Skip to main content

The impact of low pressure pneumoperitoneum in robotic assisted radical prostatectomy: a prospective, randomized, double blinded trial



Robotic surgery has revolutionized postoperative outcomes across surgical specialties. However, the use of pneumoperitoneum comes with known risks given the change in physiological parameters that accompany its utilization. A recent internal review found a 7% decrease in postoperative ileus rates when utilizing a pneumoperitoneum of 12 mmHg over the standard 15 mmHg in robotic assisted radical prostatectomies (RARP).


The purpose of this study is to prospectively evaluate the utility of lower pressure pneumoperitoneum by comparing 8 mmHg and 12 mmHg during RARP.

Design, setting and partcipants

Patients were randomly assigned to undergo robotic assisted radical prostatectomy at a pneumoperitoneum pressure of 12 mmHg or 8 mmHg.

Outcome measurements and statistical analysis

The primary outcome was development of postoperative ileus and secondary outcomes were length of operation, estimated blood loss and positive surgical margin status.

Results and limitations

A total of 201 patients were analyzed; 96 patients at 8 mmHg and 105 patients at 12 mmHg. The groups were adequately matched as there were no differences between demographic parameters or medical comorbidities. There was a decrease in postoperative ileus rates with lower pneumoperitoneum pressures; 2% at 8 mmHg and 4.8% at 12 mmHg. There were no clinically significant differences in estimated blood loss, total length of operative time and positive margin status.


Lower pressure pneumoperitoneum during robotic assisted radical prostatectomy is non-inferior to higher pressure pneumoperitoneum levels and the experienced surgeon may safely perform this operation at 8 mmHg to take advantage of the proposed benefits.

This is a preview of subscription content, access via your institution.



Robotic assisted radical prostatectomy


Postoperative ileus


Maintenance IVF


  1. Pasticier G, Rietbergen JBW, Guillonneau B, Fromont G, Menon M, Vallancien G (2001) Robotically assisted laparoscopic radical prostatectomy: feasibility study in men. Eur Urol 40(1):70–74

    Article  CAS  Google Scholar 

  2. Lowrance WT, Eastham JA, Savage C et al (2012) Contemporary open and robotic radical prostatectomy practice patterns among urologists in the United States. J Urol 187(6):2087–2092

    Article  Google Scholar 

  3. Ploussard G (2018) Robotic surgery in urology: facts and reality. What are the real advantages of robotic approaches for prostate cancer patients? Curr Opin Urol 28(2):153–158

    Article  Google Scholar 

  4. Srivastava A, Niranjan A (2010) Secrets of safe laparoscopic surgery: anaesthetic and surgical considerations. J Minim Access Surg 6(4):91–94

    Article  Google Scholar 

  5. Hsu RL, Kaye AD, Urman RD (2013) Anesthetic challenges in robotic-assisted urologic surgery. Rev Urol 15(4):178–184

    PubMed  PubMed Central  Google Scholar 

  6. Ferroni MC, Abaza R (2019) 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 124(2):308–313

    Article  CAS  Google Scholar 

  7. Rohloff M, Cicic A, Christensen C, Maatman TK, Lindberg J, Maatman TJ (2019) Reduction in postoperative ileus rates utilizing lower pressure pneumoperitoneum in robotic-assisted radical prostatectomy. J Robot Surg 13:671–674

    Article  Google Scholar 

  8. Clavien PA, Barkun J, De Oliveira ML et al (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250(2):187–196

    Article  Google Scholar 

  9. Vather R, Trivedi S, Bissett I (2013) Defining postoperative ileus: results of a systematic review and global survey. J Gastrointest Surg 17(5):962–972

    Article  Google Scholar 

  10. Gurusamy KS, Vaughan J, Davidson BR (2014) Low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy. Cochrane Database Syst Rev (3):CD006930.

  11. Matsuzaki S, Vernis L, Bonnin M et al (2017) Effects of low intraperitoneal pressure and a warmed, humidified carbon dioxide gas in laparoscopic surgery: a randomized clinical trial. Sci Rep 7(1):11287

    Article  Google Scholar 

  12. Mayhew PD, Pascoe PJ, Kass PH, Shilo-benjamini Y (2013) Effects of pneumoperitoneum induced at various pressures on cardiorespiratory function and working space during laparoscopy in cats. Am J Vet Res 74(10):1340–1346

    Article  Google Scholar 

  13. Mahajan S, Shankar M, Garg V, Gupta V, Sorout J (2017) Intraoperative safety of low pressure pneumoperitoneum cholecystectomy: a comparative study. Int Surg J 4(11):3679–3684

    Article  Google Scholar 

  14. Moschini M, Morlacco A, Kwon E, Rangel LJ, Karnes RJ (2017) Treatment of M1a/M1b prostate cancer with or without radical prostatectomy at diagnosis. Prostate Cancer Prostatic Dis 20(1):117–121

    Article  CAS  Google Scholar 

  15. Iyer S, Saunders WB, Stemkowski S (2009) Economic burden of postoperative ileus associated with colectomy in the United States. J Manag Care Pharm 15(6):485–494

    Article  Google Scholar 

  16. Asgeirsson T, El-badawi KI, Mahmood A, Barletta J, Luchtefeld M, Senagore AJ (2010) Postoperative ileus: it costs more than you expect. J Am Coll Surg 210(2):228–231

    Article  Google Scholar 

  17. Murphy MM, Tevis SE, Kennedy GD (2016) Independent risk factors for prolonged postoperative ileus development. J Surg Res 201(2):279–285

    Article  Google Scholar 

  18. Vandehei MS, Papageorge CM, Murphy MM, Kennedy GD (2017) The effect of perioperative fluid management on postoperative ileus in rectal cancer patients. Surgery 161(6):1628–1632

    Article  Google Scholar 

  19. La Falce S, Novara G, Gandaglia G et al (2017) Low pressure robot-assisted radical prostatectomy with the AirSeal system at OLV hospital: results from a prospective study. Clin Genitourin Cancer 15(6):e1029–e1037

    Article  Google Scholar 

Download references


We would like to acknowledge Sam Wisniewski for his assistance in statistical analysis.

Author information

Authors and Affiliations



MR project development, manuscript writing, data analysis. GP data collection, manuscript writing. JS project development, data collection, manuscript writing. TM project development, data collection, manuscript writing.

Corresponding author

Correspondence to Matthew Rohloff.

Ethics declarations

Conflict of interest

The authors declare they have no conflicts of interest.

Research involving human participants

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the IRB at Metro Health Hospital in Wyoming, Michigan. This trial is registered at (NCT03370016).

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Rohloff, M., Peifer, G., Shakuri-Rad, J. et al. The impact of low pressure pneumoperitoneum in robotic assisted radical prostatectomy: a prospective, randomized, double blinded trial. World J Urol 39, 2469–2474 (2021).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Postoperative ileus
  • Robotic assisted radical prostatectomy
  • Low pressure pneumoperitoneum
  • Laparoscopy