What are the pre-anesthetic considerations for patients undergoing radical prostatectomy?

Pre-Anesthetic Considerations for Radical Prostatectomy

The optimal pre-anesthetic approach for radical prostatectomy should include evaluation of cardiovascular and respiratory comorbidities, planning for multimodal analgesia with paracetamol and NSAIDs, and tailoring the regional anesthetic technique based on surgical approach (TAP block for robotic/laparoscopic procedures and intravenous lidocaine for open procedures). 1

Preoperative Evaluation

• Thoroughly assess cardiovascular and respiratory comorbidities, as these patients are often older with multiple comorbidities 1
• Evaluate preoperative erectile function, as this directly relates to postoperative recovery of this function 1
• Verify absence of contraindications to NSAIDs and other planned analgesics (peptic ulcer disease, renal insufficiency, bleeding risk, concomitant therapeutic anticoagulation) 1, 2
• Distinguish between open, laparoscopic, or robotic prostatectomy approaches, as analgesic techniques differ according to the surgical method 1, 2
• Note that robotic-assisted surgery is generally less painful than open prostatectomy, which influences the choice of analgesic techniques 2, 3

Anesthetic Planning

• For open radical prostatectomy:

  • Plan for continuous intravenous lidocaine administration during surgery (not to be used simultaneously with local anesthetic infiltration) 2, 1
  • Prepare for local wound infiltration as a systematic approach for analgesia 2
  • Anticipate greater blood loss compared to minimally invasive approaches (median 550 mL vs 200 mL) 3

• For robotic-assisted/laparoscopic prostatectomy:

  • Plan for bilateral transverse abdominal plane (TAP) block as the first-choice regional analgesic technique 2, 1
  • Prepare for steep Trendelenburg positioning, which affects cerebrovascular, respiratory, and hemodynamic homeostasis 4
  • Anticipate longer anesthesia time but less blood loss compared to open procedures 3

Multimodal Analgesia Plan

• Administer paracetamol and NSAIDs (selective or non-selective) preoperatively or intraoperatively and continue postoperatively 2, 1

• Reserve opioids as rescue analgesics during the postoperative period 2

• For open prostatectomy:

  • Administer intravenous lidocaine continuously during surgery (shown to reduce pain scores and 24-hour morphine consumption) 2, 1
  • Plan for systematic local wound infiltration in the absence of intravenous lidocaine 2

• For laparoscopic/robotic prostatectomy:

  • Perform bilateral TAP block as the first-choice regional analgesic technique 2, 1
  • Be aware that TAP blocks have demonstrated a reduction in pain scores in robot-assisted procedures 2, 1

Non-Recommended Techniques

• Avoid epidural analgesia despite its efficacy, due to its invasive nature and risks of side effects (hypotension, dural puncture, epidural hematoma) 2, 1
• Do not use caudal block due to lack of evidence of its efficacy 2, 1
• Avoid intrathecal morphine as a first-line treatment despite its efficacy, due to side effects (nausea, vomiting, risk of respiratory depression) 2, 1
• Routine use of arterial lines or central venous catheters is not necessary for most patients undergoing radical prostatectomy 5

Special Considerations

• For robotic-assisted procedures:

  • Be prepared for potential complications related to pneumoperitoneum in steep Trendelenburg position 4
  • Anticipate higher incidence of postoperative nausea and vomiting compared to open procedures (33% vs 16%) 3
  • Plan for greater intraoperative opioid requirements compared to open procedures 3

• For all approaches:

  • Adequate anesthesia with isoflurane and fentanyl may provide good to excellent surgical conditions in approximately two-thirds of patients without muscle relaxants, though vecuronium significantly improves surgical field quality 6
  • Be aware that continuous subfascial infusion of local anesthetic has not shown benefit in reducing opioid requirements or improving pain scores 7
  • Anticipate potentially significant blood loss, which can be reduced by careful control of peri-prostatic vessels 1