Robot-assisted adrenalectomy:Step-by-step technique and surgical outcomes at a high-volume robotic center

Objective In the last years,robotic surgery was introduced in several different settings with good perioperative results.However,its role in the management of adrenal masses is still debated.In order to provide a contribution to this field,we described our step-by-step technique for robotic adrenalectomy(RA)and related modifications according to the type of adrenal mass treated.Methods We retrospectively analyzed 27 consecutive patients who underwent RA at Onze-Lieve-Vrouw hospital(Aalst,Belgium)between January 2009 and October 2022.Demographic,intra-and post-operative,and pathological data were retrieved from our prospectively maintained institutional database.Continuous variables are summarized as median and interquartile range(IQR).Categorical variables are reported as frequencies(percentages).Results Twenty-seven patients underwent RA were included in the study.Median age,body mass index,and Charlson's comorbidity index were 61(IQR:49-71)years,26(IQR:24-29)kg/m^(2),and 2(IQR:0-3),respectively,and 16(59.3%)patients were male.Median tumor size at computed tomography scan was 6.0(IQR:3.5-8.0)cm.Median operative time and blood loss were 105(IQR:82-120)min and 175(IQR:94-250)mL,respectively.No intraoperative complications were recorded.Overall postoperative complications rate was 11.1%,with a postoperative transfusion rate of 3.7%.A total of 10(37.0%)patients harbored malignant adrenal masses.Among them,3(11.1%)had adrenocortical carcinoma,6(22.2%)secondary metastasis,and 1(3.7%)malignant pheochromocytoma on final pathological exam.Only 1(10.0%)patient had positive surgical margins.Conclusion We described our step-by-step technique for RA,which can be safely performed even in case of high challenging settings as malignant tumors,pheochromocytoma,and large masses.The standardization of perioperative protocol should be encouraged to maximize the outcomes of this complex surgical procedure.

Three-dimensional automatic artificial intelligence driven augmented-reality selective biopsy during nerve-sparing robot-assisted radical prostatectomy:A feasibility and accuracy study

Objective:To evaluate the accuracy of our new three-dimensional(3D)automatic augmented reality(AAR)system guided by artificial intelligence in the identification of tumour’s location at the level of the preserved neurovascular bundle(NVB)at the end of the extirpative phase of nerve-sparing robot-assisted radical prostatectomy.Methods:In this prospective study,we enrolled patients with prostate cancer(clinical stages cT1ce3,cN0,and cM0)with a positive index lesion at target biopsy,suspicious for capsular contact or extracapsular extension at preoperative multiparametric magnetic resonance imaging.Patients underwent robot-assisted radical prostatectomy at San Luigi Gonzaga Hospital(Orbassano,Turin,Italy),from December 2020 to December 2021.At the end of extirpative phase,thanks to our new AAR artificial intelligence driven system,the virtual prostate 3D model allowed to identify the tumour’s location at the level of the preserved NVB and to perform a selective excisional biopsy,sparing the remaining portion of the bundle.Perioperative and postoperative data were evaluated,especially focusing on the positive surgical margin(PSM)rates,potency,continence recovery,and biochemical recurrence.Results:Thirty-four patients were enrolled.In 15(44.1%)cases,the target lesion was in contact with the prostatic capsule at multiparametric magnetic resonance imaging(Wheeler grade L2)while in 19(55.9%)cases extracapsular extension was detected(Wheeler grade L3).3D AAR guided biopsies were negative in all pathological tumour stage 2(pT2)patients while they revealed the presence of cancer in 14 cases in the pT3 cohort(14/16;87.5%).PSM rates were 0%and 7.1%in the pathological stages pT2 and pT3(<3 mm,Gleason score 3),respectively.Conclusion:With the proposed 3D AAR system,it is possible to correctly identify the lesion’s location on the NVB in 87.5%of pT3 patients and perform a 3D-guided tailored nerve-sparing even in locally advanced diseases,without compromising the oncological safety in terms of PSM rates.

Three-dimensional imaging reconstruction of the kidney’s anatomy for a tailored minimally invasive partial nephrectomy:A pilot study

Objective:The aim of the study was to evaluate three-dimensional virtual models(3DVMs)usefulness in the intraoperative assistance of minimally-invasive partial nephrectomy in highly complex renal tumors.Methods:At our institution cT1-2N0M0 all renal masses with Preoperative Aspects and Dimensions Used for an Anatomical classification score≥10 treated with minimally-invasive partial nephrectomy were considered for the present study.For inclusion a baseline contrast-enhanced computed tomography in order to obtain 3DVMs,the baseline and postoperative serum creatinine as well as estimated glomerular filtration rate values were needed.These patients,in which 3DVMs were used to assist the surgeon in the planning and intraoperative guidance,were then compared with a control group of patients who underwent minimally-invasive partial nephrectomy with the same renal function assessments,but without 3DVMs.Multivariable logistic regression models were used to predict the margin,ischemia,and complication score achievement.Results:Overall,79 patients met the inclusion criteria and were compared with 143 complex renal masses without 3DVM assistance.The 3DVM group showed better postoperative outcomes in terms of baseline-weighted differential estimated glomerular filtration rate(-17.7%vs.-22.2%,p=0.03),postoperative complications(16.5%vs.23.1%,p=0.03),and major complications(Clavien Dindo>III,2.5%vs.5.6%,p=0.03).At multivariable logistic regression 3DVM assistance independently predicted higher rates of successful partial nephrectomy(odds ratio:1.42,p=0.03).Conclusion:3DVMs represent a useful tool to plan a tailored surgical approach in case of surgically complex masses.They can be used in different ways,matching the surgeon's needs from the planning phase to the demolitive and reconstructive phase,leading towards maximum safety and efficacy outcomes.