Perspective Chapter: Perioperative Considerations for Patients Undergoing Robotic Radical Prostatectomy

Abstract

Robotic radical prostatectomy has become the dominant surgical approach for men with clinically localized prostate cancer, surpassing open and laparoscopic techniques. The robotic platform offers magnified, stereoscopic vision, and endo-wristed instruments to improve surgical dissection and suturing which enhances patient outcomes. The minimally invasive approach offers similar oncological and functional results to the open procedure, but has the advantage of reduced hospital length of stay, shorter catheter time and fewer complications. These important gains in patient care can be maximized with a complete understanding of the relevant perioperative considerations. The outcomes and patient experience for men undergoing robotic radical prostatectomy can be maximized with a careful and personalized approach that is integrated into their care before, during and after surgery.

1. Introduction

Prostate cancer is the second most prevalent male malignancy worldwide, with approximately 1.4 million new cases diagnosed annually [1]. Its prevalence increases with age and contributes a significant health burden globally. Robotic assisted prostatectomy has become the preferred option for the management of localized prostate cancer. Robotic surgery offers the advantages of minimally invasive surgery whilst providing better access and dexterity within the confined limits of the pelvis. Yaxley et al. found robotic assisted radical prostatectomy (RARP) to have shorter operative times, less blood loss and lower rates of intraoperative complications when compared to open prostatectomy in their landmark paper [2, 3]. The paper also found patients who underwent RARP had less post operative pain at early time points and shorter stays in hospital and that there long-term functional and oncological outcomes were similar [2, 3]. With further technological advancements and techniques combined with improved surgical experience, the robotic approach to prostatectomy will gain further advantages.

In this chapter, we delve into the pertinent peri-operative considerations for patients who are undergoing RARP. Focus will be directed towards pre-operative optimization, patient selection, intra-operative preparation, access and standards of post-operative management.

2. Pre-operative considerations

2.1 Patient selection

Radical prostatectomy is a treatment option for patient with localized prostate cancer, along with external beam radiation therapy, brachytherapy, and in some cases active surveillance. Preoperative counseling should include both the patient, and where relevant, their support person to address the practical and emotional issues surrounding radical prostatectomy. Presurgical psychosocial interventions may be useful in improving quality of life following surgery. In addition, patients should be counseled regarding modification of high-risk health behaviors such as smoking and weight loss.

The selection of patients includes an assessment of the patient’s physical health and function, a discussion about goals of care and potential adverse outcomes.

Patients are assessed for life expectancy as curative treatments including RARP, are generally offered to patients who have an estimated life expectancy of greater than 10–15 years.

Specifically, assessment includes; co-morbidities, nutrition, cognition and function. These parameters can be associated with overall survival, rates of return to baseline function and risks of post-operative adverse events such as delirium and extended hospitalization [4, 5]. Other considerations include extensive previous surgery, which may present a technical challenge due to adhesions.

For patients for whom there is concern regarding physical and cognitive function, a formal physician assessment may be beneficial. A range of screening scores are used in assessing overall health, including the Geriatric 8 (G8) screening tool and the Clinical Frailty Scale (CFS). In particular, the G8 score is useful in discriminating between fit and frail patients, with frail patients at higher risk of mortality and treatment related morbidity [6]. Current guidelines from the European Association of Urology (EAU) recommends the use of these scales prior to treatment of prostate cancer, as well as the use of comprehensive geriatric assessment for patients who are at high risk (e.g. patients with G8 score ≤ 14) [7].

Although the standard recommendations for curative treatment for prostate cancer is an estimated life expectancy of greater than 10 years, there is increasing evidence that older patients are under-treated and have potential benefit from robotic prostatectomy. Patients over 75, in several retrospective trials have shown similar functional and oncological outcomes compared to their younger counterparts, suggesting a select proportion of healthy, elderly prostate cancer patients can be offered treatment [8, 9]. In any case, decision to proceed with RARP should be shared. The patients’ values and preferences need to be considered in addition to objective function assessment.

2.2 Neo-adjuvant therapy

The use of neo-adjuvant androgen deprivation therapy (ADT) has been the focus of several randomized controlled trials. Although histopathological improvements have been demonstrated (including downstaging, reduced positive margins and lower incidence of positive lymph nodes), clinical oncological parameters of PSA-relapse free survival and cancer specific survival remained static [10]. These findings, supported by a systematic review and meta-analysis, affirm that the use of neo-adjuvant ADT is not routinely recommended prior to radical prostatectomy [11]. However, with the introduction of novel antiandrogens (daralutomide, enzalutamide), there are clinical trials currently underway, assessing the oncological benefits for men receiving these drugs in the neoadjuvant setting [12]. Furthermore, the impact that these drugs have on perioperative outcomes, such as complications and length of hospital stay, is another important consideration that these trials will shed light on.

