Robotic Adrenalectomy

My Clinical Approach

Adrenal disease combines endocrinology and surgery in a way that requires careful, individualised assessment. Before we even consider the surgical approach, two basic questions must be answered: does the lesion produce hormones, and is there suspicion of malignancy?

The robotic approach is a tool — valuable in many cases, but not a panacea. In practice, patient safety depends far more on correct hormonal preparation, oncological strategy, and team experience than on the technological platform itself.

• I do not recommend surgery for every adrenal incidentaloma.
• I always screen for pheochromocytoma before any invasive action.
• I do not choose the robotic approach when oncological safety rules it out.
• I explain clearly that partial adrenalectomy is not suitable for every tumour.
• I do not promise lifelong steroids, or their absence, in advance — it depends on the case.

What Are the Adrenal Glands

There are two adrenal glands, one above each kidney. They produce important hormones, including:

• Cortisol (adrenal cortex).
• Aldosterone (adrenal cortex).
• Catecholamines — adrenaline/noradrenaline (adrenal medulla).
• Adrenal androgens (adrenal cortex).

This page focuses on the surgical procedure of adrenalectomy — it is not a complete endocrinology textbook.

What Is Adrenalectomy

When Is Removal of the Adrenal Gland Needed?

Potential indications, according to current guidance:

• Hormonally active adrenal tumour.
• Pheochromocytoma.
• Aldosterone-producing adenoma / selected unilateral primary aldosteronism.
• Clinically relevant cortisol-producing lesion.
• Lesion suspicious for malignancy.
• Adrenocortical carcinoma (ACC).
• Selected adrenal metastasis.
• Enlarging/indeterminate lesion in the appropriate context.
• Symptomatic large benign lesion in selected cases.

Adrenal Incidentaloma – Does It Always Need Surgery?

Many adrenal incidentalomas are benign, non-functioning, and can be safely monitored without surgery, depending on their imaging and hormonal characteristics.

The evaluation must answer:

1. 1.Does it produce hormones?
2. 2.Does it have benign or suspicious imaging characteristics?
3. 3.Does it need surgery or surveillance?

Functional vs Non-Functional Lesion

Robotic Adrenalectomy for Pheochromocytoma

Pheochromocytoma secretes catecholamines and can cause:

• Hypertension.
• Episodic headaches.
• Palpitations.
• Sweating.
• Adrenergic crises.

Preoperative Adrenergic Preparation

In pheochromocytoma, appropriate preoperative adrenergic blockade is usually required, according to current endocrine guidance, aiming for haemodynamic stabilisation before surgical manipulation of the tumour.

Adrenalectomy & Primary Aldosteronism

In selected patients with unilateral aldosterone overproduction ( Conn’s syndrome), adrenalectomy may be a treatment option.

In appropriate patients, adrenal vein sampling (AVS) may be required, according to current guidelines. Not every adrenal nodule in a hypertensive patient should be assumed to be a Conn adenoma.

What Is Adrenal Vein Sampling (AVS)

AVS compares hormone secretion from the two adrenal glands and can help identify unilateral aldosterone overproduction.

It is not mandatory for all patients. Selection and exceptions are determined by current endocrine guidance and are individualised on a case-by-case basis.

Autonomous Cortisol Secretion and Adrenalectomy

There is not just a simple distinction of " Cushing’s syndrome or not". There are degrees of autonomous cortisol secretion.

The decision for surgery should take into account:

• Biochemical findings.
• Comorbidities.
• Age.
• General health.
• Patient preference.
• Lesion characteristics.

According to current European Society of Endocrinology (ESE) guidance.

Postoperative Adrenal Insufficiency

After adrenalectomy for a cortisol-producing lesion, the following may be needed:

• Temporary glucocorticoid replacement.
• Endocrine monitoring.

This is due to suppression of the contralateral, healthy adrenal gland’s hypothalamic-pituitary-adrenal axis. We do not give fixed doses or a taper schedule here — these are determined individually by the endocrinologist.

Suspected or Confirmed Adrenal Cancer

Robotic/minimally invasive adrenalectomy should not be presented as automatically appropriate for a large invasive tumour, local invasion, or high suspicion of ACC. The choice between open and minimally invasive surgery is based on tumour characteristics, invasion, surgeon/centre expertise, oncological principles, and current guideline recommendations.

Open Surgery for Suspected Malignancy

Open surgery may be preferable when:

• Local invasion is suspected.
• En-bloc resection may be required.
• Tumour manipulation/rupture risk is a concern.
• Oncologic exposure is important.

