Radical prostatectomy

10 min read Last updated April 9, 2026

Surgical approach

  • Indication: curative surgery for localised prostate cancer ± pelvic lymph node dissection
  • Approaches
    • Open retropubic (lower midline incision, extraperitoneal/retropubic space, prostate + seminal vesicles removed, vesico-urethral anastomosis, pelvic drain, urethral catheter)
    • Laparoscopic / robot-assisted (RARP): pneumoperitoneum + steep Trendelenburg, port placement, dissection and anastomosis intracorporeally, usually less blood loss but longer time and more physiological disturbance from position/CO2
    • Perineal (less common, limited lymph node access)
  • Key intra-operative features relevant to anaesthesia
    • Potential for significant venous bleeding (dorsal venous complex, pelvic venous plexus), especially open surgery
    • RARP: steep head-down (often 25–45°) + pneumoperitoneum (10–15 mmHg) for prolonged periods
    • Urinary tract reconstruction: vesico-urethral anastomosis, urethral catheter left in situ (often 7–14 days)

Anaesthetic management

  • Type of anaesthesia
    • General anaesthesia is standard (especially for RARP). Regional techniques used as adjuncts for analgesia (intrathecal opioid, epidural, TAP/rectus sheath blocks, local infiltration).
  • Airway
    • Cuffed ETT recommended (Trendelenburg + pneumoperitoneum + long duration, aspiration risk, need for controlled ventilation). SGA generally inappropriate.
  • Duration
    • Open: commonly ~2–4 hours (variable with lymph node dissection/complexity).
    • RARP: commonly ~3–6 hours (learning curve may be longer).
  • Pain severity
    • Moderate (open &gt, robotic). Visceral pain + catheter discomfort, consider multimodal analgesia and antimuscarinic/antispasmodic strategies if needed.
  • Monitoring and access
    • Standard monitoring + temperature, consider arterial line for major comorbidity, expected blood loss, or prolonged RARP with steep Trendelenburg.
    • Two good IV cannulae, group &amp, save/crossmatch depending on approach and local practice.
  • Ventilation strategy (RARP)
    • Pressure-controlled or volume-controlled with attention to peak/plateau pressures, apply PEEP, accept permissive hypercapnia if safe, recruitment manoeuvres as needed.
    • Trendelenburg + pneumoperitoneum reduce FRC and compliance, higher airway pressures and V/Q mismatch are common.
  • Fluid and haemodynamic strategy
    • Avoid excessive crystalloid (facial/airway oedema in steep Trendelenburg, pulmonary oedema risk). Use goal-directed approach where available.
    • RARP: pneumoperitoneum increases SVR and may reduce venous return, Trendelenburg increases venous return and CVP, interpret CVP cautiously.
  • Positioning and pressure care
    • Steep Trendelenburg with shoulder supports/straps: protect brachial plexus, eyes, pressure points, ensure secure fixation to prevent sliding.
    • Lithotomy risks: common peroneal nerve injury, compartment syndrome, DVT, limit time, pad well, check legs after positioning.
  • PONV prophylaxis
    • Often high-risk due to pneumoperitoneum and opioids: use multimodal prophylaxis (e.g., dexamethasone + ondansetron ± droperidol) and consider TIVA.
  • Extubation considerations (RARP)
    • Assess for airway oedema (face/tongue swelling, conjunctival oedema, prolonged steep head-down, large fluids). Consider cuff leak test, extubate fully awake, low threshold for delayed extubation/HD/ICU if concerns.

Pre-operative assessment

  • Patient factors
    • Typically older males with cardiovascular disease, diabetes, obesity, OSA, assess functional capacity and frailty.
    • Smoking/COPD: important for pneumoperitoneum/Trendelenburg tolerance.
  • Cancer and prior treatments
    • Androgen deprivation therapy: metabolic syndrome, anaemia, reduced muscle mass, consider cardiovascular risk.
    • Previous pelvic surgery/radiotherapy: may increase operative time, bleeding, and postoperative pain/ileus.
  • Medications and anticoagulation
    • High VTE risk surgery: plan peri-operative anticoagulant/antiplatelet management, ensure neuraxial safety if epidural/spinal opioid planned.
  • Investigations
    • FBC (anaemia), U&amp,E, coagulation if indicated, ECG, consider echocardiography/cardiopulmonary testing based on risk.
    • Group &amp, save, crossmatch depending on open vs RARP and local transfusion triggers.

