Impact of the combination of abdominal peripheral nerve block and neuromuscular blockade on the surgical space during robot-assisted laparoscopic surgery: a prospective randomized controlled study.

PURPOSE: The impact of the combination of abdominal peripheral nerve block (PNB) and the depth of neuromuscular blockade on the surgical field were assessed. METHODS: Thirty-eight patients undergoing elective robot-assisted laparoscopic radical prostatectomy (RARP) were randomized into two groups: a PNB group (moderate neuromuscular block [train-of-four 1-3 twitches] with abdominal PNB) and a non-PNB group (deep neuromuscular block [post-tetanic count 0-2 twitches] without abdominal PNB). The primary outcome was the change in the depth of the abdominal cavity relaxation assessed by the change in the distance (Δdistance) between the umbilicus port and peritoneum upon pneumoperitoneal pressure increase from 8 to 12 mmHg. The secondary outcomes were the CO2 usage for the pneumoperitoneal pressure increase and the subjective differences in the Surgical Rating Score (SRS) during surgery. RESULTS: The Δdistance and the CO2 usage from 8 to 12 mmHg did not differ significantly between the non-PNB and PNB groups (1.34 ± 0.65 vs. 1.28 ± 0.61 cm, p = 0.763 and 3.64 ± 1.68 vs. 4.34 ± 1.44 L, p = 0.180, respectively). There was also no significant difference in SRS. Comparisons of the Δdistance values for pressure increases from 6 to 8 mmHg, 6 to 10 mmHg and 6 to 12 mmHg between the non-PNB and PNB groups also showed no between-group differences, despite significant intra-group differences (p < 0.001) by pressure increment. CONCLUSIONS: Our findings indicate that moderate neuromuscular block with abdominal PNB maintained an adequate surgical space for RARP, with no significant difference from the space achieved by deep neuromuscular block.

Video versus ultrasound pupillometry for detecting increased pupillary diameters due to nociceptive stimuli: a prospective observational study.

PURPOSE: Ultrasound pupillometry (UP) is a potential alternative to video pupillometry (VP) for assessing changes in patients' pupillary diameter (ΔPD) due to surgical nociception, but the reproducibility of UP and VP has been unclear. We evaluated the reproducibility of nociceptive ΔPD measured with both methods. SUBJECTS AND METHODS: This prospective observational trial with 15 healthy volunteers aged ≥ 18 years was conducted at a Japanese teaching hospital. The ΔPD due to tetanic stimuli randomly applied at 10-60 mA was measured with VP and UP. The primary outcome was the correlation between the ΔPD measured with VP and that measured with UP. The secondary outcome was the agreement between the methods. We also evaluated ΔPD pattern changes due to the raised pain intensity in each method. RESULTS: The noxious ΔPD values of UP were weakly but significantly correlated with those of VP (Spearman's ρ = 0.38, p < 0.001). A significant constant error was identified between the two measurements (Bland-Altman: mean of the difference in ΔPD (VP - UP), - 0.4 [95% CI: - 0.52 to - 0.28, p < 0.001], generalized estimating equation: a beta estimator of ΔPD: 0.41, [95% CI: 0.26-0.56, p < 0.001]). The ΔPD pattern changes due to the raised tetanic stimuli were almost the same in the two methods. CONCLUSION: Due to the significant constant error, we consider the reproducibility of the measured ΔPD between UP and VP moderate. Trial registry number UMIN 000047145. Prior to the subjects' enrollment, the trial was registered with the University Hospital Medical Information Network (Principal investigator: Mao Konno, Date of registration: 3.11.2022). https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000053778 .

Anesthetic management of external iliac artery transection in a morbidly obese patient with Klippel-Trenaunay-Weber syndrome: a case report.

BACKGROUND: We report the anesthetic management of an external iliac artery transection in a morbidly obese patient with Klippel-Trenaunay-Weber syndrome (KTWS). CASE PRESENTATION: A 47-year-old man with KTWS was scheduled for a right external iliac artery transection. Preoperative CT showed a right external iliac artery aneurysm, a right superficial femoral artery aneurysm, and developed collateral vessels. General anesthesia was maintained with desflurane, remifentanil, and rocuronium bromide. After the transection of the right external iliac artery, the regional saturation of oxygen (rSO2) value of the right femoral did not decrease. There was no significant hemodynamic change before or after the transection. A non-ultrasound-guided rectus abdominis sheath block was performed due to the many collateral vessels. After extubation, the patient did not complain of postoperative pain. CONCLUSIONS: In the transection of lower-extremity blood arteries under laparotomy in patients with KTWS, rSO2 monitoring, hemodynamic monitoring, and combined regional anesthesia could be useful.