2.3 Anesthetic considerations

Patients undergoing RARP should be pre-operatively screened with a thorough medical history and physical examination. Focus should be drawn to any cardiac and respiratory history, including the regular use of anticoagulation or antiplatelets, diabetes, obesity, reflux, and renal abnormalities (especially in the context of prostatic obstruction).

General cardiac risk should be assessed at the time of pre-operative screening to determine the need for further investigations and management to reduce the risk of cardiac complications. History of ischaemic heart disease, congestive heart failure, cerebral vascular disease, renal dysfunction, and pre-operative insulin treatment are all indicators of high cardiac risk [13].

An important consideration for anesthesia in RARP is the combination of high intra-abdominal pressures due to the pneumoperitoneum and the steep Trendelenburg positioning [14]. Patients at particularly high risk in this context include cardio-respiratory conditions (Table 1), morbid obesity, raised intracranial pressure (ICP) and glaucoma [15]. The specifics of intra-operative management of these will be discussed later in this chapter.

Absolute contraindications

Metastatic prostate cancer

Life expectancy <10 years

Active peritoneal inflammatory process

Relative contraindications

Morbid obesity

Extensive peritoneal, perineal, or pelvic surgery

Glaucoma

Table 1.

Absolute and relative contraindications for robotic radical prostatectomy.

At our institution, the pre-operative anesthetic assessment includes electrocardiogram, full blood count, electrolytes, and chest X-ray. Men with high-risk co-morbidities are referred to relevant specialists to ensure they are maximally optimized prior to the procedure. If perioperative risks are considered too great, then alternative forms of treatment for their cancer may be necessary (Table 2).

High risk co-morbidities in robotic prostatectomy

Severe or decompensated heart failure (both left and right sided)

Severe valvular disease (particularly aortic stenosis)

Significant arrhythmias

Ischaemic heart disease (including recent myocardial infarction, angina)

Severe respiratory disease (particularly COPD, poorly controlled asthma, pulmonary hypertension)

Table 2.

High risk co-morbidities in robotic prostatectomy. Patients with any of the above cardiac conditions (italicized) are recommended by AHA/ACC guidelines to have either delay or cancelation of non-emergent procedures [13].

2.4 Obesity and weight loss

As with other abdominal or pelvic procedures, obesity remains a technical challenge for the surgeon during RARP. Obesity in RARP can result in reduced overall working space, difficulties with trocar placement, reduced intra-peritoneal vision and anesthetics risks. Obesity is associated with higher complication rates as compared to normal weight controls [16].

Patients are encouraged and provided with strategies to reduce weight prior to surgery. In our institution, we often recommend low calorie diet plans for patients with a body max index over 30 kg/m². We utilize Optifast very low calorie diet program which is a commercially available meal replacement product plan with less than 800 calories per day. This can be associated weight loss of 1–2.5 kg per week [17]. Pharmacological therapy with Semaglutide, a glucagon-like peptide-1 (GLP-1), is a recently available option which has proven efficacious for weight loss in obese patients which can be considered when available [18].

Simultaneously, the operating team should be aware of the physical limitations and potential complications that accompany obese patients, and appropriate adjustments and preparations made. Although obesity can make RARP challenging, the access that the robotic camera and instruments allow into the deep pelvis, permits the surgical removal of the prostate where it would not have been possible with conventional open or laparoscopic techniques.

2.5 Patient education and preparation

Important patient outcomes following RARP is the return of continence and erectile function. Intra-operative techniques such as nerve-sparing, bladder slings [19] and specific re-anastomosis sutures [20] have allowed for improvements in functional recovery and will be discussed further separately. The use of pre-operative pelvic floor exercises can optimize the recovery of these functional deficits, particularly incontinence. One systematic review and meta-analysis has shown an improved rate of return of continence post-radical prostatectomy [21]. However, there is a lack of uniformity in the regimens used as well as the definitions of continence. Pelvic floor exercise regimes are commenced 1 month prior to surgery and patients are instructed to continue post-operatively. This is run by a specialist pelvic floor physiotherapist to educate on appropriate exercises. This is supplemented by biofeedback and pelvic floor ultrasound to help patients recruit the appropriate pelvic floor muscles.

During the pre-operative period, patients should be provided with education about the procedure itself. This gives the opportunity to discuss expectations and most importantly, a shared, informed consent can be obtained. Patient understanding has been demonstrated to improve long-term patient satisfaction following radical prostatectomy [22]. The use of adjuncts in this process including multi-media tools and 3D models further enhance patient understanding [23, 24].

