Original contribution
A retrospective comparison of anesthetic management of robot-assisted laparoscopic radical prostatectomy versus radical retropubic prostatectomy

https://doi.org/10.1016/j.jclinane.2008.09.005Get rights and content

Abstract

Study Objective

To compare anesthetic management and postoperative outcomes in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALP) and radical retropubic prostatectomy (RRP) with general anesthesia.

Design

Retrospective database study of RALP and RRP patients at Duke University Medical Center from 6/2003 to 6/2006.

Setting

University teaching hospital.

Patients

541 ASA physical status I, II, and III men, 280 of whom were RRP patients and 256 RALP patients.

Measurements

Patient demographics, intraoperative fluids and blood products, hemodynamic parameters, pain scores in the Postanesthesia Care Unit (PACU), intraoperative and postoperative analgesic consumption, need for rescue antiemetics in the PACU, and intraoperative use of vasopressors and antihypertensives, were all recorded. Additional data included postoperative transfusion data; clinical status of the patient's cancer preoperatively and postoperatively; hematocrit, platelet count, and creatinine levels; and length of hospital stay.

Main Results

Estimated blood loss (EBL) was higher for RRP than RALP patients (mean ± SD; 1,087 ± 853 mL vs. 287 ± 317 mL; P < 0.0001). Likewise, 24% of RRP patients received red blood cell (RBC) transfusions intraoperatively, compared with 0.4% RALP patients (P < 0.0001). Intraoperatively, RALP patients received more antihypertensive agents (37% vs. 21%; P < 0.0001), and fewer vasopressors (63% vs. 78%; P < 0.0001) than did RRP patients. The two groups had similar morphine-equivalent opioid use intraoperatively, but in the PACU, RALP patients required fewer morphine equivalents (mean ± SD; 11.4 ± 7.7 mg vs. 14.9 ± 9.8 mg; P < 0.0001). The RALP patients had longer surgical times (mean ± SD; 296 ± 76 vs.193 ± 69 min; P < 0.0001) but shorter PACU stays (mean ± SD; 113 ± 55 min vs. 143 ± 58 min; P < 0.0001) and shorter hospital stays (mean ± SD; 44 ± 77 hrs vs. 56 ± 26 hrs; P = 0.009).

Conclusions

Duration of surgery was greater with RALP, but it was associated with less EBL, fewer transfusions of blood products, and shorter PACU and hospital stays.

Introduction

Treatment of prostate cancer by surgical resection has been performed since the nineteenth century [1]. The retropubic approach was developed in 1945 and, together with the perineal approach, has been the standard of care for surgical resection [2], [3]. In 1997, laparoscopic retropubic prostatectomy (LRP) was developed [4] and then refined in 1999 [5]. This technique purportedly offered better surgical visualization, less blood loss, and better preservation of surrounding structures [6], [7]. In spite of these potential advantages, outcomes for LRP patients were not much improved over open radical prostatectomy [8], [9], [10], [11], [12]. Furthermore, LRP was considered difficult to learn, with an estimated 50 or more operations needed before the technique was mastered [9], [13], [14].

The development of robot-assisted laparoscopic prostatectomy (RALP) soon followed LRP, with the introduction of a telerobotic surgical system in 1999 [15]. In 2004, RALP represented 10% of all prostatectomies performed in the United States [16], [17]. Because of better translation of surgical skills compared with those for LRP, it is estimated that 8 to 25 RALP procedures need to be performed until surgeons can complete the surgeries in less than 4 hours, which is less than the number required for LRP [13], [18], [19].

While RALP may be associated with reduced blood loss compared with RRP, it presents additional challenges for the anesthesiologist. For example, RALP is a laparoscopic urologic procedure like LRP and it presents many of the problems associated with laparoscopic surgeries such as CO2 absorption and pneumoperitoneum. In addition, management of RALP requires knowledge of the implications of the steep Trendelenburg position needed for this approach.

Although much has been written about the surgical outcomes of RALP, little data exist regarding the perioperative anesthetic management of these cases. Therefore, we performed a retrospective database review of patients who presented to our institution for either RALP or radical retropubic prostatectomy (RRP), beginning from the inception of our RALP program from June 2003 to June 2006. The goal of this study was to compare intraoperative and postoperative management and outcomes between these two surgical approaches.

Section snippets

Materials and methods

Following Duke University Medical Center IRB approval, the perioperative database for patients who underwent RRP or RALP with general anesthesia from 1/2003 until 6/2006 was searched. Patients who underwent additional procedures other than pelvic lymphadenectomies or who received an epidural for the surgical procedure or postoperative pain management, were excluded from the study. We collected information concerning patient demographics, intraoperative fluid management, hemodynamic parameters,

Results

Data from 707 patients who underwent RRP or RALP was obtained from the perioperative database. After exclusion of data from patients who underwent additional procedures other than pelvic lymphadenectomies (n = 146) or who received an epidural (n = 25), 536 patients remained and were included in the study (no RALP patients received epidurals). The data from a total of 256 RALP patients and 280 RRP patients were studied. The Urology database matched 219 RALP patients and 251 RRP patients.

Of the

Discussion

In this study we found that patients who underwent RALP had less EBL, less transfusion of blood products, and shorter PACU and hospital stays than did RRP patients. The RALP patients also were discharged with higher Hct and platelet levels. Patients underoing RALP had a longer surgical time, transient increases in postoperative creatinine levels, and increased intraoperative use of anti-hypertensive agents.

One concern of many anesthesiologists is the steep Trendelenburg position required for

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Financial support: This study was supported solely by departmental funds.

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