A commentary on ‘Safety and effectiveness of minimally invasive adrenalectomy versus open adrenalectomy in patients with large adrenal tumors (≥5 cm): a meta-analysis and systematic review’

The deep anatomy of the adrenal gland, surrounded by abundant blood vessels and organs, makes it vulnerable to serious complications due to injury in the operation. Preventing complications is an ongoing goal of the surgeon. Currently, larger adrenal tumors (≥5 cm) are one of the most challenging procedures in urological surgery, with the incidence from 8.6 to 38.6% of adrenal tumors. In the last decade, urologists have become increasingly interested in minimally invasive adrenalectomy (MIA), such as laparoscopic adrenalectomy and robot-assisted adrenalectomy. With the addition of experience and the development of state-of-the-art techniques, a mountain of evidence suggests that MIA is safe and feasible in carefully selected patients and converted to open if the local invasion is identified during the laparoscopic procedure1–3. Therefore, some centers propose MIA as an alternative treatment. However, there is still some controversy about the advantages of MIA over open adrenalectomy in recent urology surgery. Recently, we read with great enthusiasm the article published by Gan et al4. We sincerely congratulate the authors for publishing an excellent systematic review and meta-analysis (using PRISMA guidelines) about the safety and effectiveness of MIA versus open adrenalectomy in patients with large adrenal tumors (≥5 cm). Based on 10 studies (five retrospective and five prospective), including 898 patients, the authors concluded that MIA offers advantages over open adrenalectomy in the management of patients. MIA is associated with shorter length of stay, drainage time, fasting time, and reduced blood transfusion, while operative time and complications are similar. The authors should be acknowledged for conducting a meta-analysis on this controversial topic to present interesting results which are relevant to clinical practice and learning of junior surgeons. Since the introduction of laparoscopic adrenalectomy in 1992 by Gagner et al5, this has become a standard procedure for performing adrenalectomy. However, for large adrenal tumors, laparoscopic surgery is still quite difficult and complications are relatively high. Robotic systems with articulation, three-dimensional views, and stable surgical platforms overcome the limitations of laparoscopy6. Here, we would like to offer some humble suggestions and experiences about MIA. (1) Experience with laparoscopic adrenal surgery and skill in robotic procedures are mandatory for preventing complications. Causes of conversion to laparoscopic or open adrenalectomy from robotic surgery have been reported to be due to visceral injury, difficulty in hemostasis, malposition of robotic trocars, and prolonged operation time. (2) The risk of surgery is either damage to the surrounding organs or bleeding. Therefore, the surrounding organs should be well protected during surgery and not actively combined with organ removal. (3) Specimens need to be removed through a large incision, which traditionally requires dissection of the lumbar muscles, resulting in significant postoperative pain for the patient. We can bag the specimen and place it into the pelvis and take it out through an incision in the lower midsection. This not only does not require dissection of the muscle tissue but the incision in that area can be sufficiently stretched. Alternatively, if the preoperative diagnosis is an adrenal medullary lipoma, the specimen can be bagged and then mashed with an aspirator before being taken out. (4) Transperitoneal has a better vision and clearer anatomical signs, which facilitates the rapid separation of the tumor, thereby avoiding damage to the surrounding organs and rendering the operation less complex, which makes it a safe and effective treatment for large adrenal tumors. (5) As the adrenal gland is fragile, it is essential not to clamp the gland or tumor directly throughout the separation procedure. (6) For large functional adrenal tumors, blood pressure fluctuates considerably in the perioperative period and hemodynamic stability is critical to the success of the procedure. Overall, we thank Gan and colleagues from the bottom of our hearts for their concerted efforts in investigating the therapeutic efficiency of MIA in larger adrenal tumors. They have made a meaningful step forward on this important topic. MIA is an efficient and safe procedure that can provide an alternative to the open procedure. However, more prospective studies and/or high-quality case-matched comparative studies are needed in the future to further clarify the advantages and disadvantages of MIA. Ethical approval None. Sources of funding None. Authors’ contribution Z.T.: writing. S.F. and H.W.: data collection and data analysis. J.W.: study design. Conflicts of interest disclosure The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) None. Guarantor Jiansong Wang and Haifeng Wang. Provenance and peer review Commentary, internally reviewed.

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