2.6 Peri-procedural medications

The risk of withholding antiplatelet and anticoagulation must be weighed against their indications, particularly for patients with previous cardiac percutaneous interventions, metallic valve replacement and venous thromboembolism. An individualized medication plan is employed with discussion with other specialists if there is concern or the patient is high-risk. RARP can be safely performed on aspirin, but this is at the surgeon’s discretion. A range of antiplatelet and anticoagulants and their cessation recommendations are listed in Table 3 [25].

Medication	Time to withhold prior to robotic prostatectomy
Enoxaparin	24 hours
NOACs (e.g. rivaroxaban, dabigatran, apixaban)	24–72 hours (depending on renal function)
NSAIDs, antiplatelets (e.g. aspirin)	5 days
Warfarin	5 days (with INR check 2 days prior to procedure)
Other antiplatelets (e.g. clopidogrel, ticagrelor)	7 days

Table 3.

Duration of withholding of common anticoagulants and antiplatelets prior to robotic prostatectomy. Adapted from Guidelines on Perioperative Management of Anticoagulation and Antiplatelet Agents, CEC [25].

Diabetic patients need careful managed to optimize wound and anastomotic healing. It also reduces peri-procedural diabetic complications such as diabetic ketoacidosis, hyperglycaemic hyperosmolar state and severe hypoglycaemia in the fasting pre-operative patient. Regular diabetic medications are withheld the morning of surgery in the fasting patient. The increased use of sodium-glucose cotransporter 2 inhibitors (SGLT-2) has raised another issue of euglycemic diabetic ketoacidosis. These medications need to be withheld for at least 3 days.

Bowel preparation is not typically utilized prior to robotic prostatectomy, as the risk of rectal injury is low. The use of bowel preparation is considered in select cases such as salvage prostatectomy, when rectal injury is more likely [26].

2.7 Prostatectomy associated urinary tract infection

Prior to RARP, a urine microscopy and culture is sent to rule out urinary tract infection or asymptomatic bacteriuria. Our institution performs this at the pre anesthetic assessment, 1–2 weeks prior to procedure. This allows time for culture growth and sensitivities and appropriate antibiotic treatment.

3. Intra operative considerations

3.1 Patient positioning and room set up

Patient positioning and room ergonomics are critical when incorporating a robotic platform into the theater environment. The robotic platform consists of the surgeon’s console, computer control tower, patient docking cart and viewing screens which all take up additional space and can limit patient access [27, 28].

Close communication between the surgeon and anesthetist ensures optimal patient positioning for operative efficiency. The most common positioning for RARP is lithotomy with Trendelenburg with the docking cart between the legs or at the patients’ side [29].

In preparation for Trendelenburg, a non-slip foam mat may be used to prevent patient movement [27, 30]. This is important as once the robot arms are docked to the ports, movement can cause injury to the incision sites or result in instrument movement within the patient causing injury [27, 30, 31]. Other methods of securing the patient include straps or bolsters at the shoulders but we have found these additional methods to be unnecessary.

The patient’s legs are placed in lithotomy stirrups. Care is taken to avoid extreme flexion of the hip or knees and ensure well-padded stirrups are used to reduce the risk of lower limb pressure areas or neuropraxia [32].

Peripheral access lines and pulse oximetry are well padded to prevent pressure areas and gel pads used to prevent pressure where the hand contacts the lithotomy stirrup. The arm should be secured in a relaxed and neutral position to reduce the risk of neuropraxia [30, 31]. We recommend the palm face the body with the thumbs up to reduce strain on the ulnar nerve. A method used in our institution is to use soft orthopedic padding to wrap the arms to prevent pressure areas from lines and the surroundings prior to securing the arm in position at the patients’ side by using a pillowcase tucked underneath the patients’ torso, around the arm and then back under the patient for loose but secure immobilization [33].

Once the patient is positioned and in the desired Trendelenburg position a final check is made prior to docking the robotic arms.

3.2 Monitoring and access

Careful arrangement of lines and monitoring is a critical concern for the anesthesiologist as there is less access once the patient is draped, and the robot docked. Access to the airway is also partially obstructed by the proximity of the robotic arms to the face. This is particularly relevant should emergent access be required to the face and chest area for cardiopulmonary resuscitation should the situation arise. For these reasons we also recommend the endotracheal tube is well secured and the face is protected to limit accidental contact with the robot [27].

3.3 Trendelenburg

RARP requires steep Trendelenburg positioning to optimize access and vision within the pelvis. The 20–30 degree Trendelenburg allows the bowel to drop cephalad out of the pelvic cavity, an affect which is more evident once any restricting abdominal adhesion are released [27, 30, 34]. In our institution we use a protractor to measure the Trendelenburg angle and ensure the minimal angle for the desired affect is used.

