A critical analysis of available evidence for best positioning, in terms of care and management,

of patients undergoing Robotic Assisted Laparoscopic Prostatectomy (RALP) under General

Anaesthesia
I. Introduction

Per Sung et al. (2021) report, the World Health Organization (WHO) reports prostate

cancer is expected to be the third most common cancer in 2020. With 1,414,259 instances which

is 7.3% of the overall, prostate cancer is only predated by pulmonary and colon cancer, which

have 2,206,771 and 1,148,515 cases, which account for 11.4 and 10.0%, correspondingly. It is

the most prevalent ailment recorded in more than half of the world's nations, which is 112 of 185

countries, and its prevalence varies enormously among nations with a high Human Development

Index (HDI) and those that have a low HDI - 37.5 vs. 11.3 per 100,000 people - accordingly. The

fatality rate is less varied, around 8.1 vs. 5.9 per 100,000 people. Prostate cancer is a diverse

illness with incidence ranging from 6.3 to 83.4 per 100,000 individuals worldwide.

Approximately 52,300 new instances of prostate cancer are diagnosed annually in the United

Kingdom, which amounts to more than 140 per day as per data recorded between 2016 - 2018.

Prostate cancer is the most common cancer in men in the United Kingdom, with approximately

52,300 new cases per year. Prostate cancer incidence rates are most significant in men aged 75

to 79 in the United Kingdom. Incidence rates of prostate cancer in men in the United Kingdom

have grown by 8% over the past decade. Males in England have lower prostate cancer incidence

rates among Asians and those of mixed or multiple ethnicities but higher incidence rates among

Blacks (Cancer Research UK, n.d.).

Robot-Assisted Laparoscopic Prostatectomy (RALP) is a surgical technique frequently

performed to treat men with prostate cancer. Among the therapeutic interventions for initial

prostate cancer are surgical procedures to remove the seminal vesicles and a portion of the

surrounding tissue (Costello, 2020). Because the prostate gland is close to the urine tract and
encircled by essential nerves for erectile function, excision must be done with extreme caution to

increase the probability of recovery while maintaining continence and sexual function.

II. Critical Analysis

A. RALP Positioning with Shoulder Support

As with every treatment will depend, dangers and problems are inevitable. It is

advisable to consult with a urologist or surgeon to prevent any adverse effects. One must

review the preparation one needs to take to the surgeon before the robotic-assisted

prostatectomy, as they can differ depending on the individual. Coughlin & Patel (2011)

indicated that Several typical adverse reactions of robotic-assisted prostatectomy might

happen, which are frequent in all radical prostate cancer therapy. These include urinary

retention and sexual function difficulties like erectile dysfunction, including urine

management concerns. Cestari et al. (2010) find that these complications are reduced if a

high-volume physician conducts a robotic-assisted laparoscopic prostatectomy. The

surgeon would be able to go over these concerns in further depth.

The surgical patient's positioning is a crucial element of anesthetic management,

and focusing on the physical and physiological repercussions of positioning could assist

minimize major adverse events and problems (Joseph, Vicente, Madeb, Erturk, & Patel,

2005). Joseph et al. add that the ideal patient placement involves balancing surgical

convenience with the hazards associated with the patient's posture. As a result, during the

preoperative assessment, patient placement during the operation must be examined.

Patient placement is frequently addressed after the onset of general anesthesia and the

installation of arterial and venous tubes (Gezginci, et al., 2015). The surgeon and
 anesthesiologist share responsibilities for positioning. Positioning the neurosurgical

patient is challenging and necessitates an acceptable anesthetic level, hemodynamic

stability, indications of sufficient oxygen, and the maintenance of intrusive monitoring

(Chitlik, 2011). As a result, pulse oximetry and arterial pressure must be monitored

throughout positioning, and chest tubes shouldn't be constricted. The location of the neck

and head, in particular, necessitates particular consideration. Rha (2009) indicated that

Following anesthetic induction, the patient is positioned in a customized lithotomy

posture with all pressure areas cushioned (Gainsburg, Anesthetic concerns for robotic-

assisted laparoscopic radical prostatectomy, 2012).

The patient's hands are nestled at his sides. A horizontal three-inch tape, as well as

Velcro straps, are used to fasten the chest. The patient's stabilization in steep

Trendelenburg must be checked at this point. But first, the patient needs to be prepared

and covered. Valdivieso, Hueber, and Korn (Valdivieso, Hueber, & Zorn, 2013) each

used a different strategy for placing and positioning the patient during RALP.

