Low-pressure pneumoperitoneum in robot-assisted radical prostatectomy: a systematic review, meta-analysis and trial sequential analysis of randomized controlled trials

Abstract

Abstract Purpose Low-pressure (LP) pneumoperitoneum (intra-abdominal pressure [IAP] <12 mmHg) has been proposed to reduce pain after robot-assisted radical prostatectomy (RARP), but earlier syntheses combined randomized with non-randomized data, pooled mixed urological procedures, or applied variable pressure definitions. We synthesized the randomized evidence restricted to RARP. Methods PubMed, Embase, and Cochrane CENTRAL were searched to 30 April 2026. RCTs comparing IAP <12 mmHg with IAP ≥12 mmHg in adults undergoing RARP were eligible. Every extracted value was verified against the source publication. Mean differences (MDs) and risk ratios were pooled under random-effects models with Hartung–Knapp sensitivity analyses; trial sequential analysis used outcome-appropriate required information sizes, and certainty was rated with GRADE. Results Five RCTs enrolling 576 patients (280 LP, 296 SP) were included. Pain did not differ at the earliest postoperative assessment (3 trials, n= 277; MD −0.43 points, 95% CI −1.14 to 0.28) nor at 1, 6, 12 or 24 h, and opioid consumption was unchanged. The information needed to detect a 1-point pain difference had been accrued without the trial sequential monitoring boundary being crossed. LP was associated with greater blood loss (MD +44.7 mL, +6.0 to +83.5) and longer surgery (MD +7.5 min, +1.2 to +13.9), with no difference in transfusion, complications, ileus or length of stay. Conclusion Randomized evidence shows no analgesic benefit of low-pressure pneumoperitoneum in RARP at any assessed time point, and the associated increases in blood loss and operative time are too small to matter clinically. Current evidence supports neither routine adoption nor avoidance; pressure should be individualized to surgical exposure, bleeding risk, and cardiopulmonary tolerance. Registration PROSPERO CRD420261396874