Two cases of circulatory collapse due to suspected remimazolam anaphylaxis.

BACKGROUND: Remimazolam was approved in Japan in January 2020. We report two cases of circulatory collapse due to suspected remimazolam anaphylaxis during anesthetic induction. CASE PRESENTATION: Case 1: A 74-year-old male was scheduled for debridement and skin grafting for a severe burn injury. We induced anesthesia with 4 mg of remimazolam and 20 mg of ketamine. The patient subsequently developed treatment-resistant severe hypotension. Case 2: A 59-year-old male was scheduled for laparoscopic-assisted sigmoid colectomy. We induced anesthesia with 9 mg of remimazolam. Within a few minutes, the patient developed treatment-resistant severe hypotension. As serum tryptase was elevated in both cases and only intravenous administration of adrenaline was effective, we considered the circulatory collapse might be due to anaphylaxis. CONCLUSION: We experienced two cases of circulatory collapse due to suspected remimazolam anaphylaxis during anesthetic induction. The prevalence of remimazolam anaphylaxis is not yet known, and further research is needed.

The role of neutrophil gelatinase-associated lipocalin and iron homeostasis in object recognition impairment in aged sepsis-survivor rats.

Older adult patients with sepsis frequently experience cognitive impairment. The roles of brain neutrophil gelatinase-associated lipocalin (NGAL) and iron in older sepsis patients remain unknown. We investigated the effects of lipopolysaccharide-induced sepsis on novel object recognition test, NGAL levels, an inflammatory mediator tumor necrosis factor-α (TNFα) levels, and iron ion levels in the hippocampus and cortex of young and aged rats. The effect of an iron chelator deferoxamine pretreatment on aged sepsis rats was also examined. Young sepsis-survivor rats did not show impaired novel object recognition, TNFα responses, or a Fe2+/Fe3+ imbalance. They showed hippocampal and cortical NGAL level elevations. Aged sepsis-survivor rats displayed a decreased object discrimination index, elevation of NGAL levels and Fe2+/Fe3+ ratio, and no TNFα responses. Pretreatment with deferoxamine prevented the reduction in the object recognition of aged sepsis-survivor rats. The elevation in hippocampal and cortical NGAL levels caused by lipopolysaccharide was not influenced by deferoxamine pretreatment. The lipopolysaccharide-induced Fe2+/Fe3+ ratio elevation was blocked by deferoxamine pretreatment. In conclusion, our findings suggest that iron homeostasis in the cortex and hippocampus contributes to the maintenance of object recognition ability in older sepsis survivors.

Intra-operative intravascular effect of the difference in colloid solutions during acute normovolemic hemodilution.

BACKGROUND: Acute normovolemic hemodilution (ANH) is used to reduce the risk of peri-operative allogeneic blood transfusion. Although crystalloid and/or colloid solutions have been used for volume replacement during ANH, no studies have examined the differences among solutions on the volume status, electrolytes, acid-base balance, and hemodynamic status during surgery with ANH. METHODS: We retrospectively compared the effect of Ringer's lactate with 3% dextran-40 (Saviosol®, DEX group) and 6% hydroxyethyl starch 130/0.4 in 0.9% sodium chloride (Voluven®, HES group) on blood hemoglobin serum electrolytes and estimated blood volume before induction of anesthesia (baseline), after ANH and after blood transfusion following surgery in patients undergoing open gynecological surgery (n = 111 and 67, respectively). The primary outcomes were the changes in hemoglobin and electrolytes after ANH. RESULTS: There were no differences in hemoglobin or electrolytes between the two groups at baseline. Postoperative hemoglobin was significantly higher (11.0 ± 1.5 g/dL vs 9.9 ± 1.3 g/dL) (mean ± SD) in the DEX group than in the HES group (p = 0.03). Postoperative potassium was significantly decreased from the baseline both in the DEX group (137.9 ± 2.5 mmol/L vs 136.3 ± 2.7 mmol/L) and in the HES group (138.3 ± 2.0 mmol/L vs 137.8 ± 2.5 mmol/L) (p < 0.001 for both); however, it was significantly higher than in the DEX group after surgery (p < 0.001). Estimated blood volume after surgery was significantly increased after ANH in both groups; however, it was larger in the HES group than in the DEX group. CONCLUSIONS: Postoperative hemoglobin and potassium were significantly higher, and estimated blood volume was significantly smaller in the DEX than in the HES group.