Intra-operative physiology (pneumoperitoneum + steep Trendelenburg)

  • Respiratory effects
    • ↓ FRC, ↓ compliance, ↑ atelectasis, ↑ airway pressures, V/Q mismatch, hypercapnia from CO2 absorption.
    • Increased risk in obesity/OSA/COPD, consider higher PEEP, recruitment, and careful titration of ventilation.
  • Cardiovascular effects
    • Pneumoperitoneum: ↑ SVR/MAP, may ↓ venous return and CO (especially hypovolaemia/right heart disease).
    • Trendelenburg: ↑ venous return and CVP, may worsen cardiac filling pressures, interpret CVP as positional/pressure-dependent rather than volume status.
  • Neurological/ocular effects
    • ↑ intracranial pressure and intraocular pressure, rare risk of postoperative visual loss/ischemic optic neuropathy (prolonged duration, hypotension, anaemia, raised venous pressure).
    • Avoid excessive hypotension, maintain perfusion, protect eyes, avoid external pressure on globes.
  • Renal effects
    • Pneumoperitoneum can reduce renal blood flow and urine output, oliguria may be physiological—treat cause (pressure, haemodynamics) rather than chasing urine output with fluid boluses.

Analgesia strategy

  • Multimodal baseline
    • Paracetamol + NSAID (if renal function/bleeding risk acceptable) + opioid as required, consider gabapentinoids cautiously (sedation in older/OSA).
  • Neuraxial/blocks
    • Open surgery: thoracic/lumbar epidural can provide excellent analgesia and reduce opioids but must balance hypotension, mobilisation, and anticoagulation timing.
    • Intrathecal opioid (e.g., diamorphine/morphine) can be useful for both open and RARP, monitor for delayed respiratory depression.
    • RARP: TAP/rectus sheath blocks or port-site infiltration may help, pain often less than open but catheter discomfort common.
  • Catheter-related discomfort
    • Bladder spasm/urgency: consider antimuscarinic (e.g., oxybutynin) or other local protocols, ensure catheter patency and avoid traction.

Blood loss and transfusion considerations

  • Expected blood loss
    • Open retropubic: can be moderate–major (wide variation).
    • RARP: typically lower blood loss but not negligible, venous bleeding can be brisk if pneumoperitoneum lost or major venous injury.
  • Strategies
    • Ensure adequate IV access, consider cell salvage (often acceptable in cancer surgery with appropriate filtration and local policy).
    • Maintain normothermia, correct coagulopathy, use TXA per local protocol/risk assessment.

Post-operative care

  • Destination
    • Most to PACU then ward, consider HDU/ICU for major comorbidity, significant blood loss, difficult ventilation, or airway oedema concerns after prolonged steep Trendelenburg.
  • Key complications to monitor
    • Bleeding/haematoma, anastomotic leak, ileus, infection, VTE, urinary retention/blocked catheter, pain and PONV.
    • RARP-specific: facial/airway oedema, corneal abrasion, neuropraxia, rare compartment syndrome (legs).
  • VTE prophylaxis
    • High-risk surgery: mechanical + pharmacological prophylaxis unless contraindicated, coordinate with neuraxial catheter management.

Test yourself…

You are anaesthetising a 72-year-old man for robot-assisted radical prostatectomy. What are your main anaesthetic concerns and plan?

Structure: patient factors → effects of pneumoperitoneum/Trendelenburg → monitoring/access → ventilation/fluids → positioning/eye/nerve protection → emergence.