Trendelenburg position causes venous congestion leading to raised intraocular pressure (IOP) [35]. The raised IOP is time dependent and decreases when returned to the supine position [15, 35]. Normal IOP is 10–21 millimeters of mercury (mmHg) and pressures greater than 21 mmHg reduce ocular perfusion pressure and risks retinal detachment, post operative visual loss, glaucoma and ischemic optic neuropathy [15, 35]. The reduced venous return and increased episcleral venous pressure from pneumoperitoneum exacerbates this affect [36]. Propofol may reduce IOP compared to sevoflurane and neuromuscular blockade may also reduce IOP by aiding aqueous humor drainage by relaxing the extraocular musculature [34, 35].

The limited access to the face and proximity to the robotic arms in Trendelenburg can cause accidental contact to the patients face leading to corneal abrasion, the most common ocular complication [34]. A review of 1500 consecutive robotic assisted radical prostatectomies found a decrease in corneal abrasion from 3% to 1% with the use of eye patches instead of tapes [34, 37]. More recently, Trendelenburg positioning itself has also been shown to be a risk factor for corneal abrasion due to increased corneal thickness because of elevated intraocular and episcleral venous pressure and conjunctival oedema [34, 36, 38].

Trendelenburg combined with the effects of pneumoperitoneum increase intracranial pressure (ICP) [30, 34]. A proposed mechanism is the reduced drainage of the lumbar venous plexus and the vasodilatory effects of hypercarbia increasing cerebral blood volume and CSF volume [30]. The Monroe Kellie hypothesis explains an equilibrium between the CSF, blood volume and parenchymal tissue in the fixed space of the skull dictating a rise in ICP with a rapid rise in any of these constituents. Caution should be taken in patients with pre-existing intracranial hypertension or pathology [34, 39]. Despite the known increases in ICP, Weisinger et al. demonstrate no change in cerebral oxygenation during 45-degree Trendelenburg for procedures up to 5 hours in length and no change in post operative mental function as measured by a mini mental status examination [40].

We recommend careful control of CO₂ to maintain normocarbia, minimizing total time in Trendelenburg and minimize the angle used. Nishikawa et al. found performing RARP with a 25-degree angle compared to 30-degree angle of Trendelenburg reduced intraoperative IOP and did not increase operative time or estimated blood loss in their series of 30 cases [41]. Another proposed strategy by Raz et al. is a modified Z Trendelenburg position whereby the head and shoulders are elevated to the horizontal whilst in Trendelenburg (Figure 1) [42]. In their randomized control trial study, they found this modification reduced IOP and did not impact anesthesia, the procedure of the operative field [42].

Figure 1.

Modified Z Trendelenburg position. Reproduced from Raz et al. [42]. a, horizontal supine position with lithotomy. b, 23-degree Trendelenburg position with lithotomy. c, modified Z Trendelenburg position.

3.4 Pneumoperitoneum

Abdominal CO₂ insufflation is used to create intra-abdominal working space. The pressures commonly used range from 12 to 15 mmHg [30, 34]. The European Association for Endoscopic Surgery recommend using the lowest possible pressure required for adequate vision of the surgical field [43].

The hemodynamic effects of pneumoperitoneum are dynamic when combined with steep Trendelenburg [30, 34, 44]. Mean arterial pressure (MAP) and systemic vascular resistance (SVR) increased with pneumoperitoneum [44]. This affect is produced from the increased afterload from intra-abdominal pressure causing local compression of the aorta as well as neurohumoral factors [30, 34]. When combined with Trendelenburg, SVR returns to basal levels but MAP remains elevated [44]. Trendelenburg also raises the CVP, the mean pulmonary artery pressure (MPAP) and the pulmonary capillary wedge pressure (PCWP) [44]. The net effect is a 25% increase in MAP, and a more than 2-fold increase in CVP, MPAP and CVP [44]. Heart rate, stroke volume and cardiac output were unchanged by these effects however the left ventricular stroke work index and right ventricular stroke work index increased by 35% and 65% respectively [44]. This indicated that cardiac function is maintained in the patient with cardiac reserve, but caution needs to be taken in patients with impaired baseline function [30, 34]. The observed hemodynamic changes all returned to baseline on exsufflation and returning to the horizontal position [44]. When treatment is required, the aim is often afterload reduction given this is a major component of the observed changes [45].

The cephalad displacement of the diaphragm by insufflation reduces lung functional reserve capacity (FRC) and decreases pulmonary compliance [30, 34]. The affect is compounded by the gravitational forces of the abdominal contents on the diaphragm and mediastinum from Trendelenburg positioning and associated raised pulmonary pressures [30, 34]. With a 11–12 mmHg insufflation pressure and 45-degree Trendelenburg, Lestar et al. measured a fall in total lung compliance from 60 to 28 mm/cm of water [44]. The net result is increased peak inspiratory pressures to maintain minute ventilation and the associated increased risk of barotrauma [30, 34].

