Impact of low-pressure pneumoperitoneum on post-operative pain in robotic urological surgery: a systematic review

Robotic technology has revolutionised minimally invasive urological surgery, enhancing precision and minimising surgical complications. Recent evidence suggests that utilising lower pneumoperitoneum pressures improves clinical outcomes but the comparative impact on post-operative pain remains uncertain. This systematic review analyses the literature on low-pressure pneumoperitoneum to investigate its impact on pain and recovery following robotic-assisted urological surgeries, including prostatectomy, partial ephrectomy, and cystectomy. Post-operative opioid consumption, total operating time, estimated intra-operative bleeding, and total inpatient stay were investigated as secondary outcomes. PubMed, NHS Knowledge and Library Hub, Cochrane Central databases, and EMBASE were searched between January 2010 and May 2024. Any identified studies were reviewed against eligibility criteria by two independent authors prior to inclusion. The review was written in compliance with Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Nine studies were included: six focused on prostatectomy, two on partial nephrectomy, and one on cystectomy. Low-pressure pneumoperitoneum was found to result in reduced postoperative pain scores, particularly in the immediate recovery period and on postoperative day 1. Despite these improvements, post-operative opioid consumption remained consistent with standard pressures. The surgical workspace was not compromised when pneumoperitoneum pressures were lower. Lowering pneumoperitoneum pressures in robotic-assisted urological surgery appears to reduce immediate postoperative pain scores without increasing overall complications. This has not led to a noticeable reduction in post-operative opioid consumption. The lack of consistent reduction in opioid use and limited high-quality studies highlight the need for further research, particularly for partial nephrectomy and cystectomy.