Stesura Seveso Archivio Italiano di Urologia e Andrologia 2023; 95, 2 126 LETTER TO EDITOR Submitted 14 March 2023; Accepted 23 March 2023 To the Editor, Although postoperative pain associated with robot-assisted radical prostatectomy (RARP) is less than pain following the open technique, it remains a fundamental issue as it can be a significant source of discomfort for the patient and length- en recovery times after surgery. The optimal management of pain after RARP is far from being fully elucidated and many factors have to be evaluated to choose the best analgesic approach (1). Pain management in the postoperative period is classically achieved through the administration of intermittent or continuous intravenous drugs; opioids and non-steroidal anti-inflammatory drugs (NSAIDs) represent the cornerstones of this approach. These drugs have many potential adverse effects (AEs). NSAIDs can affect renal and platelet function leading to kidney injury and significant bleeding, while opi- oids can be associated with delayed recovery of gut motility, urinary retention, dizziness, nausea, vomiting, and immuno- suppression (2). Spinal anesthesia is emerging as an alternative technique to control the postoperative pain or even to avoid general anesthesia not only in urological but also in cardiac, gynecological, and spine laparoscopic and robotic sur- gery (Table 1) (3-6). It allows to reduce the drugs dosage and, consequently, their AEs. However, several additional advantages can be identified. Spinal anesthesia is performed before the induction of general anesthesia and its analgesic effect covers also the intraoperative period, so lower dosage of intraoperative opioids can be used along with lower min- imum alveolar concentration of inhalational anesthetics, thus leading to an important reduction of postoperative nausea and vomiting along with a faster recovery of consciousness after general anesthesia; furthermore, the reduction of anal- gesic drugs during anesthesia can contribute to the hemodynamic stability. Recently, some concerns have been raised about the immunosuppressive effect of opioids and, consequently, the potential risk of promoting metastatic spread of cancer cells; therefore, reducing opioid administration in the perioperative period is even more important (7). Pikramenos et al. reported their experience in 60 men, underwent combined spinal/epidural anaesthesia during radical retropubic prostatectomy: They showed that combined spinal/epidural anaesthesia is a safe procedure to perform and is associated with less intraoperative blood loss and potentially reduced risks of postoperative complications (8). The role of spinal anesthesia should also be considered in the management of the bladder spasm and the discomfort due to urethral catheter which can impact on the patient satisfaction and on the ability to early recover autonomous walk- ing, with possible dramatic consequences on the risk of thromboembolism and on the length of hospital stay (9). Interestingly, several adjuvants can be added to the solution injected in the subarachnoid space thus increasing the ability to achieve the desired effects with very small amounts of drugs. Ketamine, dexmedetomidine, midazolam, and clonidine are some examples of drugs which are commonly used with or without opioids to prolong and/or potentiate the effect of the local anesthetic. Many combinations of these drugs for spinal anesthesia have so far been reported in literature and appropriate use of their different pharmacological properties can be employed to manage not only postoperative pain but also intraoperative analgesia, allowing RARP to be performed only with spinal anesthesia and light sedation. No study is currently available on the topic, however, as part of a clinical trial, we have begun performing the first cases of RARP under spinal anesthesia in our center, with encouraging preliminary results demonstrating the feasibility and potential of this novel technique. Some authors have expressed concerns regarding the risk-benefit ratio of spinal anesthesia, as this technique can cause severe AEs. An accidental puncture of an epidural blood or a spinal nerve can lead to permanent injuries such as motor and senso- ry loss of the lower limbs, loss