ABSTRACT Introduction: To evaluate the influence of previous experience as bedside assistants on patient selection, perioperative and pathological results in robot assisted laparoscopic radical prostatectomy. Materials and Methods: The first 50 cases of two robotic surgeons were reviewed retrospectively. Group 1 consisted of the first 50 cases of the surgeon with previous experience as a robotic bedside assistant between September 2016-July 2018, while Group 2 included the first 50 cases of the surgeon with no bedside assistant experience between February 2009-December 2009. Groups were examined in terms of demographics, prostate volume, presence of median lobe, prostate specific antigen (PSA), preoperative Gleason score, positive core number, clinical stage, console surgery time, estimated blood loss, postoperative Gleason score, pathological stage, positive surgical margin rate, postoperative complications, length of hospital stay and biochemical recurrence rate. Results: Previous abdominal surgery and the presence of median lobe hypertrophy rates were higher in Group 1 than in Group 2 (20% vs. 4%, p=0.014; 24% vs. 6%, p=0.012; respectively). In addition, patients in Group 1 were in a higher clinical stage than those in Group 2 (cT2: 70% vs. 28%, p=0.001). Median console surgery time and median length of hospital stay was significantly shorter in Group 1 than in Group 2 (170 min vs. 240 min, p=0.001; 3 vs. 4, p=0.022; respectively). Clavien grade 3 complication rate was higher in Group 2 but was statistically insignificant. Conclusion: Our findings might reflect that previous bedside assistant experience led to an increase in self-confidence and the ability to manage troubleshooting and made it more likely for surgeons to start with more difficult cases with more challenging patients. It is recommended that novice surgeons serve as bedside assistants before moving on to consoles.

ABSTRACT Introduction: The success of the robot assisted radical prostatectomy (RARP) procedures depend on a successful team, however the literature focuses on the performance of a console surgeon. The aim of this study was to evaluate surgical outcomes of the surgeons during the learning curve in relation to the bedside assistant's experience level during RARP. Materials and Methods: We retrospectively reviewed two non - laparoscopic, beginner robotic surgeon's cases, and we divided the patients into two groups. The first surgeon completed the operations on 20 patients with a beginner bedside assistant in February - May 2009 (Group-1). The second surgeon completed operations on 16 patients with an experienced (at least 150 cases) bedside assistant in February 2015 - December 2015 (Group-2). The collected data included age, prostate volume, prostate specific antigen (PSA), estimated blood loss, complications and percent of positive surgical margins. In addition, the elapsed time for trocar insertion, robot docking, console surgery, specimen extraction and total anesthesia time were measured separately. Results: There were no significant differences between the groups in terms of age, comorbidity, prostate volume, PSA value, preoperative Gleason score, number of positive cores, postoperative Gleason score, pathological grade, protection rate of neurovascular bundles, surgical margin positivity, postoperative complications, length of hospital stay, or estimated blood loss. The robot docking, trocar placement, console surgery, anesthesia and specimen extraction times were significantly shorter in group 2 than they were in group 1 (17.75 ± 3.53 min vs. 30.20 ± 7.54 min, p ≤ 0.001; 9.63 ± 2.71 min vs. 14.40 ± 4.52 min, p = 0.001; 189.06 ± 27.70 min vs. 244.95 ± 80.58 min, p = 0.01; 230.94 ± 30.83 min vs. 306.75 ± 87.96 min, p = 0.002; 10.19 ± 2.54 min vs. 17.55 ± 8.79 min, p = 0.002; respectively). Conclusion: Although the bedside assistant's experience in RARP does not appear to influence the robotic surgeon's oncological outcomes during the learning curve, it may reduce the potential complications by shortening the total operation time.

Justificativa e objetivos:Embora muitas características da prostatectomia robótica sejam semelhantes àquelas de laparoscopias urológicas convencionais (como a prostatectomia por laparoscopia), o procedimento está associado a alguns inconvenientes, incluindo acesso intravenoso limitado, tempo cirúrgico relativamente longo, posição de Trendelenburg profunda e pressão intra-abdominal alta. O objetivo principal foi descrever as alterações respiratória e hemodinâmica e as complicações relacionadas à pressão intra-abdominal elevada e à posição de Trendelenburg profunda em pacientes submetidos à prostatectomia robótica. O objetivo secundário foi revelar critérios seguros de alta do centro cirúrgico.Métodos:Foram inscritos prospectivamente 53 pacientes submetidos à prostatectomia robótica entre dezembro de 2009 e janeiro de 2011. As medidas de desfecho primário foram: monitoramento não invasivo, monitoramento invasivo e gasometria feita em decúbito dorsal (T0), Trendelenburg (T1), Trendelenburg + pneumoperitônio (T2), Trendelenburg pré-desinsuflação (T3), Trendelenburg pós-desinsuflação (T4) e posições supinas (T5).Resultados:O principal desafio clínico em nosso grupo de estudo foi a escolha da estratégia de ventilação para controlar a acidose respiratória, que é detectada por meio da pressão de dióxido de carbono expirado e da gasometria. Além disso, a pressão arterial média permaneceu inalterada e a frequência cardíaca diminuiu significativamente e precisou de intervenção. Os valores da pressão venosa central também estavam acima dos limites normais.Conclusão:A acidose respiratória e sintomas clínicos "semelhantes à obstrução das vias aéreas"foram os principais desafios associados aos procedimentos de prostatectomia robótica.