The most practical remedy for hypercapnia from peritoneal CO₂ absorption is hyperventilation, however the increased peak inspiratory pressures need to be considered in increasing minute ventilation [27, 30, 39]. If normocapnia proves difficult to maintain, permissive hypercapnia may be considered, or alternatively temporary lowering of pneumoperitoneum pressures may be required to facilitate a period of hyperventilation [39].

Subcutaneous emphysema is a common complication of pneumoperitoneum which self resolves with exsufflation and is rarely of a magnitude to cause clinical concern as CO₂ is highly soluble when compared to air [30, 34, 45]. However, severe cases can cause hypercarbia complicating ventilation. If permissive hypercarbia is required to manage the resultant hypercarbia, the patient may benefit from remaining mechanically ventilated at the end of surgery until corrected to reduce an increased work of breathing [30, 39]. The other concern is for the spread of subcutaneous emphysema in pre fascial planes causing pneumothorax or pneumomediastinum [30, 45]. If there is subcutaneous emphysema extending to the thorax or neck, we recommend evaluation with mobile chest Xray. While CO₂ is rapidly absorbed into the bloodstream, large quantities could necessitate the need for surgical decompression with a chest tube [45].

Venous gas embolism is a life-threatening complication that should be suspected when there is unexplained cardiovascular collapse and correlating capnographic changes [30, 45]. High risk periods for gas entry into the circulation are during insufflation and ligation of the dorsal venous complex [30, 34]. It is not uncommon for the surgeon to use transiently higher insufflation pressures up to 20 mmHg during the dorsal veinous complex ligation to limit venous blood loss. While the rapid absorbability of CO₂ compared to air minimizes the risk of embolus, should clinically apparent gas embolus be suspected, insufflation should be immediately ceased [27, 45].

3.5 Ventilation

The requirements for paralysis, pneumoperitoneum and Trendelenburg to perform RARP necessitates general anesthesia with a cuffed endotracheal tube secured and mechanically ventilated [45]. Once the patient is positioned for docking, we recommend rechecking tube position. The cephalad pressure effect of pneumoperitoneum and Trendelenburg causes shortening of the trachea and can result in endobronchial intubation [30, 34, 46].

The establishment of pneumoperitoneum and Trendelenburg leads to increased airway pressures. A degree of ventilation difficulty should be expected in patients with chronic pulmonary disease or the morbidly obese [27, 45]. Managing peak airway pressure to prevent barotrauma while also regulating end tidal CO₂ to maintain normocapnia can be a challenge [30, 34]. Kalmar et al. suggest reducing tidal volume and increasing respiratory rate and the duration of the inspiratory phase to reduce peak airway pressure [39]. An alternative is to use a pressure-controlled volume guarantee ventilation mode to deliver the tidal volume required for the lowest possible airway pressure [39].

A consequence of the upper body venous congestion caused by Trendelenburg positioning is facial and laryngeal oedema. An assessment for facial or conjunctival oedema should be performed prior to extubation and if present should alert for caution on extubating [30, 34]. A cuff leak test prior to extubating can be performed in this circumstance and if significant upper airway oedema is suspected delayed extubating may be required [30, 34, 45].

3.6 Fluid management

The intraoperative administration of intravenous (IV) fluid requires careful consideration. Excess IV fluid during Trendelenburg can exacerbate the dependent cephalad venous congestion and increase the risk of upper airway oedema, ICP and IOP [30, 34, 45]. Upper air way oedema increases the risk of post operative respiratory distress and the possible need for reintubation [30, 34, 45]. It has been suggested that total intraoperative fluids be limited to less than 2000 ml [30, 34, 45].

Intraoperative urine output is an unreliable measure of volume status with oliguria being a known effect of pneumoperitoneum [34, 45]. The mechanism may be due to reduced renal blood flow and this affect recovers on exsufflation [34, 45]. A transient rise in post operative serum creatinine may be noted but it does not cause permanent renal derangement [30, 45].

The timing of fluid administration is important, with reduced IV fluids prior to completion of the urethra-vesical anastomosis to improve vision in the surgical field. This reduces urine from the open bladder spilling into the dependent pelvic cavity [30, 34, 45]. Once the anastomosis is complete, an increase in IV fluid is desirable to mitigate against volume depletion and post operative oliguria [27, 30]. Ensuring adequate post operative urine output also serves the purpose of ensuring patency of the post operative catheter by flushing out any residual blood clot.

3.7 Neuropraxia and compartment syndromes

Mills et al. found the incidence of neuropraxia post RARP to be 7.3% in their review of 137 cases performed over 2 years [47]. Neuropraxia risk factors include operative time, time in theater, IV fluids administered and American Society of Anesthesiologists (ASA) physical status [47].

