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(1) Background: Regional anesthesia, achieved through nerve blocks, has gained widespread acceptance as an effective pain management approach. This research aimed to evaluate the efficacy of laparoscopic (LAP) transversus abdominis plane (TAP) block in patients undergoing laparoscopic radical prostatectomy. (2) Methods: From January 2023 to July 2023, 60 consecutive patients undergoing minimally invasive radical prostatectomy were selected. Patients were split into two groups receiving ultrasound-guided (US) or laparoscopic-guided TAP block. The primary outcome was a pain score expressed by a 0−10 visual analog scale (VAS) during the first 72 h after surgery. (3) Results: Both LAP-TAP and US-TAP block groups were associated with lower pain scores postoperatively. No statistically significant differences were observed between the two groups in surgery time, blood loss, time to ambulation, length of stay, and pain after surgery (all p > 0.2). In the LAP-TAP block group, the overall operating room time was significantly shorter than in the US-TAP block group (140 vs. 152 min, p = 0.04). (4) Conclusions: The laparoscopic approach, compared to the US-TAP block, was equally safe and not inferior in reducing analgesic drug use postoperatively. Moreover, the intraoperative LAP-TAP block seems to be a time-sparing procedure that could be recommended when patient-controlled analgesia cannot be delivered. [ABSTRACT FROM AUTHOR]

Background: The benefits of a valid pneumoperitoneum in laparoscopic surgery are counterbalanced by the possible negative effects of increased abdominal pressure and carbon dioxide (CO2) insufflation, which are crucial factors in causing postoperative pain. The purpose of this work is to evaluate the effectiveness of the valveless trocar (VT) insufflation system in decreasing postoperative pain and influencing operative time, compared to a standard insufflation system. Methods: A systematic research was performed using MEDLINE, EMBASE, Central Cochrane Library, and CINAHL Plus for studies published up to June 2020. Randomized controlled trials (RCTs) on adult population evaluating the effects of VT versus a standard insufflation system in laparoscopic surgery and reporting postoperative pain level and operative time were included in the analysis. Data and study quality indicators were extracted independently by 2 authors using a standardized form. Statistical analysis was based on a random effect model, using the inverse variance method. Results: We identified 3 RCTs for a total of 245 patients. The meta-analysis showed a statistically significant reduction in shoulder pain with the use of VT at 24 hours: mean difference (MD) -7.9% (95% confidence interval [95% CI]: -1.29 to 0.29; z = 3.08; P = .002) and a nonstatistically significant increase in operation time: MD 5.80 (95% CI: -8.93 to 20.54; P = .44). Conclusion: Our study suggests a better shoulder pain control at 24 hours postoperation using new-generation VT for laparoscopic surgery compared to standard insufflation system. Weak evidence of increased operating time with the VT was observed considering only two of the three RCTs. PROSPERO registration number: CRD42020191835. [ABSTRACT FROM AUTHOR]

