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Keating K, Holdren C, Eames R, Pulford C, O'Pry E, Peifer D, Rohloff M, Fletcher J, Maatman TJ. The impact of low pressure pneumoperitoneum in robotic assisted radical prostatectomy II: a prospective, randomized, double blinded trial. World J Urol 2024; 42:347. [PMID: 38789638 DOI: 10.1007/s00345-024-05038-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
OBJECTIVE To analyze postoperative ileus rates and postoperative complications between the different pneumoperitoneum settings. The secondary objective was to evaluate narcotic use and intraoperative blood loss between the different pneumoperitoneum settings. METHODS A prospective, randomized, double blinded study was conducted at pneumoperitoneum pressures of either 12 mmHg or 15 mmHg for patients undergoing robotic assisted radical prostatectomy with bilateral pelvic lymph node dissection by a single high volume surgeon. RESULTS The risk of ileus in the 12 mmHg group was 1.9% (2/105) compared to 3.2% (3/93) in the 15 mmHg group (OR 0.58, 95%CI 0.1-3.6). There was no difference in the risk of any complication with a complication rate of 4.8% (5/105) in the 12 mmHg arm compared to 4.3% (4/93) in the 15 mmHg arm (OR 1.1, 95% CI 0.3 - 4.3). CONCLUSION Pneumoperitoneum pressure setting of 12 mmHg has no significant difference to 15 mmHg in the rate of postoperative complications, narcotic use, and intraoperative bleeding. Additional research is warranted to understand the optimal.
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Affiliation(s)
- Kevin Keating
- Department of Urological Surgery, University of MI Health - West, 5900 Byron Center Ave., Wyoming, MI, 49519, USA.
| | - Charla Holdren
- Department of Urological Surgery, University of MI Health - West, 5900 Byron Center Ave., Wyoming, MI, 49519, USA
| | - Richard Eames
- Department of Urological Surgery, University of MI Health - West, 5900 Byron Center Ave., Wyoming, MI, 49519, USA
| | - Christopher Pulford
- Department of Urological Surgery, University of MI Health - West, 5900 Byron Center Ave., Wyoming, MI, 49519, USA
| | - Emiley O'Pry
- Department of Urological Surgery, University of MI Health - West, 5900 Byron Center Ave., Wyoming, MI, 49519, USA
| | - David Peifer
- Department of Urological Surgery, University of MI Health - West, 5900 Byron Center Ave., Wyoming, MI, 49519, USA
| | - Matthew Rohloff
- Department of Urological Surgery, University of MI Health - West, 5900 Byron Center Ave., Wyoming, MI, 49519, USA
| | - Jeffery Fletcher
- Department of Urological Surgery, University of MI Health - West, 5900 Byron Center Ave., Wyoming, MI, 49519, USA
| | - Thomas J Maatman
- Department of Urological Surgery, University of MI Health - West, 5900 Byron Center Ave., Wyoming, MI, 49519, USA
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2
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Ippolito A, Mulier J, Hahn M, Wenzel M, Mandel P, Flinspach AN, Wenger KJ. Moderate Intra-Abdominal Pressure Levels in Robot-Assisted Radical Prostatectomy Seem to Have No Negative Impact on Clinical Outcomes. J Clin Med 2024; 13:1202. [PMID: 38592056 PMCID: PMC10932126 DOI: 10.3390/jcm13051202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/27/2024] [Accepted: 02/06/2024] [Indexed: 04/10/2024] Open
Abstract
Introduction: Radical prostatectomy is increasingly performed laparoscopically with robot assistance (RALRP). RALRP, as with all laparoscopic procedures, requires a pneumoperitoneum, which might result in peritoneal inflammatory response reactions and postoperative pain. The aim of this retrospective single-centre study was to analyse the effects of a pneumoperitoneum during RARLP on clinical outcomes. Methods: All patients who underwent robot-guided prostatectomy in our clinic were included, with the exception of patients who were converted to open prostatectomy. C-reactive protein was used as a marker for the primary outcome, namely the postoperative inflammatory response. Intra-abdominal pressure (IAP) was evaluated as a potential factor influencing inflammation. In addition, the waist-hip ratio was used to estimate the amount of visceral adipose tissue, and the administration of dexamethasone was considered as a factor influencing inflammation. The Visual Analogue Scale (VAS) was used to determine postoperative pain. Patients were consecutively recruited between 1 September 2020 and 31 March 2022. Results: A total of 135 consecutive patients were included. The median waist-hip ratio was 0.55. The median duration of the pneumoperitoneum was 143 min. The median values of the average and maximum IAP values were 10 mmHg and 15 mmHg, respectively. The mean CRP of the first postoperative day was 6.2 mg/dL. The median VAS pain level decreased from 2 to 1 from the first to the third postoperative day. On the first postoperative day, 16 patients complained of shoulder pain. In addition, 134 patients were given some form of opioid pain treatment following surgery. Conclusion: We could not identify any relevant associations between the duration and IAP of the pneumoperitoneum and the indirect markers of inflammation or indicators of pain, or between the latter and the amount of visceral adipose tissue. In addition, we found no significant effect of the administration of dexamethasone on postoperative inflammation. The results point to a noninferior tolerability of moderate pressure during the procedure compared to the commonly utilised higher pressure, yet this must be confirmed in randomised controlled trials.