Upper limb neuropathy from RARP is often associated with techniques used to prevent the patient sliding cephalad in the Trendelenburg position. Brachial plexus injuries have been reported with the use of shoulder braces which may cause undue pressure over the acromioclavicular joint [27, 30, 31, 34]. The use of crossed chest straps has been proposed as an alternative; however this may contribute to the reduced pulmonary compliance from pneumoperitoneum [30].

We recommend avoiding shoulder braces or beanbags and utilizing a non-slip or egg crate patient mat to prevent the patient sliding cephalad in combination with wrapping of the arms by the patients’ sides [30, 45]. Care needs to be taken with wrapping of the arms to prevent pressure area and ulnar neuropathy [30].

Patients undergoing RARP are at a low but serious risk of developing lower limb compartment syndrome [48]. The lower limbs have the lowest perfusion pressure due to their elevated position from lithotomy and Trendelenburg positioning [39]. Any direct compression or pressure from lithotomy stirrup positioning may exacerbate the reduced blood flow and contribute to the cascade of hypoxia and swelling [48]. Pridgeon et al. found the incidence of compartment syndrome in RARP patients to be 0.29% in their multicenter UK analysis and most of these patients required fasciotomy in treatment. They identified the patient factors of peripheral vascular disease and diabetes and peri-operative factors of patient positioning, surgeon learning curve and operative console time greater than 4 hours as risk factors [48].

Care needs to be taken to ensure the lithotomy stirrups are properly sized and positioned to ensure the supporting pressure is exerted through the heel and not the calf and that the upper calf is clear from the stirrups support [39, 46].

Lithotomy positioning and any exaggerated stretch or compression caused by the tilting into Trendelenburg position is associated with a significant risk of lower limb neuropraxia [29]. The most common lower limb neuropathies associated with lithotomy procedures are common perineal and sciatic [32]. The sciatic nerve may experience excessive stretch from over flexion of the hip and extension of the knee when placing the position into the lithotomy position [32, 49]. The common perineal nerve superficially traverses the head of fibular at the knee and therefore is susceptible to injury from direct pressure if incorrectly positioned [32, 49].

We therefore recommend due care in shifting the patient in and out of lithotomy stirrups and ensuring adequate padding particularly at the lateral leg to prevent these common nerve injuries [32].

3.8 Emergency management

Robotic radical prostatectomy carries the potential risk of intraoperative emergencies [50]. Having a well-coordinated emergency response team is essential, involving surgeons, anesthetists and operating room nurses [51, 52, 53, 54]. Each team member should understand their designated roles and responsibilities in case of an emergency. Clarity regarding individual roles during emergencies is vital for each team member. Regular training sessions and simulated scenarios can bolster the team’s readiness and ability to effectively manage critical situations.

3.8.1 Emergency undocking

Undocking the robotic system during surgery is a precise step that requires a clear understanding of potential risks. There are instances where unexpected complications prompt the surgeon to undock the robot promptly. This decision must be made cautiously, as abrupt robot withdrawal can result in bleeding, organ injury, and incomplete surgical steps. Effective communication among team members, including the anesthetists and nursing staff, is crucial to maintaining patient stability during this transition.

Undocking necessitates a thorough patient evaluation and consideration of potential conversion to open surgery. A well-defined undocking plan outlining steps for instrument withdrawal and patient positioning. Surgeons should remain aware of the situation, closely monitor vital signs, and ensure proper anesthesia management throughout the undocking process.

3.8.2 Robotic failure

In 0.2% of cases, perioperative robotic failure was observed. In one instance, the da Vinci surgical system malfunctioned during surgery, prompting the use of an alternative robot. In three other cases, intraoperative delays resulted from software failures, all of which were resolved in the operating room without any complications. Notably, no instance of robotic failure led to surgery cancelation or early anesthesia emergency [55].

3.8.3 Converting to open surgery

Switching from a minimally invasive approach to open surgery is a significant decision. Complications that cannot be managed safely using the robotic system, such as excessive bleeding or unexpected anatomical variations, often prompt this conversion [56]. Transitioning to open surgery necessitates seamless coordination, with the surgical team being well-versed in open surgical techniques, instrument handling, and patient positioning [57].

Effective communication between team members ensures a smooth transition to open surgery. Surgeons collaborate with anesthetists, nursing staff, and support personnel to facilitate an efficient shift. Adequate preoperative planning should involve discussions about scenarios that might require conversion to open surgery, along with available resources and equipment in the operating room.

3.8.4 Cardiac arrest management

Although rare, cardiac arrest can occur during RARP and demands swift and effective management. Rapid recognition and initiation of cardiopulmonary resuscitation (CPR), and immediate collaboration with the anesthesia team is crucial. Time is a crucial factor in crisis situations, and the restricted patient access inherent in robotic surgery can lead to delays in initiating effective responses. Performing undocking drills on simulators in line with well-structured emergency undocking protocols speeds up this process. These drills enhance the competence, knowledge, and confidence of the entire operating team during emergency scenarios. Integrating training sessions on emergency undocking into robotic surgery curricula is essential, ensuring that both surgeons and anesthetists are well-informed about these procedures [58].

