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Article

Impact of Low- Versus Standard-Pressure Pneumoperitoneum on Postoperative Recovery in Patients with Obesity Undergoing Robot-Assisted Radical Prostatectomy: A Retrospective Cohort Study

by
Resul Sobay
*,
Hasan Samet Güngör
,
Abdurrahman İnkaya
,
Murat Beyatlı
,
Ahmet Tahra
and
Eyüp Veli Küçük
Department of Urology, Umraniye Training and Research Hospital, 34764 Istanbul, Turkey
*
Author to whom correspondence should be addressed.
Medicina 2025, 61(7), 1253; https://doi.org/10.3390/medicina61071253
Submission received: 31 May 2025 / Revised: 29 June 2025 / Accepted: 8 July 2025 / Published: 10 July 2025
(This article belongs to the Special Issue Robot-Assisted Urologic Cancer Surgery: Current Challenges and Future Perspectives)
Browse Figure
Versions Notes

Abstract

Background and Objectives: Low-pressure pneumoperitoneum (PP) during robot-assisted radical prostatectomy (RARP) has been shown to improve postoperative recovery in patients with non-obesity. However, its efficacy in individuals with obesity remains unclear. This study aimed to evaluate postoperative outcomes in patients with obesity undergoing RARP with low-pressure (7 mmHg) versus standard-pressure (12 mmHg) PP. Materials and Methods: In this retrospective cohort study, 130 patients with obesity (BMI > 30 kg/m2) undergoing RARP were divided into low-pressure (n = 60) and standard-pressure (n = 70) groups. Postoperative recovery was assessed using the Quality of Recovery-15 (QoR-15) questionnaire on postoperative days (POD) 1, 3, and 30. Secondary outcomes included surgical workspace (SWS) scores, operative time, blood loss, intraoperative and postoperative complications, hospital stay, and pathological results. ANCOVA and chi-square tests were used for analysis. Results: QoR-15 scores were significantly higher in the low-pressure group on POD1 (123.58 vs. 111.41), POD3 (128.37 vs. 116.41), and POD30 (132.88 vs. 125.61; p < 0.001). Operative time (98.5 vs. 71.57 min; p < 0.001) and blood loss (129 vs. 97.07 mL; p = 0.039) were higher in the low-pressure group. SWS scores were lower in the low-pressure group (p < 0.001). There were no significant differences between groups in complication rates, hospital stay, or positive surgical margins. Conclusions: In patients with obesity undergoing RARP, low-pressure PP improves postoperative recovery without increasing complications. Despite longer operative times and higher blood loss, this approach is a viable option to enhance recovery in this population.

1. Introduction

Prostate cancer is a prevalent malignancy among men, and robot-assisted radical prostatectomy (RARP) is widely used for localized disease due to its precision and lower morbidity compared with open surgery [1]. During RARP, standard pneumoperitoneum (PP) pressure (12–15 mmHg) ensures adequate surgical workspace. However, this may exacerbate cardiopulmonary and inflammatory responses, particularly in patients with obesity [2]. Obesity—an increasingly prevalent comorbidity among patients with prostate cancer—reduces abdominal compliance and increases surgical risk [3]. Patients with obesity undergoing RARP face unique challenges including altered anatomical landmarks, increased visceral fat, reduced abdominal compliance, and heightened risk of perioperative complications. These factors significantly impact surgical visualization, workspace adequacy, and postoperative recovery trajectories [4]. Recent studies have highlighted the correlation between BMI and prostate volume, which significantly affects surgical complexity and workspace quality [5].
While low-pressure PP (6–8 mmHg) has been shown to improve recovery in patients with non-obesity, its efficacy in the obese population remains underexplored [6]. This study aimed to investigate whether low-pressure PP (7 mmHg) improves postoperative quality of recovery compared with standard-pressure PP (12 mmHg) in patients with obesity undergoing RARP, using the QoR-15 questionnaire and intraoperative outcomes.

