Low‐ versus standard‐ pneumoperitoneum in patients undergoing robot‐assisted radical prostatectomy: a randomised, triple‐blinded study

Abstract

ObjectiveTo investigate the effectiveness and impact of low‐pressure pneumoperitoneum (Pnp) on postoperative quality of recovery (QoR) and surgical workspace (SWS) in patients with prostate cancer undergoing robot‐assisted radical prostatectomy (RARP).Patients and MethodsA randomised, triple‐blinded trial was conducted in a single centre in Denmark from March 2021 to January 2022. A total of 98 patients with prostate cancer undergoing RARP were randomly assigned to either low‐pressure Pnp (7 mmHg) or standard‐pressure Pnp (12 mmHg). Co‐primary outcomes were postoperative QoR measured via the QoR‐15 questionnaire on postoperative Day 1 (POD1), POD3, POD14, and POD30, and SWS assessed intraoperatively by a blinded assessor (surgeon) via a validated SWS scale. Data analysis was performed according to the intention‐to‐treat principle.ResultsPatients who underwent RARP at low Pnp pressure demonstrated better postoperative QoR on POD1 (mean difference = 10, 95% confidence interval [CI] 4.4–15.5), but no significant differences were observed in the SWS (mean difference = 0.25, 95% CI −0.02 to 0.54). Patients allocated to low‐pressure Pnp experienced statistically higher blood loss than those in the standard‐pressure Pnp group (mean difference = 67 mL, P = 0.01). Domain analysis revealed significant improvements in pain (P = 0.001), physical comfort (P = 0.007), and emotional state (P = 0.006) for patients with low‐pressure Pnp. This trial was registered at ClinicalTrials.gov, NCT04755452, on 16/02/2021.ConclusionPerforming RARP at low Pnp pressure is feasible without compromising the SWS and improves postoperative QoR, including pain, physical comfort, and emotional state, compared to the standard pressure.

Moderate Intra-Abdominal Pressure Levels in Robot-Assisted Radical Prostatectomy Seem to Have No Negative Impact on Clinical Outcomes

“…Previous studies prospectively stratified patients into groups with very low pressures and higher pressures. A recent, randomised clinical trial assessed the impact of the IAP on the postoperative quality of recovery, measured with the QoR-15 questionnaire, and stratified patients undergoing RALRP into two IAP groups (low pressure = 7 mmHg vs. standard pressure = 12 mmHg) [ 10 ]. The results demonstrated several advantages of low IAP for a beneficial postoperative outcome, including higher QoR-15 scores, and significant improvements in physical and emotional well-being.…”

“…Both inflammatory responses and adhesions caused by capnoperitoneum can result in increased pain levels [ 20 ]. It has been demonstrated in previous studies that low IAP is associated with less postoperative pain [ 10 , 15 , 21 ].…”

“…During the procedure, patients are most commonly placed in the steep Trendelenburg position [ 5 ]. The surgical positioning together with the insufflation of the abdominal cavity can affect cardiovascular and pulmonary functions [ 3 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 ]. Due to its absorption, CO 2 decreases the peritoneal pH level.…”