Robotic Partial Adrenalectomy for 10-cm Angiomyolipoma.

Introduction: Angiomyolipoma belongs to the family of PEComas. They are various mesenchymal tumors that all show perivascular epithelioid cell differentiation. Generally, the angiomyolipoma is found in the kidney. Extrarenal angiomyolipoma is uncommon, and the most common extrarenal site is the liver. As our knowledge, only five cases of adrenal angiomyolipoma have been reported so far. We report a video of robot-assisted partial adrenalectomy of 10-cm adrenal angiomyolipoma. The run time of the video is 6.02 minutes. Materials and Methods: Due to abdominal pain, a 47-year-old woman underwent abdominal ultrasound scanner that showed a well-defined 10×9-cm right adrenal mass (incidentaloma); moreover, it revealed a uterine solid mass 3×4 cm. Abdominal computed tomography scan and magnetic resonance imaging showed a right adrenal mass with features of angiomyolipoma and a uterine mass suspicious for leiomyoma. Laboratory investigations, that is, serum catecholamine, cortisol, and urinary vanillylmandelic acid (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 were 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 was placed along the median line above umbilicus, and a 5-mm auxiliary port was placed along the median line to lift up the liver. The robotic cart is docked into a position at the patient s right shoulder. The frozen-section examination revealed to be an adrenal angiomyolipoma, so we performed a laparoscopic robotically assisted partial adrenalectomy. Results and Conclusion: Operative time was 180 minutes, and blood loss was 150 mL. Histological diagnosis was adrenal angiomyolipoma of 10×9 cm; the immunohistochemical analysis showed negative for melanocytic markers: S100, HMB45, and melan-A/MART1. Overall hospital stay was 5 days. No postoperative complications occurred. No hormonal replacement therapy was necessary. 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 of robotic surgery such as new instruments, smaller robotic arms, tactile feedback, and a fourth arm represent an undeniable advantage and prompt us to revaluate the clinical indications in adrenal surgery.