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Affiliation(s)
- Angelo Ippolito
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany
| | - Jan Mulier
- Department of Anaesthesiology, Intensive Care and Reanimation, AZ Sint Jan Brugge, 8000 Bruges, Belgium
- Department of Anesthesiology, KULeuven, 3000 Leuven, Belgium
- Department of Anesthesiology, UGhent, 9000 Ghent, Belgium
| | - Marta Hahn
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany
| | - Mike Wenzel
- Department of Urology, University Hospital Frankfurt, Goethe-University Frankfurt, 60590 Frankfurt am Main, Germany
| | - Philipp Mandel
- Department of Urology, University Hospital Frankfurt, Goethe-University Frankfurt, 60590 Frankfurt am Main, Germany
| | - Armin N. Flinspach
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany
| | - Katharina J. Wenger
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe-University Frankfurt, 60528 Frankfurt am Main, Germany
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3
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Vasdev N, Martin N, Hackney AB, Piedad J, Hampson A, Shan G, Prasad V, Chilvers M, Ebon M, Smith P, Tegan G, Decaestecker K, Baydoun A. Comparing different pneumoperitoneum (12 vs. 15 mmHg) pressures with cytokine analysis to evaluate clinical outcomes in patients undergoing robotic-assisted laparoscopic radical cystectomy and intracorporeal robotic urinary diversion. BJUI COMPASS 2023; 4:575-583. [PMID: 37636200 PMCID: PMC10447212 DOI: 10.1002/bco2.240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 03/05/2023] [Accepted: 03/17/2023] [Indexed: 08/29/2023] Open
Abstract
Background Robotic cystectomy is the mainstay surgical intervention for treatment-refractory nonmuscle-invasive and muscle-invasive bladder cancer. However, paralytic ileus may complicate the postoperative recovery and may be a consequence of an inflammatory response associated with transient gut ischaemia. We have therefore investigated clinical, operative and inflammatory biomarker associations between paralytic ileus in the context of robotic cystectomy and intracorporeal ileal conduit urinary diversion. Methods Prospective consective patients referred for robotic cystectomy were consented and included in the study, while patients >75 years old and converted to open procedure were excluded. The pneumoperitoneum pressure (PP) for carbon dioxide insufflation required to perform the procedure efficiently and safely was recorded (12 or 15 mmHg). We also recorded the postoperative days patients passed flatus and stools, whether they developed ileus, as well as other standard clinical and demographic data. The expression of select proinflammatory and anti-inflammatory cytokines was determined by multiplex analysis using a cytometric bead array with changes in profiles correlated with the pressures applied and with the existence of an ileus. Results Twenty-seven patients were recruited, but only 20 were used in the study with 10 patients in each PP group. Seven patients were excluded all of whom had an extracorporeal ileal conduit formation. There were differences in the 40-min shorter operative time and 1 day shorter length of stay, as well as passing flatus 1 day and stools 1.5 days earlier in the 12 mmHg compared with the 15 mmHg group. More patients had ileus in the 15 mmHg group vs 12 mmHg group (30% vs. 10.0%). These were not statistically significant. Similarly, there were no statistical differences in the expression of proinflammatory cytokines at the two different pressures or between patient groups, but there were outliers, with the median indicating nonsymmetrical distribution. By comparison, anti-inflammatory cytokines showed some significant differences between groups, with IL-6 and IL-10 showing elevated levels postsurgery. No statistical difference was observed between pressures or the existence of an ileus, but the maximum levels of IL-6 and IL-10 detected in some patients reflect a pressure difference. Conclusions The initial findings of this novel scientific study indicated a higher risk of paralytic ileus postrobotic cystectomy and robotic intracorporeal urinary diversion when a higher pressure of 15 mmHg is used compared with 12 mmHg. Although further studies are required to establish the linkage between cytokine profile expression, pressure and ileus, our initial data reinforces the advantages of lower pressure robotic cystectomy and intracorporeal urinary diversion in patient outcomes.