Clotting functional stability of withdrawing blood in storage for acute normovolemic hemodilution: a pilot study.

PURPOSE: This study was conducted to time-course changes of clotting function of withdrawing blood for acute normovolemic hemodilution (ANH). METHODS: Twelve enrolled patients who underwent ANH from August, 2018 to January, 2019. Blood was withdrawn into blood collection pack and shaken at 60-80 rpm for 24 h in room temperature. Clot formation was evaluated using rotational thromboelastometry (ROTEM™) just after blood withdrawal (control) and 4, 8, 12 and 24 h after blood withdrawal. We compared with the control value and each value of extrinsically-activated test with tissue factor (EXTEM), intrinsically-activated test using ellagic acid (INTEM) and fibrin-based extrinsically activated test with tissue factor (FIBTEM). RESULTS: Maximum clot firmness (MCF) of FIBTEM did not change significantly. MCF of EXTEM was significantly decreased time-dependent manner but all MCF of EXTEM were within a normal range. Maximum percent change in MCF of EXTEM was 12.4% [95% confidence interval (CI): 9.0-15.8%]. The difference in the maximum clot elasticity (MCE) between EXTEM and FIBTEM (MCEEXTEM-MCEFIBTEM) was significantly decrease from 8 h after blood withdrawal. Maximum percent change in MCEEXTEM-MCEFIBTEM was 30.2% (95% CI:17.6-42.9%) at 24 h after blood withdrawal. CONCLUSION: Even though the MCE significantly decreased in a time-dependent manner, MCF of FIBTEM and EXTEM was normal up to 24 h storage. The blood of ANH can use for the purpose of hemostasis at least 8 h stored at room temperature after blood withdrawal. Future studies are needed to elucidate the clinical impact on the patient after delayed transfusion of ANH blood with regard to patient's hemostasis.

Factors affecting phantom limb pain in patients undergoing amputation: retrospective study.

PURPOSE: The efficacy of preemptive analgesia for prevention of phantom limb pain has been controversial although pain management before amputation is empirically important. The aim of this study was to determine the associated factors with perioperative phantom limb pain. METHODS: Following approval by the Medical Ethics Committee in our university, medical records of patients receiving limb amputation surgery in our hospital between April 1, 2013 and October 31, 2017 were retrospectively reviewed. To determine which pre-operative factors could affect the development of phantom limb pain, we performed univariate analysis to find candidate factors (p < 0.05), and then did multivariate regression analysis. RESULTS: Incidence of phantom limb pain was 50% (22/44). There was no difference between the groups in types of anesthesia and post-operative pain levels. The multivariate logistic regression including possible confounders suggested that diabetes mellitus and uncontrollable preoperative pain with non-steroidal anti-inflammatory drugs (NSAIDs) were independently associated with the development of phantom limb pain (Adjusted odds ratio (OR) 0.238 [95% confidential interval (CI) 0.0643-0.883], p = 0.032, Adjusted OR 6.360 [95% CI 1.280-31.50], p = 0.024, respectively). CONCLUSION: The types of anesthesia and the degree of postoperative pain were not related to the development of phantom limb pain. The present data suggest that insufficient preoperative pain with NSAIDs and diabetes mellitus would give an impact on the development of phantom limb pain.

Anesthetic management of a patient with chronic inflammatory demyelinating polyneuropathy by combination of total intravenous and regional anesthesia.

Chronic inflammatory demyelinating polyneuropathy (CIPD) is a rare acquired immune-mediated progressive and relapsing disorder that causes peripheral neuropathy lasting more than 2 months. We report the successful anesthetic management of a 66-year-old man with CIPD undergoing the laparoscopic Hartmann procedure. We induced and maintained total intravenous anesthesia (TIVA) using propofol, remifentanil, and ketamine without muscle relaxants. We performed ultrasound-guided transversus abdominis plane and rectus sheath blocks with 60 ml of 0.25% levobupivacaine for achieving good surgical conditions. For postoperative analgesia, we intravenously administered fentanyl (200 µg) and acetaminophen (1000 mg). The patient was uneventfully extubated in the operating room after confirming adequate spontaneous breathing. The postoperative course was uneventful without any respiratory complications such as respiratory depression, aspiration pneumonia, or progression of CIPD symptoms.

