The Role of Anesthesia in Decision-making for Robotic/Laparoscopic Urological Surgery: A Propensity Score Matching Analysis

The Role of Anesthesia in Decision-making for Robotic/Laparoscopic Urological Surgery: A Propensity Score Matching Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Role of Anesthesia in Decision-making for Robotic/Laparoscopic Urological Surgery: A Propensity Score Matching Analysis Mei-Yu Wei, Ce Zhang, Dong-Nan Hou, Li-Jie Wen, Bo Yang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5324394/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Comparative studies between robotic and laparoscopic surgeries primarily focus on surgical aspects, with less emphasis on anesthesia. This study explores the role of the anesthesia team in making complex decisions between robotic-assisted laparoscopic surgery (RALS) and conventional laparoscopic surgery (CLS) by comparing postoperative indicators from Enhanced Recovery After Surgery (ERAS). Methods : This retrospective analysis included patients who underwent partial nephrectomy and radical prostatectomy for prostate and renal cancer at the Urological Surgery Department of the Second Affiliated Hospital of Dalian Medical University from 2021 to 2023. Propensity score matching (PSM) with a 1:1 ratio was used, considering variables such as age, gender, BMI, operation type, and preoperative comorbidities. Primary outcomes included anesthesia, surgery, and recovery times. Secondary outcomes included resting and activity Visual Analog Scale (VAS) scores, voluntary activities, and the incidence of nausea/vomiting, dizziness, surgical site pain, respiratory depression, and anxiety on postoperative day one (POD1). Results : A total of 252 cases were assigned to experienced RALS and CLS groups. The anesthesia and surgery times for RALS were 158.52 and 140.15 minutes, respectively, significantly longer than those for CLS (136.56 and 125.34 minutes) (P < 0.05). However, there were no differences in PACU recovery times (24.63 vs. 26.51 minutes) or rest-VAS scores (0.96 vs. 1.06) between the RALS and CLS groups. Activity-VAS scores showed a statistically significant difference between RALS (2.19) and CLS (1.86) (P < 0.05). The occurrence rates of voluntary activity, nausea/vomiting, dizziness, and anxiety were 19.5% vs. 29.1% (P < 0.01), 33% vs. 27.9% (P < 0.05), 25% vs. 18% (P < 0.05), and 12.6% vs. 16.8% (P < 0.05) for the RALS and CLS groups, respectively. No significant differences were observed in pharyngeal pain (6.3% vs. 10.1%), respiratory depression (0.5% vs. 1.7%), or oxygen requirement (5.2% vs. 7.8%) between groups. Conclusions : From the anesthetist’s perspective, RALS extends surgery and anesthesia durations, increasing the potential risks to respiratory, circulatory, and central nervous systems during the perioperative period. RALS also increases the patient's financial burden. Therefore, it is crucial to consider the patient’s physical condition when selecting the surgical approach, alongside tumor prognosis and economic costs in clinical decision-making. Robotic-Assisted Laparoscopic Surgery (RALS) Conventional Laparoscopic Surgery (CLS) Anesthesia Decision-making Urological Surgery Postoperative Recovery 1. Introduction There are numerous factors influencing surgical decision-making, which encompass disease characteristics, baseline of patients, economic circumstances, and the extent of surgical care. Patients with urological complications often present with relative old age and frailty, therefore, prioritizing life expectancy, the management of comorbidities, and the preservation of organ function is crucial when making surgical plans. The development of minimally invasive surgeries, in the likes of laparoscopic procedures, have mitigated the limitations associated with open surgery through smaller incisions, resulting in reduced postoperative pain and blood lose, expedited recovery, shorter postoperative inpatient time, and lower complication rates [1] [2] [3] [4] .In the last decade, the robotic assisted surgery, offering superior surgical ergonomics, has further eliminated the limitations poised by complex cases; it endows surgeons more mobility when operating on obese patients [5] [6] . .However, consensus has not been reached regarding which amongst the three techniques is the best, as superior oncological outcomes remain inconclusive. An Italian study on prostate cancer indicated that younger healthy patients should opt for RALS, while other studies have shown that RALS is best used in complex procedures for elderly individuals or those with deeper pelvic lesions [7] [8] [9] [10] [11] .In research in radical prostatectomy, some scholars have found that, compared to open and laparoscopic surgeries, RALS exhibited better short-term postoperative outcomes, which was also linked to long-term functional improvement. However, conflicting results from other studies indicated that for patients who have undergone radical cystectomy, CLS was correlated with significantly reduced overall complications at 30 days and 90 days postoperative compared to RALS [12] .Both CLS and RALS require CO2 insufflation and the patient to be in Trendelenburg position, which may damage patient’s overall physiology; the difference being that the angle of Trendelenburg required is steeper in robotic surgery, with relatively longer preparation and operation times, inevitably increasing perioperative risks for patients with poor cardio pulmonary baseline [13] [14] .As a consequence, postoperative life expectancy, complications, and impact on quality