of sphincters continence, and typical neuropathic symptoms. These complications are actual- ly very rare; for example, the reported incidence of spinal hematoma is about 1:220,000 cases and a careful medical history along with appropriate management of anti-platelet and anticoagulant drugs can significantly reduce the risk (10). Absolute contraindications to spinal anesthesia are patient refusal, injection site infection, increased intracranial pressure (except for pseudotumor cerebri), allergy to the drugs to be injected, and uncorrected hypovolemia (as spinal anesthesia Role of spinal anesthesia in robot-assisted radical prostatectomy: Gamble or opportunity? Lorenzo Spirito 1, Annachiara Marra 2, Vincenzo Mirone 3, Celeste Manfredi 1, Ferdinando Fusco 1, Luigi Napolitano 3, Giuseppe Servillo 2, Nicola Logrieco 2, Pasquale Buonanno 2 1 Urology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy; 2 Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, Naples, Italy; 3 Urology Unit, Department of Neurosciences, Reproductive Sciences and Odontostomatology, Urology Unit, University of Naples "Federico II", Naples. DOI: 10.4081/aiua.2023.11311 Archivio Italiano di Urologia e Andrologia 2023; 95, 2 L. Spirito, A. Marra, V. Mirone, C. Manfredi, F. Fusco, L. Napolitano, G. Servillo, N. Logrieco, P. Buonanno 127 causes vasodilation due to sympathetic block). Relative contraindications are sepsis, coagulopathy, fixed cardiac output states, aortic stenosis (previously considered an absolute contraindication), indeterminate neurological disease, multiple sclerosis and other demyelinating diseases (as demyelinated nerves seem more susceptible to local anesthetic toxicity (11). In conclusion spinal anesthesia to perform RARP can be a gamble or an opportunity depending on the players who take part to the match: the appropriate assessment and selection of the patient, the correct management of the drugs affect- ing coagulation and platelet function, and the proper use of adjuvants in the solution to be injected are essential for a successful and safe spinal anesthesia. However, the role of spinal anesthesia in the context of RARP needs to be evaluat- ed in randomized controlled trials with adequate sample size and follow-up. Not only the impact on the postoperative pain but also on other sources of possible discomfort for the patient should be investigated. The feasibility and relative advantages and disadvantages of spinal anesthesia when used as a replacement for general anesthesia should be clarified with adequate comparative studies. Moreover, future studies should compare the spinal anesthesia with novel techniques of regional analgesia such as erector spinae plane and transversus abdominis plane blocks, which are less invasive and consequently safer than the intrathecal administration of drugs. REFERENCES 1. Joshi GP, Jaschinski T, Bonnet F, Kehlet H. PROSPECT collaboration. Optimal pain management for radical prostatectomy surgery: what is the evidence? BMC Anesthesiol. 2015; 15:159. 2. Koh JC, Lee J, Kim SY, et al. Postoperative Pain and Intravenous Patient-Controlled Analgesia-Related Adverse Effects in Young and Elderly Patients: A Retrospective Analysis of 10,575 Patients. Medicine (Baltimore). 2015; 94:e2008. 3. Gontero P, Oderda M, Calleris G, et al. Awake Da Vinci robotic partial nephrectomy: First case report ever in a situation of need. Urol Case Rep. 2022; 42:102008. 4. Giampaolino P, Della Corte L, Mercorio A, et al. Laparoscopic gynecological surgery under minimally invasive anesthesia: a prospective cohort study. Updates Surg. 2022; 74:1755-1762. 5. Dhawan R, Daubenspeck D, Wroblewski KE, et al. Intrathecal Morphine for Analgesia in Minimally Invasive Cardiac Surgery: A Randomized, Placebo-controlled, Double-blinded Clinical Trial. Anesthesiology. 