B. RALP without Shoulder Support

When pressure is administered to this instrument, soft granules allow it to expand

and collapse uniformly. The device is compressed using a hand-held compressor after the

patient is placed, and its malleable form fits the curves of the patient's body, limiting

slipping. To reduce brachial plexus damage, arms are curled with cushion sheets in the

palms of both hands, and 'renal' molded shoulder restraints are adequately placed across

the acromioclavicular joint. Over the thromboembolic (TED) stockings, sequential

compression stockings are placed (Valdivieso, Hueber, & Zorn, 2013). Next, an oral
gavage catheter could be inserted to deflate the gastrointestinal tract. Finally, a 20Fr

Foley catheter is often used to empty the bladder while ensuring that it is entirely

decompressed and out of the port insertion area (Haas, Haese, Goetz, & Kubitz, 2011).

Once this pretreatment is finished, the patient is placed in a Trendelenburg posture at a

20-25 degree slope to enhance pelvic content access. According to research, individuals

who undergo this operation in a high Trendelenburg position for 3-4 hours have no

substantial cerebrovascular, pulmonary, or hemodynamic issues (Valdivieso, Hueber, &

Zorn, 2013). Nonetheless, lengthier operative times should be avoided, particularly for

those with glaucoma, because extended Trendelenburg positioning can raise intra-ocular

strain.

Placement aims to allow the best possible access to the operative site while

maintaining safety and quality of care. There are numerous postures utilized for various

surgical procedures. The most common are lithotomy, steep Trendelenburg, lateral, and

prone (Saito, et al., 2015). The pose with the highest risk of patient injury is lithotomy in

steep Trendelenburg, primarily employed in robotic-assisted laparoscopic prostatectomy,

hysterectomy, and related gynecological procedures (Jun, et al., 2018). The patient cart

must be positioned between the legs during the robotic-assisted prostatectomy to quickly

attain the patient's lower pelvic region (Tewari, et al., 2012). The steep Trendelenburg is

40 degrees from horizontal, with elbows, curled and legs in the saddle (Chitlik, 2011).

Scooting and levering, pressure sores, septic shock, ulnar nerve damage, DVT venous

pooling, reduced lung ability, rear tension, blood accumulating in the upper chest, raised

blood pressure, cerebral perfusion stress, fluid changing, congestion and atelectasis, and
 morbidities are among the risks (Reece, Dangerfield, & Coombs, 2019). Brachial plexus

damage is the most prevalent consequence.

To avoid brachial plexus damage, keep the head in a median posture, arms at the

sides, elbows softly locked to discharge the nerve fibers, forearm supinated, and wrists

straight. Should shoulder restraints be prevented to relieve the pressure on the patient's

shoulder. If shoulder braces are essential, they should be used with caution and

cushioning (Gainsburg, Anesthetic concerns for robotic-assisted laparoscopic radical

prostatectomy, 2012). Several NHS hospitals within the UK utilize a gelatin cushion on

which the patient lies, with a thin draw blanket under the gel pad and arms folded with a

nest cushion (Milliken, et al., 2020).

C. Analysis in Care Management Using RALP

Steep Trendelenburg causes the patient to slide towards the head, mainly if the

patient is obese. Sliding causes dermal injuries and can modify the initial position,

perhaps causing organ damage due to the robotic arms placed in the belly. A gel cushion

from head to thigh is positioned on the OR bed if the patient must be in steep

Trendelenburg for the surgery (Chitlik, 2011). A cover should never be placed between

the patient and the gel pad since it reduces friction and increases the likelihood of the

patient slipping (Watson, et al., Decreasing the prospect of upper extremity neuropraxia

during robotic assisted laparoscopic prostatectomy: a novel technique, 2020). Bean bags

can also be utilized to prevent injury in steep trendelbergs. However, they are most

commonly employed in the lateral position (Samavedi, Abdul-Muhsin, Pigilam,

Sivaraman, & Patel, 2014). If the surgery lasts more than two hours, anti-embolic or
 sequential compressive stockings can be used to prevent DVTs. It is recommended to

reduce the level of Trendelenburg and the duration of the surgical procedure (Coughlin &

Patel, 2011). Each time a patient is in lithotomy and steep Trendelenburg, the patient's

chance of nerve damage, including peripheral nerve, brachial, and ulnar sciatica,

increases 100-fold (McEwen, 1996). When a prostatectomy lasts more than two hours,

the circulator should evaluate the patient's placement and watch for sliding signs. As with

lithotomy, it is critical to keep the patient's natural body position concerning the knees

and hips so that they are not externally or internally twisted (Fawcett, 2004). Placement

involves a collaborative effort by the circulator, surgical technician, anesthesiologist, and

physician. Positioning is critical since the bed cannot be adjusted sans undocking the

patient trolley.

