<title>ABSTRACT</title><sec><title>Objectives:</title><p>To compare the effects of CO₂ insufflation on hemodynamics and oxygen levels and on acid-base level during Robot-Assisted Radical Prostatectomy (RARP) with transperitoneal (TP) versus extra-peritoneal (EP) accesses.</p></sec><sec><title>Materials and Methods:</title><p>Sixty-two patients were randomly assigned to TP (32) and EP (30) to RARP. Pre-operation data were collected for all patients. Hemodynamic, respiratory and blood acid-base parameters were measured at the moment of induction of anesthesia (T0), after starting CO₂ insuffation (T1), and at 60 (T2) and 120 minutes (T3) after insufflation. In all cases, the abdominal pressure was set at 15 mmHg. Complications were reported according to the Clavien-Dindo classification. Student's two–t-test, with a significance level set at p<0.05, was used to compare categorical values between groups. The Mann-Whitney U-test was used to compare the median values of two nonparametric continuous variables.</p></sec><sec><title>Results:</title><p>The demographic characteristics of the patients in both groups were statistically comparable. Analysis of intra-operative anesthesiologic parameters showed that partial CO₂ pressure during EP was significantly higher than during TP, with a consequent decrease in arterial pH. Other parameters analysed were similar in the two groups. Postoperative complications were comparable between groups. The most important limitations of this study were the small size of the patient groups and the impossibility of maintaining standard abdominal pressure throughout the operational phases, despite attempts to regulate it.</p></sec><sec><title>Conclusions:</title><p>This prospective randomized study demonstrates that, from the anesthesiologic viewpoint, during RARP the TP approach is preferable to EP, because of lower CO₂ reabsorption and risk of acidosis.</p></sec>

Introduction With improved understanding of the precise anatomy, surgical techniques during robot-assisted radical prostatectomy (RARP) have been refined, with the aim of improving functional outcomes without compromising oncological adequacy and results. Nevertheless, postoperative urinary incontinence remains a frustrating side-effect. Anatomically, bladder neck (BN) serves as an internal sphincter. The longitudinal fibres of BN may be identified and isolated with a meticulous dissection at the prostato-vesical junction, contributing to earlier return of urinary continence. The purpose of this video is to show an anatomical athermal dissection of BN during RARP.Materials and Methods After incision of endopelvic fascia and anterior defatting, the morphology of prostate not only laterally, but also at the level of bladder-prostatic junction is well visualized. With an athermal dissection of the plane between prostate and bladder we can minimize the traumatic effects on the longitudinal fibres of BN. A cold section of the preserved BN permits the complete preservation of integrity of this sphincteric structure.Results With this technique we preserve the longitudinal fibres of BN, allowing the sparing of the sphincteric mechanism of BN. The finding of a difficult athermal dissection of these plans may make you suspect the presence of an infiltration, suggesting to sacrifice BN in order to avoid a positive surgical margin. In our series no increase of PSM has been recorded using this technique.Conclusions This surgical technique preserving the natural BN mechanism appears to improve urinary continence, allowing at the same time an easy identification of a neoplastic infiltration.