Adrenalectomy for adrenocortical carcinoma: A national assessment of trends in the utilization of the robotic approach.

BACKGROUND: Current operative guidelines recommend open adrenalectomy for adrenocortical carcinoma. Despite this recommendation, minimally invasive approaches have been adopted. We hypothesize that minimally invasive adrenalectomy for adrenocortical carcinoma has increased over time, driven by robotic-assisted approaches, and has not compromised oncologic outcomes. METHODS: A retrospective review of patients undergoing surgical resection of adrenocortical carcinoma from the National Cancer Database was performed. Separate multivariable logistic regression models were built to compare factors associated with robotic surgery relative to open and laparoscopic approaches. Survival was assessed using Kaplan-Meier curves and Cox regression analysis. RESULTS: Of 2,481 patients who underwent adrenalectomy for adrenocortical carcinoma from 2010 to 2022, 1,618 (65.2%) underwent open adrenalectomy, 555 (22.4%) underwent laparoscopic adrenalectomy, and 308 (11.9%) underwent robotic adrenalectomy. The proportion of robotic cases increased from 2010 (4.5%) to 2022 (20.7%). Patients who underwent resection after 2018 had a higher probability of undergoing a robotic adrenalectomy compared with open adrenalectomy (odds ratio, 1.76; 95% confidence interval [CI], 1.23-2.52; P = .002) and a higher likelihood of undergoing a robotic adrenalectomy compared with laparoscopic adrenalectomy (odds ratio, 2.49; 95% CI, 1.71-3.62; P < .001). There were no differences in margin positivity by approach: robotic adrenalectomy versus open adrenalectomy (odds ratio, 0.79; 95% CI, 0.50-1.23; P = .291) and robotic adrenalectomy versus laparoscopic adrenalectomy (odds ratio, 0.65; 95% CI, 0.40-1.05; P = .081). Five-year overall survival rates by surgical approach were open adrenalectomy = 48%, laparoscopic adrenalectomy = 51%, and robotic adrenalectomy = 55% (P = .063). Cox regression revealed that surgical approach was not associated with survival (robotic adrenalectomy versus open adrenalectomy [hazard ratio, 1.13; 95% CI, 0.82-1.55; P = .510]). CONCLUSION: Minimally invasive surgery, specifically the robotic approach, for adrenocortical carcinoma has increased over the past decade with no associated compromise in oncologic efficacy.