Adrenal Metastasis

Adrenal metastasectomy may be considered only in carefully selected oncological patients.

The decision depends on:

• Primary cancer.
• Systemic disease status.
• Disease-free interval.
• Resectability.
• Performance status.
• Multidisciplinary team (MDT) assessment.

It is not a routine treatment for every adrenal metastasis.

Adrenal Myelolipoma

Most adrenal myelolipomas are benign.

Surgery may be considered in selected cases based on:

• Symptoms.
• Size in context.
• Growth.
• Haemorrhage risk.
• Diagnostic uncertainty.

There is no universal size cutoff without current evidence.

Adrenal Cyst

Most adrenal cysts do not automatically need surgery.

Treatment may be considered for symptoms, a large/complicated lesion, uncertain diagnosis, or suspicious features. An adrenal cyst should not be confused with a kidney cyst.

What Testing Is Needed Before Adrenalectomy

Depending on the clinical context, evaluation may be required for:

• Autonomous cortisol secretion.
• Pheochromocytoma.
• Aldosterone excess in hypertensive/hypokalaemic patients.
• Sex steroids/steroid precursors in selected suspicious tumours.

There is no one-size-fits-all hormonal panel — it is individualised according to clinical context and current guideline recommendations.

Excluding Pheochromocytoma Before Any Invasive Procedure

Is a Biopsy Needed Before Adrenalectomy?

Adrenal biopsy has a limited role and may be used in selected cases, mainly when:

• Metastatic disease is suspected.
• Pathology would change management.
• Pheochromocytoma has been appropriately excluded, where relevant.

It is not part of routine work-up.

CT Characterisation

CT can assess:

• Lesion size.
• Homogeneity.
• Unenhanced attenuation.
• Enhancement characteristics.
• Local invasion.

We do not quote fixed Hounsfield unit or washout thresholds here — these are interpreted in the context of the overall clinical picture, according to current ESE (2023) guidance.

MRI & FDG PET/CT

MRI may be useful in selected lesions: lipid assessment, vascular relationships, or when there are factors such as pregnancy, contrast, or radiation considerations. It is not mandatory for everyone.

FDG PET/CT may have a role in selected suspected malignant/metastatic disease. It is not used routinely for every incidentaloma.

What Does the Robotic Approach Offer

Potential technical advantages:

• Articulated instruments.
• Stable, magnified three-dimensional view.
• Precise tissue dissection.
• Better ergonomics for the surgeon.
• Intracorporeal dexterity.
• Useful access in selected anatomically complex cases.

Robotic vs Laparoscopic Adrenalectomy

We do not claim robotic surgery is universally superior. Comparative studies vary in their findings on hospital stay and blood loss, but the choice mainly depends on the tumour, anatomy, and team experience.

Robotic vs Open Adrenalectomy

Open surgery is not presented as a failure of modern technology.

Transperitoneal vs Retroperitoneal Approach

Potential approaches:

• Transperitoneal.
• Retroperitoneal.

Selection depends on:

• Lesion size/location.
• Previous abdominal surgery.
• Body habitus.
• Bilateral disease.
• Surgeon experience.
• Need for intra-abdominal access.

Neither approach is universally better.

Right vs Left Adrenalectomy & Adrenal Vein

Adrenal venous anatomy is important, especially the short right adrenal vein draining into the inferior vena cava and the different left-sided venous drainage pattern. We do not provide a detailed dissection/clipping sequence here.

How the Procedure Is Performed

This description is deliberately kept at a general level — it is not a surgical manual.

Specimen Handling in Suspected Malignancy

In suspected malignancy, oncologic principles are followed:

• Avoiding tumour rupture.
• Avoiding direct spillage.
• Intact specimen retrieval where appropriate.

We do not provide technical extraction instructions here.

Partial or Total Adrenalectomy?

Partial adrenalectomy (cortical-sparing surgery) may have particular value in selected cases:

• Bilateral tumours.
• Hereditary syndromes.
• A solitary functional adrenal gland.
• Selected small benign functional tumours.

with the aim of reducing the risk of permanent adrenal insufficiency.

Hereditary Pheochromocytoma & Cortical-Sparing Surgery

In selected hereditary syndromes or bilateral pheochromocytoma, cortical-sparing surgery may be discussed in a specialist context, depending on current guidance and an individualised risk/benefit assessment.

