The anesthesia impact of regionalized insufflation with transvesical single port robot-assisted radical prostatectomy

To evaluate for any differences between the intraoperative oxygenation and ventilation outcomes between single port (SP) extraperitoneal (EP) and transvesical (TV) robot-assisted radical prostatectomy (RARP) with the standard multi-port (MP) transperitoneal (TP) approach.

A retrospective review was performed on the prospectively maintained, IRB-approved database to identify 962 consecutive patients who underwent MP TP, SP EP, and SP TV RARP between 2015 and 2024. A 1:1 propensity-matched analysis was completed based on the patient's age, Body Mass Index (BMI), as well as comorbidities based on the Charlson Comorbidity Index (CCI) and American Society of Anesthesiologists' (ASA) physical status classification score. Intraoperative anesthesia parameters collected included the lowest recorded oxygen saturation (SpO2), highest end-tidal carbon dioxide (ETCO2), highest respiratory rate (RR), the highest positive end-expiratory pressure (PEEP) setting, as well as the total intraoperative doses of propofol, rocuronium, and fentanyl.

Based on our propensity-matched analysis, 603 patients were included, which comprised 201 cases of MP TP, SP EP, and SP TV RARP, respectively. Our cohort had a median age of 63.5 years (IQR 58.5-68.1 years), a median BMI of 28.4 kg/m² (IQR 25.9-31.7 kg/m²), a median CCI of 4 (IQR 3-5), and a median ASA Score of 3 (IQR 2-3). All procedures were completed without any conversion, intraoperative complications, or need for blood transfusion. Notably, the SP TV RARP was associated with significant improvements in both SpO2 and ETCO2 (median lowest SpO2, MP TP 95% vs. SP EP 96% vs. SP TV 98%, P<0.001; median highest ETCO2, MP TP 45 vs. SP EP 42 vs. SP TV 40 mmHg, P<0.001). Compared to MP-RARP, the SP technique was associated with a significantly decreased use of intraoperative fentanyl (median, MP TP 200 vs. SP EP 175 vs. SP TV 150 mcg, P<0.001) yet without any statistically significant differences between the SP EP and SP TV approaches (P=0.223).

Herein, we demonstrated the benefits of pneumovesicum with the regionalized SP TV approach in improving intraoperative oxygenation, ventilation, as well as perioperative analgesia requirements, especially when compared to the standard TP MP-RARP. These resulting improvements hold promise for further enhancements in perioperative outcomes and patient safety, especially in patients with pre-existing cardiopulmonary comorbidities.