Prostate Cancer Smart Surgery Treatment Trifecta

Robotic-Assisted vs Open Radical Prostatectomy

Intraoperative Management of Robotic-Assisted Versus Open Radical Prostatectomy


Daniel M. Gainsburg, David Wax, David L. Reich, John R. Carlucci, David B. Samadi

Abstract
Background and Objectives:
Minimally invasive surgery has been shown to decrease postoperative morbidity and length of stay for several laparoscopic procedures. We sought to retrospectively compare intraoperative surgical and anesthetic parameters, postanesthetic care unit (PACU) length of stay, and hospital length of stay of patients who underwent roboticassisted laparoscopic radical prostatectomy (RAP) versus open radical retropubic prostatectomy (ORP). Methods: A retrospective investigation was performed using a urologic surgery database and an anesthesia electronic medical record. We queried information regarding 106 ORP patients from 2002 through 2007 and 575 RAP patients from 2007 through 2008. Results: Patients in the RAP group compared with ORP patients had reductions in surgical time, anesthesia time, estimated blood loss, crystalloid administration, and PACU and hospital length of stays. Compared with ORP procedures, intraoperative respiratory rates, peak inspiratory pressures, and arterial pressures in RAP procedures were higher; tidal volumes and heart rates were decreased; but end-tidal carbon dioxide concentrations were not different. In the RAP group, intraoperative complications included severe bradycardia, corneal abrasions, and 2 patients required reintubation. Surgically, no rectal perforations were noted, and no operative mortalities occurred. Conclusions: Our data demonstrate the safety and efficacy of RAP due to a combination of surgical and anesthetic factors.

Introduction
Robotic-assisted laparoscopic radical retropubic prostatectomy (RAP) is a technique that has gained popularity among urologists, gradually supplanting the traditional open radical retropubic prostatectomy (ORP)1 for the treatment of prostate cancer. The intraoperative management of robotic procedures creates both advantages and challenges that have been previously reported. Specifically, reduced blood2 and fluid requirements, decreased recovery time, and hospital length of stay are major advantages. The challenges that arise include airway edema related to the steep Trendelenburg position, brachial plexus injuries, and corneal abrasions.3–9 The change in practice pattern at the authors’ institution (where the use of the robotic approach is now prevalent) has created an opportunity for a review of the surgical and anesthetic databases. The authors hypothesized that intraoperative surgical parameters, hemodynamic stability, blood and fluid requirements, and postanesthesia care unit length of stay would be improved with the robotic approach. Additionally, we hypothesized that our hospital length of stay data would show a similar pattern to that in previous reports.

Materials and Methods
Prior to 2007, radical retropubic prostatectomies (ORP) were typically performed in our center by one of several experienced urologic surgeons using an open surgical technique. Since 2007, with the addition of a robotically trained urologic surgeon, all of the robotic- assisted laparoscopic prostatectomies (RAP) in this study have been performed by one surgeon. With Institutional Review Board approval for a retrospective investigation and waiver of informed consent, we queried our anesthesia electronic medical record (CompuRecord, Philips Medical Systems, Andover, MA) as well as a dedicated urologic surgery database to identify radical prostatectomy cases performed using 1 of the 2 techniques. Cases involving combined procedures (eg, radical cystectomy) or laparoscopy without robotic assistance were excluded.