Emergency undocking can lead to four distinct outcomes based on the underlying cause (Figure 2). In emergency undocking scenarios involving airway complications, cardiac arrest, bradycardia, anaphylaxis, and code red situations (fire hazards), anesthetist play a pivotal role [59].

Figure 2.

The four cardinal causes and outcomes of emergency undocking. Reproduced from Shah et al. [59].

For emergencies, the console surgeon takes charge in cases of robotic malfunction, technical issues, extensive surgical emphysema, and uncontrolled hemorrhage [60, 61, 62]. Regular simulation drills based on institutional protocols minimize patient access time (undocking time), enhance familiarity with predetermined critical actions, and boost the overall team’s confidence in emergency undocking. These training sessions should take place in the actual robotic theater environment, employing the robotic patient cart alongside a mannequin or training torso. Participants’ confidence, knowledge, and performance are assessed through formative simulations, followed by review sessions including lectures and reading materials [55, 63]. Summative simulations re-evaluate performance, confidence, and knowledge through multiple-choice questions and participant feedback (Figure 3).

Figure 3.

Roles and responsibilities of the different members of the medical team during emergency situations in robotic surgery. Reproduced from Shah et al. [59].

4. Post operative considerations

4.1 Post operative complications

A possible, but infrequent complication following RARP is postoperative ileus which causes abdominal distention, nausea and delayed oral intake, with an occurrence rate of 1.7%. For most patients, conservative management with intravenous fluids and bowel rest suffice, while a small subset require gastric decompression using a nasogastric tube. More serious early post-operative complications that may require further surgical intervention, include bowel injury, port site hernias, intrabdominal bleeding, and anastomotic disruption. All these complications are exceedingly rare and can be avoided by careful surgical dissection at the time of RARP. Anemia following surgery, defined by hemoglobin levels below 10 g dL, is found in 1.0% of cases, leading to blood transfusions. Postoperative pulmonary emboli occur in 0.2% of patients and are prevented by appropriate venous thromboembolism (VTE) prophylaxis including calf compressors intra-operatively, TEDS and prophylactic anticoagulation [64, 65, 66].

The European Association of Urology (EAU) guidelines for thromboprophylaxis suggests a risk stratified approach for the prescription of extended prophylaxis for 4 weeks post operatively (Table 4) [67]. Recommendations are specific to radical prostatectomy and are adjusted for the lower risk post RARP compared to open and for whether the patient underwent a pelvic lymph node dissection (PLND) which confers greater risk.

Risk group	Risk factors	Likelihood of VTE
Low	—	1X
Medium	One of the following: age ≥ 75 years BMI ≥35 VTE in a 1st degree relative	2X
High	Previous VTE ≥ 2 of the above risk factors	4X

Table 4.

Venous thromboembolism risk stratification. Reproduced and adapted from the EAU guidelines for thromboprophylaxis [67].

Patients undergoing RARP without PLND are not recommended for pharmacological prophylaxis. Patients undergoing RARP with standard PLND are recommended for pharmacological prophylaxis if high risk only. Patients undergoing RARP with extended PLND are recommended for pharmacological prophylaxis if medium or high. All patients undergoing RARP, except for low-risk patient undergoing RARP without PLND, have a weak recommendation for mechanical prophylaxis until ambulation [67].

A recent randomized clinical trial on VTE post RARP comparing mechanical prophylaxis with pharmacological prophylaxis during admission demonstrates contemporary experience of VTE post RARP [68]. The rate of overall VTE at 30 days was 2.8% with pharmacological prophylaxis and 2.9% without [68]. All VTE episodes occurred in patients who underwent PLND [68]. There was no increase in symptomatic lymphocele, bleeding or other complications with the use of pharmacological VTE prophylaxis [68].

4.2 Enhanced recovery after surgery

The implementation of Enhanced Recovery After Surgery (ERAS) protocols has revolutionized postoperative care following robotic prostatectomy, offering a comprehensive approach to improving patient outcomes and recovery. ERAS protocols are designed to streamline perioperative care, reduce complications, and accelerate patient recovery through evidence-based practices. In the context of robotic prostatectomy, the integration of ERAS protocols holds significant promise.

ERAS protocols following robotic prostatectomy encompass a range of interventions that span the preoperative, intraoperative, and postoperative phases [59, 60, 61, 62]. Preoperative elements often involve patient education, nutritional optimization, and the reduction of preoperative fasting period. These measures not only enhance patient understanding but also contribute to improved physical condition, better immune function, and overall preparedness for surgery. Intraoperatively, strategies such as minimal invasive techniques, judicious fluid management, and opioid-sparing anesthesia aim to minimize the physiological stress of surgery, reducing the risk of complications and expediting postoperative recovery [55, 61, 63, 69, 70, 71].