Efficacy of abdominal peripheral nerve block and caudal block during robot-assisted laparoscopic surgery: a retrospective clinical study.

PURPOSE: We retrospectively analyzed the efficacy of abdominal peripheral nerve block (PNB) and caudal block (CB) in patients undergoing robot-assisted laparoscopic radical prostatectomy (RARP). METHODS: Patients who underwent elective RARP at our hospital (Jan. 2015-Sept. 2016) were enrolled. We reviewed the 188 patients' anesthesia charts and medical records and divided the patients into three groups based on the anesthesia used in their cases: 76 patients in the total intravenous anesthesia (TIVA) group, 51 patients in the TIVA + abdominal PNB group (TI-PB group), and 61 patients in the TIVA + abdominal PNB + CB (TI-PB-CB group). We compared the groups' amounts of anesthetic drug usage, anesthesia times, and the presence/absence of additional opioid administration in the recovery room. RESULTS: The perioperative opioid use during anesthesia was significantly greater in the TIVA group than in the TI-PB-CB group. The total amount of muscle relaxant was significantly higher (p < 0.001) in the TIVA group than the TI-PB-CB group: 60.0 (50.0-70.0) mg vs. 50.0 (40.0-60.0) mg. Although there were no significant differences in the operation time, the frequency of the use of additional opioid administration was significantly higher (p < 0.01) in the TIVA group than the TI-PB group: 23.7% vs. 2.0%, respectively. CONCLUSIONS: Although there was no influence on the anesthesia time, the muscle relaxant dose and the perioperative amount of opioid use were significantly less in the combined PNB + CB group. Our analyses suggest that not only PNB but also CB was useful for perioperative management in RARP. CLINICAL TRIAL REGISTRATION: 2016-1059.

Significance of preoperative butyrylcholinesterase level as an independent predictor of survival in patients with upper urinary tract urothelial carcinoma treated with nephroureterectomy.

OBJECTIVES: Butyrylcholinesterase (BChE) is an alpha-glycoprotein synthesized in the liver. Its serum levels are reportedly correlated with disease activity in patients with cancer. The aim of this study was to estimate the potential prognostic significance of preoperative serum BChE levels in patients with upper urinary tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy (RNU). METHODS: Of the 220 patients with UTUC who underwent RNU between 1995 and 2016 at Hirosaki University Hospital, 149 patients with available laboratory data were included for analysis. Covariates included age, sex, preoperative laboratory data, clinical T and N grades, tumor grade, tumor location and preoperative chemotherapy. Univariate and multivariate analyses were performed to identify clinical factors associated with overall survival (OS) and disease-free survival (DFS). Univariate analysis was performed using the Kaplan-Meier and log-rank methods, and the multivariate analysis was performed using a Cox proportional hazard model. RESULTS: The median BChE level was 276 U/l and the optimal cut-off point for the serum BChE level was determined to be 218 IU/ml. The 5-year OS and DFS rates were 81.0% and 73.7%, respectively. The 5-year OS and DFS rates were significantly greater in the BChE ≥ 218 than <218 U/l groups (86.6% vs. 53.7%, P < 0.001 and 76.4% vs. 58.3%, P = 0.049, respectively). In multivariate analysis, BChE levels were most significantly associated with OS, whereas BChE level and tumor grade were significantly associated with DFS. CONCLUSIONS: This study validated preoperative serum BChE levels as an independent prognostic factor for UTUC after RNU.

Impact of acute changes in perfusion index and blood pressure on the accuracy of non-invasive continuous hemoglobin concentration measurements during induction of anesthesia.

