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Background: Robot-assisted laparoscopic prostatectomy (RALP) frequently entails postoperative pulmonary complications (PPCs) due to the Trendelenburg position and pneumoperitoneum. Diaphragm thickening fraction (TF) as an imaging marker can offer the advantage of predicting respiratory outcomes. Therefore, we evaluated the effect of diaphragm TF on the occurrence of PPCs in RALP., Methods: We measured the preoperative thickness of the diaphragm at peak inspiration ( T pi ) and end expiration ( T ee ) using ultrasonography. Diaphragm TF was calculated as TF = ( T pi - T ee )/ T ee . A receiver operating characteristic (ROC) curve analysis of TF was performed. After dividing patients into two groups according to the optimal TF cut-off value, we compared the occurrence of PPCs between the groups. The predictivity of diaphragm TF for the occurrence of PPCs was evaluated., Results: Of 145 patients, 40 patients (27.6%) developed PPCs. Patients with PPCs had a significantly lower TF than those without PPCs (0.31 ± 0.09 vs. 0.39 ± 0.11, P < 0.001). In the ROC curve analysis, the optimal TF cut-off value was 0.28. The patients were divided into TF ≥ 0.28 group ( n = 114) and TF < 0.28 group ( n = 31). The incidence of PPCs was significantly higher in the TF < 0.28 group than in the TF ≥ 0.28 group (51.6% vs. 21.1%, P = 0.001). Diaphragm TF < 0.28 was associated with a higher incidence of PPCs than diaphragm TF ≥ 0.28 (odds ratio = 4.534, 95% confidence interval [1.763-11.658], P = 0.002)., Conclusion: Preoperative diaphragm TF < 0.28 was associated with an increased incidence of PPCs, suggesting that diaphragm TF as a prognostic imaging marker provides useful information on PPCs in RALP requiring the Trendelenburg position and pneumoperitoneum. Trial Registry Number . This trial is registered with KCT0005028., Competing Interests: All authors declared no competing interests., (Copyright © 2021 Jihion Yu et al.)

Background: The present study investigated the association between Postoperative Cognitive Dysfunction (POCD) and increased serum S100B level after Robotic-Assisted Laparoscopic Radical Prostatectomy (RALRP)., Methods: The study included 82 consecutive patients who underwent RALRP. Serum S100B levels were determined preoperatively, after anesthesia induction, and at 30 minutes and 24 hours postoperatively. Cognitive function was assessed using neuropsychological testing preoperatively and at 7 days and 3 months postoperatively., Results: Twenty-four patients (29%) exhibited POCD 7 days after surgery, and 9 (11%) at 3 months after surgery. Serum S100B levels were significantly increased at postoperative 30minutes and 24 hours in patients displaying POCD at postoperative 7 days (p = 0.0001 for both) and 3 months (p = 0.001 for both) compared to patients without POCD. Duration of anesthesia was also significantly longer in patients with POCD at 7 days and 3 months after surgery compared with patients without POCD (p = 0.012, p = 0.001, respectively), as was duration of Trendelenburg (p = 0.025, p = 0.002, respectively). Composite Z score in tests performed on day 7 were significantly correlated with duration of Trendelenburg and duration of anesthesia (p = 0.0001 for both)., Conclusions: S100B increases after RALRP and this increase is associated with POCD development. Duration of Trendelenburg position and anesthesia contribute to the development of POCD., Trial Registry Number: Clinicaltrials.gov (N° NCT03018522)., (Copyright © 2020 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.)

The effects of a recruitment manoeuvre (RM) with positive end-expiratory pressure (PEEP) on lung compliance (C LUNG ) are not well characterised in robot-assisted laparoscopic radical prostatectomy (RARP). Patients were allocated to group R (n = 10; with an RM) or C (n = 9; without an RM). An RM involved sustained inflation of 30 cmH 2 O for 30 s. The lungs were ventilated with volume-controlled ventilation with tidal volume of 7 mL kg -1 of predicted body weight and fraction of inspired oxygen of 0.5. End-tidal carbon dioxide pressure was maintained at normocapnia. Patients were in the horizontal lithotomy position (pre-op). After pneumoperitoneum, patients underwent RARP in a steep Trendelenburg lithotomy position at a PEEP level of 0 cmH 2 O (RARP0). An RM was used in the R group but not in the C group. Patients were then ventilated with 5 cmH 2 O PEEP for 1 h after RARP0 (RARP5.1) and 2 h after RARP0 (RARP5.2). Oesophageal pressure and airway pressure were measured for calculating C LUNG and chest wall compliance. C LUNG significantly decreased from pre-op to RARP0 and did not significantly increase from RARP0 to RARP5.1 and RARP5.2 in either group. C LUNG differed significantly between groups at RARP5.1 and RARP5.2 (103 ± 30 vs. 68 ± 11 mL cm -1 H 2 O and 106 ± 35 vs. 72 ± 9 mL cm -1 H 2 O; P < 0.05). In patients undergoing RARP, with the addition of RM, the C LUNG was effectively increased from the horizontal lithotomy position to the steep Trendelenburg lithotomy position under pneumoperitoneum.