2. Materials and Methods

This retrospective cohort study was conducted at Ümraniye Training and Research Hospital, a tertiary referral center in Istanbul, Turkey. One hundred and thirty male patients with obesity (BMI > 30 kg/m2) who underwent RARP between January 2023 and December 2024 were included. Patient assignment to low-pressure versus standard-pressure groups was based on chronological periods: standard-pressure procedures were performed from January 2023 to June 2023, while low-pressure procedures were performed from July 2023 to December 2024. Patients were divided into two groups based on PP pressure: low-pressure (7 mmHg, n = 60) and standard-pressure (12 mmHg, n = 70). This study was approved by the Ethics Committee of University of Health Sciences Ümraniye Training and Research Hospital(Approval No: 2025/58, Approval Date: 13 March 2025).
Inclusion criteria were histologically confirmed prostate cancer and BMI > 30 kg/m2. Exclusion criteria included prior pelvic radiotherapy or inability to complete the QoR-15 questionnaire.
The primary outcome was the postoperative quality of recovery, assessed using the 15-item Quality of Recovery-15 questionnaire (QoR-15) on postoperative days (POD) 1, 3, and 30. The QoR-15 evaluates five domains: pain, physical comfort, physical independence, psychological support, and emotional state, with scores ranging from 0 to 150 [5]. Secondary outcomes included surgical workspace (SWS) score (rated 3–5 by the surgeon), operative time (minutes), intraoperative blood loss (mL), number of retrieved lymph nodes, postoperative complications (graded using the Clavien–Dindo classification), length of hospital stay (days), and histopathological outcomes (pathological stage, ISUP grade, margin status).
All procedures were performed using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) by a surgeon with experience in over 1000 RARP cases. PP pressure was set using a CO2 insufflator (ENDOFLATOR; Karl Storz, Tuttlingen, Germany).
Data were collected from electronic medical records. QoR-15 questionnaires were administered in person on POD1 and POD3, and via telephone on POD30.
The sample size was calculated to detect a clinically meaningful 8-point difference in QoR-15 scores between low- and standard-pressure groups, based on the minimal clinically important difference (MCID) for QoR-15 [7]. Assuming a standard deviation of 15, 80% power, and 5% type I error (two-tailed), approximately 56 patients per group were required. To accommodate potential data loss in the retrospective design (estimated at 20%), the target sample size was set at 140 patients.
Normality was assessed using the Shapiro–Wilk test. Continuous variables were compared using independent t-tests or ANOVA; categorical variables were analyzed using chi-square, Fisher–Freeman–Halton, or Fisher’s exact tests. Analysis of covariance (ANCOVA) was used to adjust QoR-15 scores for BMI. Missing data (<5%) were handled with listwise deletion. The randomness of missing data was verified using the Shapiro–Wilk test (p > 0.05). A p-value < 0.05 was considered significant. All analyses were performed using SPSS v.28 (IBM Corp., Armonk, NY, USA).

3. Results

Baseline characteristics were comparable between the groups in terms of age, PSA level, prostate volume, hypertension, diabetes mellitus, prior abdominal surgery, clinical T stage, and ISUP grade (p > 0.05; Table 1). However, the low-pressure group had a significantly higher mean BMI (33.32 ± 2.42 vs. 32.16 ± 1.33 kg/m2; p = 0.001).
QoR-15 data were missing for three patients (2.1%) on POD1, two patients (1.4%) on POD3, and five patients (3.5%) on POD30, primarily due to incomplete questionnaire responses. As the missing rate was low and confirmed to be random (Shapiro–Wilk test, p > 0.05), these cases were excluded using listwise deletion. Operative time and blood loss data were completed for all patients. A total of 130 patients (60 in the low-pressure group and 70 in the standard-pressure group) were included in the final analysis.
The low-pressure group exhibited significantly higher QoR-15 scores at POD1 (123.58 ± 3.16 vs. 111.41 ± 2.52), POD3 (128.37 ± 2.81 vs. 116.41 ± 2.64), and POD30 (132.88 ± 2.82 vs. 125.61 ± 3.04; all p < 0.001; Figure 1). Domain-specific analysis revealed improvements in pain, physical comfort, psychological support, and emotional state across all time points (p < 0.001), while physical independence differed only on POD3 (p = 0.005; Table 2).
Among patients who underwent lymph node dissection, the mean number of retrieved lymph nodes was comparable between groups (low-pressure: 12.8 ± 4.2 vs. standard-pressure: 13.1 ± 3.8; p = 0.697).
Operative time was significantly longer in the low-pressure group (98.5 ± 16.5 vs. 71.57 ± 12.02 min; p < 0.001), and intraoperative blood loss was higher (129 ± 108.73 vs. 97.07 ± 48.4 mL; p = 0.039; Table 3). SWS scores were lower in the low-pressure group, with 53.3% scoring SWS 3 compared with 0% in the standard-pressure group (p < 0.001). Patients with SWS 3 had higher BMI (p = 0.015) and a history of abdominal surgery (p = 0.004).
No differences were observed between the groups in terms of hospital stay (2.3 ± 0.83 vs. 2.09 ± 0.33 days; p = 0.064), rate of lymph node dissection (50.0% vs. 44.3%; p = 0.515), positive surgical margins (13.3% vs. 8.6%; p = 0.383), postoperative transfusion rates (5% vs. 1.4%; p = 0.335), or Clavien–Dindo complication grades (p = 0.185). The low-pressure group had a higher proportion of pT2a (23.3% vs. 8.6%) and ISUP grade 1 (65.0% vs. 47.1%) tumors, while the standard-pressure group had more pT2c (65.7% vs. 45.0%) and ISUP grade 2 tumors (18.6% vs. 6.7%; p = 0.017 and p = 0.037, respectively; Table 3).