2021; 135:864-876. Table 1. Use of spinal anesthesia and analgesia in robotic and laparoscopic surgery (see Supplementary material for references). Article Study design Surgery Groups Duration of intervention Outcomes Beilstein CM et al, 2022 RCT Urological/RARP or open General anesthesia associated with: Group SSS: 282 min [240; 322] No differences in QoR; radical prostatectomy Subarachnoid analgesia (SSS) Group TAS: 270 min [240; 300] no differences in postoperative pain Transversus abdomnis plane block (TAP) Group SA: 274 min [240; 312] Systemic lidocaine (SA) Gontero P. et al, 2022 Case report Urologicalc/robotic partial Continuous subarachnoid anesthesia 2h 45 min Patient hemodinamically stable; nephrectomy no intraoperative desaturation; optimal postoperative analgesia Dhawan R et al, 2021 RCT Cardiac/robotic totally endoscopic General anesthesia without (groups GA) Group GA: 290 (238–346) min Group SA showed less postoperative pain, coronary artery bypassor with subarachnoid analgesia (group SA) Group SA: 315 (235–366) min less need for postoperative morphine, and less cough Shim JW et al, 2021 RCT Urological/RARP General anesthesia with (group non-ITMB) group non-ITMB: 120 (108-143)) min Group ITMB less postoperative pain or without (group ITMB) intrathecal group ITMB: 120 (115-130 min and opioids consumption morphine and bupivacaine Shim JW et al, 2020 Prospective Urological /RALP General anesthesia with: Group IV-PCA: 123 (109-145) min Group ITMB required less intraoperative observational Group IV-PCA: intravenous Group RSB: 123 (100-141) min opioids and showed less postoperative patient-controlled analgesia Group ITMB: 123 (114-138) min pain with a lower postoperative Group RSB: rectus sheath bupivacaine block consumption of opioids, better QoR. Group ITMB: intrathecal morphine and bupivacaine Bae J et al, 2017 RCT Urological/RALP General anesthesia with Group ITM: Group ITM: 171 ± 42 min Group ITM showed less postoperative pain intrathecal morphine+ intravenous Group IV-PCA: 164 ± 41 min and morphine consumption atient-controlled analgesia Group IV-PCA: only intravenous patient-controlled analgesia Segal D et al, 2014 RCT Urogynecological/robotic General anesthesia without (group GA) Group SA showed less postoperative pain, sacrocervicopexy or with subarachnoid anesthesia (SA) lower postoperative consumption of opioids, and a higher satisfaction of patients and nurses Ross SB et al, 2013 RCT General surgery/Laparo-endoscopic General anesthesia (group GA) Group GA: 65.2 ± 25.1 min Group EA showed less postoperative pain single-site (LESS) cholecystectomy vs Epidural anesthesia (group EA) Group EA: 64.5 ± 21.5 min QoR: quality of recovery; RALP: robot-assisted laparoscopic prostatectomy; RCT: randomized control trial. Archivio Italiano di Urologia e Andrologia 2023; 95, 2 128 Spinal anesthesia and robot-assisted radical prostatectomy 6. Gao S, Wei J, Li W, et al. Accuracy of Robot-Assisted Percutaneous Pedicle Screw Placement under Regional Anesthesia: A Retrospective Cohort Study. Pain Res Manag. 2021; 2021:6894001. 7. Lee BM, Singh Ghotra V, Karam JA, et al. Regional anesthesia/analgesia and the risk of cancer recurrence and mortality after prostatectomy: a meta-analysis. Pain Manag. 2015; 5:387-95. 8. Pikramenos K, Zachou M, Apostolatou E, et al. The effects of method of anaesthesia on the safety and effectiveness of Radical Retropubic Prostatectomy. Arch Ital Urol Androl 2022; 94:396-400. 9. Morgan MS, Ozayar A, Friedlander JI, et al. An Assessment of Patient Comfort and Morbidity After Robot-Assisted Radical Prostatectomy with Suprapubic Tube Versus Urethral Catheter Drainage. J Endourol. 2016; 30:300-5. 10. Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990-1999. Anesthesiology 2004; 101:950-9. 11. Carpenter RL, Caplan RA, Brown DL, et al. Incidence and risk factors for side effects of spinal anesthesia. Anesthesiology 1992; 76:906-16. Correspondence Lorenzo Spirito, MD lorenzospirito@msn.com Celeste Manfredi, MD manfredi.celeste@gmail.com Ferdinando Fusco, MD ferdinando-fusco@libero.it Urology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples Annachiara Marra, MD dottmarraannachiara@gmail.com Giuseppe Servillo, MD giuseppe.servillo@unina.it Nicola Logrieco, MD nicola.logrieco@unina.it Pasquale Buonanno, MD pasquale.buonanno@unina.it Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, Naples, Italy Vincenzo Mirone, MD mirone@unina.it Luigi Napolitano, MD (Corresponding Author) dr.luiginapolitano@gmail.com Department of Neurosciences, Reproductive Sciences and Odontostomatology University of Naples “Federico II” Via Pansini 5, 80131 Naples, Italy Conflict of interest: The authors declare no potential conflict of interest.