Effects of Increased Optic Nerve Sheath Diameter on Inadequate Emergence from Anesthesia in Patients Undergoing Robot-Assisted Laparoscopic Prostatectomy: A Prospective Observational Study

Abstract

(1) Background: Robot-assisted laparoscopic prostatectomy (RALP) is preferred over open prostatectomy because it offers superior surgical outcomes and better postoperative recovery. The steep Trendelenburg position and pneumoperitoneum required in Robot-assisted laparoscopic prostatectomy, however, increase intracranial pressure (ICP). The present study aimed to evaluate the effects of elevated ICP on the quality of emergence from anesthesia. (2) Methods: Sixty-seven patients undergoing RALP were enrolled. We measured optic nerve sheath diameter at four timepoints during surgery. Primary outcome was inadequate emergence in the operating room (OR). Secondary outcomes were postoperative neurologic deficits of dizziness, headache, delirium, cognitive dysfunction, and postoperative nausea and vomiting (PONV). (3) Results: A total of 69 patients were screened for eligibility and 67 patients completed the study and were included in the final analysis. After establishing pneumoperitoneum with the Trendelenburg position, ONSD increased compared to baseline by 11.4%. Of the 67 patients, 36 patients showed an increase of 10% or more in optic nerve sheath diameter (ONSD). Patients with ΔONSD ≥ 10% experienced more inadequate emergence in the OR than those with ΔONSD < 10% (47.2% vs. 12.9%, p = 0.003). However, other variables related to the quality of emergence from anesthesia did not different significantly between groups. Similarly, neurologic deficits, and PONV during postoperative day 3 showed no significant differences. (4) Conclusions: ICP elevation detected by ultrasonographic ONSD measurement was associated with a transient, inadequate emergence from anesthesia.

Assessing Stress Induced by Fluid Shifts and Reduced Cerebral Clearance during Robotic-Assisted Laparoscopic Radical Prostatectomy under Trendelenburg Positioning (UroTreND Study)

“…Moreover, research on the anesthesiologic management of patients undergoing RALP is limited. Although brain tissue oxygenation seems not to be affected even after three to four hours of steep Trendelenburg positioning [38,39], several studies reported a rise in the ONSD [13,19] and intraocular pressure [40]. We believe that more research is warranted to investigate the effect of steep head-down tilt on brain tissue homeostasis.…”

“…The effect on postoperative cognitive performance in this patient population remains underinvestigated and is therefore not conclusively understood. Patients with a high intraoperative ONSD are more likely to appear disoriented during the awakening period or in the recovery room [19]. Due to the increasing use of RALP (80% of radical prostatectomies in the USA [20]), it is important to better investigate neurological complications and to develop a better monitoring strategy and awareness of potential transient brain damage.…”

Ultrasound Assessment of Optic Nerve Sheath Diameter during Surgery in the Trendelenburg Position

“…Bang et al [27] enrolled 67 patients Undergoing Robot-Assisted Laparoscopic Prostatectomy, 36 patients had an ONSD increase of 10% or more and only five patients showed increased values of ONSD (>5.7 mm). Significant differences in inadequate emergence were observed only after extubation.…”

The intraoperative management of robotic-assisted laparoscopic prostatectomy

“…Measurement of the optic nerve sheath diameter (ONSD) by ultrasound can accurately monitor changes in IOP [41]. A small observational study found that 50% of the patients had an increase of 10% or more in ONSD after pneumoperitoneum and Trendelenburg position were established [42 ▪ ]. However, there were no significant differences in the emergence from anesthesia or neurological deficits between the groups.…”