4. Discussion

This study is the first to evaluate low-pressure (7 mmHg) versus standard-pressure (12 mmHg) PP during RARP in patients with obesity (BMI > 30 kg/m2), a population with unique anatomical and physiological challenges. Our findings demonstrate that low-pressure PP significantly improves postoperative quality of recovery, as measured by the QoR-15 questionnaire, on POD 1, 3, and 30, without an increase in complication rates (Figure 1). However, longer operative times, increased intraoperative blood loss, and reduced SWS scores highlight trade-offs that require careful consideration [1,2]. These results position low-pressure PP as a transformative strategy for optimizing outcomes in high-risk patients in line with enhanced recovery after surgery (ERAS) principles [8].
The superior QoR-15 scores in the low-pressure group, particularly in pain, physical comfort, psychological support, and emotional state domains, suggest that lower insufflation pressure may mitigate the physiological stress of laparoscopy. Preclinical studies indicate that higher insufflation pressure induces peritoneal stretch, triggering the release of pro-inflammatory cytokines (e.g., IL-6, TNF-α) and oxidative stress that exacerbate postoperative pain and delayed recovery [9,10]. In patients with obesity, who already exhibit baseline inflammation due to adipose tissue, low-pressure PP likely attenuates these responses, which may explain the sustained improvements in QoR-15 scores observed in our cohort [11]. Notably, physical independence did not differ at POD1 and POD30, possibly due to the limited sensitivity of this domain in early recovery or the confounding effect of obesity-related mobility constraints [12]. These findings extend prior evidence from non-obese populations, where low-pressure PP improved early pain outcomes but lacked long-term assessment [13].
The significant BMI difference between our study groups (33.32 vs. 32.16 kg/m2) represents a potential confounder that may have influenced our results. Higher BMI is associated with increased abdominal wall thickness, altered respiratory mechanics, and greater inflammatory burden, all of which could independently affect recovery outcomes [14]. While we used ANCOVA to adjust for BMI differences, residual confounding cannot be entirely excluded, and this limitation should be considered when interpreting our findings.
Our results align with randomized trials and meta-analyses in non-obese RARP cohorts. For instance, Alhusseinawi et al. reported a 10-point QoR-15 improvement with low-pressure PP (8 mmHg) but excluded patients with BMI > 30 kg/m2 [6]. Similarly, Ferroni and Abaza demonstrated reduced pain with ultra-low-pressure PP (6 mmHg), yet their cohort was limited to patients with non-obesity [13]. A meta-analysis by El-Taji et al. found no differences in complications or oncologic outcomes between low- and standard-pressure PP, consistent with our data [15]. Unlike these studies, our focus on patients with obesity addresses a critical gap, as obesity increases laparoscopic complexity due to reduced abdominal compliance and excess visceral fat [3]. The absence of increased complications in our low-pressure group refutes concerns that reduced workspace compromises surgical safety, a hypothesis raised in the earlier laparoscopic literature [16].
The increased operative time (mean difference: 26.93 min) and blood loss (mean difference: 31.93 mL) in the low-pressure group reflect the reduced tamponade effect on venous bleeding and a narrower visual field, necessitating meticulous dissection [17]. These findings are consistent with those of Rohloff et al., who noted a 20 min increase in operative time with low-pressure PP [18]. However, the lack of increased transfusion rates or prolonged hospital stays suggests that these differences are clinically negligible [19]. Surgeons adopting low-pressure techniques should be aware of these challenges, particularly in patients with BMI > 35 kg/m2 or prior abdominal surgeries, who exhibited lower SWS scores in our cohort [20]. Training in advanced visualization techniques or using high-definition imaging systems may mitigate these limitations [21].
The substantial proportion of patients (53.3%) with an SWS score of 3 in the low-pressure group raises important concerns about the technical feasibility and generalizability of this approach. An SWS score of 3 indicates significantly compromised surgical workspace, which may limit the technique’s applicability, particularly in less experienced centers or in patients with higher BMI or previous abdominal surgery. This finding suggests that low-pressure pneumoperitoneum should be implemented with careful patient selection and adequate surgical expertise [22].
The comparable lymph node retrieval rates between groups (12.8 vs. 13.1 nodes) provide reassurance that oncologic adequacy is maintained despite reduced workspace. This finding suggests that, despite the reduced surgical workspace in the low-pressure group, lymph node identification and dissection were not significantly compromised, possibly due to the surgeon’s experience. Future implementation of low-pressure techniques might benefit from the routine incorporation of enhanced visualization techniques like free-indocyanine green and fluorescence imaging, particularly in patients with obesity where anatomical identification can be challenging [23,24].
Despite reduced SWS, oncologic outcomes, including positive surgical margins (13.3% vs. 8.6%), were comparable between groups, affirming the oncologic safety of low-pressure PP [25]. The higher proportion of pT2a and ISUP 1 tumors in the low-pressure group, contrasted with the greater frequency of pT2c and ISUP 2 in the standard-pressure group, may reflect selection bias or underlying differences in tumor biology [26]. Patients with obesity often present with less aggressive prostate cancer, potentially explaining these histopathological variations [27]. The higher proportion of lower grade tumors in the low-pressure group may reflect selection bias or temporal changes in patient characteristics over the study period. Future prospective studies should include comprehensive preoperative imaging with multiparametric MRI and standardized biopsy protocols to minimize such bias [28]. Future studies should explore whether low-pressure PP influences pathological staging through altered intraoperative dynamics, such as reduced tissue manipulation [29].
The integration of low-pressure PP into ERAS protocols offers a patient-centered approach, particularly for patients with obesity at risk of delayed recovery [8]. Clinically, it should be prioritized for patients with high BMI and low-risk prostate cancer, where extended operative times pose minimal risk. Experienced surgical teams may incorporate this technique with minimal workflow disruption, although those with less robotic experience may require additional training to maintain adequate SWS [30]. Combining low-pressure PP with multimodal analgesia and early mobilization could further enhance recovery according to ERAS principles [31].
Our study had several limitations. First, its retrospective design introduces the possibility of selection bias, as low-pressure PP may have been selectively applied to patients with favorable anatomical characteristics. Although adjusted statistically, the higher mean BMI in the low-pressure group may have exaggerated SWS and operative time differences [32]. Second, our relatively small sample size of 130 patients, while adequately powered for the primary outcome, may limit the generalizability of our findings and reduce the ability to detect smaller but clinically relevant differences in secondary outcomes [33]. Third, we did not assess inflammatory biomarkers (e.g., C-reactive protein), limiting mechanistic insight, though the literature suggests low-pressure PP reduces peritoneal trauma [10]. Fourth, long-term functional outcomes such as urinary continence and erectile function were not assessed, representing a critical limitation. These outcomes are paramount in prostate cancer surgery and should be prioritized in future prospective studies to provide a comprehensive evaluation of low-pressure pneumoperitoneum benefits [34]. Finally, the substantial proportion of patients with poor surgical workspace (SWS 3) in the low-pressure group raises concerns about the technique’s feasibility and reproducibility across different surgical settings and experience levels [35]. Our study was conducted at a high-volume center, potentially limiting generalizability to community settings with less experienced teams [26].
Despite these limitations, our study offers novel and clinically relevant insights. Given the rising global obesity prevalence and the increasing use of robotic techniques, our findings support the use of low-pressure PP in patients with obesity undergoing RARP. Future studies should assess long-term oncologic and functional outcomes to validate the durability of its benefits. In an era of rising obesity, low-pressure PP has the potential to redefine patient-centered outcomes in robotic surgery, offering a scalable strategy to enhance recovery while addressing the challenges of high-risk populations.