of life must be considered when making surgical decisions. Preoperative assessment becomes more crucial for those patients with varying physiological capacities to tolerate perioperative risks [15] [16] [17] .However, the postoperative recovery index plays a crucial role in determining the prognosis of patients with poor preoperative baseline conditions, thus emphasizing the significance of investigating this index across different surgical methods. Previous studies on the postoperative anesthesia recovery indicators between the two aforementioned types of procedures are limited. This study aims to examine the differences in postoperative recovery indicators between urological RALS and CLS evaluating their advantages and disadvantages from an anesthesiologist’s perspective, and thus exploring the role of anesthesia in urological surgical decision-making. 2. Materials and Methods 2.1 Participants and Characteristics: Approved by the Ethics Committee of the Second Affiliated Hospital of Dalian Medical University, a total of 831 urological patients who underwent RALS and CLS between 2021 and 2023 and aged 23-85 years old were selected in this study. Inclusion criteria: American Society of Anesthesiologists (ASA) Ⅰ-Ⅲ class; preoperative diagnosis of renal or prostate cancer; treatment plan included partial nephrectomy and radical prostatectomy; the patients had no underlying diseases or only had concurrent hypertension, diabetes, and coronary heart disease (cardiac function I-II grade); the same team of anesthesiologists and surgeons was selected and all the surgeons received similar robotic training. Exclusion criteria: perioperative blood transfusion, transferred to ICU after the operation, and data deficiency. In the end, 789 cases were included in the study. 2.2 Methods and Data Collection: We collected primary health information, which included age, gender, BMI, and preoperative comorbidities, and the observed data that included anesthesia time, surgery time, recovery time, resting visual analogue scale (VAS), activity VAS, automatic activities, and incidence rate of nausea and vomiting, sore throat, anxiety, respiratory depression and dizziness of POD1 during PACU. All of the data was obtained from the EHR (electronic health record) and the input from the postoperative care team. In this study, recovery time is defined as the duration spent in the post-anesthesia recovery unit (PACU); postoperative pain is evaluated by VAS, where 0 is absence of pain, 1-3 is mild tolerable pain, 4-6 is moderate pain affecting sleep quality, and 7-10 is severe unbearable pain. The activities status is categorized into four levels: Level 1 is free activities, Level 2 is activities by assistance or at bedside, Level 3 is on bed activity, and Level 4 is complete immobility. Nausea and vomiting are classified as follows: 0 is none of nausea, 1 is mild to moderate nausea, and 2 is severe nausea. All groups were anesthesia induced and sustained by the same narcotic regimen and unified PCA (patient-controlled analgesia) pump. 2.3 Statistical Analysis: Statistical analysis was performed using R4.2.1, employing two-tailed tests with α=0.05 significance level. Continuous data were presented as mean (standard deviation), and independent samples t-test was used for between-group comparisons. Categorical data were presented as frequency (percentage), and chi-square test was employed for between-group comparisons. Propensity score matching in a 1:1 ratio was utilized to ensure comparability of general data across the two groups. 3. Results 3.1 The Propensity Score Matching The propensity score matching was performed to achieve a 1:1 match between RALS and CLS groups, with a caliper value at 0.02. Prior to matching, a total of 789 cases were included, comprising 307 cases in the CLS group and 482 in the RALS group, with significant differences in gender, hypertension, and diabetes between the two groups. A total of 504 cases were successfully matched, with 252 cases in each group. Statistically significant differences were minimized after PSM (all P>0.05), proving the robust effectiveness and comparability between the matched cohorts as presented in Table 1. Table 1 The PSM results demonstrate a satisfactory alignment with the fundamental criteria of both groups Variable level Before PSM After PSM CLS (n=307) RALS (N=482) p CLS (N=252) RALS (N=252) p age (mean (SD)) Con 60.85 (12.07) 60.62 (12.77) 0.79 61.02 (12.22) 59.77 (13.10) 0.27 Cases and Percentage of＞70y（%） Con 91(29.7) 136(28.2) 0.18 82(28.8) 87(31.3) 0.26 Cases and Percentage of＜70y（%） Con 216(70.3) 346(71.8) 0.22 170(71.2) 165(68.8) 0.18 gender (%) Male 201(65.5) 350 (72.6) 0.03* 171 (67.9) 171 (67.9) 1.00 Man 106 (34.5) 132 (27.4) 81 (32.1) 81 (32.1) BMI (mean (SD)) Con 24.77 (3.16) 25.22 (3.58) 0.07 24.74 (2.96) 24.72 (3.17) 0.92 hypertension (%) None 205 (66.8) 356 (73.9) 0.03 * 175 (69.4) 179 (71.0) 0.77 Yes 102 (33.2) 126 (26.1) 77 (30.6) 73 (29.0) diabetes (%) None 257 (83.7) 429 (89.0) 0.04 * 222 (88.1) 223 (88.5) 1 ． 