Anesthetic management in robotic-assisted laparoscopic radical prostatectomy

Robotic-assisted laparoscopic prostatectomy (RALP) is the only robotic surgical procedure covered by national health insurance in Japan, and its application has been spreading rapidly. This procedure is performed with the patient in the steep Trendelenburg position under pneumoperitoneum, and anesthesiologists have to understand the physiological influences and accompanying risks. Regarding the pulmonary function, the lung compliance and functional residual capacity decrease as the airway pressure rises. It is important to appropriately maintain the airway pressure and prevent barotrauma and atelectasis. It is also necessary to pay attention to the risk of subcutaneous emphysema, brachial plexus palsy, peroneal neuropathy, pharyngeal edema, gas embolism, and postoperative ischemic optic nerve disorder. To prevent operative complications, such as anastomotic leak between the bladder and urethra, the restrictive fluid management until the surgeon completes the vesicourethral anastomosis is recommended. It is important to load transfusion after the completion of anastomosis and pay attention to the water balance in order to prevent postoperative acute kidney injury. For RALP, close coordination among the surgeons, anesthesiologist and medical staffs is essential for safe perioperative management.