5. Conclusions

In conclusion, low-pressure PP (7 mmHg) during RARP significantly improves postoperative recovery in patients with obesity without compromising oncologic outcomes. Despite longer operative times and increased blood loss, its integration into ERAS protocols appears feasible and beneficial for this high-risk patient population. However, the substantial proportion of patients with compromised surgical workspace and the potential for selection bias warrant careful consideration and further investigation through randomized controlled trials. Implementation should be accompanied by appropriate patient selection, surgical expertise, and consideration of enhanced visualization techniques to optimize outcomes.

Author Contributions

Conceptualization, R.S. and H.S.G.; Methodology, M.B.; Software, H.S.G.; Validation, R.S.; Formal Analysis, A.İ.; Investigation, R.S.; Resources, M.B.; Data Curation, M.B.; Writing—Original Draft Preparation, R.S.; Writing—Review and Editing, A.T.; Visualization, A.İ.; Supervision, E.V.K.; Project Administration, E.V.K. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

This study was approved by the Ethics Committee of University of Health Sciences Ümraniye Training and Research Hospital (Approval No: 2025/58, Approval Date: 13 March 2025).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patients to publish this paper.

Data Availability Statement

The data presented in this study are available on request from the corresponding author.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
BMIBody mass index
ERASEnhanced recovery after surgery
MCIDMinimal clinically important difference
ISUPInternational Society of Urological Pathology.
QORQuality of recovery
PODPostoperative day
PPPneumoperitoneum
PSAProstate specific antigen
RARPRobot-assisted radical prostatectomy
SWSSurgical workspace