Background: We evaluated the relationship between ultrasonographical acquired parameters and short-term postoperative cognitive function in patients undergoing robotic-assisted radical prostatectomy (RALP)., Methods: Ninety elderly patients scheduled for RALP had their optic nerve sheath diameter (ONSD), the cross-sectional area (CSA) of the internal jugular vein (IJV) and the IJV valve (IJVV) competency assessed by ultrasound. The patients were analyzed in 2 groups based on whether displayed IJVV incompetency (IJVVI). The 3 parameters were measured before anesthesia (T0), immediately after induction of general anesthesia (T1), 5 minutes after establishing pneumoperitoneum (T2), 5 minutes after placing the patient in the Trendelenburg position (T3), and 5 minutes after the release of the pneumoperitoneum in the supine position (T4). Regional cerebral tissue oxygen saturation (rSO2) was also measured by near-infrared spectroscopy intraoperatively. The Mini-Mental State Examination (MMSE) and Confusion Assessment Method (CAM) were performed the day before surgery and on postoperative days 1, 3, and 7., Results: We found that 52% of patients had evidence of IJVVI after being placed in the Trendelenburg position after pneumoperitoneum was established (T4). Patient with IJVVI showed a significant increase of ONSD and CSA at T1, T2, T3, T4 but there was no associated decrease in rSO2. MMSE scores were reduced at postoperative day 1 and the 7 patients that developed postoperative delirium came from Group IJVVI., Conclusions: Our observations suggest that elderly patients that show IJVVI after adequate positioning for RALP may develop elevated intracranial pressure as well as mildly compromised postoperative cognitive function in the short term.

Study Objective: To study the effects of intraoperative dexmedetomidine on the intraocular pressure (IOP) in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALRP) under propofol-remifentanil anesthesia., Design: Double-blind, randomized controlled trial., Setting: Operating room., Patients: Forty consenting male patients aged ≥20 to <80 years with American Society of Anesthesiologists physical status classes I and II., Interventions: The patients were randomly assigned to either dexmedetomidine (DEX) (n = 20) or control (n = 20) group. Anesthesia was induced and maintained using propofol, remifentanil, and rocuronium. In the dexmedetomidine group, dexmedetomidine was administered at 0.4 μg/kg/h immediately after anesthesia induction until the end of the surgery, whereas normal saline was administered as placebo in the control group., Measurements: IOP was measured using a rebound tonometer. Time points of measuring IOP were as follows: T1: before anesthesia induction, T2: 5 min after intubation, T3: 60 min after placing patient in the Trendelenburg position, T4: 120 min after placing patient in the Trendelenburg position, T5: 180 min after placing patient in the Trendelenburg position, T6: 5 min after placing patient in a horizontal position, T7: 5 min after extubation, and T8: 30 min after extubation., Main Results: A linear mixed model analysis demonstrated a significant intergroup difference in IOP over time and during pneumoperitoneum in the steep Trendelenburg position. IOP at T5 was significantly lower in the dexmedetomidine group than in the control group even after post-hoc analysis in the steep Trendelenburg position periods with Bonferroni correction., Conclusions: Dexmedetomidine combined with propofol decreases IOP in the steep Trendelenburg position during RALRP., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Robot-assisted radical prostatectomy (RARP) is commonly performed using the transperitoneal (TP) approach with six trocars over an 8-cm distance in the steep Trendelenburg position. In this study, we investigated the feasibility and the benefit of using the extraperitoneal (EP) approach with six trocars over a 4-cm distance in a flat or 5° Trendelenburg position. We also introduced four new steps to the surgical procedure and compared the surgical results and complications between the EP and TP approach using propensity score matching., Methods: Between August 2012 and August 2016, 200 consecutive patients without any physical restrictions underwent RARP with the EP approach in a less than 5° Trendelenburg position, and 428 consecutive patients underwent RARP with the TP approach in a steep Trendelenburg position. Four new steps to RARP using the EP approach were developed: 1) arranging six trocars; 2) creating the EP space using laparoscopic forceps; 3) holding the separated prostate in the EP space outside the robotic view; and 4) preventing a postoperative inguinal hernia. Clinicopathological results and complications were compared between the EP and TP approaches using propensity score matching. Propensity scores were calculated for each patient using multivariate logistic regression based on the preoperative covariates., Results: All 200 patients safely underwent RARP using the EP approach. The mean volume of estimated blood loss and duration of indwelling urethral catheter use were significantly lower with the EP approach than the TP approach (139.9 vs 184.9 mL, p = 0.03 and 5.6 vs 7.7 days, p < 0.01, respectively). No significant differences in the positive surgical margin were observed. None of the patients developed an inguinal hernia postoperatively after we introduced this technique., Conclusions: The EP approach to RARP was safely performed regardless of patient physique or contraindications to a steep Trendelenburg position. Our method, which involved using the EP approach to perform RARP, can decrease the amount of perioperative blood loss, the duration of indwelling urethral catheter use, and the incidence of postoperative inguinal hernia development.