Background Laparoscopic prostatectomy (LRP) may activate clotting system influencing the risk of perioperative thrombosis in patients with prostate cancer. Moreover, different anaesthetic techniques can also modify coagulant factors. Thus, the aim of this study was to investigate the effects on pro- and anti-coagulant and fibrinolytic factors of two established types of anaesthesia in patients with prostate cancer undergoing elective LRP. Methods 102 patients with primary prostate cancer, who underwent conventional LRP or robotassisted laparoscopic prostatectomy (RALP), were studied and divided into 2 groups to receive total intravenous anesthesia with target-controlled infusion (TIVA-TCI) or balanced inhalation anaesthesia (BAL) prior to surgery. Before the induction of anaesthesia (T0), 1 hr (T1) and 24 hrs post-surgery (T2), some pro-coagulant factors, fibronolysis markers, pselectin and haemostatic system inhibitors were evaluated. Results Both TIVA-TCI and BAL patients showed a marked and significant increase in pro-coagulant factors and consequent reduction in haemostatic system inhibitors in the early post operative period (p ⩽ 0.004 for each markers). Use of RALP showed a significant increase in prothrombotic markers as compared to LRP. In TIVA patients undergoing LRP, a significant reduction of p-selectin levels between T0 and T2 (p = 0.001) was observed as compared to BAL, suggesting a better protective effect on platelet activation of anaesthetic agents used for TIVA. Conclusions Both anaesthetic techniques significantly seem to increase the risk of thrombosis in prostate cancer patients undergoing LRP, mainly when the robotic device was utilized, encouraging the use of a peri-operative thromboembolic prophylaxis in these patients. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the technical feasibility, safety and functional outcomes of zero ischaemia laparoscopic and robotic partial nephrectomy with controlled hypotension for renal tumours larger than 4 cm. Methods: We evaluated 121 consecutive patients with American Society of Anaesthesiologists (ASA) scores 1-2 who underwent laparoscopic ( n = 70) or robotic ( n = 51) partial nephrectomy with controlled hypotension with either tumour size ≤4 cm (group 1, n = 78) or tumour size >4 cm (group 2, n = 43) performed by a single surgeon from December 2010 to December 2011. Operative data, complications, serum creatinine, estimated glomerular filtration rates and effective renal plasma flow calculated from 99mTc-mercaptoacetyltriglycine renal scintigraphy were compared. Differences between groups were evaluated by the Chi-square test and the Student's t test. Results: A significant difference in mean intraoperative blood loss and postoperative complications was found between the two groups: 168 ml (range: 10-600 ml in group 1) and 205 ml (range: 90-700 ml in group 2); p = 0.005, and 6.4 % versus 18.6 %; p = 0.004, respectively. The mean percentage decrease of ERPF of the operated kidney was 1.8 % in group 1 and 4.1 % in group 2. Conclusions: Laparoscopic and robotic partial nephrectomy with controlled hypotension for tumours >4 cm in ASA 1-2 patients was feasible with significant higher intraoperative blood loss and postoperative complications compared to smaller renal masses. The benefits of avoiding hilar clamping to preserve kidney function seem excellent. [ABSTRACT FROM AUTHOR]

Purpose: We evaluated the feasibility and safety of laparoscopic and robotic assisted partial nephrectomy with controlled hypotensive anesthesia to avoid hilar clamping and eliminate renal ischemia. Materials and Methods: A total of 60 patients with renal tumors who were candidates for nephron sparing surgery and had no contraindication to hypotensive anesthesia underwent partial nephrectomy without hilar clamping and with controlled hypotension during tumor excision. A total of 40 laparoscopic partial nephrectomies and 20 robotic assisted partial nephrectomies were done. All patients who were candidates for laparoscopic or robotic assisted partial nephrectomy regardless of tumor site, size or growth pattern were included in study. The surgical field was assessed for bleeding and visibility using a numerical rating scale. Results: Median tumor size was 3.6 cm (range 1.8 to 10), median operative time was 2 hours (range 1 to 3.5), median blood loss was 200 ml (range 30 to 700 ml) and median hospital stay was 3 days (range 3 to 8). All margins were negative. The median duration of controlled hypotension with a median mean arterial pressure of 65 mm Hg (range 55 to 70) was 14 minutes (range 7 to 16). No patient required intraoperative transfusion but 4 (6.6%) required transfusion postoperatively. Complications developed postoperatively in 3 patients, ie port site bleeding, hemorrhage and hematoma, respectively. Median preoperative and postoperative serum creatinine was 0.9 and 1.10 mg/dl, respectively. The median preoperative and postoperative estimated glomerular filtration rate was 87.20 and 75.60 ml/minute/1.73 m2, respectively. Conclusions: Controlled hypotension allowed laparoscopic and robotic assisted partial nephrectomy to be done without renal hilar clamping. All procedures were completed safely and perioperative outcomes are encouraging. [ABSTRACT FROM AUTHOR]