00 Yes 50 (16.3) 53 (11.0) 30 (11.9) 29 (11.5) coronary heart disease (%) None 291 (94.8) 454 (94.2) 0.84 239 (94.8) 242 (96.0) 0.67 Yes 16 (5.2) 28 (5.8) 13 (5.2) 10 (4.0) Percentage partial nephrectomy (%) 203 (66.2) 338 (70.1) 0.02 * 166 (65.9) 171(67.8) 0.89 Percentage radical prostatectomy (%) 104 (33.8) 144 (29.9) 0.03 * 86 (34.1) 81(32.2) 0.74 Con means continuous value. * p<0.05 3.2 Comparison of Observational Indicators between groups after Matching We compare the differences of each index after matching using the t-test and Chi-square test of two independent samples. The results revealed that the RALS group exhibited significantly longer anesthesia time, operation time, and higher VAS-activity compared to the CLS group (all P < 0.05), as shown in Table 2. Moreover, the incidence of autonomic activity was lower in the RALS group than in the CLS group, while the incidence of nausea and vomiting was significantly higher (all P < 0.05), as shown in Table 3. Additionally, dizziness occurred more frequently in the RALS group but anxiety was less prevalent compared to the CLS group (P 0.05). Table 2 The differences in recovery time and VAS between groups were assessed after matching level CLS (N=252) RALS (N=252) p Duration of anesthesia (min mean (SD)) Continuous 136.56 (48.35) 158.52 (56.89) 0.035* Duration of operation (min mean (SD)) Continuous 125.34 (47.10) 140.15 (55.21) 0.002* Duration of PACU (min mean (SD) Rest-VAS (mean (SD)) Continuous Continuous 26.51(19.41) 1.06 (1.45) 24.63(20.35) 0.96 (1.20) 0.337 0.403 Activity-VAS (mean (SD)) Continuous 1.86 (1.61) 2.19 (1.58) 0.047* * p<0.05 Table 3 Disparities in postoperative automatic activity levels and incidence of nausea and vomiting were observed between the two matched groups level CLS (N=208) RALS (N=208) p Activity status n (%) 1.Autonomic mobility Rank 52 （ 29.1 ） 37 (19.5) <0.001** 2.Bedside or support mobility Rank 13 （ 7.3 ） 16 （ 8.4 ） 0.327 3.Bed Mobility Rank 92 （ 51.4 ） 115 （ 60.5 ） 0.873 4.None mobility Rank 22 （ 12.3 ） 21 （ 11.1 ） 0.763 Nausea & vomiting n (%) 1.None Rank 129 （ 72.1 ） 128 （ 67.0 ） 0.043* 2.Mild & moderate Rank 50 （ 27.9 ） 28（29.8） 0.651 3. Severe Rank 0 （ 0 ） 6（3.1） 0.026* * p<0.05 Table 4 The occurrence of other postoperative complications differed between groups after matching level CLS (N=252) RALS (N=252) p Postoperative oxygen uptake rate (%) categorical 14(7.8) 10 (5.2) 0.739 pharyngalgia incidence (%) categorical 18(10.1) 12 (6.3) 0.12 Anxiety incidence (%) categorical 30(16.8) 24 (12.6) 0.048* Incidence of respiratory depression (%) categorical 3 (1.7) 1(0.5) 0.144 Incidence of dizziness (%) categorical 32(18) 47(25) 0.032* * p<0.05 4. Discussion Consensus in the comparison of anesthesia recovery between RALS and CLS has not been reached. A study on endometrial cancer found no differences in complications and hospital stay between the two surgical methods, though RALS had a longer operating time, which also largely depends on the proficiency and experience of the surgeons [ 18 ] .Our study revealed that preparation time was longer in RALS group, leading to a significantly prolonged operation and anesthesia times compared to those in CLS group, which is consistent with previous findings [ 13 ][ 14 ] .We anticipated that this might affect recovery, but the results indicated no notable differences in recovery time; this result is consistent with a randomized controlled trial where no significant variations in post-anesthesia care unit (PACU) time were found between the two methods [ 19 ] ..In the aforementioned endometrial cancer study, the correlation between perioperative anesthetic dose and extended recovery times after RALS was observed, with the multivariate analysis suggesting that the dependency of recovery time rest upon the total anesthetic dose and surgical technique [ 18 ] .The length of emergence period is believed to be largely dependent on intrinsic disturbances such as the accumulation of anesthetic drugs, blood loss, carbon dioxide retention, or hyperventilation, though we assume prolonged surgery and anesthesia may also influence the emergence postoperatively. In this study, short-acting anesthetics like remifentanil and propofol were administered to maintain anesthesia; deep muscle relaxation technology was used to reduce the higher pneumoperitoneum pressure required for RALS; and in the end of surgeries, antagonism with Sugammadex was infused. The perioperative management team consisted of fixed urology specialists in anesthesia and surgery. Given the consistency in anesthetic regimen, perioperative management, and surgical protocol, differences in intraoperative blood loss were minimized. Furthermore, the propensity score matching performed in this study minimized bias from potential errors, such as age, BMI, preoperative comorbidities, and type of surgery. Thus, under standard anesthesia protocols, no differences in postoperative recovery time was appreciated, comparing CLS and RALS. Minimally invasive surgery has proven to reduce the use of postoperative analgesics, promote earlier recovery of bowel function, decrease postoperative complications, and shorten hospital stays [ 20 ][ 21 ] .Regarding postoperative pain management, some studies suggest that RALS results in less pain and faster recovery [ 22 ][ 23 ] .However, comparative studies on postoperative pain between laparoscopic and robotic surgeries are limited. Tewari et al reported a significant reduction in VAS on day one post operatively (POD 1) for patients undergoing RALS [ 24 ] .Conversely, Webster [ 25 ] et al observed a statistical difference only in the early postoperative period, with no significant differences in pain scores on POD 1 or POD 14 and only a slight difference in morphine demand. In our study, when utilizing PCA (patient-controlled analgesia) pumps, there was no difference in resting-VAS between the two groups; however, the RALS group had significantly higher VAS scores during mobilization, which may be attributed to the higher number of trocar incisions and port sites required by RALS. Some studies [ 26 ][ 27 ] proposed that the primary source