Background/aim: The aim of this study was to quantify the changes in middle ear pressure (MEP) during robot-assisted radical prostatectomy (RARP)., Materials and Methods: Thirty patients undergoing RARP were included in this study. MEP was obtained at the following time points: awake (T1), postintubation (T2), pneumoperitoneum + 1 h of Trendelenburg position (T3), pneumoperitoneum + 2 h of Trendelenburg position (T4), pneumoperitoneum + 3 h of Trendelenburg position (T5), desufflation + supine position (T6), and 1 h after extubation in the postanesthesia care unit (T7). Heart rate, mean arterial pressure (MAP), peak airway pressure (PAP), tidal volume, minute ventilation, EtCO 2 , and blood gas values were recorded., Results: MEP was significantly higher at T4, T5, T6, and T7 as compared to T1 values. PAP values were significantly increased at T3, T4, and T5 compared to T2. MAP values at T3, T4, and T5 were significantly higher compared to T1. PaCO 2 increased significantly at T4, T5, and T6 and pH decreased significantly at T4 and T5 when compared to T2., Conclusion: The combination of steep Trendelenburg position and pneumoperitoneum during RARP caused a significant increase in MEP, PaCO 2 , and EtCO 2 levels. This propensity for increased MEP may cause problems in patients with preexisting ear disease.

