Radical prostatectomy

10 min read Last updated April 8, 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 > 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 & 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&E, coagulation if indicated; ECG; consider echocardiography/cardiopulmonary testing based on risk.
    • Group & 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.
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&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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