PURPOSE: Several factors affect the accuracy of non-invasive continuous hemoglobin concentration (SpHb) measurements. We had previously shown an increase in the perfusion index (PI) following induction of anesthesia which was associated with an increase in the difference between SpHb and total hemoglobin (tHb) (SpHb-tHb). We hypothesized that blunting the increase in PI by maintaining blood pressure during induction of anesthesia would improve the agreement between SpHb and tHb measurements. METHODS: Twenty-nine adult patients were enrolled. Patients were randomly assigned by use of sequentially numbered, opaque sealed envelopes to a control (group C) or a phenylephrine group (group P). Anesthesia was induced and maintained with propofol, remifentanil, and ketamine. In group P, phenylephrine was infused at 0.5 µg/kg/min during induction of anesthesia. SpHb and PI were monitored with a Radical-7 Pulse CO-Oximeter. tHb and hematocrit were measured with the ABL800 blood gas analyzer. RESULTS: Following induction of anesthesia, PI increased significantly in both groups (p < 0.001 and p < 0.05 in groups C and P, respectively). However, the increase in PI was significantly smaller in group P than in group C (2.6 ± 1.3 vs 0.8 ± 1.4%, p < 0.001). Similarly, the change in SpHb-tHb was significantly smaller in group P than in group C (0.40 ± 0.78 vs 0.97 ± 0.70 g/dl, p < 0.05). Changes in SpHb-tHb are correlated with changes in PI (r = 0.46, p < 0.05). CONCLUSIONS: The findings suggest that blunting the increase in PI by maintaining arterial pressure during induction of anesthesia improves the agreement between SpHb and tHb values.

[Update on the Use of Lower Extremity Peripheral Nerve Blocks and its Future].

Regional anesthesia for lower limb surgery not only provides satisfactory analgesia, but also improves the overall postoperative outcome with less postoperative nausea and vomiting by decreasing the opioid con- sumption, encouraging early postoperative mobility. Therefore, high-quality anesthesia and postoperative analgesia accelerate the rehabilitation process and shorten the hospital stay. In the past decade, ultra- sound-guided lower extremity peripheral nerve blocks have become popular in Japanese hospitals. This tech- nique enables the visualization of thee target nerve structures, controlles needle movement and the spread of injected local anesthetic solution in a real real-time manner, and this has been adapted not only for tradi- tional blocks, but also in "new approach" blocks such as adductor canal blocks, depending solely on ultra- sound images. In the decades to come, we hope to obtain more established evidence supporting the utility of ultra- sound-guided techniques for lower extremity nerve blocks based on high-quality clinical studies. These findings may support the development of sustained- release formulation local anesthetics and new devices or techniques in the future.

Anesthetic management of a patient with narcolepsy by combination of total intravenous and regional anesthesia: a case report.

Narcolepsy is a neurological disease characterized by excessive daytime sleepiness, cataplexy, and/or a sudden loss of muscle tone due to malfunction of the orexinergic system, which may cause delayed emergence from general anesthesia. We report a successful anesthetic management of 24-year-old female narcoleptic patient undergoing left anterior cruciate ligament reconstruction. Anesthesia was induced and maintained with total intravenous anesthesia (TIVA) using propofol and remifentanil. Ultrasound-guided left femoral nerve block was also performed with 0.375% ropivacaine 20 ml. Acetaminophen 1000 mg was intravenously administered as part of a multimodal analgesia. After the surgery, the trachea was extubated 9 min after termination of TIVA, and then, the patient correctly responded to verbal commands. The postoperative course was uneventful without any narcoleptic symptoms.

Rebound hyperkalemia after cessation of ritodrine in a parturient undergoing cesarean section.

A 36-year-old parturient with a suspicion of placenta accreta under tocolytic therapy with ritodrine infusion underwent emergency cesarean section under general anesthesia with propofol, ketamine, and remifentanil because massive bleeding was anticipated. The ritodrine infusion was discontinued 1 h before cesarean section. The baby was delivered 6 min after induction of anesthesia. However, after the manual removal of the placenta from the uterus, the bleeding was massive and uncontrollable. We rapidly transfused crystalloid, colloid, and red blood cells through potassium removal filter. Hyperkalemia (5.8 mmol/L) was detected just before blood transfusion. One hour later, hemostasis was still difficult, and hyperkalemia was promoted (6.1 mmol/L). Thus, glucose insulin therapy started with intravenous furosemide to treat hyperkalemia. Gynecologists decided to induce the Bakri balloon tamponade for the treatment of postpartum hemorrhage. At the end of surgery, plasma potassium level also reduced to 5.5 mmol/L. In the ICU, the bleeding still continued, and then radiologists performed bilateral internal iliac artery embolization for full hemostasis. Postoperative plasma potassium level was stable and 3.3 mmol/L in the next morning. Although one of the common adverse reactions of ritodrine is hypokalemia, we should also beware of a rebound hyperkalemia after its cessation.