References

  1. Mottet, N.; van den Bergh, R.C.; Briers, E.; Van den Broeck, T.; Cumberbatch, M.G.; De Santis, M.; Fanti, S.; Fossati, N.; Gandaglia, G.; Gillessen, S.; et al. EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer—2020 Update. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur. Urol. 2021, 79, 243–262. [Google Scholar] [CrossRef]
  2. Neudecker, J.; Sauerland, S.; Neugebauer, E.; Bergamaschi, R.; Bonjer, H.J.; Cuschieri, A.; Fuchs, K.-H.; Jacobi, C.; Jansen, F.W.; Koivusalo, A.-M.; et al. The European Association for Endoscopic Surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery. Surg. Endosc. 2002, 16, 1121–1143. [Google Scholar] [CrossRef] [PubMed]
  3. Tao, W.; Lagergren, J. Clinical management of obese patients with cancer. Nat. Rev. Clin. Oncol. 2013, 10, 519–533. [Google Scholar] [CrossRef] [PubMed]
  4. Jaber, A.R.; Saikali, S.; Moschovas, M.C.; Gamal, A.; Patel, E.; Sandri, M.; Rogers, T.; Patel, V. Impact of Class III Obesity (Morbid Obesity) on the Perioperative, Functional, and Oncological Outcomes of Robotic-Assisted Radical Prostatectomy. Cancers 2025, 17, 709. [Google Scholar] [CrossRef] [PubMed]
  5. Barone, B.; Amicuzi, U.; Massanova, M.; Napolitano, L.; Reccia, P.; Mirto, B.F.; Balsamo, R.; Del Giudice, F.; Ferro, M.; Busetto, G.M.; et al. The Correlation Between Body Mass Index and Prostate Volume: A Retrospective Analysis of Pre and Postoperative Measurements in Prostate Cancer Patients. Prostate 2025, 85, 433–442. [Google Scholar] [CrossRef]
  6. Alhusseinawi, H.; Sander, L.; Rosenvinge, P.M.; Jensen, S.L.; Bruun, N.H.; Kingo, P.S.; Jensen, J.B.; Rasmussen, S. Low- versus standard-pneumoperitoneum in patients undergoing robot-assisted radical prostatectomy: A randomised, triple-blinded study. BJU Int. 2023, 132, 560–567. [Google Scholar] [CrossRef]
  7. Stark, P.A.; Myles, P.S.; Burke, J.A. Development and psychometric evaluation of a postoperative quality of recovery score: The QoR-15. Anesthesiology 2013, 118, 1332–1340. [Google Scholar] [CrossRef]
  8. Kehlet, H.; Wilmore, D.W. Evidence-based surgical care and the evolution of fast-track surgery. Ann. Surg. 2008, 248, 189–198. [Google Scholar] [CrossRef]
  9. Brokelman, W.J.A.; Lensvelt, M.; Rinkes, I.H.M.B.; Klinkenbijl, J.H.G.; Reijnen, M.M.P.I. Peritoneal changes due to laparoscopic surgery. Surg. Endosc. 2011, 25, 1–9. [Google Scholar] [CrossRef]
  10. Ng, C.S.; Whelan, R.L.; Lacy, A.M.; Yim, A.P. Is minimal access surgery for cancer associated with immunologic benefits? World J. Surg. 2005, 29, 975–981. [Google Scholar] [CrossRef]
  11. Albers, K.I.; Polat, F.; Helder, L.; Panhuizen, I.F.; Snoeck, M.M.; Polle, S.B.W.; de Vries, H.; Dias, E.M.; Slooter, G.D.; de Boer, H.D.; et al. Quality of recovery and innate immune homeostasis in patients undergoing low-pressure versus standard-pressure pneumoperitoneum during laparoscopic colorectal surgery (RECOVER): A randomized controlled trial. Ann. Surg. 2022, 276, 664–673. [Google Scholar] [CrossRef]
  12. Kleif, J.; Edwards, H.M.; Sort, R.; Vilandt, J.; Gögenur, I. Translation and validation of the Danish version of the postoperative quality of recovery score QoR-15. Acta Anaesthesiol. Scand. 2015, 59, 912–920. [Google Scholar] [CrossRef] [PubMed]
  13. Ferroni, M.C.; Abaza, R. Feasibility of robot-assisted prostatectomy performed at ultra-low pneumoperitoneum pressure of 6 mmHg and comparison of clinical outcomes vs standard pressure of 15 mmHg. BJU Int. 2019, 124, 308–313. [Google Scholar] [CrossRef]
  14. Baltayian, S. A brief review: Anesthesia for robotic prostatectomy. J. Robot. Surg. 2008, 2, 59–66. [Google Scholar] [CrossRef]
  15. El-Taji, O.; Howell-Etienne, J.; Taktak, S.; Hanchanale, V. Lower vs standard pressure pneumoperitoneum in robotic-assisted radical prostatectomy: A systematic review and meta-analysis. J. Robot. Surg. 2023, 17, 303–312. [Google Scholar] [CrossRef] [PubMed]
  16. Dindo, D.; Demartines, N.; Clavien, P.A. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann. Surg. 2004, 240, 205–213. [Google Scholar] [CrossRef] [PubMed]
  17. Dexter, S.P.; Vucevic, M.; Gibson, J.; McMahon, M.J. Hemodynamic consequences of high- and low-pressure capnoperitoneum during laparoscopic cholecystectomy. Surg. Endosc. 1999, 13, 376–381. [Google Scholar] [CrossRef]
  18. Rohloff, M.; Peifer, G.; Shakuri-Rad, J.; Maatman, T.J. The impact of low pressure pneumoperitoneum in robotic assisted radical prostatectomy: A prospective, randomized, double blinded trial. World J. Urol. 2021, 39, 2469–2474. [Google Scholar] [CrossRef]