Background and objectives:Although many features of robotic prostatectomy are similar to those of conventional laparoscopic urological procedures (such as laparoscopic prostatectomy), the procedure is associated with some drawbacks, which include limited intravenous access, relatively long operating time, deep Trendelenburg position, and high intra-abdominal pressure. The primary aim was to describe respiratory and hemodynamic challenges and the complications related to high intra-abdominal pressure and the deep Trendelenburg position in robotic prostatectomy patients. The secondary aim was to reveal safe discharge criteria from the operating room.Methods:Fifty-three patients who underwent robotic prostatectomy between December 2009 and January 2011 were prospectively enrolled. Main outcome measures were non-invasive monitoring, invasive monitoring and blood gas analysis performed at supine (T0), Trendelenburg (T1), Trendelenburg + pneumoperitoneum (T2), Trendelenburg-before desufflation (T3), Trendelenburg (after desufflation) (T4), and supine (T5) positions.Results:Fifty-three robotic prostatectomy patients were included in the study. The main clinical challenge in our study group was the choice of ventilation strategy to manage respiratory acidosis, which is detected through end-tidal carbon dioxide pressure and blood gas analysis. Furthermore, the mean arterial pressure remained unchanged, the heart rate decreased significantly and required intervention. The central venous pressure values were also above the normal limits.Conclusion:Respiratory acidosis and "upper airway obstruction-like" clinical symptoms were the main challenges associated with robotic prostatectomy procedures during this study.

Justificación y objetivos:Aunque muchas características de la prostatectomía robótica sean similares a las de las laparoscopias urológicas convencionales (como la prostatectomía laparoscópica), el procedimiento está asociado con algunos inconvenientes, incluyendo el acceso intravenoso limitado, tiempo quirúrgico relativamente largo, posición de Trendelenburg profunda y presión intraabdominal alta. El objetivo principal fue describir las alteraciones respiratorias y hemodinámicas y las complicaciones relacionadas con la presión intraabdominal elevada y con la posición de Trendelenburg profunda en pacientes sometidos a prostatectomía robótica. El objetivo secundario fue revelar criterios seguros de alta del quirófano.Métodos:Cincuenta y tres pacientes sometidos a prostatectomía robótica entre diciembre de 2009 y enero de 2011 fueron incluidos en un estudio prospectivo. Las principales medidas de resultado fueron: monitorización no invasiva, monitorización invasiva y gasometría realizada en decúbito dorsal (T0), Trendelenburg (T1), Trendelenburg + neumoperitoneo (T2), Trendelenburg predesinsuflación (T3), Trendelenburg posdesinsuflación (T4) y posiciones supinas (T5).Resultados:Cincuenta y tres pacientes sometidos a prostatectomía robótica fueron incluidos en el estudio. El principal reto clínico en nuestro grupo de estudio fue la elección de la estrategia de ventilación para controlar la acidosis respiratoria, que es detectada por medio de la presión de dióxido de carbono espirado y la gasometría. Además, la presión arterial media permaneció inalterada, y la frecuencia cardíaca disminuyó significativamente y fue necesario intervenir. Los valores de la presión venosa central también estaban por encima de los límites normales.Conclusión:La acidosis respiratoria y los síntomas clínicos «similares a la obstrucción de las vías aéreas» fueron los principales desafíos asociados con los procedimientos de prostatectomía robótica.

