Prostate Cancer

Radical prostatectomy approach - Most are now done robotically or laparoscopically rather than open. The minimally invasive approaches mean shorter stays and fewer blood transfusions, but hemorrhage is still the most commonly reported complication of the robotic operation. Type and screen, and put in access that lets you keep up.

Steep Trendelenburg plus pneumoperitoneum - This is the defining physiologic insult of the robotic case. Lung compliance and FRC fall while peak inspiratory pressure climbs, giving V/Q mismatch, pulmonary shunting, hypoxemia, and respiratory acidosis. ICP and intraocular pressure rise, renal perfusion falls, and aspiration risk goes up. Insufflation above 18 mm Hg drops venous return and cardiac output, and vagal stimulation brings bradycardia and hypotension.

Before extubation - After hours head-down, look at the face and conjunctivae and confirm a cuff leak before the tube comes out.

Extended pelvic lymph node dissection - High-risk patients get a dissection that reaches beyond the pelvis to the common iliac, para-aortic, perirectal, and presacral nodes. Longer case, more raw surface, more chance you are chasing blood loss.

Long-term androgen deprivation and the heart - Reports conflict, but long-term ADT is linked to cardiovascular risk and metabolic syndrome, and the men who get hurt are the ones with pre-existing heart disease. Risk of an acute cardiovascular event is highest in the first year of therapy, when three-monthly checkups are recommended. Get a baseline ECG and ask what the cardiology follow-up showed.

Bone loss is fast - Bone density falls about 13% per year on hormonal treatment and skeletal fractures rise roughly fourfold over baseline after two years; two-thirds of these men already have osteoporosis before ADT is even started. A DEXA T score below -2.5 identifies the fragile ones. Transfer, position, and pad accordingly.

Bone metastases and cord compression - Metastatic disease seeds the vertebrae, pelvis, hips, ribs, and proximal femur. Cord compression presents as tingling, leg weakness, pain, paralysis, and urinary or fecal incontinence. Document a motor and sensory exam before any neuraxial technique and before you position an anesthetized patient.

Obstructed ureters - Sub-trigonal extension can block both ureters and drive renal failure quietly, without pain. Check the creatinine before dosing renally cleared drugs.

Systemic therapy shows up in the labs - Docetaxel is added to hormonal therapy in high-volume metastatic disease, and Lutetium-177 PSMA radioligand therapy causes anemia in about 32% with marrow suppression afterward. Get a CBC. Anemia with a raised alkaline phosphatase points to advanced disease.

Brachytherapy cases - Seeds are placed transperineally under transrectal ultrasound guidance in lithotomy. Radioactive seed embolization is reported in up to 55% of brachytherapy patients.

Pain baseline - Men with bone metastases often arrive on chronic opioids alongside bisphosphonates or denosumab and palliative radiation. Take the home opioid dose into account when you plan analgesia rather than starting from zero.

Prostate cancer is the most commonly diagnosed male malignancy worldwide and the fifth leading cause of cancer death in men, accounting for about 1.4 million new cases and 375,000 deaths in 2020. Most tumors are low-grade and slow-growing, which is why so many men are simply monitored rather than treated.

Growth is androgen-driven, so testosterone deprivation is the backbone of therapy for advanced disease. Locally advanced tumor can extend sub-trigonally and obstruct both ureters, producing hydronephrosis and progressive renal failure. About 90% of castrate-resistant disease progresses to bone — vertebrae, pelvis, hips, ribs, and the proximal femur — bringing severe pain, pathologic fractures, and spinal cord compression. Perioperatively you meet these men either for radical prostatectomy or years into hormonal therapy with fragile bone and accumulated cardiac risk.