Anesthesiologic Effects of Transperitoneal Versus Extraperitoneal Approach During Robot-Assisted Radical Prostatectomy: Results of a Prospective Randomized Study

Abstract

Objectives:To compare the effects of CO2 insufflation on hemodynamics and oxygen levels and on acid-base level during Robot-Assisted Radical Prostatectomy (RARP) with transperitoneal (TP) versus extra-peritoneal (EP) accesses.Materials and Methods:Sixty-two patients were randomly assigned to TP (32) and EP (30) to RARP. Pre-operation data were collected for all patients. Hemodynamic, respiratory and blood acid-base parameters were measured at the moment of induction of anesthesia (T0), after starting CO2 insuffation (T1), and at 60 (T2) and 120 minutes (T3) after insufflation. In all cases, the abdominal pressure was set at 15 mmHg. Complications were reported according to the Clavien-Dindo classification. Student's two–t-test, with a significance level set at p<0.05, was used to compare categorical values between groups. The Mann-Whitney U-test was used to compare the median values of two nonparametric continuous variables.Results:The demographic characteristics of the patients in both groups were statistically comparable. Analysis of intra-operative anesthesiologic parameters showed that partial CO2 pressure during EP was significantly higher than during TP, with a consequent decrease in arterial pH. Other parameters analysed were similar in the two groups. Postoperative complications were comparable between groups. The most important limitations of this study were the small size of the patient groups and the impossibility of maintaining standard abdominal pressure throughout the operational phases, despite attempts to regulate it.Conclusions:This prospective randomized study demonstrates that, from the anesthesiologic viewpoint, during RARP the TP approach is preferable to EP, because of lower CO2 reabsorption and risk of acidosis.

Complications in robotic urological surgeries and how to avoid them: A systematic review

“…In order to create extraperitoneal space, balloon dissection is helpful during an extraperitoneal approach [26] . A lower incidence of gastrointestinal complications and shorter hospital stay have been seen in some series of extraperitoneal approach, especially in obese patients [27] , [28] , [29] . Prior abdominal surgery, pregnancy, vascular aneurysms, and abdominal wall hernia require further consideration for access approach choice.…”

“…Although rare, insufflation complications take place when the Veress needle is accidentally placed into visceral structures, after prolonged carbon dioxide (CO 2 ) absorption (hypercarbia, acidosis, venous gas embolism) or if the abdomen is rapidly inflated [29] , [33] .…”

“…Fast peritoneal insufflation can result in hypotension, bradycardia or even asystole due to vagal response, especially in patients with cardiovascular disease [6] . Thus, slow gas insufflation may reduce such complications [29] .…”

Anaesthesiologist: The ‘Best Man’ for the Robotic Patient

“…Indeed, the decision to use the extraperitoneal route in approaching the surgical field (i.e. during radical prostatectomy) is burdened by a greater risk of having a partial CO 2 pressure significantly higher in comparison with the transperitoneal approach ( 4 ).…”

Why should a “gasless” oncologic robotic procedure be performed?

“…There are some situations associated with an increased CO 2 absorption, such as the extraperitoneal approach during RARP as we recently demonstrated. [ 2 ]…”