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Affiliation(s)
- Nikhil Vasdev
- Department of Urology, Lister HospitalEast and North Hertfordshire NHS TrustStevenageUK
- School of Life and Medical SciencesUniversity of HertfordshireHatfieldUK
| | - Naomi Martin
- Faulty of Health and Life SciencesDe Montfort UniversityLeicesterUK
- Department of Respiratory SciencesUniversity of LeicesterLeicesterUK
| | - Amon B. Hackney
- Department of Respiratory SciencesUniversity of LeicesterLeicesterUK
| | - John Piedad
- Department of Urology, Lister HospitalEast and North Hertfordshire NHS TrustStevenageUK
| | - Alexander Hampson
- Department of Urology, Lister HospitalEast and North Hertfordshire NHS TrustStevenageUK
| | - Gowrie‐Mohan Shan
- Department of Anaesthetics, Lister HospitalEast and North Hertfordshire NHS TrustStevenageUK
| | - Venkat Prasad
- Department of Anaesthetics, Lister HospitalEast and North Hertfordshire NHS TrustStevenageUK
| | - Michael Chilvers
- Department of Anaesthetics, Lister HospitalEast and North Hertfordshire NHS TrustStevenageUK
| | - Martin Ebon
- Department of Research, Lister HospitalEast and North Hertfordshire NHS TrustStevenageUK
| | - Philip Smith
- Department of Research, Lister HospitalEast and North Hertfordshire NHS TrustStevenageUK
| | - Gary Tegan
- Research and DevelopmentCONMED CorporationLargoFloridaUSA
| | - Karel Decaestecker
- Department of UrologyMaria Middelares General HospitalGhentBelgium
- Department of UrologyGhent University HospitalGhentBelgium
| | - Anwar Baydoun
- Department of Respiratory SciencesUniversity of LeicesterLeicesterUK
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4
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The Impact of intra-abdominal Pressure on Perioperative Outcomes in Robotic-Assisted Radical Prostatectomy: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. JOURNAL OF ONCOLOGY 2022; 2022:4974027. [DOI: 10.1155/2022/4974027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/23/2022] [Accepted: 10/31/2022] [Indexed: 11/16/2022]
Abstract
Objective. The aim of the study is to analyze the impact of intra-abdominal pressure (IAP) on perioperative outcomes in robotic-assisted radical prostatectomy (RARP). Methods. We searched the PubMed, Cochrane Library, Science, Embase, and CNKI databases systematically, and the retrieval date was from the inception of the databases to April 2022. Randomized controlled trials on high intraabdominal pressure (HIAP) and low intraabdominal pressure (LIAP) in RARP were included. The meta-analysis was performed using Review Manager software (version 5.3). Results. Six studies involving 2,271 patients were included in the meta-analysis. Compared with patients who experienced HIAP, those who experienced LIAP had a lower incidence of postoperative ileus (POI) (risk ratio (RR): 0.42; 95% confidence interval (CI): 0.24 to 0.72;
). However, there were no significant differences in hematoma (RR 2.22; 95% CI, 0.61 to 8.15;
), positive margin rate (RR, 1.06; 95% CI, 0.84 to 1.32;
), urinary retention (RR, 0.99; 95% CI, 0.51 to 1.94;
), operative time (mean difference (MD), −0.36; 95% CI, −12.24 to 6.12;
), or intraoperative blood loss (MD, −21.80; 95% CI, −55.28 to 11.68;
) among patients undergoing LIAP and HIAP. Conclusion. Our study of published trials indicates that using LIAP during RARP may reduce the incidence of POI, and there were no differences in terms of hematoma, positive margin rate, urinary retention, operative time, or intraoperative blood loss.