Study Objective: Limited data are available regarding the anesthetic management and outcome of patients undergoing pure laparoscopic radical prostatectomy (LRP) and robotic-assisted LRP (RALP). Therefore, our primary objective was to compare the anesthetic management between these 2 groups. Our secondary objective was to determine the incidence of adverse outcomes associated with RALP, which requires an extreme Trendelenburg position., Design: A retrospective observational study., Setting: University teaching hospital., Patients: A total of 223 men, consisting of 97 LRP patients and 126 RALP patients, treated during a 3-year period (January 2010-December 2012) were retrospectively studied., Interventions: None., Measurements: Information on patient demographics, type of anesthesia, anesthetic/pneumoperitoneum/surgical times, intraoperative fluids and blood products, estimated blood loss, intraoperative and postoperative opioid use, postoperative analgesic consumption, length of stay in the postanesthesia care unit, postoperative complications, and hospital stays was collected and compared., Main Results: The estimated blood loss was higher in LRP patients than in RALP patients (median, 550 mL vs 200 mL; P < .001). Likewise, 24% of the LRP patients received intraoperative transfusions compared with 0.79% of the RALP patients (P < .001). The RALP patients had a longer anesthesia time (median, 276 vs 259 minutes; P = .032) and a greater intraoperative use of opioids (P < .001). The incidence of complications was similar in both groups with the exception of postoperative nausea and vomiting, which were observed more frequently among the RALP patients than among the LRP patients (33% vs 16%; P = .007)., Conclusions: This is the first report to compare the anesthetic management of RALP vs LRP. Anesthesiologists can expect RALP surgery to be associated with less blood loss and a need for fewer blood products than traditional LRP surgery. The anesthetic outcome of RALP was generally satisfactory except for a high incidence of postoperative nausea and vomiting., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: To evaluate postoperative pain and neuromuscular complications associated with positioning after robotic assisted laparoscopic radical prostatectomy (RALP)., Methods: Between September 2010 and June 2014, 534 patients who underwent RALP were evaluated. Patients were positioned in operating theater by operating room staff, and two independent urologists noted postoperative follow-up. Patient's demographic data, postoperative complications associated with positioning, pain score according to visual analogue scale, and hospital stay were recorded. Statistical analyses were performed and p < 0.05 was considered significant., Results: Postoperative pain and neuromuscular complications were observed in 54 (10.1 %) and 27 (5 %) patients, respectively. We found ASA, BMI, and comorbidities were significantly associated with postoperative pain levels in univariate analyses (p = 0.01, p = 0.013, and p = 0.01, respectively). Additionally, ASA, previous operations, and comorbidities were significantly associated with postoperative neuromuscular complications (p = 0.04, p = 0.01, and p = 0.02, respectively). According to statistical analyses, BMI < 30 and presence of an implant were significantly associated with postoperative pain in multivariate logistic regression analyses (p = 0.010 and p = 0.033, respectively). Additionally, having comorbidities was significantly associated with postoperative neuromuscular complications in multivariate analyses (p = 0.04)., Conclusions: Patients with previous operations, comorbidities, and high ASA score are at risk of neuromuscular complications during RALP. Lower BMI and having an implant also lead to higher postoperative pain. Operating room staff and anaesthesia team should be very careful with patients undergoing RALP in steep Trendelenburg and low-lithotomy position.

Bloody otorrhagia in the perioperative period is an uncommon event. We present a case of bilateral bloody otorrhagia after uncomplicated robotic-assisted laparoscopic prostatectomy in a 66-year-old man. Anesthetic management was unremarkable. No symptoms were noted by the patient. Postoperative otolaryngology evaluation revealed bilateral ear canal hematomas with intact tympanic membranes. The patient was discharged with Ciprodex ear drops on postoperative day 1. One-month otolaryngology follow-up revealed no long-term sequelae. Although the etiology is unclear, there seems to be a trend in the literature toward occurrence with laparoscopy in the Trendelenburg position.

Study Objective: Robotic-assisted laparoscopic prostatectomy requires patients to be secured in a steep Trendelenburg position for several hours. Added to the CO2 pneumoperitoneum that is created, this positioning invariably restricts diaphragmatic and chest wall excursion, which can adversely affect respiratory gas exchange. This study sought to measure the extent of respiratory gas change during this procedure., Design: Retrospective, institutional review board approved., Setting: Operating room., Patients: N = 186 males, American Society of Anesthesiologists 2-3, with prostatic carcinoma undergoing robotic-assisted laparoscopic radical prostatectomy., Interventions: Arterial blood gases and noninvasive respiratory measurements were recorded for those patients (n = 32) in whom a radial arterial catheter had been inserted intraoperatively, specifically timed to different phases of the procedure: supine lithotomy, steep Trendelenburg, and return to supine. Ventilatory parameters were standardized., Measurements: Systemic blood pressure, heart rate, respiratory rate, Pao2, Paco2, oxygen saturation as measured by pulse oximetry, and end-tidal carbon dioxide pressure., Main Results: Although no patients developed perioperative respiratory complications, the Pao2 invariably fell (395 vs 316 mm Hg; P = .001) while the patients were in steep Trendelenburg, and the Paco2-end-tidal carbon dioxide pressure rose (10.0 vs 13.4 mm Hg; P < .0001). Upon return to supine, patients' respiratory measurements promptly returned to within 15% of baseline. Subgroup analysis for high-BMI vs low-BMI patients as well as for patients with pulmonary disease and/or a smoking history showed similar individual effects and only small, although significant, respiratory gas exchange aberrations., Conclusions: Positioning patients with a CO2 pneumoperitoneum in steep Trendelenburg for several hours imposes restriction of diaphragmatic and chest wall movement sufficient for respiratory gas exchange to be adversely affected. Return of function to within 15% of baseline occurred within minutes after return to supine and release of the CO2 pneumoperitoneum. No patients during the study period developed pulmonary complications that required alteration in their level of care., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: To assess whether retinal and central nervous system (CNS) comorbidities are risk factors for complications following robotic assisted laparoscopic prostatectomy (RALP)., Materials and Methods: A retrospective review of our RALP database identified 1868 patients who underwent RALP by a single surgeon between December 10, 2003-March 14, 2014. We hypothesized that patients with preexisting retinal or CNS comorbidities were at a greater risk of suffering retinal and CNS complications following RALP. Perioperative complications and risk of recurrence were graded using the Clavien and D'Amico systems, respectively., Results: 40 (2.1%) patients had retinal or CNS-related comorbidities, of which 15 had a history of retinal surgery and 24 had a history of cerebrovascular accident, aneurysm and/or neurosurgery. One additional patient had a history of both retinal and CNS events. Patients with retinal or CNS comorbidities were significantly older, had elevated PSA levels and CCI (Charlson Comorbidity Index) scores than the control group. Blood loss, length of stay, surgical duration, BMI, diagnostic Gleason score and T-stage were not statistically different between groups. No retinal or CNS complications occurred in either group. The distribution of patients between D'Amico risk categories was not statistically different between the groups. There was also no difference in the incidence of total complications between the groups., Conclusions: RALP-associated retinal and CNS complications are rare. While our RALP database is large, the cohort of patients with retinal or CNS-related comorbidities was relatively small. Our dataset suggests retinal and CNS pathology presents no greater risk of suffering from perioperative complications following RALP.