  • Pre-op: assess cardiorespiratory reserve (IHD, HF, COPD, obesity/OSA), anaemia, anticoagulants, discuss risks of prolonged head-down and postoperative airway swelling.
  • GA with cuffed ETT, controlled ventilation, consider TIVA to reduce PONV, neuromuscular blockade to facilitate surgical conditions.
  • Monitoring: standard + temperature, consider arterial line (comorbidity/prolonged case/expected instability). Two IV cannulae, G&amp,S ± crossmatch.
  • Ventilation: expect ↓ compliance and ↑ airway pressures, use PEEP, recruitment, adjust minute ventilation for CO2, consider pressure-controlled ventilation.
  • Haemodynamics/fluids: avoid fluid overload (airway oedema), treat hypotension with vasopressors rather than large boluses, interpret CVP with caution.
  • Positioning: steep Trendelenburg + lithotomy—secure patient, pad pressure points, protect eyes, avoid shoulder braces causing brachial plexus injury, check legs for peroneal nerve pressure.
  • Emergence: assess for airway oedema (cuff leak, facial/tongue swelling), extubate awake, consider HDU if concerns.
Describe the physiological effects of pneumoperitoneum and steep Trendelenburg relevant to anaesthesia.

Separate pneumoperitoneum effects from position, then combine and state clinical implications.

  • Respiratory: CO2 absorption → ↑ PaCO2/EtCO2, ↑ airway pressures, ↓ compliance and FRC, atelectasis and V/Q mismatch, risk greatest in obesity/COPD.
  • Cardiovascular: pneumoperitoneum ↑ SVR and MAP, may ↓ venous return and CO (especially hypovolaemia), Trendelenburg ↑ venous return/CVP and may increase cardiac filling pressures.
  • CNS/eye: ↑ ICP and ↑ IOP, conjunctival/facial oedema, rare risk of visual complications—avoid hypotension/anaemia and protect eyes.
  • Renal/splanchnic: reduced renal blood flow and urine output, avoid reflex fluid loading if haemodynamics acceptable.
How would you ventilate a patient during RARP if airway pressures rise significantly after insufflation and Trendelenburg?

Aim: maintain oxygenation/ventilation while limiting barotrauma and haemodynamic compromise.

  • Check basics: ETT position (head-down can advance tube), circuit obstruction/kink, bronchospasm, pneumothorax (rare), adequacy of paralysis.
  • Optimise ventilator settings: consider pressure-controlled ventilation, increase PEEP cautiously, recruitment manoeuvres, adjust I:E, accept modest permissive hypercapnia if appropriate.
  • Increase minute ventilation to manage CO2, monitor plateau pressures and driving pressure, target lung-protective tidal volumes (e.g., 6–8 mL/kg IBW).
  • Liaise with surgeons: reduce insufflation pressure if possible, temporary desufflation if severe, consider reducing Trendelenburg angle if feasible.
What are the key positioning complications in radical prostatectomy and how do you prevent them?

Think: steep Trendelenburg + lithotomy + long duration.

  • Nerve injuries: brachial plexus (shoulder braces/arm abduction), ulnar nerve, common peroneal nerve (fibular head), femoral nerve stretch.
  • Eye injury: corneal abrasion, increased IOP, avoid external pressure on eyes, tape lids, lubricate, regular checks.
  • Pressure/compartment: prolonged lithotomy → lower limb compartment syndrome, ensure padding, avoid excessive flexion, minimise duration, maintain perfusion, reassess legs after positioning and before wake-up.
  • Sliding/falls: secure patient with appropriate straps, ensure table tilt safety, confirm all lines/ETT secured before docking robot.
A common FRCA viva theme: discuss extubation and postoperative airway concerns after prolonged steep Trendelenburg.

Main issue: airway oedema and safe extubation planning.

  • Risk factors: prolonged steep Trendelenburg, high fluid balance, obesity/OSA, difficult airway, long pneumoperitoneum time.
  • Assessment: facial/tongue swelling, conjunctival oedema, cuff leak test, consider direct laryngoscopy only if necessary and safe.
  • Plan: extubate fully awake with head-up positioning, ensure full reversal of NMB, have reintubation plan (video laryngoscope, bougie) and consider delayed extubation/ICU if doubt.
  • Post-op: monitor for stridor/obstruction, consider nebulised adrenaline/steroids per local practice if airway swelling suspected.
Discuss analgesic options for open vs robot-assisted radical prostatectomy, including pros/cons of epidural and intrathecal opioid.