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5
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Clinical outcomes of low-pressure pneumoperitoneum in minimally invasive urological surgery. J Robot Surg 2022; 16:1183-1192. [PMID: 35094219 PMCID: PMC8800847 DOI: 10.1007/s11701-021-01349-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 11/29/2021] [Indexed: 12/22/2022]
Abstract
The adoption of minimally invasive laparoscopic techniques has revolutionised urological practice. This necessitates a pneumoperitoneum (PNP) and the impact the PNP pressure has on post-operative outcomes is uncertain. During the current COVID-19 era guidance has suggested the utilisation of lower PNP pressures to mitigate the risk of intra-operative viral transmission. Review the current literature regarding the impact of pneumoperitoneum pressure, within the field of urology, on post-operative outcomes. A search of the PubMed, Medline and EMBASE databases was undertaken to identify studies that met the inclusion criteria. The Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines were adhered to. Ten studies, that included both randomised controlled trials and retrospective case series reviews, were identified that met the inclusion criteria. The effect of PNP pressure on outcomes following prostatectomy, live donor nephrectomy, partial nephrectomy and a variety of benign upper tract procedures were discussed. Low pressure PNP appears safe when compared to high pressure PNP, potentially reducing post-operative pain and rates of ileus. When compared to general surgery, there is a lack of quality evidence investigating the impact of PNP pressures on outcomes within urology. Low pressure PNP appears non-inferior to high pressure PNP. More research is required to validate this finding, particularly post-cystectomy and nephrectomy.
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Lower vs standard pressure pneumoperitoneum in robotic-assisted radical prostatectomy: a systematic review and meta-analysis. J Robot Surg 2022; 17:303-312. [PMID: 35861890 DOI: 10.1007/s11701-022-01445-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 06/30/2022] [Indexed: 10/17/2022]
Abstract
Robotic-assisted laparoscopic radical prostatectomy (RARP) has been traditionally performed at a pneumoperitoneum insufflation pressure of 12-15 mmHg. This meta-analysis and systematic review aims to assess the current evidence comparing lower to standard pressure pneumoperitoneum in RARP. Systematic searches of MEDLINE, COCHRANE, SCOPUS and EMBASE were performed to identify articles published up until November 2021 comparing lower pressure with standard pressure pneumoperitoneum in RARP. Standard pressure was defined as > 12 mmHg and lower pressure ≤ 12 mmHg. Estimated blood loss, length of operation, length of hospital stay, post-operative ileus, 30-day readmissions, Clavien-Dindo complications and rate of positive surgical margins were extracted as endpoints of interest. Our searches identified 165 abstracts of which 4 articles with 1319 patients were eligible. Cumulative analysis demonstrated reduced length of stay when a lower pressure was used: WMD - 0.23 (- 0.45 to - 0.02) days (p = 0.03) as well as a reduced rate of post-operative ileus: OR 0.41 (0.22 to 0.77) (p = 0.006). There was no significant increase in length of operation WMD - 1.79 (- 15.96 to 12.38) (p = 0.8), estimated blood loss WMD - 2.89 (- 29.41 to 23.62) (p = 0.83), 30-day readmissions or positive surgical margins OR 1.04 (0.78 to 1.38) (p = 0.81) and RD - 0.01 (- 0.04 to 0.01) (p = 0.3) when using a lower pressure. We have demonstrated reduced length of stay and rates of post-operative ileus, when performing RARP at a lower pressure without a significant increase in length of operation, estimated blood loss, positive surgical margins or complications. The recommendation to use lower pressure pneumoperitoneum is moderate to weak and more randomised control trials are required to validate these results.
