Comparing the effect of positioning on cerebral autoregulation during radical prostatectomy: a prospective observational study

Abstract

Purpose Surgery in the prolonged extreme Trendelenburg position may lead to elevated intracranial pressure and compromise cerebral hemodynamic regulation. We hypothesized that robot-assisted radical prostatectomy with head-down tilt causes impairment of cerebral autoregulation compared with open retropubic radical prostatectomy in the supine position. Methods Patients scheduled for elective radical prostatectomy were included at a tertiary care prostate cancer clinic. Continuous monitoring of the cerebral autoregulation was performed using the correlation method. Based on measurements of cerebral oxygenation with near-infrared spectroscopy and invasive mean arterial blood pressure (MAP), a moving correlation coefficient was calculated to obtain the cerebral oxygenation index as an indicator of cerebral autoregulation. Cerebral autoregulation was measured continuously from induction until recovery from anesthesia. Results There was no significant difference in cerebral autoregulation between robot-assisted and open retropubic radical prostatectomy during induction (p = 0.089), intraoperatively (p = 0.162), and during recovery from anesthesia (p = 0.620). Age (B = 0.311 [95% CI 0.039; 0.583], p = 0.025) and a higher difference between baseline MAP and intraoperative MAP (B = 0.200 [95% CI 0.073; 0.327], p = 0.002) were associated with impaired cerebral autoregulation, whereas surgical technique was not (B = 3.339 [95% CI 1.275; 7.952], p = 0.155). Conclusion Compared with open radical prostatectomy in the supine position, robot-assisted surgery in the extreme Trendelenburg position with capnoperitoneum did not lead to an impairment of cerebral autoregulation during the perioperative period in our study population. Trial registration number: DRKS00010014, date of registration: 21.03.2016, retrospectively registered.

Intraoperative impaired cerebrovascular autoregulation and delayed neurocognitive recovery after major oncologic surgery: a secondary analysis of pooled data

“…Pooled data from three prospective observational studies were analysed. The studies were primarily designed to (1) compare cerebrovascular autoregulation (CVA) between robot-assisted radical prostatectomy in the extreme Trendelenburg position and open retropubic surgery in supine position [ 15 ]; (2) describe patterns of functional connectivity measured with 64-channel electroencephalogram and their association with cognitive function in the perioperative period (unpublished data); (3) assess the association between intraoperative CVA and DNCR after major non-cardiac surgery (unpublished data) …”

“…Impaired CVA during head-down position for robot-assisted radical prostatectomy has been observed in a prospective study [ 31 ]. By contrast, our research group has previously shown that open radical prostatectomy in the supine position and robot-assisted surgery in the extreme Trendelenburg position with capnoperitoneum do not differ with regard to CVA impairment [ 15 ]. In contrast to radical prostatectomy, which is recommended as a curative treatment option for patients with localized cancer and a life expectancy of > 10 years, procedures for solid tumors other than prostate cancer are frequently performed at more advanced disease stages and may involve patients with higher perioperative risk [ 32 ].…”

“…We performed a secondary analysis of pooled published and unpublished data from three prospective observational studies. The studies were primarily designed to (1) compare CVA between robot-assisted radical prostatectomy in the extreme Trendelenburg position and open retropubic surgery in the supine position [ 15 ]; (2) describe patterns of functional connectivity measured with a 64-channel electroencephalogram and their association with cognitive function before and after radical prostatectomy (unpublished data); and (3) assess the association between intraoperative CVA and DNCR after major non-cardiac surgery (unpublished data, NCT04101006). Data were collected prospectively between 2015 and 2017 at the Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Germany.…”

“…Cerebrovascular autoregulation was measured continuously during surgery (from incision to closure) using the time-correlation method [ 8 , 15 ]. Cerebrovascular autoregulation is represented by the cerebral oxygenation index (COx), which is calculated from the mean arterial pressure (MAP) and cerebral oxygenation (rSO 2 ).…”

What is new in microcirculation and tissue oxygenation monitoring?

“…Beck et al [ 35 ] hypothesized that an impairment in cerebrovascular autoregulation due to elevated intracranial pressure could be found in patients undergoing robot-assisted radical prostatectomy in the extreme head-down (Trendelenburg) position. Cerebral autoregulation was continuously assessed by calculating the cerebral oxygenation index, but no differences in cerebral autoregulation were demonstrated between robot-assisted (head-down position) and open radical prostatectomy (supine position).…”