of postoperative pain after RALS is from the incision site; this limits the patient’s early mobilization, which leads to a lower occurrence of autonomous movement in the RALS group. In terms of other comparable parameters, Boo-young [ 19 ] et al studied 57 prostate cancer patients and found no significant advantages in blood loss, PACU time, and hospital stay for RALS compared to CLS; on the contrary, the longer operative time for RALS increased the dosage of anesthetics and analgesics used. The incidence rate and severity of nausea and vomiting were higher in RALS group, potentially related to the longer pneumoperitoneum duration and the steep Trendelenburg position. Previous studies [ 28 ] have reported a propensity for laryngeal edema and pharyngeal pain following RALS. However, significant pharyngeal pain in the RALS group was not exhibited possibly due to the use of deep muscle relaxation to relax pharyngeal muscles and to reduce mucosal edema. There was no difference in oxygen uptake or incidence of respiratory depression between the two groups, indicating absence of residual anesthetic effects and optimal muscle relaxation antagonism. The lower postoperative anxiety in the RALS group may be attributed to the placebo effect linked to preoperative education. Conversely, the higher incidence of dizziness could be linked to increased intracranial pressure caused by prolonged steep Trendelenburg positioning. This study, focusing on the anesthesia related parameters of urological surgeries, evaluated and compared RALS and CLS; Superiority of the RALS across all aspects examined was not appreciated. Therefore, we suggest that surgical decisions should be based on a patient’s concurrent health status; this necessitates rigorous risk assessments, screenings, and pertinent pre-treatments to be carried out before operation. This is particularly important when facing prolonged pneumoperitoneum and steep Trendelenburg positions during RALS, both of which can negatively impact patients with serious cardiopulmonary dysfunction [ 29 ] .It is also important to factor in intraoperative emergency protocols. Due to the bulky robotic apparatuses, establishing resuscitation or other necessary measures is significantly more difficult and time consuming [ 30 ] .Additionally, considering the higher cost associated with robotic assisted surgeries, medical disputes may be more prone to arise in a failed scenario. The highlights of this study: it is amongst the few that dissect differences in postoperative recovery between laparoscopic and robotic surgeries from the perspective of anesthesiologists. Despite it being a retrospective study, the use of PSM effectively mitigated confounding factors such as age, gender, and surgical methodology. However, this study has also some certain limitations: although the initial dataset was large, the sample size is significantly reduced after matching. Moreover, due to the inherent limitations of a retrospective study design, the accuracy of results may not be superior to that of a randomized controlled trial (RCT) and as a single-center study, some of the observed indicators may be affected, necessitating further validation. Furthermore, we primary survey the recovery conditions from anesthesia aspect without the indicator about the operation such as blood loss intraoperative, warm ischemia time of partial nephrectomy, incidence of open transfer surgery, serious postoperative operation related complications, length of stay and total expenses. The variations trend of cardiopulmonary function index perioperative were lack, and these parts would be studied in the RCT in the future. 5. Conclusion This study compares the recovery indexes of CLS and RALS of urology surgery in terms of anesthesia, with results showing that CLS had both advantages and disadvantages. Anesthesiologist’ involvement in RALS can optimize various indicators such as reduced postoperative pain and anesthesia recovery time. However, it is important to note that the extreme steep Trendelenburg position as well as prolonged pneumoperitoneum associated with RALS may exacerbate postoperative complications like dizziness, nausea, vomiting, thereby increasing overall perioperative risk for patients with cardiopulmonary dysfunction. Therefore, preoperative high-risk screening and stringent preoperative evaluations are crucial for special individuals undergoing RALS. When necessary, establishing a preoperative high-risk clinic led by anesthesiologists, facilitating MDT (Multidisciplinary Team) approach with urologists, may further minimize operating risks. Declarations Conflict of interest The authors declare that there are no competing interests. Funding The authors have not disclosed any funding. Author Contribution Mei-yu Wei wrote the main manuscript text and Bo Yang reviewed and edited the text. Mei-yu Wei collected the data, and Ce Zhang conducted statistical analysis, and Li-jie Wen investigated it, Dong-nan Hou was in charge or supervision. All authors reviewed the manuscript.Conceptualization: Mei-yu Wei, Bo Yang. Methodology: Mei-yu Wei, Bo Yang. Formal analysis and investigation: Ce Zhang, Li-jie Wen. Writing: Mei-yu Wei. Writing—review and editing: Bo Yang. Supervision: Dong-nan Hou. Data availability No datasets were generated or analysed during the current study. References Aron M, Koenig P, Kaouk J H, et al. Robotic and laparoscopic partial nephrectomy: a matched-pair comparison from a high‐volume centre[J]. BJU international, 2008, 102(1): 86–92. https://doi.org/10.1111/j.1464-410X.2008.07580.x Novara G, Ficarra V. Robotic-assisted laparoscopic radical cystectomy: where do we stand? [J]. 