Compare surgical pain burden and balance against anticoagulation and mobilisation.

  • Open: more painful, epidural provides excellent dynamic analgesia and may reduce systemic opioids but risks hypotension, urinary retention (less relevant with catheter), motor block, and neuraxial haematoma with anticoagulation.
  • Intrathecal opioid: simple, effective, risks pruritus, PONV, urinary retention (again catheterised), and delayed respiratory depression—needs monitoring and opioid-sparing strategy.
  • RARP: often moderate pain, multimodal + local infiltration/TAP may suffice, focus on catheter discomfort and PONV prevention.
How would you manage significant venous bleeding during radical prostatectomy?

Priorities: call for help, resuscitate, correct coagulopathy, coordinate with surgeon.

  • Immediate actions: inform surgeon, increase FiO2, ensure large-bore IV access, send urgent bloods (Hb, coag), activate major haemorrhage protocol if needed.
  • Resuscitation: balanced blood component therapy guided by labs/TEG/ROTEM, calcium replacement, maintain normothermia, consider TXA per protocol.
  • Haemodynamics: vasopressors/inotropes as required, avoid excessive crystalloid.
  • Surgical factors: in RARP, loss of pneumoperitoneum may worsen venous bleeding—re-establish pressure if appropriate, consider conversion to open if uncontrolled.
What are the causes of raised end-tidal CO2 during RARP and how would you respond?

Think: increased production/absorption, reduced elimination, equipment issues.

  • Causes: CO2 absorption from pneumoperitoneum, hypoventilation due to reduced compliance/high pressures, rebreathing (exhausted soda lime/valve fault), malignant hyperthermia (rare), increased metabolic rate/sepsis/thyrotoxicosis (rare).
  • Response: check circuit/ventilator, increase minute ventilation, optimise lung mechanics (PEEP/recruitment), ask surgeon to reduce insufflation pressure or pause insufflation if severe, consider ABG to confirm PaCO2 and acid–base status.
Discuss VTE risk and prophylaxis issues in radical prostatectomy, including interaction with neuraxial techniques.

Pelvic cancer surgery + immobility = high VTE risk, neuraxial requires strict anticoagulation timing.

  • Risk: pelvic malignancy surgery, long duration, lithotomy, older age, consider extended prophylaxis per local/urology pathways.
  • Prophylaxis: mechanical (TED/SCD) + LMWH/DOAC per protocol, early mobilisation and hydration.
  • Neuraxial: follow national guidance for timing of LMWH/antiplatelets with insertion/removal, document plan clearly, avoid neuraxial if anticoagulation cannot be safely managed.
Previous FRCA-style topic: Explain why urine output may fall during pneumoperitoneum and how you would manage oliguria intra-operatively.

Differentiate physiological oliguria from hypovolaemia/renal injury.

  • Mechanisms: increased intra-abdominal pressure reduces renal blood flow, neurohumoral responses (ADH/RAAS), possible reduced CO in susceptible patients.
  • Management: assess haemodynamics, depth of anaesthesia, bleeding, check catheter patency, consider reducing insufflation pressure, treat hypotension with vasopressors if appropriate, avoid indiscriminate fluid boluses.
  • Investigate: ABG/lactate, creatinine trend post-op, consider renal-protective strategies (avoid nephrotoxins, maintain perfusion).
You are called to recovery: the patient has stridor after RARP extubation. What is your differential and immediate management?

Treat as airway emergency, consider oedema, laryngospasm, obstruction, residual NMB.

  • Differential: laryngeal oedema (Trendelenburg/fluid overload), laryngospasm, residual neuromuscular blockade, opioid-induced hypoventilation, haematoma/neck swelling (rare), aspiration/bronchospasm.
  • Immediate management: call for help, high-flow O2, jaw thrust + CPAP, assess consciousness and TOF, give reversal if residual block suspected, treat laryngospasm (CPAP, deepen anaesthesia, suxamethonium if needed).
  • If oedema suspected: nebulised adrenaline, consider IV steroid, prepare for reintubation with difficult airway equipment, consider ICU.

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