Positioning injury, rhabdomyolysis and serum creatinine kinase-concentration course in patients undergoing robot-assisted radical prostatectomy and extended pelvic lymph node dissection - Abstract

Introduction:During robot-assisted radical prostatectomy(RARP) patients remain in steep Trendelenburg position.

This can cause positioning injuries as well as rhabdomyolysis. Primary diagnostic indicator of rhabdomyolysis is elevated serum creatinine kinase(CK). We investigate whether RARP with extended pelvic lymph node dissection(ePLND) in prolonged extreme Trendelenburg position can cause positioning injuries and rhabdomyolysis.

Patients and Methods:Prospective study of the first 60 patients undergoing RARP and ePLND for organ-confined prostate cancer at our institute. Positioning injuries were graded according to 3 degrees of clinical severity. Serum-CK, serum-pH and base excess(BE) were measured before, during and for 5 days after surgery. Rhabdomyolysis was defined by serum-CK levels >5000 IU/L.

Results:Median operative time was 317 minutes(range:200-475), median time in Trendelenburg position 282 minutes(range:170-470). Serum-CK was significantly elevated 6 hours postoperatively, peaking at 18 hours postoperatively. Serum-CK levels did not correlate with pH, BE and perioperative creatinine values. Serum-CK course shows weak correlation with BMI, operative time, Trendelenburg position time and medium correlation with positioning injuries of any degree. Twenty-one of the 60(35%) patients showed positioning-related injuries: 16 patients(27%) degree I, 2 patients(3%) degree II and 3 patients(5%) degree III. Ten patients developed rhabdomyolysis. None of them receiving postoperative hypervolemic diuretic therapy nor any patient with injuries degrees I, II or III developed postoperative renal failure.

Conclusion: Clinically relevant positioning injuries and rhabdomyolysis can occur in patients subjected to prolonged extreme Trendelenburg position during RARP and ePLND especially at the beginning of the learning curve. Serum-CK increases significantly after sugery, peaking 18 hours postoperative. Serum-CK elevation alone is not predictive of positioning injury. By very long operative and Trendelenburg times as well as high BMI with visible position injuries we recommend Serum-CK measurement 6 and 18 hours postoperatively followed by hypervolemic therapy to prevent possible renal injury due to rhabdomyolysis if Serum-CK >5000 IU/L.

Written by:
Mattei A, Di Pierro GB, Rafeld V, Konrad C, Beutler J, Danuser H.   Are you the author?
Luzerner Kantosspital, Klinik für Urologie, Spitalsstrasse 6, Luzern, Switzerland, 6000.

Reference: J Endourol. 2012 Jul 6. Epub ahead of print.
doi: 10.1089/end.2012.0169

PubMed Abstract
PMID: 22770120

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