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Literature Review: Robotic-Assisted Harvest of Deep Inferior Epigastric Flap for Breast Reconstruction.[J].Ann Plast Surg, 2022, 89: 703–708 DOI: 10.1097/SAP.0000000000003326 . Seo H, Bang J, Oh J, et al. Effect of Tracheal cuff shape on intracuff pressure change during robot-assisted laparoscopic surgery: the tapered-shaped cuff tube versus the cylindrical-shaped cuff tube[J]. Journal of Laparoendoscopic & Advanced Surgical Techniques, 2015, 25(9): 724–729 https://doi.org/10.1089/lap.2015.0152 . Gainsburg D M. Anesthetic concerns for robotic-assisted laparoscopic radical prostatectomy[J]. Minerva anestesiologica, 2012, 78(5): 596. Hafiani H, Choubhi M, Ameur A, et al. Anesthetic considerations in robotic surgery: a comprehensive review[J]. Journal of Robotic Surgery, 2024, 18(1): 220 https://doi.org/10.1007/s11701-024-01974-y . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5324394","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":370570548,"identity":"1982aae0-f041-4f7e-b462-e2ee2d5c838c","order_by":0,"name":"Mei-Yu Wei","email":"","orcid":"","institution":"The Second Hospital of Dalian Medical University","correspondingAuthor":false,"prefix":"","firstName":"Mei-Yu","middleName":"","lastName":"Wei","suffix":""},{"id":370570549,"identity":"5f08dd49-5600-487d-a6a5-d00ec91db2ba","order_by":1,"name":"Ce Zhang","email":"","orcid":"","institution":"The Second Hospital of Dalian Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ce","middleName":"","lastName":"Zhang","suffix":""},{"id":370570550,"identity":"71453e6c-73da-4240-92c9-e208a9b412d5","order_by":2,"name":"Dong-Nan Hou","email":"","orcid":"","institution":"The Second Hospital of Dalian Medical University","correspondingAuthor":false,"prefix":"","firstName":"Dong-Nan","middleName":"","lastName":"Hou","suffix":""},{"id":370570551,"identity":"a94755d7-4262-462e-a502-017dfdb12bd8","order_by":3,"name":"Li-Jie Wen","email":"","orcid":"","institution":"The Second Hospital of Dalian Medical University","correspondingAuthor":false,"prefix":"","firstName":"Li-Jie","middleName":"","lastName":"Wen","suffix":""},{"id":370570552,"identity":"092c06dd-ad0f-4644-b655-9ffb1432d28e","order_by":4,"name":"Bo Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyElEQVRIiWNgGAWjYDCCA0DM2GCTAOYkFBCvJS2BgQ2kxYB4LYchWhiI0cJ3IzvtMe+O83n88t2JHx4YMMjzix3Ar0XyRu52Y94zt4sl23g3SwAdZjhzdgJ+LQY3crdJ87bdTtxwjHcDSEuCwW3itJwDadn8gxQtB0BathFni+SZt9sk555JTpzZlrvNIsFAgrBf+I7nbpN4u8MusZ/57OabPyps5PmlCWhhEEhgYOJBcCUIKAcB/gMMjD+IUDcKRsEoGAUjGAAAKKVJcwf/TLcAAAAASUVORK5CYII=","orcid":"","institution":"The Second Hospital of Dalian Medical University","correspondingAuthor":true,"prefix":"","firstName":"Bo","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2024-10-24 09:08:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5324394/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5324394/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":80486200,"identity":"dfa4d702-f6c3-4feb-ada7-8063b61b3184","added_by":"auto","created_at":"2025-04-13 15:46:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":628788,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5324394/v1/7524095b-cf9c-405c-9149-fdf7ec5ed480.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Role of Anesthesia in Decision-making for Robotic/Laparoscopic Urological Surgery: A Propensity Score Matching Analysis","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eThere are numerous factors influencing surgical decision-making, which encompass disease characteristics, baseline of patients, economic circumstances, and the extent of surgical care. Patients with urological complications often present with relative old age and frailty, therefore, prioritizing life expectancy, the management of comorbidities, and the preservation of organ function is crucial when making surgical plans. The development of minimally invasive surgeries, in the likes of laparoscopic procedures, have mitigated the limitations associated with open surgery through smaller incisions, resulting in reduced postoperative pain and blood lose, expedited recovery, shorter postoperative inpatient time, and lower complication rates\u003csup\u003e[1]\u003c/sup\u003e\u003csup\u003e[2]\u003c/sup\u003e\u003csup\u003e[3]\u003c/sup\u003e\u003csup\u003e[4]\u003c/sup\u003e.In the last decade, the robotic assisted surgery, offering superior surgical ergonomics, has further eliminated the limitations poised by complex cases; it endows surgeons more mobility when operating on obese patients\u003csup\u003e[5]\u003c/sup\u003e\u003csup\u003e[6]\u003c/sup\u003e\u003csup\u003e.\u003c/sup\u003e.However, consensus has not been reached regarding which amongst the three techniques is the best, as superior oncological outcomes remain inconclusive. An Italian study on prostate cancer indicated that younger healthy patients should opt for RALS, while other studies have shown that RALS is best used in complex procedures for elderly individuals or those with deeper pelvic lesions\u003csup\u003e[7]\u003c/sup\u003e\u003csup\u003e[8]\u003c/sup\u003e\u003csup\u003e[9]\u003c/sup\u003e\u003csup\u003e[10]\u003c/sup\u003e\u003csup\u003e[11]\u003c/sup\u003e.In research in radical prostatectomy, some scholars have found that, compared to open and laparoscopic surgeries, RALS exhibited better short-term postoperative outcomes, which was also linked to long-term functional improvement. However, conflicting results from other studies