Background: The use of the steep Trendelenburg position and abdominal CO2-insufflation during surgery can lead to significant reduction in pulmonary compliance and upper airway oedema. The postoperative time course of these effects and their influence on postoperative lung function is unknown. Therefore, we assessed intra- and extrathoracic airway resistance and nasal air flow in patients with or without chronic obstructive pulmonary disease (COPD) during robotic-assisted prostatectomy., Methods: In 55 patients without and 20 patients with COPD spirometric measurements and nasal resistance were obtained before operation, 40 and 120 min, and 1 and 5 days after operation. We measured vital capacity (VC), forced expiratory volume in 1 s (FEV1), maximal mid-expiratory and inspiratory flow (MEF50, MIF50), arterial oxygen saturation, and nasal flow. The occurrence of postoperative conjunctival oedema (chemosis) was also assessed., Results: In patients without COPD, MEF50/MIF50 increased and nasal flow decreased significantly after surgery (P<0.0001) and normalized within 24 h. VC and FEV1 decreased after operation with a nadir at 24 h and recovered to normal until the fifth day (P<0.0001). In patients with COPD, changes in MEF50/MIF50 and nasal flow were similar, while changes in VC and FEV1 lasted beyond the fifth day (P<0.0001)., Conclusions: Robotic-assisted prostatectomy in the steep Trendelenburg position led to an increase in upper airway resistance directly after surgery that normalized within 24 h. The development of chemosis can be indicative of increased upper airway resistance. In patients without COPD, VC and FEV1 were reduced after surgery and recovered within 5 days, while in patients with COPD, the alteration lasted beyond 5 days., (© The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background and Purpose: Because of recent advances in minimally invasive surgical techniques, robot-assisted radical prostatectomy (RARP) has become the primary treatment option in prostate cancer. RARP, however, necessitates patients to be placed in a steep Trendelenberg position, which presents multiple opportunities for complications relating to the positioning of the patient. Our study aims to study the prevalence and demographic predictors of these positioning complications and assess their impacts on length of stay (LOS) and total cost., Patients and Methods: We included patients who underwent RP from 2008 to 2009 using data extracted from the Nationwide Inpatient Sample database. Positioning complications (eye, nerve, compartment syndrome/rhabdomyolysis) were identified using patient-level diagnosis and procedural International Classification of Disease, 9th edition, Clinical Modification codes. Logistic regression models assessed relationships between demographic factors and occurrence of complications and the effects of them on prolonged LOS and total inpatient cost., Results: Positioning complications occurred in 0.4% of cases with eye complications contributing the most to this frequency. Laparoscopic RP procedure (odds ratio [OR]=2.88, P<0.01) and comorbidities (OR=2.34, P<0.01) were highly associated with increased odds of positioning complication occurrence, whereas RARP procedures (OR=0.93, P>0.4) were not associated with positioning complications. Having positioning complications increased a patient's odds of having increased inpatient costs and extended LOS by almost 400% and 300%, respectively., Conclusion: The steep Trendelenberg position used in RARP was not shown to be associated with patient positioning-related complications in this sample. The occurrence of positioning-related complications, however, places huge burdens on total inpatient costs and LOS.

