Influence of Trendelenburg position and pneumoperitoneum on the cardiovascular system during robotic-assisted radical prostatectomy

Introduction. Prostate cancer remains one of the most common malignant neoplasms of the genitourinary system. Robot-assisted radical prostatectomy (RARP) is currently considered the most effective option for the treatment of this pathology. Special conditions of this operation, such as long-term stay of the patient in the Trendelenburg position and pneumoperitoneum, affect blood pressure, vascular resistance and inotropic function of the heart. The clinical significance of this effect remains poorly understood. The aim of the study was to systematize new information about hemodynamic disorders in patients with pneumoperitoneum in the Trendelenburg position in RARP. Materials and methods. The search for relevant studies published before may 2019 was conducted in the electronic databases PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Google Scholar using the keywords: «prostatectomy», «robotic surgery», «robotic assisted», «robotic laparoscopic radical prostatectomy», «pneumoperitoneum», «Trendelenburg position», «hemodynamics», «hemodynamic changes», «cardiac function», «cardiovascular function» without restrictions on the publication language. Forty one studies were identified, of which 15 were selected according to pre-defined inclusion criteria. Results. Most studies revealed an increase in arterial and central venous pressure in patients with pneumoperitoneum in the Trendelenburg position. Changes in stroke volume and cardiac output were multidirectional. There was also an increase in pulmonary artery pressure and filling pressure, a decrease in the aortic diameter and an increase in vascular resistance, a deterioration in central hemodynamic parameters, and increased microcirculation. Eleven studies did not show a negative effect of the Trendelenburg position and pneumoperitoneum on the cardiovascular system. The developed changes were easily controlled during anesthesia, and in the postoperative period, the indicators of the cardiovascular system returned to normal. In 4 studies, the negative impact of these factors was noted: the development of mitral valve dysfunction, a significant prolongation of the QT interval and an increase in blood pressure, and hemodynamic instability. Conclusions. The position of the Trendelenburg and pneumoperitoneum and in RARP are accompanied by hemodynamic disorders, most of which are controlled and reversible. Further studies with a longer follow-up period are needed to determine their clinical safety.