5. DISCUSSION
Robotic-assisted laparoscopic technology offers significant advantages over traditional open surgery and conventional laparoscopic surgery in the resection of complex tumors[10], [11], such as those located at the renal hilum. The robotic system provides high-definition, 3D stereoscopic vision, which can magnify the surgical field more than 10 times, allowing for clearer visualization of critical anatomical structures, such as the complex vasculature and surrounding tissues of the renal hilum. Furthermore, robotic surgery reduces the physical strain on surgeons, enabling long, high-precision procedures and improving surgical efficiency[11]. Additionally, in partial nephrectomy for renal tumors, robotics can optimize the balance between tumor resection and renal function preservation, enhancing postoperative renal function retention[12]. In the case reported here, the patient had right renal atrophy and nonfunctional right kidney, necessitating maximal preservation of the left renal unit. Although the tumor’s close adhesion to the renal hilum vessels increased the surgical difficulty, the superior ergonomics, 3D magnification of the surgical field, tremor filtration, and enhanced instrument dexterity of the robotic-assisted surgical system provided a significant advantage in handling complex tumors surrounded by large blood vessels and tightly adhered to the renal hilum. The tumor was successfully resected, with the kidney’s warm ischemia time limited to only 20 minutes.
Adrenal function has long been suppressed by the high levels of cortisol secreted by ectopic tumors[13]. Although the source of high cortisol secretion is removed after surgery, adrenal function has not yet fully recovered, and the patient remains in a relative state of cortisol deficiency[13]. Therefore, glucocorticoid supplementation is necessary after the removal of any cortisol-secreting tumor to prevent symptoms of adrenal insufficiency or adrenal crisis[14]. Currently, there is no standardized replacement therapy, and there are differences in medication practices and experiences among medical centers. Generally, hydrocortisone is administered intravenously during surgery and on the day after surgery. Once oral intake is tolerated, prednisone is switched to oral administration[14], [15]. Glucocorticoids need to be gradually tapered because cortisol secretion follows a diurnal and pulsatile rhythm in a physiological state. Thus, glucocorticoid supplementation is given in multiple doses, with higher doses in the morning and lower doses in the afternoon, and the dose may be increased during times of stress[14].
Ectopic adrenal glands are rare in adults and are commonly located in the retroperitoneal axis, broad ligament, or spermatic cord. Similar to normal adrenal glands, they can develop cortical hyperplasia, nodules, or adenomas. It is rare for ectopic adrenal adenomas to cause Cushing’s syndrome. When the tumor is located near the renal hilum, the complex anatomy increases the difficulty of complete resection. The use of a robot-assisted surgical system allows for safer and more precise tumor removal.