10 cm angiomyolipoma of the right adrenal gland: robotically assisted laparoscopy.

Introduction: Angiomyolipoma is apparently a part of a family of neoplasms that derive from perivascular epithelioid cells. It is a rare mesenchymal tumor, usually found in the kidney. Extrarenal angiomyolipoma is uncommon, and the most common extrarenal site is the liver. Only five cases have been reported so far. We report the case of a woman with a large adrenal mass that we treated with robot assisted partial adrenalectomy six months later . Methods: Due to abdominal pain a 47 years-old woman has undergone to abdominal ultrasound scanner that showed a well-defined 10 × 9 cm right adrenal mass (incidentaloma); moreover it revealed an uterine solid mass 3 x 4 cm. A computerised tomography (CT) scan and abdominal RM showed a right adrenal mass with features of angiomyolipoma and an uterine mass suspicious for leiomyoma. Laboratory investigations, that is, serum catecholamine, cortisol, and urinary, VMA were within normal limits. We performed a laparoscopic excision of uterine mass that the frozen section examination revealed to be a leiomyoma. The patient was positioned in lateral decubitus on his left side. A total of six trocars was inserted, including: the optical camera placed along mammary line, above the umbilical transverse line; two robotic ports placed along the pararectal line and one along the anterior ascellar line, focused on the adrenal fossa. A 10 mm auxiliary port placed along median line above umbilicus and a 5 mm auxiliary port placed along median line to lift up the liver. The robotic cart is docked into position at the patient’s right shoulder. Results: The frozen section examination revealed to be an adrenal angiomyolipoma, so we performed a laparoscopic robotically assisted partial adrenalectomy. Operative time was 180 minutes and blood loss was 150 ml. Histological diagnosis was adrenal angiomyolipoma of 10 x 9 cm; the himmunohistochemical analysis showed negative for melanocytic markers: S100, HMB45, melan-A/MART1. Overall hospital stay was 5 days. No post-operative complications occurred. No hormonal replacement therapy was necessary. Conclusions: Surgery is indicated if the patient is symptomatic or the tumor is more than 5 cm since the risk of malignancy increases with size. Also, the risk of spontaneous rupture increases with size. Improvements such as new instruments, smaller robotic arms, tactile feedback, and a fourth arm would represent an undeniable advantage and prompt us to reevaluate the clinical indications for its use in adrenal surgery.