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7
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Karaveli A, Kavaklı AS, Özçelik M, Ateş M, İnanoğlu K, Özmen S. The effect of different levels of pneumoperitoneum pressures on regional cerebral oxygenation during robotic assisted laparoscopic prostatectomy. Turk J Med Sci 2021; 51:1136-1145. [PMID: 33387989 PMCID: PMC8283475 DOI: 10.3906/sag-2005-368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 01/01/2021] [Indexed: 11/13/2022] Open
Abstract
Background/aim This study aimed to evaluate the effect of low- and high-pressure pneumoperitoneum pressures applied during robotic-assisted laparoscopic prostatectomy (RALP) using near-infrared spectroscopy (NIRS) on regional cerebral oxygenation saturation (rSO2). Materials and methods The prospective, comparative, and observational study included patients aged 18–80 years, with the American Society of Anesthesiologists (ASA) physical status I-II, who would undergo elective RALP. The patients were divided into two groups (12 mmHg of pneumoperitoneum pressure group, n=22 and 15 mmHg of pneumoperitoneum pressure group, n=23). Patients’ demographic data, durations of anesthesia, surgery, pneumoperitoneum, and Trendelenburg position, intraoperative estimated blood loss, fluid therapy, urine output, hemodynamic and respiratory data, and rSO2 values were recorded at regular intervals. Results The rSO2 values increased significantly during the pneumoperitoneum combined with steep Trendelenburg position (from
t3
to
t6
) and at the end of the surgery (
t7
) in both groups, compared to the values 5 min after the onset of pneumoperitoneum in the supine position (
t2
) (P < 0.05), but no statistical significance was observed between the two groups. No cerebral desaturation was observed in any of our patients. Hemodynamic and respiratory parameters were preserved in both groups. The blood lactate levels were significantly higher in patients operated at high-pressure pneumoperitoneum, compared to those with low-pressure pneumoperitoneum (P < 0.05). Conclusion We believe that low-pressure pneumoperitoneum, especially in robotic surgeries, such as robotic-assisted laparoscopic prostatectomy (RALP), can be applied safely.
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Affiliation(s)
- Arzu Karaveli
- Department of Anesthesiology and Reanimation, Antalya Training and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Ali Sait Kavaklı
- Department of Anesthesiology and Reanimation, Antalya Training and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Murat Özçelik
- Department of Anesthesiology and Reanimation, Antalya Training and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Mutlu Ateş
- Department of Urology, Antalya Training and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Kerem İnanoğlu
- Department of Anesthesiology and Reanimation, Antalya Training and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Sadık Özmen
- Department of Anesthesiology and Reanimation, Antalya Training and Research Hospital, University of Health Sciences, Antalya, Turkey
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8
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Grieco M, Tirelli F, Agnes A, Santocchi P, Biondi A, Persiani R. High-pressure CO 2 insufflation is a risk factor for postoperative ileus in patients undergoing TaTME. Updates Surg 2021; 73:2181-2187. [PMID: 33811314 DOI: 10.1007/s13304-021-01043-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 03/24/2021] [Indexed: 11/26/2022]
Abstract
The aim of this study is to evaluate the influence of high-pressure CO2 insufflation during TaTME on the occurrence of postoperative ileus. All patients undergoing elective transanal total mesorectal excision (TaTME) between April 2015 and March 2019 were included in a prospective database. Eligible patients were adults with mid and low-level rectal cancer undergoing elective TaTME with colorectal anastomosis and diverting ileostomy, following a standardized ERAS pathway. Patients were divided into a low-pressure (LP) group, where surgery was performed with an intrabdominal CO2 pressure of 12 mmHg, and a high-pressure (HP) group, where the intrabdominal pressure reached 15 mmHg of CO2 once the two surgical fields were connected. Of 98 patients undergoing TaTME in the observed period, 74 met the inclusion criteria and were included in this study. There was no significant difference in postoperative complications between the LP and HP groups, except for postoperative ileus, which occurred in seven patients (13.2%) in the LP group and seven patients (33.3%) in the HP group (p value 0.046). The logistic multivariate analysis showed that a high intraabdominal CO2 pressure (OR 7040, 95% CI 1591-31,164, p value 0.01) and male sex (OR 10,343, 95% CI 1078-99,256, p value 0.043) were significantly associated with postoperative ileus after TaTME. Intraabdominal CO2 pressure should be carefully set, as it may represent a risk factor for postoperative ileus in patients undergoing TaTME.
