Considerações anestésicas para cistectomia robótica: estudo prospectivo

Hemodynamic outcome of different ventilation modes in laparoscopic surgery with exaggerated trendelenburg: a randomised controlled trial

Purpose

To compare hemodynamic effects of two different modes of ventilation (volume-controlled and pressure-controlled volume guaranteed) in patients undergoing laparoscopic gynecology surgeries with exaggerated Trendelenburg position.

Methods

Thirty patients undergoing laparoscopic gynecology operations were ventilated using either volume-controlled (Group VC) or pressure-controlled volume guaranteed mode (Group PCVG) (n = 15 for both groups). Hemodynamic variables were measured using Pressure Recording Analytical Method by radial artery cannulation in addition to peak and mean airway pressures and expired tidal volume.

Results

The only remarkable finding was a more stable cardiac index in Group PCVG, where other hemodynamic parameters were similar. Expired tidal volume increased in Group VC while peak airway pressure was lower in Group PCVG.

Conclusion

PCV-VG causes less hemodynamic perturbations as measured by Pressure Recording Analytical Method (PRAM) and allows better intraoperative hemodynamic control in exaggerated Trendelenburg position in laparoscopic surgery.

Recovery from Anesthesia after Robotic-Assisted Radical Cystectomy: Two Different Reversals of Neuromuscular Blockade

During robot-assisted radical cystectomy (RARC), specific surgical conditions (a steep Trendelenburg position, prolonged pneumoperitoneum, effective myoresolution until the final stages of surgery) can seriously impair the outcomes. The aim of the study was to evaluate the incidence of postoperative nausea and vomiting (PONV) and ileus and the quality of cognitive function at the awakening in two groups of patients undergoing different reversals. In this randomized trial, patients that were American Society of Anesthesiologists physical status (ASA) ≤III candidates for RARC for bladder cancer were randomized into two groups: In the sugammadex (S) group, patients received 2 mg/kg of sugammadex as reversal of neuromuscolar blockade; in the neostigmine (N) group, antagonization was obtained with neostigmine 0.04 mg/kg + atropine 0.02 mg/kg. PONV was evaluated at 30 min, 6 and 24 h after anesthesia. Postoperative cognitive functions and time to resumption of intestinal transit were also investigated. A total of 109 patients were analyzed (54 in the S group and 55 in the N group). The incidence of early PONV was lower in the S group but not statistically significant (S group 25.9% vs. N group 29%; p = 0.711). The Mini-Mental State test mean value was higher in the S group vs. the N group (1 h after surgery: 29.3 (29; 30) vs. 27.6 (27; 30), p = 0.007; 4 h after surgery: 29.5 (30; 30) vs. 28.4 (28; 30), p = 0.05). We did not observe a significant decrease of the PONV after sugammadex administration versus neostigmine use. The Mini-Mental State test mean value was greater in the S group.

Cardiac arrest caused by intramyometrial injection of vasopressin during a robotic-assisted laparoscopic myomectomy

Vasopressin is a locally-injected vasoconstrictor used to reduce bleeding during gynaecological surgery. However, even in these cases, vasopressin can induce adverse effects, including bradycardia, myocardial infarction and cardiac arrest. Elevated blood concentrations of vasopressin may induce the sympathoinhibitory reflex by increasing blood pressure and augment the sympathoinhibitory reflex by activating the area postrema. In addition, pneumoperitoneum formation needed for laparoscopy as well as physiological changes caused by steep Trendelenburg positions used during robotic surgeries may cause bradycardia. Shoulder braces used to prevent slipping from a steep Trendelenburg position may also be hazardous. This case report describes a 31-year-old female patient who underwent a scheduled robotic-assisted laparoscopic myomectomy in a steep Trendelenburg position. The patient experienced a cardiac arrest 2 min after the vasopressin injection and was treated accordingly. There were no abnormal findings on the postoperative laboratory studies, chest X-ray and electrocardiogram. The patient also had clear consciousness with no other notable symptoms. The patient was discharged on postoperative day 2. The report discusses the potential adverse effects of local vasopressin injection during robotic-assisted laparoscopic myomectomy.

Anaesthetic issues in robotic-assisted minimally invasive surgery

Over the past decade there has been an exponential increase in the number of robotic-assisted surgical procedures performed in Australia and internationally. Despite this growth, there are no level I or II studies examining the anaesthetic implications of these procedures. Available observational studies provide insight into the significant challenges for the anaesthetist. Most anaesthetic considerations overlap with those of non-robotic surgery. However, issues with limited patient access and extremes of positioning resulting in physiological disturbances and risk of injury are consistently demonstrated concerns specific to robotic-assisted procedures.

Computed Tomography Morphometrics and Pulmonary Intolerance in Endometrial Cancer Robotic Surgery

STUDY OBJECTIVES

To identify morphometric characteristics of obese patients that best predict pulmonary intolerance to robotic pelvic surgery using a novel method for quantifying adipose distribution.

