Robotic versus laparoscopic adrenalectomy for adrenocortical carcinoma: A national cancer database analysis

Introduction: The role of minimally invasive surgery (MIS) in adrenocortical carcinoma (ACC) remains debated due to concerns about oncologic safety. Robotic technology may overcome some limitations of laparoscopy, but comparative data specific to ACC are lacking. We aim to compare perioperative outcomes of robotic versus laparoscopic adrenalectomy for localized ACC. Methods: We analyzed patients with localized ACC (2010-2022) from the National Cancer Database (NCDB) who underwent a planned minimally invasive adrenalectomy for ACC. This study evaluated 4 main endpoints: 1) positive surgical margins (PSM) 2) Intraoperative conversion to open 3) Length of stay after surgery (≤2 vs > 2 days); 4) 30-day unplanned hospital-readmission. Multivariable logistic regression clustered by facility was used to assess associations between surgical approach (laparoscopy vs robotic) and the outcomes. Results: We included 657 patients, 413 laparoscopic vs 244 robotic. There were no significant differences in median tumor size, age, sex, or comorbidity distribution between groups. Robotic adrenalectomy was associated with lower odds of PSM (adjusted OR 0.60, 95% CI 0.37-0.98, p = 0.04) and conversion to open surgery (adjusted OR 0.54, 95% CI 0.31-0.95, p = 0.03). Robotic cases also showed a lower likelihood of prolonged hospitalization (>2 days) (adjusted OR 0.63, 95% CI 0.43-0.93, p = 0.02). No differences were observed in 30 days unplanned readmission. Conclusions: Robotic adrenalectomy for ACC was associated with lower rates of positive margins, open conversion and prolonged hospitalization compared with laparoscopy. These findings suggest that robotic technology may mitigate some perioperative challenges of MIS in ACC, warranting further validation in prospective studies.