LAUSR

We read the paper by Ye et al. with great interest [1]. It is obviously clear that day by day, urologists are beginning to have a say in adrenal surgery. Robotic surgery is one of the recent preferred minimally invasive surgical methods for adrenal surgery. As the conjunction point of technology and minimally invasive surgery, it is obviously clear that robotic surgery will be most preferred one for adrenal approach. On the other hand, urologists have a lot of experiences on retroperitoneal area. Robotic partial adrenalectomy is a recent surgical method and its mainstay is experience from results of long-term follow-up in laparoscopic partial adrenalectomy [2]. In light of all these, we would like to make an addition to Ye et al. with a case of bilateral robotic partial adrenalectomy in a patient with Cushing syndrome. This is the first report of bilateral robotic adrenalectomy in Cushing syndrome, in published literature. A 58-year-old woman admitted to internal diseases clinic with chief symptoms of dizziness and vomiting. She had Hashimoto’s thyroiditis on regular follow-up and recently oral antidiabetic use due to intermittent elevation in blood sugar in her medical history. Additionally, she had recorded irregular hypertension attacks lately. She was using two different types of antihypertensive oral medications. In magnetic resonance imaging (MRI) examination, she had bilateral adrenal adenoma. The adenoma was 20 × 13 mm on the right adrenal gland and 13 × 10 mm on the left side (Fig. 1a). Metanephrine and normetanephrine in 24-h urine and adrenocorticotropic hormone (ACTH) levels in blood were normal. In 24-h urine test, the cortisol was 2100 μg, and in the hormone profile as her cortisone levels were high. Additionally, the cortisol level was 9.4 mcg/dL after the 1 mg dexamethasone suppression test. Then, she was referred to interventional radiology unit for adrenal venous blood sampling that to diagnose which adrenal mass was hormone active. Because of venous blood sampling was non-diagnostic, the patient was referred to our clinic. We used Da Vinci® Xi (Intuitive Surgical, Inc., Sunnyvale, CA) surgical system and performed bilateral partial adrenalectomy simultaneously. Same camera trocar was used during the operation and we just changed the patient’s position on the operating table in the course of the surgery. We did not place any clips and/or seal the adrenal main vein on bilateral. First, adrenal tissue was carefully dissected and hormone active adenoma was resected/made enucleation by performing robotic partial adrenalectomy on the right side (Fig. 1b–e). Then, patient’s position was changed (Fig. 1f) and similar surgical procedures were made as partial robotic adrenalectomy was performed on the left side (Fig. 1g–i). The operating time was 132 min and estimated blood loss was minimal. At the end of the operation, we placed drainage catheter on bilateral operation field bilateral adrenal regions. There was not any complication during and after the operation. We took drainage catheters on 1st day of surgery and the patient was discharged. Pathology reported bilateral adrenal adenoma. We found that impaired blood sugar, blood pressure, and clinical symptoms were improved. We recently reported successfully performed unilateral robotic retroperitoneal partial adrenalectomy in patient with pheochromocytoma [2]. Additionally, Richards and Brody reported a case of robotic bilateral partial adrenalectomy in patient with pheochromocytoma [3]. Moreover, our case did not have pheochromocytoma but we performed transperitoneal bilateral robotic partial adrenalectomy with using the same camera trocar. In close follow-up of the patient, the cortisol level in 24-h urine and 1 mg dexamethasone suppression tests were normal after operation. It is very well known that unilateral adrenalectomy can have a risk for Addison syndrome due to adrenal stress This comment refers to the article available online at https ://doi. org/10.1007/s0034 5-019-02868 -7.