Cardiopulmonary Effects of Trendelenburg Positioning in Robotic Assisted Radical Cystectomy

Introduction: Robotic-assisted radical cystectomy (RARC) is increasingly utilized in the management of bladder cancer (BCa) and prior studies have demonstrated steep Trendelenburg positioning can result in significant cardiopulmonary perturbations. We sought to determine the physiologic changes encountered in BCa patients undergoing RARC. Materials and Methods: Consecutive patients undergoing RARC were identified with key intra-operative parameters recorded (end-tidal carbon dioxide tension (EtCO2), peak inspiratory pressure (PIP), and mean arterial pressure (MAP)) and compared between time points throughout the surgery. Multivariate linear regression was used to determine clinical and tumor characteristics associated with significant cardiopulmonary change. Results: 61 patients were included in the analysis. Mean change inEtCO2 (+5.2 mmHg), PIP (+11.2 mmHg), and MAP (+14.2 mmHg) were significantly elevated in Trendelenburg vs. supine positioning, respectively (all p<0.01). Female gender was associated with increased PIP from T1 to T4 (p=0.002) while heavy smoking history resulted in decreased PIP (p=0.02). Age range of 60-69 was associated with significantly lower EtCO2 (p=0.02). There were no significant trends in MAP seen on univariate analysis. On multivariate analysis female gender remained an independent risk for elevated PIP (p=0.048) and increasing age was significantly associated with elevated MAP (p=0.02). One patient required open conversion for poor pulmonary tolerance. Conclusions: Trendelenburg positioning during RARC was associated with significant changes in several perioperative parameters however; all variables remained within clinically allowable ranges. Conversion to open cystectomy in this cohort was rare suggesting the safety of steep Trendelenburg positioning in this highly comorbid population.