Da Vinci platform robotic adrenalectomy for adrenal neoplasms: a GRADE-assessed systematic review and meta-analysis of prospective randomized trials comparing perioperative, postoperative, and economic outcomes with laparoscopic adrenalectomy.

Robot-assisted adrenalectomy using the da Vinci platform offers theoretical advantages over conventional laparoscopy, including enhanced visualization, superior instrument articulation, and improved ergonomics. However, their comparative effectiveness remains controversial, with previous meta-analyses confounded by the inclusion of retrospective cohort studies. No systematic synthesis has exclusively evaluated prospective randomized controlled trials with formal GRADE certainty assessments. To compare the perioperative, postoperative, and economic outcomes of da Vinci robotic versus laparoscopic adrenalectomy for adrenal neoplasms through GRADE-assessed meta-analysis restricted to prospective randomized trials. This systematic review and meta-analysis was registered in PROSPERO (ID: CRD420251276037) on December 27, 2025. A systematic literature search (inception to December 2025) was performed to identify prospective randomized trials comparing robotic and laparoscopic adrenalectomy. Two independent reviewers performed the screening, extraction, and Cochrane RoB 2. Random-effects meta-analyses were used to pool operative time, blood loss, conversion, length of stay, complications, and cost. Heterogeneity was assessed using I² with pre-specified sensitivity and subgroup analyses. The GRADE system was used to evaluate the certainty of the evidence. Three randomized trials (n = 214 patients) met the inclusion criteria. Robotic adrenalectomy showed no statistically significant difference compared with laparoscopy in terms of operative time (MD 14.88 min, 95% CI - 25.18 to 54.95; P = 0.47; I²=94%; very low certainty), hospital stay (MD 0.04 days, 95% CI - 0.29 to 0.38; P = 0.80; I²=0%; low certainty), conversion rates (RR 0.72, 95% CI 0.05 to 10.58; P = 0.81; I²=60%; very low certainty), postoperative complications (RR 1.52, 95% CI 0.69 to 3.36; P = 0.30; I²=0%; low certainty), or total costs (MD $2444.02, 95% CI -$906.62 to 5794.66; P = 0.15; I²=99%; very low certainty). Estimated blood loss showed a statistically significant reduction with robotics (MD - 4.86 mL, 95% CI - 9.55 to - 0.18; P = 0.04; I²=0%; low certainty), but this 5 mL difference had no clinical relevance in procedures with typical blood loss under 50 mL. Sensitivity analysis identified Morino et al.2004 as the primary driver of heterogeneity in operative duration and conversion rates. Robotic adrenalectomy achieves perioperative and postoperative outcomes equivalent to laparoscopy for adrenal neoplasms, with low-to-very-low certainty evidence showing no meaningful differences in operative efficiency, recovery, complications or costs. Platform selection should prioritize surgeon expertise and case complexity rather than the expectation of universal benefit. Adequately powered trials in high-complexity populations are needed to identify the contexts in which robotic assistance provides measurable clinical value.