,28,29,30,32,33,35,36,37,38,39,41,44,45,46,47,48,49].

Figure 9

Clavien–Dindo ≥ III complication rate [7,25,33,35,36,37,38,41,45,46,47,49].

Figure 10

Length of hospital stay [5,7,9,13,16,28,29,30,31,32,33,35,36,37,38,39,40,41,42,43,45,46,47,48,49].

Figure 11

Readmission rate [7,33,37,42,47].

Figure 12

R1 resection margin rate [37,42,45].

Figure 13

Thirty-day mortality rate [5,7,13,16,25,27,28,29,30,32,33,36,38,39,42,45,48].

Figure 14

Cost of hospitalization [41,49].