Trendelenburg positioning in combination with pneumoperitoneum during robotic-assisted prostatic surgery possibly impairs cerebrovascular autoregulation. If cerebrovascular autoregulation is disturbed, arterial hypertension might induce cerebral hyperaemia and brain oedema, while low arterial blood pressure can induce cerebral ischaemia. The time course of cerebrovascular autoregulation was investigated during use of the Trendelenburg position and a pneumoperitoneum for robotic-assisted prostatic surgery using transcranial Doppler ultrasound. Cerebral blood flow velocity was correlated with arterial blood pressure and the autoregulation index (Mx) was calculated. In 23 male patients, Mx was assessed at baseline, after induction of general anaesthesia, during the Trendelenburg position (40-45°), and after repositioning. During the Trendelenburg position, Mx increased over time, indicating an impairment of cerebrovascular autoregulation. After repositioning, Mx recovered to baseline levels. It can be concluded that with longer durations of Trendelenburg position and pneumoperitoneum, cerebrovascular autoregulation deteriorates, and, therefore, blood pressure management should be adapted to avoid cerebral oedema and the duration of Trendelenburg position should be as short as possible., (© 2013 The Association of Anaesthetists of Great Britain and Ireland.)

Background and Purpose: During robot-assisted radical prostatectomy (RARP), patients remain in a steep Trendelenburg position. This can cause positioning injuries as well as rhabdomyolysis. The primary diagnostic indicator of rhabdomyolysis is elevated serum creatine kinase (CK). We investigate whether RARP with extended pelvic lymph node dissection (ePLND) in a prolonged extreme Trendelenburg position can cause positioning injuries and rhabdomyolysis., Patients and Methods: We performed a prospective study of the first 60 patients undergoing RARP and ePLND for organ-confined prostate cancer at our institute. Positioning injuries were graded according to three degrees of clinical severity. Serum-CK, serum-pH, and base excess (BE) were measured before, during, and for 5 days after surgery. Rhabdomyolysis was defined by serum-CK levels >5000 IU/L., Results: Median operative time was 317 minutes (range 200-475 min); median time in the Trendelenburg position was 282 minutes (range 170-470 min). Serum-CK was significantly elevated 6 hours postoperatively, peaking at 18 hours postoperatively. Serum-CK levels did not correlate with pH, BE, and perioperative creatinine values. Serum-CK course shows weak correlation with body mass index (BMI), operative time, Trendelenburg position time, and medium correlation with positioning injuries of any degree. Twenty-one of the 60 (35%) patients showed positioning-related injuries: 16 (27%) patients degree I, 2 (3%) patients degree II, and 3 (5%) patients degree III. Rhabdomyolysis developed in 10 patients. Postoperative renal failure did not develop in any patient receiving postoperative hypervolemic diuretic therapy nor any patient with injuries degrees I, II, or III. conclusion: Clinically relevant positioning injuries and rhabdomyolysis can occur in patients who are subjected to prolonged extreme Trendelenburg position during RARP and ePLND, especially at the beginning of the learning curve. Serum-CK increases significantly after surgery, peaking 18 hours postoperatively. Serum-CK elevation alone is not predictive of positioning injury. By very long operative and Trendelenburg times as well as high BMI with visible position injuries, we recommend serum-CK measurement 6 and 18 hours postoperatively followed by hypervolemic therapy to prevent possible renal injury from rhabdomyolysis if serum-CK >5000 IU/L.

We describe 3 patients who developed injury of upper and middle brachial plexus trunks during robotic-assisted prostatectomy, and review factors potentially associated with this type of injury. Three patients underwent robotic-assisted prostatectomy. Surgical exposure was facilitated by steep head-down tilt position. To secure patients and prevent sliding on the operating table, shoulders were supported with moldable beanbags. In all 3 cases, the left arm was abducted to approximately 90°, and the right arm was adducted. Postoperatively, all patients were diagnosed with left arm upper and middle trunk brachial plexopathies. The combination of arm abduction, extreme head-down position, and shoulder immobilization with beanbags resulted in several mechanistic forces that may have contributed to the development of brachial plexopathy in our patients. Steep head-down tilt may result in cephalad slide of the torso in relation to an abducted arm. When shoulder restraints are used to secure the patient, the compensatory movement of the shoulder girdle of an abducted arm is impeded. This may result in injurious stretching and compression of the brachial plexus, especially the upper and middle trunks. When steep head-down position is needed to facilitate surgical exposure, clinicians should consider adduction and tucking of both arms, and use of other methods to prevent sliding on the operating room table that do not require the use of restraints across the shoulder girdle.