indicated that for patients who have undergone radical cystectomy, CLS was correlated with significantly reduced overall complications at 30 days and 90 days postoperative compared to RALS\u003csup\u003e[12]\u003c/sup\u003e.Both CLS and RALS require CO2 insufflation and the patient to be in Trendelenburg position, which may damage patient\u0026rsquo;s overall physiology; the difference being that the angle of Trendelenburg required is steeper in robotic surgery, with relatively longer preparation and operation times, inevitably increasing perioperative risks for patients with poor cardio pulmonary baseline\u003csup\u003e[13]\u003c/sup\u003e\u003csup\u003e[14]\u003c/sup\u003e.As a consequence, postoperative life expectancy, complications, and impact on quality of life must be considered when making surgical decisions. Preoperative assessment becomes more crucial for those patients with varying physiological capacities to tolerate perioperative risks\u003csup\u003e[15]\u003c/sup\u003e\u003csup\u003e[16]\u003c/sup\u003e\u003csup\u003e[17]\u003c/sup\u003e.However, the postoperative recovery index plays a crucial role in determining the prognosis of patients with poor preoperative baseline conditions, thus emphasizing the significance of investigating this index across different surgical methods. Previous studies on the postoperative anesthesia recovery indicators between the two aforementioned types of procedures are limited. This study aims to examine the differences in postoperative recovery indicators between urological RALS and CLS evaluating their advantages and disadvantages from an anesthesiologist\u0026rsquo;s perspective, and thus exploring the role of anesthesia in urological surgical decision-making.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003e2.1 Participants and Characteristics:\u003c/strong\u003e Approved by the Ethics Committee of the Second Affiliated Hospital of Dalian Medical University, a total of 831 urological patients who underwent RALS and CLS between 2021 and 2023 and aged 23-85 years old were selected in this study. Inclusion criteria: American Society of Anesthesiologists (ASA) Ⅰ-Ⅲ class; preoperative diagnosis of renal or prostate cancer; treatment plan included partial nephrectomy and radical prostatectomy; the patients had no underlying diseases or only had concurrent hypertension, diabetes, and coronary heart disease (cardiac function I-II grade); the same team of anesthesiologists and surgeons was selected and all the surgeons received similar robotic training. Exclusion criteria: perioperative blood transfusion, transferred to ICU after the operation, and data deficiency. In the end, 789 cases were included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Methods and Data Collection:\u003c/strong\u003e We collected primary health information, which included age, gender, BMI, and preoperative comorbidities, and the observed data that included anesthesia time, surgery time, recovery time, resting visual analogue scale (VAS), activity VAS, automatic activities, and incidence rate of nausea and vomiting, sore throat, anxiety, respiratory depression and dizziness of POD1 during PACU. All of the data was obtained from the EHR (electronic health record) and the input from the postoperative care team. In this study, recovery time is defined as the duration spent in the post-anesthesia recovery unit (PACU); postoperative pain is evaluated by VAS, where 0 is absence of pain, 1-3 is mild tolerable pain, 4-6 is moderate pain affecting sleep quality, and 7-10 is severe unbearable pain. The activities status is categorized into four levels: Level 1 is free activities, Level 2 is activities by assistance or at bedside, Level 3 is on bed activity, and Level 4 is complete immobility. Nausea and vomiting are classified as follows: 0 is none of nausea, 1 is mild to moderate nausea, and 2 is severe nausea. All groups were anesthesia induced and sustained by the same narcotic regimen and unified PCA (patient-controlled analgesia) pump.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Statistical Analysis:\u003c/strong\u003e Statistical analysis was performed using R4.2.1, employing two-tailed tests with \u0026alpha;=0.05 significance level. Continuous data were presented as mean (standard deviation), and independent samples t-test was used for between-group comparisons. Categorical data were presented as frequency (percentage), and chi-square test was employed for between-group comparisons. Propensity score matching in a 1:1 ratio was utilized to ensure comparability of general data across the two groups.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3.1 The Propensity Score Matching\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe propensity score matching was performed to achieve a 1:1 match between RALS and CLS groups, with a caliper value at 0.02. Prior to matching, a total of 789 cases were included, comprising 307 cases in the CLS group and 482 in the RALS group, with significant differences in gender, hypertension, and diabetes between the two groups. A total of 504 cases were successfully matched, with 252 cases in each group. Statistically significant differences were minimized after PSM (all P\u0026gt;0.05), proving the robust effectiveness and comparability between the matched cohorts as presented in Table 1.