  19. Ficarra, V.; Novara, G.; Rosen, R.C.; Artibani, W.; Carroll, P.R.; Costello, A.; Menon, M.; Montorsi, F.; Patel, V.R.; Stolzenburg, J.-U.; et al. Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur. Urol. 2012, 62, 405–417. [Google Scholar] [CrossRef]
  20. Abaza, R.; Ferroni, M.C. Randomized trial of ultralow vs standard pneumoperitoneum during robotic prostatectomy. J. Urol. 2022, 208, 626–632. [Google Scholar] [CrossRef]
  21. Huynh, L.M.; Ahlering, T.E. Robot-assisted radical prostatectomy: A step-by-step guide. J. Endourol. 2018, 32, S28–S32. [Google Scholar] [CrossRef] [PubMed]
  22. Vickers, A.J.; Savage, C.J.; Hruza, M.; Tuerk, I.; Koenig, P.; Martínez-Piñeiro, L.; Janetschek, G.; Guillonneau, B. The surgical learning curve for laparoscopic radical prostatectomy: A retrospective cohort study. Lancet Oncol. 2009, 10, 475–480. [Google Scholar] [CrossRef] [PubMed]
  23. Dell’oGlio, P.; van Willigen, D.M.; van Oosterom, M.N.; Bauwens, K.; Hensbergen, F.; Welling, M.M.; van der Stadt, H.; Bekers, E.; Pool, M.; van Leeuwen, P.; et al. Feasibility of fluorescence imaging at microdosing using a hybrid PSMA tracer during robot-assisted radical prostatectomy in a large animal model. EJNMMI Res. 2022, 12, 14. [Google Scholar] [CrossRef]
  24. Claps, F.; De Pablos-Rodríguez, P.; Gómez-Ferrer, Á.; Mascarós, J.M.; Marenco, J.; Collado Serra, A.; Ramón-Borja, J.C.; Fons, A.C.; Trombetta, C.; Rubio-Briones, J.; et al. Free-indocyanine green-guided pelvic lymph node dissection during radical prostatectomy. Urol. Oncol. Semin. Orig. Investig. 2022, 40, 489.e19–489.e26. [Google Scholar] [CrossRef]
  25. Tewari, A.; Sooriakumaran, P.; Bloch, D.A.; Seshadri-Kreaden, U.; Hebert, A.E.; Wiklund, P. Positive surgical margin and perioperative complication rates of primary surgical treatments for prostate cancer: A systematic review and meta-analysis comparing retropubic, laparoscopic and robotic prostatectomy. Eur. Urol. 2012, 62, 1–15. [Google Scholar] [CrossRef]
  26. Novara, G.; Ficarra, V.; Mocellin, S.; Ahlering, T.E.; Carroll, P.R.; Graefen, M.; Guazzoni, G.; Menon, M.; Patel, V.R.; Shariat, S.F.; et al. Systematic review and meta-analysis of studies reporting oncologic outcome after robot-assisted radical prostatectomy. Eur. Urol. 2012, 62, 382–404. [Google Scholar] [CrossRef]
  27. McSorley, S.T.; Watt, D.G.; Horgan, P.G.; McMillan, D.C. Postoperative systemic inflammatory response, complication severity, and survival following surgery for colorectal cancer. Ann. Surg. Oncol. 2016, 23, 2832–2840. [Google Scholar] [CrossRef] [PubMed]
  28. Rapisarda, S.; Bada, M.; Crocetto, F.; Barone, B.; Arcaniolo, D.; Polara, A.; Imbimbo, C.; Grosso, G. The role of multiparametric resonance and biopsy in prostate cancer detection: Comparison with definitive histological report after laparoscopic/robotic radical prostatectomy. Abdom. Radiol. 2020, 45, 4178–4184. [Google Scholar] [CrossRef]
  29. Veldkamp, R.; Kuhry, E.; Hop, W.C.J.; Jeekel, J.; Kazemier, G.; Bonjer, H.J.; Haglind, E.; Påhlman, L.; Cuesta, M.A.; Msika, S.; et al. Laparoscopic surgery versus open surgery for colon cancer: Short-term outcomes of a randomised trial. Lancet Oncol. 2005, 6, 477–484. [Google Scholar] [CrossRef]
  30. Yaxley, J.W.; Coughlin, G.D.; Chambers, S.K.; Occhipinti, S.; Samaratunga, H.; Zajdlewicz, L.; Dunglison, N.; Carter, R.; Williams, S.; Payton, D.J.; et al. Robot-assisted radical prostatectomy versus open radical retropubic prostatectomy: Early outcomes from randomized controlled phase 3 study. Lancet Oncol. 2016, 388, 1057–1066. [Google Scholar] [CrossRef]
  31. Martinez-Pérez, A.; Carra, M.C.; Brunetti, F.; de’Angelis, N. Short-term clinical outcomes of laparoscopic vs open rectal excision for rectal cancer: A systematic review and meta-analysis. World J. Gastroenterol. 2017, 23, 7906–7916. [Google Scholar] [CrossRef] [PubMed]
  32. Myles, P.S.; Myles, D.B. An updated minimal clinically important difference for the QoR-15 scale. Anesthesiology 2021, 135, 934–935. [Google Scholar] [CrossRef] [PubMed]
  33. Faul, F.; Erdfelder, E.; Lang, A.G.; Buchner, A. G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav. Res. Methods 2007, 39, 175–191. [Google Scholar] [CrossRef] [PubMed]
  34. Ficarra, V.; Novara, G.; Ahlering, T.E.; Costello, A.; Eastham, J.A.; Graefen, M.; Guazzoni, G.; Menon, M.; Mottrie, A.; Patel, V.R.; et al. Systematic review and meta-analysis of studies reporting potency rates after robot-assisted radical prostatectomy. Eur. Urol. 2012, 62, 418–430. [Google Scholar] [CrossRef]
