title: Impact of novel techniques on minimally invasive adrenal surgery: trends and outcomes from a contemporary international large series in urology.
abstract: OBJECTIVE
  To evaluate contemporary international trends in the implementation of minimally invasive adrenalectomy and to assess contemporary outcomes of different minimally invasive techniques performed at urologic centers worldwide.
  
  
  METHODS
  A retrospective multinational multicenter study of patients who underwent minimally invasive adrenalectomy from 2008 to 2013 at 14 urology institutions worldwide was included in the analysis. Cases were categorized based on the minimally invasive adrenalectomy technique: conventional laparoscopy (CL), robot-assisted laparoscopy (RAL), laparoendoscopic single-site surgery (LESS), and mini-laparoscopy (ML). The rates of the four treatment modalities were determined according to the year of surgery, and a regression analysis was performed for trends in all surgical modalities.
  
  
  RESULTS
  Overall, a total of 737 adrenalectomies were performed across participating institutions and included in this analysis: 337 CL (46 % of cases), 57 ML (8 %), 263 LESS (36 %), and 80 RA (11 %). Overall, 204 (28 %) operations were performed with a retroperitoneal approach. The overall number of adrenalectomies increased from 2008 to 2013 (p = 0.05). A transperitoneal approach was preferred in all but the ML group (p < 0.001). European centers mostly adopted CL and ML techniques, whereas those from Asia and South America reported the highest rate in LESS procedures, and RAL was adopted to larger extent in the USA. LESS had the fastest increase in utilization at 6 %/year. The rate of RAL procedures increased at slower rates (2.2 %/year), similar to ML (1.7 %/year). Limitations of this study are the retrospective design and the lack of a cost analysis.
  
  
  CONCLUSIONS
  Several minimally invasive surgical techniques for the management of adrenal masses are successfully implemented in urology institutions worldwide. CL and LESS seem to represent the most commonly adopted techniques, whereas ML and RAL are growing at a slower rate. All the MIS techniques can be safely and effectively performed for a variety of adrenal disease.
authors.affiliation: University Hospitals Urology Institute, Case Western Reserve University, 27100 Chardon Rd, Richmond Heights, OH, 44143, USA.|Urology Clinic, Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy.
authors.forename: Nicola
authors.initials: N
authors.lastname: Pavan
authors.affiliation: University Hospitals Urology Institute, Case Western Reserve University, 27100 Chardon Rd, Richmond Heights, OH, 44143, USA. ricautor@gmail.com.
authors.forename: Riccardo
authors.initials: R
authors.lastname: Autorino
authors.affiliation: Department of Urology, University of California San Diego Health System, La Jolla, CA, USA.
authors.forename: Hak
authors.initials: H
authors.lastname: Lee
authors.affiliation: Department of Urology, San Luigi Hospital, University of Turin, Turin, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Porpiglia
authors.affiliation: Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, People's Republic of China.
authors.forename: Yinghao
authors.initials: Y
authors.lastname: Sun
authors.affiliation: Department of Urology, Romolo Hospital, Rocca di Neto, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Greco
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: S
authors.initials: S
authors.lastname: Jeff Chueh
authors.affiliation: Department of Urology, Samsung Medical Center, Seoul, Italy.
authors.forename: Deok Hyun
authors.initials: DH
authors.lastname: Han
authors.affiliation: Department of Urology, S. Pio Da Pietralcina Hospital, Vasto, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Cindolo
authors.affiliation: Department of Urology, European Institute of Oncology, Milan, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Ferro
authors.affiliation: Xiangya Hospital Central South University, Changsha, China.
authors.forename: Xiang
authors.initials: X
authors.lastname: Chen
authors.affiliation: Department of Urology, Cruz Vermelha Hospital, Curitiba, Brazil.
authors.forename: Anibal
authors.initials: A
authors.lastname: Branco
authors.affiliation: Department of Urology, Martin-Luther-University, Halle Saale, Germany.
authors.forename: Paolo
authors.initials: P
authors.lastname: Fornara
authors.affiliation: Department of Urology, Medical College, National Taiwan University, Taipei City, Taiwan.
authors.forename: Chun-Hou
authors.initials: CH
authors.lastname: Liao
authors.affiliation: Department of Urology, Keio University School of Medicine, Tokyo, Japan.
authors.forename: Akira
authors.initials: A
authors.lastname: Miyajima
authors.affiliation: Department of Urology, University of Patras, Patras, Greece.
authors.forename: Iason
authors.initials: I
authors.lastname: Kyriazis
authors.affiliation: Guy's and St Thomas' Hospitals, London, UK.
authors.forename: Marco
authors.initials: M
authors.lastname: Puglisi
authors.affiliation: Department of Urology, San Luigi Hospital, University of Turin, Turin, Italy.
authors.forename: Cristian
authors.initials: C
authors.lastname: Fiori
authors.affiliation: Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, People's Republic of China.
authors.forename: Bo
authors.initials: B
authors.lastname: Yang
authors.affiliation: Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, People's Republic of China.
authors.forename: Guo
authors.initials: G
authors.lastname: Fei
authors.affiliation: Department of Urology, Romolo Hospital, Rocca di Neto, Italy.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Altieri
authors.affiliation: Department of Urology, Samsung Medical Center, Seoul, Italy.
authors.forename: Byong Chang
authors.initials: BC
authors.lastname: Jeong
authors.affiliation: Department of Urology, S. Pio Da Pietralcina Hospital, Vasto, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Berardinelli
authors.affiliation: Department of Urology, S. Pio Da Pietralcina Hospital, Vasto, Italy.
authors.forename: Luigi
authors.initials: L
authors.lastname: Schips
authors.affiliation: Department of Urology, European Institute of Oncology, Milan, Italy.
authors.forename: Ottavio
authors.initials: O
authors.lastname: De Cobelli
authors.affiliation: Xiangya Hospital Central South University, Changsha, China.
authors.forename: Zhi
authors.initials: Z
authors.lastname: Chen
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Georges-Pascal
authors.initials: GP
authors.lastname: Haber
authors.affiliation: Xiangya Hospital Central South University, Changsha, China.
authors.forename: Yao
authors.initials: Y
authors.lastname: He
authors.affiliation: Department of Urology, Keio University School of Medicine, Tokyo, Japan.
authors.forename: Mototsugu
authors.initials: M
authors.lastname: Oya
authors.affiliation: Department of Urology, University of Patras, Patras, Greece.
authors.forename: Evangelos
authors.initials: E
authors.lastname: Liatsikos
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Luis
authors.initials: L
authors.lastname: Brandao
authors.affiliation: Guy's and St Thomas' Hospitals, London, UK.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Challacombe
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Jihad
authors.initials: J
authors.lastname: Kaouk
authors.affiliation: Department of Urology, University of California San Diego Health System, La Jolla, CA, USA.
authors.forename: Ithaar
authors.initials: I
authors.lastname: Darweesh
mesh_terms: D000307:Adrenal Gland Diseases / Q000601:surgery*; D000315:Adrenalectomy / Q000379:methods* / Q000639:trends; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007391:International Cooperation; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012371:Robotics / Q000379:methods / Q000639:trends; D013997:Time Factors; D016896:Treatment Outcome; D014572:Urology / Q000639:trends*
keywords: Adrenalectomy; LESS; Laparoscopy; Minimally invasive; Outcomes; Robotic