\u003c/p\u003e\n\u003cp\u003eTable 1 The PSM results demonstrate a satisfactory alignment with the fundamental criteria of both groups\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"633\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 113px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 42px;\"\u003e\n \u003cp\u003elevel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 217px;\"\u003e\n \u003cp\u003eBefore PSM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 236px;\"\u003e\n \u003cp\u003eAfter PSM\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eCLS\u003c/p\u003e\n \u003cp\u003e(n=307)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eRALS\u003c/p\u003e\n \u003cp\u003e(N=482)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003eCLS\u003c/p\u003e\n \u003cp\u003e(N=252)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003eRALS\u003c/p\u003e\n \u003cp\u003e(N=252)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eage (mean\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(SD))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003eCon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e60.85 (12.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e60.62 (12.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e61.02 (12.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e59.77 (13.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 139px;\"\u003e\n \u003cp\u003eCases and Percentage of＞70y（%）\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003eCon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e91(29.7) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e136(28.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e82(28.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e87(31.3)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 139px;\"\u003e\n \u003cp\u003eCases and Percentage\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eof＜70y（%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003eCon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e216(70.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e346(71.8) \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e170(71.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e165(68.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 121px;\"\u003e\n \u003cp\u003egender (%) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;201(65.5) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e350 (72.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.03*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e171 (67.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e171 (67.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003eMan\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e106 (34.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e132 (27.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e81 (32.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e81 (32.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eBMI (mean (SD))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003eCon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e24.77 (3.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e25.22 (3.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e24.74 (2.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e24.72 (3.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003ehypertension (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e205 (66.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e356 (73.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.03\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e175 (69.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e179 (71.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e102 (33.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e126 (26.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e77 (30.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e73 (29.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003ediabetes (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e257 (83.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e429 (89.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.04\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e222 (88.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e223 (88.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e1\u003cspan lang=\"ZH-CN\"\u003e．\u003c/span\u003e00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e50 (16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e53 (11.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e30 (11.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e29 (11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003ecoronary heart disease (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e291 (94.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e454 (94.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e239 (94.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e242 (96.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e16 (5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e28 (5.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e13 (5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e10 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003ePercentage\u0026nbsp;partial nephrectomy (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e203 (66.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e338 (70.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.02\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e166 (65.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e171(67.8) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003ePercentage radical prostatectomy (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e104 (33.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e144 (29.