One of the key advantages of ERAS protocols in the postoperative phase is the early initiation of oral intake, which aids in maintaining gut motility, reducing the chance of postoperative ileus, and hence reducing the duration of hospitalization. Pain management techniques that prioritize multimodal analgesia over opioids mitigate side effects and enhance patient comfort while facilitating earlier ambulation and mobilization.

Additionally, ERAS protocols emphasize the importance of early ambulation, which promotes respiratory function, prevents thromboembolic events, and contributes to faster recovery. Lastly, ERAS protocol in certain institutions mandates drain removal if output is <50 ml in a 24 hours’ period on day 1 post-operatively. This significantly reduces patient’s length of stay [64, 65, 66, 72, 73].

The implementation of ERAS protocols also addresses patient-specific factors, tailoring interventions to individual needs. This personalized approach not only improves patient satisfaction but also potentially reduces the length of hospital stay and associated costs. Furthermore, ERAS protocols emphasize the role of a multidisciplinary team, promoting effective communication among surgeons, anesthetists, nurses, and other healthcare professionals. This collaboration ensures the smooth execution of the various components of the protocol, minimizing variability in care delivery [74].

ERAS protocols have optimized recovery following robotic prostatectomy. By focusing on evidence-based practices that encompass the entire perioperative continuum, ERAS protocols enhance patient outcomes, decrease complications, and expedite recovery.

4.3 Functional rehabilitation

Pelvic floor exercises and penile rehabilitation have emerged as vital components of the comprehensive postoperative care strategy following robotic prostatectomy. This discussion underscores their significance in enhancing the quality of life and restoring sexual function in patients who have undergone this procedure.

Pelvic floor exercises, often referred to as Kegel exercises, target the muscles that support the bladder, prostate, and rectum. They have gained prominence as a non-invasive and effective approach to addressing postoperative urinary incontinence, a common concern after prostate surgery [56, 57, 58, 59, 75]. By strengthening the pelvic floor muscles, these exercises contribute to improved urinary control and minimize the extent of incontinence. Encouraging patients to engage in these exercises preoperatively and postoperatively empowers them to actively participate in their recovery journey and regain continence more swiftly [58].

Equally crucial in the realm of postoperative recovery is penile rehabilitation, which focuses on maintaining erectile function following robotic prostatectomy. The disruption of neurovascular bundles during surgery can lead to temporary or prolonged erectile dysfunction [56]. Penile rehabilitation strategies encompass a range of interventions, including pharmacological agents, vacuum erection devices, and intracavernosal injections, all of which aim to prevent the irreversible loss of penile tissue and promote vascular health. Additionally, early engagement in sexual activity and counseling play pivotal roles in facilitating psychological adaptation and optimizing sexual outcomes [75].

The integration of both pelvic floor exercises and penile rehabilitation into the postoperative care plan acknowledges the multidimensional nature of recovery after robotic prostatectomy. While these interventions primarily address specific functional concerns, they also extend their benefits to psychological well-being and overall quality of life [64, 65, 70, 71, 72, 73]. By actively involving patients in their recovery process and offering tailored solutions, healthcare providers empower individuals to take ownership of their sexual health and urinary continence.

However, successful implementation of pelvic floor exercises and penile rehabilitation necessitates patient education and adherence. Healthcare professionals play a pivotal role in imparting the significance of these interventions and providing guidance on their correct execution. Collaborative efforts between urologists, physical therapists, and sexual health specialists ensure that patients receive comprehensive support throughout their recovery journey [66, 74].

In conclusion, pelvic floor exercises and penile rehabilitation represent integral pillars of the postoperative care regimen for patients undergoing robotic prostatectomy. By addressing urinary incontinence and erectile dysfunction, respectively, these interventions contribute to improved functional outcomes and enhance the overall quality of life. The comprehensive approach to recovery that includes both physical exercises and sexual rehabilitation underscores the holistic nature of care and reflects the commitment to restoring patients’ well-being in its entirety.

5. Concluding remarks

As RARP is increasingly adopted as the surgical modality of choice for localized prostate cancer, a thorough understanding of its implications for successful perioperative care is imperative. Patient selection, pre-operative optimization and patient education are critical to prepare for success. A thorough understanding of the anesthetic and physiological implications of Trendelenburg position, lithotomy and pneumoperitoneum in combination with robotic docking is necessary for successful intraoperative management and emergency management should the need arise. Finally, attention to the principles of enhanced recovery after surgery and the specifics of post operative care following RARP is critical to maximizing patient outcomes.