Trends in Positioning for Robotic Prostatectomy: Results From a Survey of the Endourological Society

Abstract

Purpose: most robot-assisted laparoscopic prostatectomies (RALP) are performed with the patient in lithotomy, carrying risks of positioning-related complications. Newer robot models have allowed for supine positioning, potentially avoiding these pitfalls. We gauged the current sentiment on patient positioning among surgeons who perform robot-assisted surgery. Methods: we surveyed members of the Endourological Society regarding their practice settings and their opinions on positioning for robot-assisted laparoscopic prostatectomy. Summary statistics were reviewed and data were analyzed using chi-square tests and t-tests. Results: our survey had 92 eligible respondents. The majority were fellowship-trained, with 51% trained in robotics and 57% practicing in the U.S. with a mean of 13 years of practice. Most were working in an academic setting (69%) and performing at least 25 robotic prostatectomies yearly. 28 respondents used the Intuitive Surgical Inc. da Vinci® Xi™ exclusively (30%), and nearly two-thirds used it sometimes. Although 54% of respondents considered using supine positioning, less than half of these surgeons used it regularly, while 75% overall preferred lithotomy. A majority attributed this choice to surgical team familiarity with lithotomy positioning. Surgeons in the U.S. and those using the da Vinci® Xi™ were more likely to consider supine positioning. Conclusions: lithotomy position is the standard for RALP procedures; nonetheless, it poses significant risks that might be avoided with supine positioning. Our survey suggests that, although supine positioning has been considered, it has not gained momentum in practice. Addressing factors of inertia in training practices and one’s surgical team might allow for novel and safer approaches.

Perspective Chapter: Perioperative Considerations for Patients Undergoing Robotic Radical Prostatectomy

“…Close communication between the surgeon and anesthetist ensures optimal patient positioning for operative efficiency. The most common positioning for RARP is lithotomy with Trendelenburg with the docking cart between the legs or at the patients' side [29].…”

“…Lithotomy positioning and any exaggerated stretch or compression caused by the tilting into Trendelenburg position is associated with a significant risk of lower limb neuropraxia [29]. The most common lower limb neuropathies associated with lithotomy procedures are common perineal and sciatic [32].…”

Editorial Comment to Efficacy of the opened legs position for protecting against postoperative rhabdomyolysis after robot‐assisted radical prostatectomy: A propensity score‐matched analysis of perioperative outcomes

“…The safety and feasibility of radical prostatectomy in supine position is now well established and has been shown to shorten and simplify the setup time, along with significantly reduced position related injuries 3 . A recent survey of urologists showed that the majority (75%) of the respondents were performing radical prostatectomy in the lithotomy position and only 3% used the split leg position and 22% used the supine position 4 . Surgical team familiarity was the commonest reason for continuing with the lithotomy position.…”