Experiência e objetivos: a cistectomia robótica vem rapidamente se tornando parte do repertório cirúrgico de rotina para o tratamento do câncer de próstata. Nosso objetivo foi descrever os desafios respiratórios e hemodinâmicos e as complicações observadas em pacientes de cistectomia robótica. Pacientes: foram prospectivamente recrutados 16 pacientes tratados com cistectomia robótica entre dezembro de 2009 e janeiro de 2011. As medidas de desfecho primário foram monitoração não invasiva, monitoração invasiva e análise de gases sangüíneos feita nas posições supina (T0), Trendelenburg (T1), Trendelenburg + pneumoperitônio (T2), Trendelenburg antes da dessuflação (T3), Trendelenburg depois da dessuflacão (T4) e supina (T5). Resultados: houve diferencas significativas entre T0 - T1 e T0 - T2 com frequências cardíacas mais baixas. O valor médio para a pressão arterial em T1 foi significativamente mais baixo do que em T0. O valor da pressão venosa central foi significativamente mais elevado em T1, T2, T3 e T4 versus T0. Não foi observada diferença significativa no valor de PET-CO2 em qualquer ponto temporal, em comparação com T0. Também não foram notadas diferenças significativas na frequência respiratória em qualquer ponto temporal, em comparação com T0. Os valores médios de ƒ em T3, T4 e T5 foram significativamente mais elevados versus T0. A ventilação minuto média em T4 e T5 foi significativamente mais elevada versus T0. As pressões de platô e de pico médias em T1, T2, T3, T4 e T5 foram significativamente mais elevadas versus T0. Conclusões: embora a maioria dos pacientes geralmente tolere satisfatoriamente a cistectomia robótica e perceba os benefícios, os anestesiologistas devem levar em consideração as mudanças no sistema cardiopulmonar ocorrentes quando os pacientes são colocados na posição de Trendelenburg e ao ser criado um pneumoperitônio.

Background and objectives: Robotic cystectomy is rapidly becoming a part of the standard surgical repertoire for the treatment of prostate cancer. Our aim was to describe respiratory and hemodynamic challenges and the complications observed in robotic cystectomy patients. Patients: Sixteen patients who underwent robotic surgery between December 2009 and January 2011 were prospectively enrolled. Main outcome measures were non-invasive monitoring, invasive monitoring and blood gas analysis performed at supine (T0), Trendelenburg (T1), Trendelenburg + pneumoperitoneum (T2), Trendelenburg-before desufflation (T3), Trendelenburg (after desufflation) (T4), and supine (T5) positions. Results: There were significant differences between T0 - T1 and T0 - T2 with lower heart rates. The mean arterial pressure value at T1 was significantly lower than T0. The central venous pressure value was significantly higher at T1, T2, T3, and T4 than at T0. There was no significant difference in the PET-CO2 value at any time point compared with T0. There were no significant differences in respiratory rate at any time point compared with T0. The mean ƒ values at T3, T4, and T5 were significantly higher than T0. The mean minute ventilation at T4 and T5 were significantly higher than at T0. The mean plateau pressures and peak pressures at T1, T2, T3, T4, and T5 were significantly higher than the mean value at T0. Conclusions: Although the majority of patients generally tolerate robotic cystectomy well and appreciate the benefits, anesthesiologists must consider the changes in the cardiopulmonary system that occur when patients are placed in Trendelenburg position, and when pneumoperitoneum is created.

Antecedentes y objetivos: la cistectomía robótica se ha convertido rápidamente en parte del repertorio quirúrgico de rutina para el tratamiento del cáncer de próstata. Nuestro objetivo ha sido describir los retos respiratorios y hemodinámicos, junto con las complicaciones observadas en pacientes sometidos a cistectomía robótica. Pacientes: diesiséis pacientes tratados con cistectomía robótica entre diciembre de 2009 y enero de 2011 se reclutaron de forma prospectiva. Las medidas de resultado primario fueron la monitorización no invasiva, la monitorización invasiva y la gasometría sanguínea realizada en las posiciones supina (T0), Trendelenburg (T1), Trendelenburg + neumoperitoneo (T2), Trendelenburg antes del desinflado (T3), Trendelenburg después del desinflado (T4), y supina (T5). Resultados: hubo diferencias significativas entre T0-T1 y T0-T2 con frecuencias cardíacas más bajas. El valor medio para la presión arterial en T1 fue significativamente más bajo que en T0. El valor de la presión venosa central fue significativamente más elevado en T1, T2, T3, y T4 versus T0. No se observó diferencia significativa en el valor de PET-CO2 en ningún momento en comparación con T0. Tampoco se encontraron nunca diferencias significativas en la frecuencia respiratoria en comparación con T0. Los valores medios de ƒ en T3, T4, y T5 fueron significativamente más elevados versus T0. La ventilación minuto promedio en T4 y T5 fue significativamente más elevada versus T0. Las presiones de meseta y de pico promedios en T1, T2, T3, T4, y T5 fueron significativamente más elevadas versus T0. Conclusiones: aunque la mayoría de los pacientes generalmente tolere satisfactoriamente la cistectomía robótica y se dé cuenta de los beneficios, los anestesiólogos deben tener en cuenta los cambios que ocurren en el sistema cardiopulmonar cuando los pacientes se ponen en la posición de Trendelenburg, y al ser creado un neumoperitoneo.