  35. Ahlering, T.E.; Skarecky, D.; Lee, D.; Clayman, R.V. Successful Transfer of Open Surgical Skills to a Laparoscopic Environment Using a Robotic Interface: Initial Experience with Laparoscopic Radical Prostatectomy. J. Urol. 2003, 170, 1738–1741. [Google Scholar] [CrossRef]
Medicina 61 01253 g001
Figure 1. Comparison of QoR-15 total scores at POD1, POD3, and POD30 between low-pressure (7 mmHg) and standard-pressure (12 mmHg) pneumoperitoneum groups. Error bars represent mean ± standard deviation. * p < 0.001, ANCOVA (BMI used as covariate).
Figure 1. Comparison of QoR-15 total scores at POD1, POD3, and POD30 between low-pressure (7 mmHg) and standard-pressure (12 mmHg) pneumoperitoneum groups. Error bars represent mean ± standard deviation. * p < 0.001, ANCOVA (BMI used as covariate).
Medicina 61 01253 g001
Table 1. Baseline characteristics.
Table 1. Baseline characteristics.
ParameterStandard-Pressure PP
(n = 70)		Low-Pressure PP
(n = 60)		p *
Age, years, mean ± SD63.39 ± 6.462.65 ± 5.970.502
BMI, kg/m2, mean ± SD32.16 ± 1.3333.32 ± 2.420.001
PSA, ng/mL, mean ± SD7.98 ± 4.338.73 ± 4.980.359
Prostate volume, mL, mean ± SD57.21 ± 3358.5 ± 29.470.816
Hypertension, n (%)30 (42.9)34 (56.7)0.116
Diabetes mellitus, n (%)36 (51.4)29 (48.3)0.725
Prior abdominal surgery, n (%)8 (11.4)10 (16.7)0.389
Clinical T stage, n (%) 0.273
T2a28 (40.0)27 (45.0)
T2b11 (15.7)4 (6.7)
T2c31 (44.3)29 (48.3)
Clinical ISUP grade, n (%) 0.181
138 (54.3)42 (70.0)
28 (11.4)3 (5.0)
317 (24.3)13 (21.7)
47 (10.0)2 (3.3)
BMI—body mass index, PSA—prostate-specific antigen, ISUP—International Society of Urological Pathology. * Independent samples t-test, Pearson’s chi-square test, Fisher–Freeman–Halton exact test. Significant p values are written in bold.
Table 2. Comparison of QoR-15 scores on POD1, POD3, and POD30.
Table 2. Comparison of QoR-15 scores on POD1, POD3, and POD30.
CategoryTime PointStandard-Pressure PP
(Mean ± SD)		Low-Pressure PP
(Mean ± SD)		Difference
(95% CI)		p *
QoR-15 totalPOD1111.41 ± 2.52123.58 ± 3.1612.17 (11.16, 13.17)<0.001
QoR-15 totalPOD3116.41 ± 2.64128.37 ± 2.8111.95 (11.01, 12.90)<0.001
QoR-15 totalPOD30125.61 ± 3.04132.88 ± 2.827.27 (6.25, 8.29)<0.001
PainPOD113.33 ± 0.8515.60 ± 0.812.27 (1.98, 2.56)<0.001
PainPOD314.46 ± 1.0317.38 ± 0.762.93 (2.61, 3.24)<0.001
PainPOD3015.89 ± 0.8418.22 ± 0.612.33 (2.07, 2.59)<0.001
Physical comfortPOD138.10 ± 1.4842.85 ± 1.564.75 (4.22, 5.28)<0.001
Physical comfortPOD339.97 ± 1.4744.63 ± 1.294.66 (4.18, 5.15)<0.001
Physical comfortPOD3043.40 ± 1.9545.93 ± 1.332.53 (1.96, 3.11)<0.001
Physical independencePOD112.27 ± 1.0112.38 ± 1.290.11 (−0.29, 0.51)0.296
Physical independencePOD313.70 ± 0.9814.12 ± 1.010.42 (0.07, 0.76)0.005
Physical independencePOD3015.83 ± 1.0815.80 ± 1.02−0.03 (−0.39, 0.34)0.622
Psychological supportPOD118.63 ± 0.6819.27 ± 0.710.64 (0.40, 0.88)<0.001
Psychological supportPOD318.44 ± 0.7119.18 ± 0.700.74 (0.49, 0.99)<0.001
Psychological supportPOD3018.60 ± 0.7119.12 ± 0.720.52 (0.27, 0.76)<0.001
Emotional statePOD129.09 ± 1.3533.48 ± 1.854.40 (3.83, 4.97)<0.001
Emotional statePOD329.84 ± 1.5033.05 ± 2.143.21 (2.55, 3.86)<0.001
Emotional statePOD3031.90 ± 1.4733.82 ± 1.731.92 (1.35, 2.48)<0.001
QoR—quality of recovery, POD—postoperative day. * ANCOVA (BMI as covariate). Significant p values are written in bold.
Table 3. Secondary surgical outcomes.
Table 3. Secondary surgical outcomes.
OutcomeStandard-Pressure PP
(n = 70)		Low-Pressure PP
(n = 60)		p *
Console time, min, mean ± SD71.57 ± 12.0298.5 ± 16.5<0.001
Hospital stay, days, mean ± SD2.09 ± 0.332.3 ± 0.830.064
Intraoperative blood loss, mL, mean ± SD97.07 ± 48.4129 ± 108.730.039
Pathological T stage, n (%) 0.017
pT2a6 (8.6)14 (23.3)
pT2b0 (0)3 (5.0)
pT2c46 (65.7)27 (45.0)
pT3a17 (24.3)15 (25.0)
pT3b1 (1.4)1 (1.7)
ISUP grade, n (%) 0.037
133 (47.1)39 (65.0)
213 (18.6)4 (6.7)
312 (17.1)12 (20.0)
412 (17.1)4 (6.7)
50 (0)1 (1.7)
Lymph node dissection, n (%)31 (44.3)30 (50.0)0.515
Positive surgical margin, n (%)6 (8.6)8 (13.3)0.383
Clavien–Dindo complications, n (%) 0.185
057 (81.4)42 (70)
18 (11.4)7 (11.7)
25 (7.1)9 (15.0)
3a0 (0)2 (3.3)
Postoperative transfusion, n (%)1 (1.4)3 (5.0)0.335
SWS, n (%) <0.001
30 (0)32 (53.3)
427 (38.6)28 (46.7)
543 (61.4)0 (0)
SWS—surgical workspace. * Independent samples t-test, Pearson’s chi-square test, Fisher–Freeman–Halton exact test, Fisher’s exact test. Significant p values are written in bold.
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MDPI and ACS Style

