Postoperative Patient-Reported Visual Symptoms After Robot-Assisted Laparoscopic Radical Prostatectomy in Steep Trendelenburg: A Prospective Single-Center Observational Cohort Study

Background: Robot-assisted laparoscopic radical prostatectomy (RALP) requires prolonged steep Trendelenburg positioning, which increases intraocular and intracranial pressure. Although transient visual field defects have been documented after RALP using objective perimetric testing, data on patient-reported visual outcomes remain limited. We hypothesized that intraoperative optic nerve sheath diameter (ONSD) measurements and hemodynamic variables would be associated with postoperative patient-reported visual symptoms. Methods: This prospective, single-center observational cohort study enrolled consecutive adult patients undergoing RALP between March and September 2023 at Ospedale Santo Stefano, Prato, Italy. Patients with pre-existing glaucoma, ocular disease, or intracranial hypertension were excluded. Intraoperative ONSD was measured by transorbital ultrasound at three time points: before Trendelenburg (t1), 30 min after Trendelenburg (t2), and at end of Trendelenburg (t3). Postoperative visual symptoms were assessed at ≥1 month follow-up using the validated Catquest-9SF questionnaire. Rasch analysis converted ordinal responses to interval-level measures. Logistic regression explored associations between visual complaints and intraoperative predictors (Rasch scores, lowest mean arterial pressure [MAP], maximum ONSD). Results: Fifty-five patients were enrolled. Six patients (10.9%) reported new subjective visual symptoms at follow-up. Rasch-transformed scores were associated with the presence of these symptoms (coefficient 1.38; p < 0.05). Lowest intraoperative MAP (p = 0.081) and maximum ONSD (p = 0.811) did not reach statistical significance as independent factors. Conclusions: Patient-reported visual symptoms occurred in approximately 11% of patients after RALP. Postoperative Rasch-transformed visual function scores correlated with these complaints. While intraoperative ONSD was not associated with visual outcomes, the potential role of intraoperative hypotension requires further investigation in larger, powered cohorts.