Robot-assisted laparoscopic radical prostatectomy on a very large prostate gland

@#This is a case of a 74-year-old obese male presented with moderate lower urinary tract symptoms and an elevated prostate specific antigen (PSA) of 48.21ng/ml. Multiparametric MRI of the prostate revealed a markedly enlarged prostate (225grams) with a PIRADS 5 lesion at the left posterior peripheral zone. Prostate biopsy done revealed prostate adenocarcinoma Gleason 7(3+4). Metastatic workup was negative for distant metastasis hence the patient was advised robot-assisted laparoscopic prostatectomy (RALP).Several difficulties were encountered during the surgical technique. The usual posterior approach was not feasible because incising the peritoneum over the rectovesical pouch would not be able to expose the vas deferens and seminal vesicles. An anterior approach was instead done, but this was still difficult due to the lack of space for proper exposure and movement of instruments. The posterior dissection was also challenging; three successive suspension stitches were necessary in order to expose and mobilize the lateral and posterior surface of the prostate. Urethrovesical anastomosis had to be modified by performing a modified posterior repair in order to reduce tension caused by the large gap left by the excised prostate. RALP is a safe and feasible operative technique for very large prostates as long as the difficulties are foreseen and the necessary adjustments are made.Robot-assisted laparoscopic prostatectomy (RALP) has emerged as the preferred option in the treatment of localized prostate cancer. As more cases are being performed, more surgeons are encountering challenging cases, such as those with difficult anatomy, prior abdominal surgery and prior radiation therapy. Large prostate glands increase the technical difficulty of performing robot-assisted laparoscopic prostatectomy.1 Reported is a case of RALP in a patient with prostate size >200. The difficulties and concerns in such situations are also delineated.

Effect of recruitment maneuver on arterial oxygenation in patients undergoing robot-assisted laparoscopic prostatectomy with intraoperative 15 cmH₂O positive end expiratory pressure / 대한마취과학회지

BACKGROUND: This randomized, controlled study was designed to compare the effects of recruitment maneuvers (RMs) with a 15 cmH₂O positive end-expiratory pressure (PEEP) on the systemic oxygenation and lung compliance of patients with healthy lungs following robot-assisted laparoscopic prostatectomy (RALP). METHODS: Sixty patients undergoing a RALP with an intraoperative 15 cmH₂O PEEP were randomly allocated to an RM or a Control group. The patients in the RM group received a single RM through the application of a continuous positive airway pressure of 40 cmH₂O for 40 s 15 min after being placed in the Trendelenburg position. The arterial oxygen tension (PaO₂, primary endpoint) and the pulmonary dynamic and static compliances (secondary endpoints) were measured 10 min after the anesthetic induction (T1), 10 min after establishment of the pneumoperitoneum (T2), 10 min after establishment of the Trendelenburg position (T3), 10 min after the RM (T4), 60 min after the RM (T5), and 10 min after deflation of the pneumoperitoneum in the supine position (T6). RESULTS: The intergroup comparisons of the PaO₂ showed significantly higher values in the RM group than in the Control group at T4 and T5 (193 ± 35 mmHg vs. 219 ± 33 mmHg, P = 0.015, 188 ± 41 mmHg vs. 214 ± 42 mmHg, P = 0.005, respectively). However, the PaO₂ at T6 was similar in the two groups (211 ± 39 mmHg vs. 224 ± 41 mmHg, P = 0.442). Moreover, there were no statistical differences between the groups in the dynamic and static compliances of the lungs at any time point. CONCLUSIONS: The arterial oxygenation of the patients with a healthy lung function who had undergone a RALP with intraoperative 15 cmH₂O PEEP was improved by a single RM. However, this benefit did not last long, and it did not lead to an amelioration of the lung mechanics.

Hemodynamic parameters during robotic radical prostatectomy in elderly patients with increased cardiac risk

BACKGROUND: We studied the hemodynamic changes associated with steep Trendelenburg position and prolonged pneumoperitoneum during robot-assisted laparoscopic prostatectomy in elderly patients with cardiac diseases. METHODS: Hemodynamic variables were measured at baseline supine position, at 30 min, 1, 2, 3 and 4 h during CO2 insufflation in post-Trendelenburg position, and after deflation in the supine position. RESULTS: In comparison with normal subjects, the cardiac index and systemic vascular resistance index of patients with cardiac diseases were significantly affected by the Trendelenburg position and pneumoperitoneum (P < 0.001). However, other variables of heart rate, mean arterial pressure and central venous pressure were not differed between the groups. CONCLUSIONS: We conclude that attention should be paid to maintain adequate hemodynamic status during prolonged pneumoperitoneum in the Trendelenburg position, and which is unfeasible in patients with severe heart failure and unstable angina.