D. Professional and Organizational Implications

Collaboration among anesthesia physicians and proceduralists is necessary for

patient care and optimal outcomes. This concept has gained new significance in

enhanced bronchoscopy and therapeutic anesthesiology. Although atelectasis induced

by anesthesia is widespread, it is often not clinically significant. Except in the case of

advanced assisted bronchoscopic biopsies, anesthetic guidelines significantly impact

the results of other procedures. The operation's success necessitates careful breathing to

minimize undue motion, as per the article of Lundquist et al. (Lundquist, Hedenstierna,

Strandberg, Tokics, & Brismar, 1995)minimize CT-to-body distortion, maintain

dependent regions, and maximize breath-hold methods to avoid atelectasis. Pre-

oxygenation is advised with a FiO2 of 0.6 to 0.8, sustained at the minimum tolerated
 level throughout the surgery (Bowling, Kohan, Walker, Efird, & Or, 2015). Quick

intubation with a more extensive endotracheal tube and non-depolarizing muscle

relaxants is recommended over quick succession. Positive end-expiratory pressure

(PEEP) of up to 10–12 cm H2O and higher tidal volumes aid in maintaining

appropriate lung expansion, assuming the patient can handle them as decided during

recruitment. Breath-holding is required to minimize movement distortion during

intraprocedural scanning, beginning after a normal tidal breath and lasting until

pressures equalize and the scanning loop is completed. Maintaining the proper PEEP

and minimizing motion during breath-hold procedures necessitates using the pressure-

limiting valve. During directed bronchoscopy, these approaches will reduce atelectasis

and CT-to-body deviation, eliminate movement disturbance, and give a cleaner, better

realistic representation (Rothen, et al., 1995). Adhering to these guidelines will

promote a positive operation, hence potentially shortening the time to therapy by

preventing the need for further examinations. The implementation of these techniques

should be left to the judgment of the anesthesiologist and the surgeon; in all

circumstances, the best healthcare judgment should be used to safeguard the safety and

quality of care.

III. Critical Reflection

Robotic surgery has massive benefits, including higher precision, improved

flexibility of motion, better maneuverability, more accessible access, and superior

visibility for the surgeon. Patients with robotic-assisted laparoscopic surgery report less

discomfort, less postoperative healing time, and less bleeding, infection, and deformity.
Robotic-assisted surgery has ushered in a new age of surgical patient care delivery (Kim,

et al., 2020). Continuous learning, in-services, and interaction are critical components of

safe robotic surgery.

Before the operation, the intraoperative fluid should be controlled to reduce face

and airway edema and urine output, which can impair the surgical field. The management

of hypertension can assist limit internal bleeding and prevent vision impairment. After

creating the anastomosis, intravenous fluids and analgesics can be administered as needed

in preparations for extubation. Postoperative problems are uncommon and determined

mainly by the patient's preexisting conditions. Patients having cystoprostatectomy must

ideally be cared for in intensive care units or facilities that provide a comparable quality

of care (Park, et al., 2020). The most frequent postoperative consequence is an ileus of

the stomach. Prolonged recovery of intestinal permeability may cause discomfort,

distention, vomiting, and nausea and must be treated immediately to prevent further

complications. If abdominal perforation develops, management includes nasogastric

dilatation, intravenous fluid rehydration with electrolyte replenishment, and, in a

relatively small percentage of cases, corrective surgery (Kishikawa, et al., 2021). New

techniques provide unique benefits continually, but their widespread adoption in

operative treatment may take some time. By conducting RALP in the prone position,

contemporary surgical robotics systems, make it simple to avoid the risks associated with

lithotomy placement. Despite their acknowledged virtues, the latency between the

availability of novel procedures and their mainstream use appears to agree with prevalent

hypotheses regarding innovative uptake, especially the new medical technology. RALP

offers significant advantages to patients and doctors; its mass acceptance, following the
 previous hypotheses, necessitates more public discussion and local advocates promoting

it.

IV. Conclusion

Potential ethical difficulties arise when the availability of robotic surgical

techniques is unequal (Rothen, et al., 1995). Robotic surgical systems are typically

positioned in densely populated locations within hospitals or academic centers, which

may more readily obtain the funding required to run an automated surgery program.

These facilities also have a sizeable surgical volume linked to improved outcomes. This

has significant consequences for medical centers in less densely populated areas where

surgery numbers may not be adequate to provide optimal results. There were no negative

public statements or replies to media publications detailing RALP for prostate cancer

regarding social acceptance. There were no other societal, regulatory, or ethical

difficulties linked with RALP that were discovered.

Although patients prefer minimally invasive surgical treatments to traditional

open therapies, no data on variations in patient values between minimally invasive

procedures, like RALP, could be found. Companies seeking to generate competition are

actively developing several robotic surgical technologies.

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