DESIGN

Retrospective study (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

Fifty-nine patients with endometrial cancer who underwent robotic hysterectomy and lymphadenectomy between April 2008 and May 2014 and also underwent perioperative computed tomography (CT) imaging within 1 year.

INTERVENTION

Visceral fat volume (VFV) and subcutaneous fat volume (SFV) were quantified through waist circumference measurements along with average volume estimation of slices taken at 3 levels: mid-waist, L2-L3, and L4-L5. Mean and maximum values were obtained for intraoperative physiological data.

MEASUREMENTS AND MAIN RESULTS

The patients' mean body mass index (BMI) was 34 (range, 20-59). Along with waist circumference, VFV and SFV quantified by CT at the mid-waist, L2-L3, and L4-L5 levels were all significant independent predictors for peak airway pressure (PAP; average and maximum) and plateau airway pressure (Pplat; average and maximum) on multivariate regression analysis after adjustment for age, ethnicity, diabetes, hypertension, pulmonary disease, smoking, obstructive sleep apnea, American Society of Anesthesiologists classification, and duration of anesthesia. Compared with the other CT parameters, L2-L3 VFV was the best predictor of average PAP (β = 0.398; p = .002), maximum PAP (β = 0.493; p < .001), average Pplat (β = 0.536; p < .001), and maximum Pplat (β = 0.573; p < .001).

CONCLUSION

These novel CT morphometric measurements represent valid predictors of pulmonary intolerance to robotic surgery in obese patients. Of the measures analyzed, VFV at L2-L3 best predicts pulmonary tolerance in obese patients.

Enhanced Recovery After Robot-assisted Radical Cystectomy: EAU Robotic Urology Section Scientific Working Group Consensus View

CONTEXT

Radical cystectomy (RC) is associated with frequent morbidity and prolonged length of stay (LOS) irrespective of surgical approach. Increasing evidence from colorectal surgery indicates that minimally invasive surgery and enhanced recovery programmes (ERPs) can reduce surgical morbidity and LOS. ERPs are now recognised as an important component of surgical management for RC. However, there is comparatively little evidence for ERPs after robot-assisted radical cystectomy (RARC). Due to the multimodal nature of ERPs, they are not easily validated through randomised controlled trials.

OBJECTIVE

To provide a European Association of Urology (EAU) Robotic Urology Section (ERUS) policy on ERPs to guide standardised perioperative management of RARC patients.

EVIDENCE ACQUISITION

The guidance was formulated in four phases: (1) systematic literature review of evidence for ERPs in robotic, laparoscopic, and open RC; (2) an online questionnaire survey formulated and sent to ERUS Scientific Working Group members; (3) achievement of consensus from an expert panel using the Delphi process; and (4) a standardised reporting template to audit compliance and outcome designed and approved by the committee.

EVIDENCE SYNTHESIS

Consensus was reached in multiple areas of an ERP for RARC. The key principles include patient education, optimisation of nutrition, RARC approach, standardised anaesthetic, analgesic, and antiemetic regimens, and early mobilisation.

CONCLUSIONS

This consensus represents the views of an expert panel established to advise ERUS on ERPs for RARC. The ERUS Scientific Working Group recognises the role of ERPs and endorses them as standardised perioperative care for patients undergoing RARC. ERPs in robotic surgery will continue to evolve with technological and pharmaceutical advances and increasing understanding of the role of surgery-specific ERPs.

PATIENT SUMMARY

There is currently a lack of high-level evidence exploring the benefits of enhanced recovery programmes (ERPs) in patients undergoing robot-assisted radical cystectomy (RARC). We reported a consensus view on a standardised ERP specific to patients undergoing RARC. It was formulated by experts from high-volume RARC hospitals in Europe, combining current evidence for ERPs with experts' knowledge of perioperative care for robotic surgery.

Enhanced recovery protocols (ERP) in robotic cystectomy surgery. Review of current status and trends

Open radical cystectomy with pelvic lymphadenectomy and urinary diversion is associated with a high complication rate. Robotic-assisted laparoscopic radical cystectomy is increasingly performed in many urologic surgical departments in an effort to reduce surgical stress and decrease perioperative morbidity. Robotic cystectomy survival studies demonstrate similar oncologic outcomes compared to the open procedure. Enhanced recovery protocols (ERP) after major surgery are multimodal perioperative interventions to reduce surgical stress, complications, and patient convalescence. Evidence for different ERP interventions are currently mainly from colorectal surgery and recently adapted to major urologic operations including cystectomy. Guidelines for perioperative care after open radical cystectomy for bladder cancer were recently published, but these recommendations may differ when considering a robotic approach. Therefore, we look at the current evidence for ERP in both open and robotic radical cystectomy and the potential for improving ERPs in robotic cystectomy by utilizing a totally intracorporeal robotic cystectomy approach. We also present the Karolinska ERP currently utilized in totally intracorporeal robotic cystectomy.