During laparoscopic surgery, the role of PEEP to improve outcome is controversial. Mechanistically, PEEP benefits depend on the extent of alveolar recruitment, which prevents ventilator-induced lung injury by reducing lung dynamic strain. The hypotheses of this study were that pneumoperitoneum-induced aeration loss and PEEP-induced recruitment are inter-individually variable, and that the recruitment-to-inflation ratio (R/I) can identify patients who benefit from PEEP in terms of strain reduction. Sequential study. Operating room. Seventeen ASA I-III patients receiving robot-assisted prostatectomy during Trendelenburg pneumoperitoneum. Patients underwent end-expiratory lung volume (EELV) and respiratory/lung/chest wall mechanics (esophageal manometry and inspiratory/expiratory occlusions) assessment at PEEP = 0 cmH 2 O before and after pneumoperitoneum, at PEEP = 4 and 12 cmH 2 O during pneumoperitoneum. Pneumoperitoneum-induced derecruitment and PEEP-induced recruitment were assessed through a simplified method based on multiple pressure-volume curve. Dynamic and static strain changes were evaluated. R/I between 12 and 4 cmH 2 O was assessed from EELV. Inter-individual variability was rated with the ratio of standard deviation to mean (CoV). Pneumoperitoneum reduced EELV by (median [IqR]) 410 mL [80–770] (p < 0.001) and increased dynamic strain by 0.04 [0.01–0.07] (p < 0.001), with high inter-individual variability (CoV = 70% and 88%, respectively). Compared to PEEP = 4 cmH 2 O, PEEP = 12 cmH 2 O yielded variable amount of recruitment (139 mL [96–366] CoV = 101%), causing different extent of dynamic strain reduction (median decrease 0.02 [0.01–0.04], p = 0.002; CoV = 86%) and static strain increases (median increase 0.05 [0.04–0.07], p = 0.01, CoV = 33%). R/I (1.73 [0.58–3.35]) estimated the decrease in dynamic strain (p ≤0.001, r = −0.90) and the increase in static strain (p = 0.009, r = −0.73) induced by PEEP, while PEEP-induced changes in respiratory and lung mechanics did not. Trendelenburg pneumoperitoneum yields variable derecruitment: PEEP capability to revert these phenomena varies significantly among individuals. High R/I identifies patients in whom higher PEEP mostly reduces dynamic strain with limited static strain increases, potentially allowing individualized settings. • Optimal PEEP for laparoscopy is debated. Aeration loss and recruitment vary among patients, warranting personalized settings. • IIn this study, 17 patients undergoing robot-assisted prostatectomy during Trendelenburg pneumoperitoneum were studied. • Pneumoperitoneum variably reduced FRC. PEEP 12 cmH 2 0 yielded variable recruitment, leading to diverse effects on lung strain. • EELV-derived R/I well reflected the effect of PEEP on lung strain, identifying patients benefiting the most from higher PEEP. [ABSTRACT FROM AUTHOR]

Abstract: Background: Laparoscopic nephroureterectomy (LNU) is increasingly being used instead of open nephroureterectomy (ONU) for the treatment of urothelial carcinoma (UC) of the upper urinary tract (UUT), but the evidence of equal oncologic effectiveness is still lacking. Objective: To present perioperative and oncologic results from a prospective randomised study comparing ONU and LNU. Design, setting, and participants: Eighty patients with nonmetastatic UUT UC and without previous history of UC were enrolled. Of those, 40 patients (group A) randomly received ONU and 40 patients (group B) randomly received LNU. Interventions: ONU was performed through a flank incision with a lower quadrant incision to allow excision of a bladder cuff. Transperitoneal LNU was performed with a four-trocar technique, and bladder cuff was detached with a 10-mm LigaSure device. Measurements: Perioperative data were compared with the student t test. Bladder tumour–free survival (BTFS), metastasis-free survival (MFS), and cancer-specific survival (CSS) curves for both groups were compared with the log-rank test before and after stratifying patients for pT category and tumour grade. Results and limitations: Operative times were comparable, while mean blood loss and mean time to discharge were significantly lower in group B (both p values <0.001). At a median follow-up of 44 mo, BTFS, CSS, and MFS were not significantly different between the two groups (log rank test; BTFS: p =0.86; CSS: p =0.2; MFS: p =0.124). When matched for pT3 and high-grade tumours, CSS and MFS were significantly different between the two groups in favour of ONU (p =0.039 and p =0.004, respectively, for pT3 tumours; p =0.078 and p =0.014, respectively, for high-grade tumours). The limitations of our study include the small sample size, the single-centre experience, the personal choice of laparoscopic technique, and not performing lymphadenectomies. Perioperative data and preliminary oncologic results were presented at 22nd Congress of the European Association of Urology, Berlin, Germany. Conclusions: In patients with organ-confined UUT UCs, LNU has the advantages of minimal invasiveness and oncologic outcomes comparable to those of ONU, while its effectiveness in patients with advanced stage diseases remains to be proven. [Copyright &y& Elsevier]