Robotic-Assisted Radical Prostatectomy
Patient phenotype
Localized prostate cancer, age 50-75, otherwise often healthy. Steep Trendelenburg + insufflation = unique anesthesia challenge.
Procedure
Da Vinci robot, 6 trocars, EXTREME Trendelenburg (30-45° head down) + insufflation (12-15 mmHg). Prostate removed, vesico-urethral anastomosis. ~2-4 hours.
Anesthetic plan
GETA, RSI not always required (stomach decompressed by OG), tight head support, minimal IV fluids (avoid airway + facial edema). Multimodal pain. Foley + Foley alarm for surgical access.
Setup
- ·Standard ASA + Foley + temp
- ·Two PIVs
- ·OG tube (decompress stomach for trocar)
- ·Head support — gel pad, shoulder support, FACE FREE of pressure
- ·Eye protection (taped + checked frequently)
- ·Forced air warmer (long case)
- ·Type & screen
Biggest concerns by phase
Position-related risks reviewed + consented
Steep Trendelenburg + 3-4h = catastrophic ocular/cerebral risks. Pre-op discussion: corneal abrasion, ION (ischemic optic neuropathy), facial edema, brachial plexus injury. Pre-existing glaucoma is relative contraindication.
Standard induction + careful tube fixation
Standard GA. Tube secured well (head will be inverted, gravity pulls tube). OG tube placement to decompress stomach. Eye lubrication + eye taping (gravity makes eyelids open in head-down).
Steep Trendelenburg + insufflation = airway + cerebral effects
↑ICP + ↑IOP, facial edema, atelectasis, ↑PIP. Use PEEP 8-12 + lower TV (6-8 mL/kg IBW). Pressure-control mode often better. Limit FiO₂ to minimum needed.
Restricted IV fluid — avoid edema
Total fluids 500-1000 mL for case. Excess → airway + facial edema (can't extubate safely). Use vasopressors for hypotension, not fluid bolus. Document UOP — Foley diverted at start.
Cerebral perfusion + IOP — eye + head checks
Document MAP > 65 throughout. Frequent face + eye checks (q15-30 min). Watch for: forehead edema, eye chemosis, retinal hemorrhage suggestion. Pre-op + post-op vision exam.
Slow position change + airway recheck
Return supine slowly (15-30 sec). Recheck airway: laryngeal edema possible from prolonged Trendelenburg + ETT pressure. Cuff leak test. Awake extubation. Eye exam in PACU.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
Robotic prostatectomy, you're 3 hours in, patient at 35° Trendelenburg + insufflation. You note significant facial edema, eye chemosis. PIP rose from 28 to 38. ETCO2 50. Surgeon says they'll be done in 30 min. What do you do?
What an examiner probes for
- ▹Recognize position-related compromise
- ▹Adjust ventilation: pressure mode, PEEP, increase MV
- ▹Verify position is needed — could surgeon work in less steep angle?
- ▹Anticipate post-op: laryngeal edema → extubation caution, cuff leak test, possible prolonged intubation
Sources
- Miller's Ch 67
- ASA POVL Practice Advisory
- Olsen robotic anesthesia review
Anatomy reference
Sourced reference images. 4 matches for "prostate pelvis bladder".
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