Sobay, R.; Güngör, H.S.; İnkaya, A.; Beyatlı, M.; Tahra, A.; Küçük, E.V. Impact of Low- Versus Standard-Pressure Pneumoperitoneum on Postoperative Recovery in Patients with Obesity Undergoing Robot-Assisted Radical Prostatectomy: A Retrospective Cohort Study. Medicina 2025, 61, 1253. https://doi.org/10.3390/medicina61071253

AMA Style

Sobay R, Güngör HS, İnkaya A, Beyatlı M, Tahra A, Küçük EV. Impact of Low- Versus Standard-Pressure Pneumoperitoneum on Postoperative Recovery in Patients with Obesity Undergoing Robot-Assisted Radical Prostatectomy: A Retrospective Cohort Study. Medicina. 2025; 61(7):1253. https://doi.org/10.3390/medicina61071253

Chicago/Turabian Style

Sobay, Resul, Hasan Samet Güngör, Abdurrahman İnkaya, Murat Beyatlı, Ahmet Tahra, and Eyüp Veli Küçük. 2025. "Impact of Low- Versus Standard-Pressure Pneumoperitoneum on Postoperative Recovery in Patients with Obesity Undergoing Robot-Assisted Radical Prostatectomy: A Retrospective Cohort Study" Medicina 61, no. 7: 1253. https://doi.org/10.3390/medicina61071253

APA Style

Sobay, R., Güngör, H. S., İnkaya, A., Beyatlı, M., Tahra, A., & Küçük, E. V. (2025). Impact of Low- Versus Standard-Pressure Pneumoperitoneum on Postoperative Recovery in Patients with Obesity Undergoing Robot-Assisted Radical Prostatectomy: A Retrospective Cohort Study. Medicina, 61(7), 1253. https://doi.org/10.3390/medicina61071253

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