Robotic-assisted ipsilateral adrenalectomy after robotic-assisted partial nephrectomy: a case report

Robotic-assisted adrenalectomy (RA) was established since 2001 as an alternative to open and laparoscopic adrenalectomy, although re-operative RA after upper pole partial nephrectomy is uncommon. Here, we describe RA for presumed renal cell carcinoma (RCC) recurrence after ipsilateral upper pole robotic-assisted partial nephrectomy (RPN), using the da Vinci Xi. A 43-year-old male underwent left RPN in November 2017 for a 3.3 cm upper pole enhancing solid renal mass. Pathology revealed clear cell, RCC, FG 2, pT1a, negative margins. Seven months later, routine surveillance CT scan demonstrated a 2.09 cm enhancing left adrenal nodule, suspicious for recurrent RCC. MRI was performed and confirmed the presence of enhancing adrenal nodularity suspicious for tumor recurrence. Percutaneous biopsy of the adrenal lesion was performed and it was inconclusive. The multidisciplinary tumor board recommended excision, and a robotic approach was selected. The RA was performed using three 8 mm robotic Xi trocars, one midline 12 mm blunt tip Hasson trocar, and one 5 mm AirSeal trocar for assistant ports. The 8 mm robotic Xi instruments (fenestrated bipolar forceps, monopolar curved scissors and permanent cautery hook) were used during the procedure. Total operation time was 249 minutes. Total console time was 134 minutes. Blood loss was 250 mL and there were no complications. He was discharged on post-operative day one. Pathology showed adrenal gland without significant histopathological changes. The gland measured 8.3 cm × 7.6 cm × 2.8 cm and weighed 63.2 grams. The final pathology report showed that there was no evidence of involvement by RCC. The post-operative course was unremarkable. The da Vinci Xi RA is a safe and feasible procedure for adrenal masses after ipsilateral RPN. Surgeons attempting the procedure should be comfortable with the inflammation and adhesions encountered in re-operative surgery and should work with an experienced team to avoid damage to surrounding organs (such as the spleen, pancreas, colon and stomach) and major vessels (such as the aorta, renal artery and vein). For masses of unclear etiology proceeding with adrenal mass biopsy prior to re-operative surgery should be considered as false-positive imaging results are possible.