Robot-Assisted Radical Prostatectomy: The Impact of Patient Positioning and Surgical Access on Intraoperative...

Our goal was to evaluate the role of supine extraperitoneal single-port radical prostatectomy on intraoperative ventilatory and cardiovascular parameters and on surgical outcomes compared with a cohort of patients treated with the Trendelenburg-associated transperitoneal approach.

Data from all consecutive patients who underwent radical prostatectomy between September 2019 and January 2024 were prospectively collected and retrospectively analyzed. Patients were divided into 2 groups based on the surgical approach: single-port supine extraperitoneal (SP-EP-RARP) and multiport or single-port transperitoneal (MP-TP-RARP or SP-TP-RARP) radical prostatectomy. Intraoperative ventilatory and cardiovascular parameters were collected from anesthesia induction to the end of the procedure, and perioperative surgical outcomes were assessed.

A total of 211 patients who underwent robot-assisted radical prostatectomy were analyzed: 97 (46%) underwent MP-TP-RARP or SP-TP-RARP, whereas 114 (54%) underwent SP-EP-RARP. The median peak inspiratory pressure and end-tidal CO₂ were significantly lower throughout the surgery in the SP-EP-RARP group (P < .001 and P = .02, respectively). Similar results were found for median systolic and diastolic blood pressure. SP-EP-RARP was associated with lower postoperative pain, fewer narcotic administrations, shorter length of stay, and fewer postoperative complications. After adjusting for age, American Society of Anesthesiologists score, and Charlson Comorbidity Index, the transperitoneal approach was found to be an independent risk factor for complications.

The supine SP-EP approach improved intraoperative ventilatory and cardiovascular outcomes, reducing postoperative pain, length of stay, and complications. This finding is constrained by the retrospective design and the involvement of 4 surgeons with differing experience. Notably, the surgeon with the highest volume was also the sole user of the SP-EP approach, introducing biases.