Introduction: The aim of our work was to present a review of technical features and complications of general anesthesia during robot-assisted laparoscopic radical prostatectomy (RALRP)., Materials and Methods: Data on RALRP and general anesthesia were explored on Medline using the following MeSH terms: radical prostatectomy; morbidity; anesthesia complications; laparoscopy; robotics; Trendeleburg. Publications were considered on the following criteria: methodology, relevance and date of publication., Results: There was no data of level of evidence 1 available. The first RALRP was reported in 2000. Technological innovation brought by the robot with its 3-D vision, the acquisition of degrees of mobility and a more ergonomic position for the surgeon, have led to a growing interest from new teams in the western world. However, the RALRP generates constraints for the anesthesia team who need to incorporate the rules of laparoscopy and the patient's specific installation to guarantee maximum safety. There are inherent complications with the installation of the patient himself in the Trendelenburg position (ocular, neurological, hemodynamic, respiratory) and respiratory complications related to the specific procedure in gaseous atmosphere due to pneumoperitoneum. One of the criteria of the quality of publications in the field of surgery is related to the objective evaluation of complications by appropriate scale systems and the complications of general anesthesia must also be absolutely recorded., Conclusion: RALRP had deeply modified the anatomical landmarks of the surgical removal of prostate cancer. However, the perioperative environment has also been completely altered and the installation of RALRP in the daily routine of a service requires from the anesthesia team to adapt their behavior to this sophisticated surgical access., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Background and Objective: Robot-assisted prostatectomy requires pneumoperitoneum in a steep Trendelenburg position, which may induce endobronchial intubation or accidental extubation. The aim of the study was to evaluate the effect of pneumoperitoneum in 30 degrees Trendelenburg position on the displacement of the tracheal tube and to measure the changes in trachea length using fiberoptic bronchoscope., Methods: Thirty male patients scheduled for robot-assisted radical prostatectomy were enrolled. After induction of general anaesthesia, the distance between the vocal cords and the tracheal tube tip (DeltaVE), between the tracheal tube tip and the carina (DeltaEC) and between the vocal cords and the carina (DeltaVC) was measured using a fiberoptic bronchoscope before and 10 min after pneumoperitoneum in neutral position (T1 and T2, respectively), and 2 h after pneumoperitoneum in 30 degrees Trendelenburg position (T3)., Results: The DeltaVC and DeltaEC decreased significantly 10 min after pneumoperitoneum in neutral position (T2) and 2 h after pneumoperitoneum in Trendelenburg position (T3) compared with those before pneumoperitoneum in neutral position (T1) (all P < 0.001). The changes in DeltaVE were not statistically significant., Conclusion: The confirmation of the tracheal tube position is recommended after pneumoperitoneum in steep Trendelenburg position during robot-assisted prostatectomy because the displacement of the tracheal tube may result in endobronchial intubation due to shortening of the carina-to-tube tip distance.

A 52-year-old patient, ASA physical status IV, undergoing a radical prostatectomy for cancer with a robotic system had a cardiac arrest 3 hours into the case. All attempts to resuscitate were unsuccessful, and several hours later he was pronounced dead. Underlying patient comorbidity and procedural issues contributed to the patient's death. The patient had a history of coronary artery disease that required the placement of drug-eluting stents 2 years before this surgical procedure. The preoperative cardiac evaluation and pharmacological management of patients with drug-eluting coronary stents are reviewed. There are a number of positional and technical considerations for patients undergoing robotic surgical procedures, especially in relation to the requirement of low-lithotomy and steep Trendelenburg positions. The cardiac and respiratory systems are especially vulnerable to the extreme and lengthy head-down position. The needed positioning, combined with the problems associated with insufflation, presents a unique challenge in anesthetic management. This course reviews the current literature on the surgical implications for patients with drug-eluting stents and the physiologic factors related to position and pneumoperitoneum and their associated stressors. By using a review of the contemporary literature, a best-evidence approach to anesthetic management is reviewed.