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Limited studies examined the effects of pneumoperitoneum during robot-assisted radical prostatectomy (RARP) and with AirSeal. The aim of this study was to assess the effect on hemodynamics of lower pressure pneumoperitoneum (8 mmHg) with AirSeal, during RARP in steep Trendelenburg 45 degrees, proving how the combination of steep Trendelenburg, lower pressure pneumoperitoneum and the extreme surgeon's experience allows to safely perform RARP using a low-impact surgery. Background: Limited studies examined effects of pneumoperiotneum during robot-assisted radical prostatectomy (RARP) and with AirSeal. The aim of this study was to assess the effect on hemodynamics of a lower pressure pneumoperitoneum (8 mmHg) with AirSeal, during RARP in steep Trendelenburg 45 degrees (ST). Materials and Methods: This is an institutional review board-approved, prospective, interventional, single-center study including patients treated with RARP at OLV Hospital by one extremely experienced surgeon (July 2015-February 2016). Intraoperative monitoring included: arterial pressure, central venous pressure, cardiac output, heart rate, stroke volume, systemic vascular resistance, intrathoracic pressure, airways pressures, left ventricular end-diastolic and end-systolic areas/volumes and ejection fraction, by transesophageal echocardiography, an esophageal catheter, and FloTrac/Vigileo system. Measurements were performed after induction of anesthesia with patient in horizontal (T0), 5 minutes after 8 mmHg pneumoperitoneum (TP), 5 minutes after ST (TT1) and every 30 minutes thereafter until the end of surgery (TH). Parameters modification at the prespecified times was assessed by Wilcoxon and Friedman tests, as appropriate. All analyses were performed by SPSS v. 23.0. Results: A total of 53 consecutive patients were enrolled. The mean patients age was 62.6 +/- 6.9 years. Comorbidity was relatively limited (51% with Charlson Comorbidity Index as low as 0). Despite the ST, working always at 8 mmHg with AirSeal, only central venous pressure and mean airways pressure showed a statistically significant variation during the operative time. Although other significant hemodynamic/respiratory changes were observed adding pneumoperitoneum and then ST, all variables remained always within limits safely manageable by anesthesiologists. Conclusion: The combination of ST, lower pressure pneumoperitoneum and extreme surgeon's experience enables to safely perform RARP. (C) 2017 Elsevier Inc. All rights reserved.