Do I Need Both Adrenal Glands?

However, the following factors can change postoperative management:

• Cortisol-producing lesions.
• Bilateral disease.
• Previous contralateral surgery.
• Adrenal insufficiency.

What Happens If Both Are Removed?

Bilateral total adrenalectomy leads to a permanent need for hormone replacement. We do not give dosing regimens here — these are determined and monitored by the endocrinologist.

Anaesthesia

Robotic adrenalectomy is performed under general anaesthesia, in an operating-room setting. Hormonally active tumours require tailored anaesthetic planning.

How Long Does the Procedure Take

There is no universal duration for every patient. Duration depends on tumour size, side, anatomy, previous surgery, body weight, partial vs total resection, functional tumour type, adhesions, and oncological complexity.

Hospital Stay

Length of stay varies according to the tumour, hormonal status, complexity of the surgery, recovery, any complications, and the need for endocrine monitoring. We do not guarantee next-day discharge.

Pain, Incisions & Return to Activity

The minimally invasive approach uses small incisions/ports. Postoperative discomfort varies. We do not describe it as "pain-free" surgery.

Return to walking, office work, driving, physical work, and exercise depends on recovery and the operation performed — we do not give a fixed universal day/week without individualisation.

Recovery Timeline

Blood Pressure, Potassium & Cortisol After Surgery

In functional lesions, blood pressure may change significantly after surgery — for example in pheochromocytoma, primary aldosteronism, or cortisol excess. Medication requirements may need reassessment.

After removal of a Conn adenoma, potassium and blood pressure require postoperative monitoring.

We do not give a universal supplementation/withdrawal protocol or a self-diagnosis algorithm here — medical reassessment is required.

What Does the Histology Show

The specimen is evaluated for:

• Tumour type.
• Size.
• Resection margins.
• Invasion.
• Other relevant pathological features.

In suspected ACC, specialised pathological criteria may be used. We do not attempt an oversimplified self-interpretation score here.

Is Follow-Up Needed After Surgery?

Yes, but the strategy depends on the final pathology:

There is no universal CT schedule for everyone.

Genetic Testing

Genetic evaluation may be relevant in selected patients with:

• Pheochromocytoma/paraganglioma.
• Young age.
• Bilateral/multifocal disease.
• Family history.
• Syndromic features.

according to current guidance. Genetic testing is not recommended for every incidentaloma.

Possible Complications

We do not present complications as common, nor do we quote unsourced percentages.

Conversion to Open Surgery & Bleeding

It may be done for reasons of bleeding, anatomy, tumour invasion, oncologic safety, or patient safety.

Adrenal surgery occurs near major vessels. Significant bleeding is uncommon but important. We do not promise "bloodless surgery".

Risk of Adrenal Insufficiency

The risk is particularly relevant with:

• Bilateral adrenal surgery.
• Cortisol-producing tumours.
• Pre-existing adrenal dysfunction.

Treatment/monitoring must be endocrine-guided.

Red Flags After Surgery

Robotic Adrenalectomy & Oncological Safety

Technology must not override:

• Tumour biology.
• Invasiveness.
• Resectability.
• Surgeon/centre expertise.

The Patient Journey

Key Questions in Plain Language

Frequently Asked Questions (FAQ)

Related Topics

Scientific References

1. Fassnacht M, et al. European Society of Endocrinology clinical practice guidelines on the management of adrenal incidentalomas, in collaboration with ENSAT. Eur J Endocrinol. 2023;189(1):G1–G42.
2. Ball MW, Hemal AK, Allaf ME. International Consultation on Urological Diseases and EAU International Consultation on Minimally Invasive Surgery in Urology: laparoscopic and robotic adrenalectomy. BJU Int. 2017;119(1):13–21.
3. Economopoulos KP, et al. Laparoscopic versus robotic adrenalectomy: a comprehensive meta-analysis. Int J Surg. 2017;38:95–104.
4. Buller DM, Hennessey AM, Ristau BT. Open versus minimally invasive surgery for suspected adrenocortical carcinoma. Transl Androl Urol. 2021;10(5):2246–2263.
5. Hughes AJ, McDow AD, Ritter HE, Yang AD. Contemporary Approaches to Adrenocortical Carcinoma. Hematol Oncol Clin North Am. 2026;40(1):25–37.

Surgical Team

Robotic adrenalectomy is performed in collaboration with a specialised surgical centre and urology team, ensuring access to modern robotic infrastructure.