Low Intra-Abdominal Pressure with Complete Neuromuscular Blockage Reduces Post-Operative Complications in Major Laparoscopic Urologic Surgery: A before–after Study

Abstract

Most urological interventions are now performed with minimally invasive surgery techniques such as laparoscopic surgery. Combining ERAS protocols with minimally invasive surgery techniques may be the best option to reduce hospital length-of-stay and post-operative complications. We designed this study to test the hypothesis that using low intra-abdominal pressures (IAP) during laparoscopy may reduce post-operative complications, especially those related to reduced intra-operative splanchnic perfusion or increased splanchnic congestion. We applied a complete neuromuscular blockade (NMB) to maintain an optimal space and surgical view. We compared 115 patients treated with standard IAP and moderate NMB with 148 patients treated with low IAP and complete NMB undergoing major urologic surgery. Low IAP in combination with complete NMB was associated with fewer total post-operative complications than standard IAP with moderate NMB (22.3% vs. 41.2%, p < 0.001), with a reduction in all medical post-operative complications (17 vs. 34, p < 0.001). The post-operative complications mostly reduced were acute kidney injury (15.5% vs. 30.4%, p = 0.004), anemia (6.8% vs. 16.5%, p = 0.049) and reoperation (2% vs. 7.8%, p = 0.035). The intra-operative management of laparoscopic interventions for major urologic surgeries with low IAP and complete NMB is feasible without hindering surgical conditions and might reduce most medical post-operative complications.

Perioperative Renal Ultrasonography of Arterio-to-Venous Coupling Predicts Postoperative Complications after Major Laparoscopic Urologic Surgery

“…Moreover, the monophasic IRVF pattern was associated with worst outcomes compared with the continuous or biphasic patterns; these findings are supported by the influence of splanchnic congestion on postoperative complications [23][24][25][26] even if the amount of intraoperative fluid administered and pneumoperitoneum pressures were relatively low, according to the ERAS protocols of our center [27]. Even if differences in the intrabdominal pressures during pneumoperitoneum were statistically different between patients who eventually developed postoperative AKI or any complications compared with those who didn't, they were not predictive of AKI or any complication and we must say that the absolute value of these pressures was very close, and thus unhelpful in the clinical practice.…”

Analgesic Strategies for Urologic Videolaparoscopic or Robotic Surgery in the Context of an Enhanced Recovery after Surgery Protocol: A Prospective Study Comparing Erector Spinae Plane Block versus Transversus Abdominis Plane Block

“…The study involved 190 consecutive patients undergoing any type of major elective urologic surgery by laparoscopic or robotic-assisted techniques. All patients followed a consolidated perioperative ERAS program as previously described [7]. The only exclusion criteria were the inability to perform an inter-fascial blockage due to infection at the injection site, known allergy or hypersensitivity to local anesthetics, or serious heart arrhythmia.…”

“…In accordance with ERAS protocols, the anesthetic and analgesic techniques have been changing for years and nowadays, multimodal strategies for post-operative pain management have been identified in order to spare partially or totally the use of opioids and non-steroid anti-inflammatory drugs (NSAIDs) [6]. Opioids are in fact responsible for nausea, vomiting, or respiratory depression while NSAIDs increase the risk of postoperative acute kidney injury (PO-AKI), especially in urologic patients [6,7].…”

Perioperative Intravenous Amino Acid Infusion in Major Urologic Surgery

“…Post-operative acute kidney injury (PO-AKI) is defined as a decrease in kidney function occurring within seven days from surgery and is one of the most frequent post-operative complications after major abdominal surgery. In major laparoscopic urologic surgery, PO-AKIs have been described to occur in 15.5% of cases [1]. PO-AKIs, diagnosed according to the KDIGO classification [2,3], are associated with an increased risk of short-term adverse outcomes, including dialysis, cardiovascular events, lung injury, delirium and infection; all these adverse events can lead to increased long-term morbidity and mortality [4].…”

“…The latter condition has been recently reported as a risk factor for PO-AKI [8]. Reducing the intra-abdominal pressure and the time in the Trendelenburg position has been adopted to reduce the risk of post-operative complications, especially PO-AKIs [1,[9][10][11].…”