Interference with pulse oximetry by the Stealth Station™ Image Guidance System.

BACKGROUND: A pulse oximeter is one of the most important monitors to save patients undergoing anesthesia and monitored sedation. The authors report a case of orthopedic surgery, in which interference of pulse oximetry occurred when using a Stealth Station™ navigation system (Medtronic Sofamor Danek, Memphis, TN). Applying a black plastic shield (Masimo Ambient Shield: Masimo Corporation, Irvine, CA) completely eliminated the interference. CASE PRESENTATION: A 37-year-old male patient with a giant cell tumor of the left femur was scheduled to undergo curettage of the femur using an intraoperative CT three-dimensional imaging system (O-arm™) and Stealth Station™ navigation system. During the surgery, the SpO2 value, which was maintained between 97 and 99% until the time, disappeared suddenly with abnormal pulse wave. Because a distortion in the SpO2 value was reproduced by repeated movement of cameras on the head of the Stealth Station™ navigation system, we recognized that the interference signal was coming from the navigation system. To eliminate the infrared light, the pulse oximetry probe was covered with a black plastic shield and the interference was completely eliminated. CONCLUSIONS: The Stealth Station™ navigation system was found to interfere with the SpO2 value, and a black plastic shield was useful for eliminating the interfering signal. Anesthesiologists should understand the risk of interference by the neuro-navigation system and know how to solve the problem.

A case report of sudden thrombocytopenia detected only by in vitro analysis.

We experienced an unexpected thrombocytopenia detected only in vitro during radical prostatectomy for a 66-year-old patient. Thrombocytopenia with platelet aggregation was observed in a blood sample obtained using a heparinized syringe (not by ethylene diamine tetra-acetic acid tube). Although we could not exclude platelet agglutination in vivo, no thrombosis or coagulation disorder was observed. We changed the anti-coagulant in the arterial catheter carrier fluid (saline) from heparin to argatroban, and continued with the operation. No embolic complications were observed during the perioperative period. Although pseudothrombocytopenia or heparin-induced thrombocytopenia was highly suspected in the present case, we were not able to confirm which of the two developed. Multi-directional attention and care may be required for perioperative unexpected thrombocytopenia.

Significance of preoperative butyrylcholinesterase as an independent predictor of biochemical recurrence-free survival in patients with prostate cancer treated with radical prostatectomy.

BACKGROUND: Butyrylcholinesterase (BChE) is an alpha-glycoprotein found in the nervous system and liver. Its serum level is reduced in many clinical conditions, such as liver damage, inflammation, injury, infection, malnutrition, and malignant disease. In this study, we analyzed the potential prognostic significance of preoperative BChE levels in patients with prostate cancer (PCa) undergoing radical prostatectomy (RP). METHODS: We retrospectively evaluated 535 patients with PCa who underwent RP from 1996-2014 at a single institution. Serum BChE was routinely measured in all patients before operation. Covariates included age, preoperative laboratory data [prostate-specific antigen (PSA), hemoglobin, total protein, albumin, BChE, lactate dehydrogenase, C-reactive protein], clinical T, biopsy Gleason score, D'Amico risk classification, and RP with/without neoadjuvant therapy. Univariate and multivariate analyses were performed to identify clinical factors associated with biochemical recurrence-free survival (BRFS). Univariate analyses were performed using the Kaplan-Meier and log-rank methods, and multivariate analysis was performed using a Cox proportional hazard model. RESULTS: The median BChE level was 255 U/L (normal range 168-470 U/L). The median age of the enrolled patients was 68 years, and the median PSA level at diagnosis of PCa was 8.39 ng/mL. The median follow-up period was 65 months. The 5-year BRFS rate was 72.9 %. The 5-year BRFS rates in the BChE ≥ 168 and ≤ 167 U/L groups were 77.7 and 55.0 %, respectively (P < 0.001). In univariate analysis, BChE, cT, biopsy Gleason score, and D'Amico risk classification were significantly associated with BRFS. Multivariate analysis revealed that BChE was significantly associated with BRFS. CONCLUSIONS: This study validated preoperative serum BChE levels as an independent prognostic factor for PCa after RP.