The impact of low pressure pneumoperitoneum in robotic assisted radical prostatectomy: a prospective, randomized, double blinded trial

Background Robotic surgery has revolutionized postoperative outcomes across surgical specialties. However, the use of pneumoperitoneum comes with known risks given the change in physiological parameters that accompany its utilization. A recent internal review found a 7% decrease in postoperative ileus rates when utilizing a pneumoperitoneum of 12 mmHg over the standard 15 mmHg in robotic assisted radical prostatectomies (RARP). Objective The purpose of this study is to prospectively evaluate the utility of lower pressure pneumoperitoneum by comparing 8 mmHg and 12 mmHg during RARP. Design, setting and partcipants Patients were randomly assigned to undergo robotic assisted radical prostatectomy at a pneumoperitoneum pressure of 12 mmHg or 8 mmHg. Outcome measurements and statistical analysis The primary outcome was development of postoperative ileus and secondary outcomes were length of operation, estimated blood loss and positive surgical margin status. Results and limitations A total of 201 patients were analyzed; 96 patients at 8 mmHg and 105 patients at 12 mmHg. The groups were adequately matched as there were no differences between demographic parameters or medical comorbidities. There was a decrease in postoperative ileus rates with lower pneumoperitoneum pressures; 2% at 8 mmHg and 4.8% at 12 mmHg. There were no clinically significant differences in estimated blood loss, total length of operative time and positive margin status. Conclusions Lower pressure pneumoperitoneum during robotic assisted radical prostatectomy is non-inferior to higher pressure pneumoperitoneum levels and the experienced surgeon may safely perform this operation at 8 mmHg to take advantage of the proposed benefits.