Anesthesia for Robotic Prostatectomy

Introduction^1-5

• Prostatectomy is utilized for both benign (benign prostatic hyperplasia) and malignant (prostate cancer) indications.
• A radical prostatectomy is the complete removal of the entire prostate, seminal vesicles, and vas deferens and is the primary surgical intervention for prostate cancer.
• A simple prostatectomy is indicated when a higher prostate size precludes the implementation of endoscopic approaches for severe benign prostatic hyperplasia with lower urinary tract symptoms, including urinary retention.
• Robotic-assisted surgery can be utilized for both simple and radical prostatectomies.
• Robotic approach for prostatectomy has become the predominant modality in the United States, with potential benefits including lower rates of blood loss, blood transfusions, and shorter hospital stays versus the open method.
• Multiple analyses have suggested non-significant long-term differences in open versus robotic radical prostatectomy, including cancer outcomes, urinary function, and sexual function. However, this is highly dependent on the surgeon’s experience and technique.

Preoperative Evaluation^4,6,7

• Given the typical age distribution of prostate dysfunction and incidence of prostate cancer, most patients presenting for a robotic prostatectomy will be at mid-life or later with medical comorbidities associated with aging.
• A thorough cardiovascular and pulmonary history is necessary to assess the associated risk of prolonged steep Trendelenburg position and pneumoperitoneum.
• Patients with severe obesity, severe cardiopulmonary dysfunction, a history of glaucoma, increased intraocular pressure, increased intracranial pressure, or severe obstructive lung disease may be poor candidates for robotic surgery and benefit from an open procedure.
• Surgical considerations such as prior complex abdominal or pelvic surgery, obesity, large prostate or median lobe, presence of hernia, and prior radiation or prostate surgery can make prostatectomy challenging.

Intraoperative Management^4,7-11

Case Preparation

• Robotic surgical cases should be performed with general endotracheal tube anesthesia.
• Given port placement, insufflation, patient position, and length of surgery, a neuraxial technique is contraindicated.
• Patient positioning typically requires both arms tucked, which, aside from positioning precautions, may require further vascular access.
• Primary positioning options include either supine with legs together, supine with use of a split-leg table, or lithotomy; this is often at the discretion of the surgeon.
• Intraoperative urine output is often difficult to ascertain as the Foley catheter is not readily available to anesthesia, and the urinary tract is intentionally divided to remove the prostate.

Intraoperative Considerations

• The two main intraoperative challenges of robotic prostatectomies include pneumoperitoneum and steep Trendelenburg positioning, both of which can have profound effects on various organ systems, as detailed in Table 1.
• Please see the OA summary “Patient Positioning: Physiologic Effects.” Link

• Adequate padding and some mechanisms to prevent patient sliding are necessary for safe head-down positioning.
• Nonslip pads underneath the patient and shoulder supports are the most commonly used devices to prevent patients from slipping during the steep Trendelenburg position.

Pneumoperitoneum

• Abdominal insufflation can exacerbate many of the challenges previously discussed with head-down surgical positioning, as seen in Table 2.
• Typical pneumoperitoneum is set to 15 mm Hg, though lower and/or higher settings may be utilized in a given case.
• Notice the many physiological derangements similar to a steep Trendelenburg.
• Please see the OA summary “Anesthesia for Laparoscopic and Robotic Surgery” for more details. Link

Analgesia

• Multimodal analgesia is preferred including non-steroidal anti-inflammatories and acetaminophen along with opioids.
• Epidural usage has shown little postoperative benefit and is contraindicated intraoperatively due to the potential for a high block in the steep head-down position in a traditional approach.
• Some surgeons have employed a single-port transvesical approach, which limits insufflation in the intraperitoneal space and allows for safe regional techniques.¹²
• There is mixed evidence that transverse abdominis plane blocks benefit patients with early postoperative pain.¹³

Intraoperative Surgical Complications

• Acute blood loss, rectal injury, urine leak, lymphocele, trocar injury, vascular injury, and ureteral injury are possible intraoperative surgical complications.

Postoperative Considerations^4,7,8,11

• Airway edema should be suspected in every postoperative dyspneic patient following a prolonged robotic prostatectomy, attributed to both positioning and judicious fluid administration.
• Typically, airway edema is accompanied with periorbital edema.
• There is a lower incidence of postoperative venous thromboembolism (VTE) in robotic prostatectomies compared to open procedures, but the patient incidence is still 0.5%
• Tobacco use, a large prostate, and longer operating room time are all associated with an increased risk of VTE.

Postoperative Surgical Complications

• The most common chronic functional complications encountered following robotic prostatectomy include incisional hernia, urinary incontinence, and erectile dysfunction
• These incidences are all lower than with open prostatectomy; however, long-term analysis has failed to show clinically significant differences in quality of life.
• In general, surgical functional outcomes are heavily influenced by key factors such as surgeon experience and technique at the time of prostatectomy.