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Affiliation(s)
- Michele Grieco
- General Surgery Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma-Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00168, Rome, Italy.
| | - Flavio Tirelli
- General Surgery Department, Fondazione Policlinico Universitario A Gemelli IRCCS Roma, L.go A. Gemelli 8, 00168, Rome, Italy
| | - Annamaria Agnes
- General Surgery Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma-Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00168, Rome, Italy
| | - Pietro Santocchi
- General Surgery Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma-Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00168, Rome, Italy
| | - Alberto Biondi
- General Surgery Department, Fondazione Policlinico Universitario A Gemelli IRCCS Roma, L.go A. Gemelli 8, 00168, Rome, Italy
| | - Roberto Persiani
- General Surgery Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma-Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00168, Rome, Italy
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Comparison of the Safety and Efficacy of Valveless and Standard Insufflation During Robotic Partial Nephrectomy: A Prospective, Randomized, Multi-institutional Trial. Urology 2021; 153:185-191. [PMID: 33577899 DOI: 10.1016/j.urology.2021.01.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/18/2021] [Accepted: 01/25/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To use a randomized, prospective, multi-institutional study to compare the safety and efficacy of conventional insufflation (CIS) and valveless insufflation (AirSeal Insufflation - AIS) at the conventional pressure of 15 mm Hg in robot-assisted partial nephrectomy - a surgery where AIS has gained popularity for maintaining visualization despite suction. This study was also powered to evaluate the effect of decreasing pneumoperitoneum by 20% in the valveless system. MATERIALS AND METHODS Three high-volume institutions randomized subjects into CIS 15, AIS 15, and AIS 12 mm Hg cohorts. Endpoints included rates of subcutaneous emphysema (SCE), pneumothorax (PTX), pneumomediastinum (PMS), intraoperative end-tidal carbon dioxide (ET CO2), and peak airway pressure (PAP), as well as hospital stay, post-operative pain, and complications. Given the substantial proportion of retroperitoneal surgery, a secondary analysis evaluated the effect of surgical approach. RESULTS Two hundred and two patients were accrued. SCE was decreased in the AIS 12 mm Hg group (p=0.003). PTX and PMS rates were not statistically significantly different across the 3 insufflation groups. Higher rates of SCE and PMS, although not PTX, were noted in all retroperitoneal surgery groups - with lower SCE rates for AIS 12 mm Hg regardless of surgical approach. CONCLUSION AIS is often preferred for complex procedures including retroperitoneal and transperitoneal robotic-assisted partial nephrectomy, for its maintenance of pneumoperitoneum despite continuous suction necessary for visualization. This study shows that AIS is safe when compared to CIS at 15 mm Hg, and shows improvement in outcomes when pneumoperitoneum pressure is reduced by 20% to 12 mmHg.
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Tuğcu V, Akça O, Şimşek A, Yiğitbaşı İ, Şahin S, Yenice MG, Taşçı Aİ. Robotic-assisted perineal versus transperitoneal radical prostatectomy: A matched-pair analysis. Turk J Urol 2019; 45:265-272. [PMID: 30978167 DOI: 10.5152/tud.2019.98254] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 03/04/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We compared the outcomes of robotic-assisted radical perineal prostatectomy (r-PRP) versus robotic-assisted transperitoneal laparoscopic radical prostatectomy (RARP). MATERIAL AND METHODS Between November 2016 and September 2017 in our center, 40 patients underwent r-PRP, and 40 patients underwent RARP. All patients also underwent multiparametric magnetic resonance imaging (mpMRI) to exclude the cases with locally advanced disease. Patients with localized prostate cancer (C-T2N0M0) were included in the study. The exclusion criteria were contraindications for undergoing robotic radical prostatectomy; the Gleason score ≥4+3; extracapsular extension proven on biopsy or suspected on mpMRI; clinical stage ≥T2c; required pelvic lymph dissection according to Partin's normogram; previous radiation therapy; hormonal therapy; any previous prostatic, urethral, or bladder neck surgery; and preoperative urinary incontinence or erectile dysfunction. Patients were placed in the exaggerated lithotomy position with 15° Trendelenburg for r-PRP and 40° Trendelenburg for RARP. RESULTS The mean age for the r-PRP and RARP groups were 61.2 (46-73) and 62.2 (50-75) years, respectively. The mean body mass index was significantly higher in the r-PRP group (p=0.02). The mean procedure duration time was 169.4 (100-255) minutes for the r-PRP group and 173.1 (130-210) minutes for the RARP group. The mean console time and anastomosis time were significantly lower for the r-PRP group. The mean estimated blood loss was significantly lower for the r-PRP group (p=0.002). Immediate continence rates in the r-PRP and RARP groups following the urethral catheter removal were 42% and 35% (p=0.30), respectively. Continence rates increased to 94.2% in the r-PRP and 72% in RARP (p=0.001) group at the 6th month, and to 95% in the r-PRP and 85.2% in RARP (p=0.02) group at the 9th month follow-up period. According to the International Index of Erectile Function-5 (IIEF-5), the erectile function rates at the 3-, 6-, and 9-month follow-up in the r-PRP group were 44%, 66%, and 75%, respectively. The rates in the RARP group at the 3-, 6-, and 9-month follow-up were 25%, 42%, and 66% (p=0.001), respectively. CONCLUSION In our experience, r-PRP has acceptable morbidity, excellent surgical and pathological outcomes, and satisfactory oncologic and functional results compared to RARP.
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Affiliation(s)
- Volkan Tuğcu
- Department of Urology, Health Sciences University, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Oktay Akça
- Deparment of Urology, Health Sciences University, Dr. Lütfi Kırdar Training and Research Hospital, İstanbul, Turkey
| | - Abdulmuttalip Şimşek
- Department of Urology, Health Sciences University, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - İsmail Yiğitbaşı
- Department of Urology, Health Sciences University, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Selçuk Şahin
- Department of Urology, Health Sciences University, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Mustafa Gürkan Yenice
- Department of Urology, Health Sciences University, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Ali İhsan Taşçı
- Department of Urology, Health Sciences University, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
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Ferroni MC, Abaza R. Feasibility of robot-assisted prostatectomy performed at ultra-low pneumoperitoneum pressure of 6 mmHg and comparison of clinical outcomes vs standard pressure of 15 mmHg. BJU Int 2019; 124:308-313. [DOI: 10.1111/bju.14682] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
| | - Ronney Abaza
- OhioHealth Robotic Urologic Surgery; Dublin OH USA
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Reduction in postoperative ileus rates utilizing lower pressure pneumoperitoneum in robotic-assisted radical prostatectomy. J Robot Surg 2019; 13:671-674. [PMID: 30604275 DOI: 10.1007/s11701-018-00915-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 12/13/2018] [Indexed: 12/12/2022]
Abstract
Robotic-assisted radical prostatectomy (RARP) is the most commonly performed surgery for prostate cancer. This is a study comparing differences in postoperative outcomes between pneumoperitoneum pressures of 15 mmHg and 12 mmHg. Retrospective chart review was performed on 400 patients undergoing RARP over a 5 year period. A combination of Fisher's exact test and ANOVA were utilized for statistical analysis. Age, BMI, Gleason score, positive margin rate, complication rates, blood loss, and operative times were similar in both groups. Length of stay and postoperative ileus rates were significantly less in the 12 mmHg group (p < 0.05). RARP can be safely performed utilizing a lower pressure pneumoperitoneum. Decreasing insufflation pressures from 15 to 12 mmHg can further lead to decreased rates of postoperative ileus.
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