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.03\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e86 (34.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e81(32.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCon\u0026nbsp;means continuous value.\u0026nbsp;* p\u0026lt;0.05\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Comparison of Observational Indicators between groups after Matching\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe compare the differences of each index after matching using the t-test and Chi-square test of two independent samples. The results revealed that the RALS group exhibited significantly longer anesthesia time, operation time, and higher VAS-activity compared to the CLS group (all P \u0026lt; 0.05), as shown in Table 2. Moreover, the incidence of autonomic activity was lower in the RALS group than in the CLS group, while the incidence of nausea and vomiting was significantly higher (all P \u0026lt; 0.05), as shown in Table 3. Additionally, dizziness occurred more frequently in the RALS group but anxiety was less prevalent compared to the CLS group (P \u0026lt; 0.05), as shown in Table 4. No significant differences between groups were observed for other indicators (P \u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003eTable 2 The differences in recovery time and VAS between groups were assessed after matching\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"554\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 42.3146%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.9241%;\"\u003e\n \u003cp\u003elevel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.179%;\"\u003e\n \u003cp\u003eCLS\u003c/p\u003e\n \u003cp\u003e(N=252)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.179%;\"\u003e\n \u003cp\u003eRALS\u003c/p\u003e\n \u003cp\u003e(N=252)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.40325%;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 42.3146%;\"\u003e\n \u003cp\u003eDuration of anesthesia (min mean (SD))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9241%;\"\u003e\n \u003cp\u003eContinuous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.179%;\"\u003e\n \u003cp\u003e136.56 (48.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.179%;\"\u003e\n \u003cp\u003e158.52 (56.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.40325%;\"\u003e\n \u003cp\u003e0.035*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 42.3146%;\"\u003e\n \u003cp\u003eDuration of operation (min mean (SD)) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9241%;\"\u003e\n \u003cp\u003eContinuous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.179%;\"\u003e\n \u003cp\u003e125.34 (47.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.179%;\"\u003e\n \u003cp\u003e140.15 (55.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.40325%;\"\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 42.3146%;\"\u003e\n \u003cp\u003eDuration of PACU (min mean (SD)\u003c/p\u003e\n \u003cp\u003eRest-VAS (mean (SD))\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9241%;\"\u003e\n \u003cp\u003eContinuous\u003c/p\u003e\n \u003cp\u003eContinuous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.179%;\"\u003e\n \u003cp\u003e26.51(19.41)\u003c/p\u003e\n \u003cp\u003e1.06 (1.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.179%;\"\u003e\n \u003cp\u003e24.63(20.35)\u003c/p\u003e\n \u003cp\u003e0.96 (1.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.40325%;\"\u003e\n \u003cp\u003e0.337\u003c/p\u003e\n \u003cp\u003e0.403\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 42.3146%;\"\u003e\n \u003cp\u003eActivity-VAS (mean (SD))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9241%;\"\u003e\n \u003cp\u003eContinuous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.179%;\"\u003e\n \u003cp\u003e1.86 (1.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.179%;\"\u003e\n \u003cp\u003e2.19 (1.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.40325%;\"\u003e\n \u003cp\u003e0.047*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* p\u0026lt;0.05\u003c/p\u003e\n\u003cp\u003eTable 3 Disparities in postoperative automatic activity levels and incidence of nausea and vomiting were observed between the two matched groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41.2052%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.81759%;\"\u003e\n \u003cp\u003elevel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.5668%;\"\u003e\n \u003cp\u003eCLS\u003c/p\u003e\n \u003cp\u003e(N=208)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.2638%;\"\u003e\n \u003cp\u003eRALS\u003c/p\u003e\n \u003cp\u003e(N=208)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.1466%;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41.2052%;\"\u003e\n \u003cp\u003eActivity status n (%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.Autonomic mobility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.81759%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRank\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.5668%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e52\u003cspan lang=\"ZH-CN\"\u003e（\u003c/span\u003e29.1\u003cspan lang=\"ZH-CN\"\u003e）\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.2638%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e37 (19.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.1466%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41.2052%;\"\u003e\n \u003cp\u003e2.Bedside or support mobility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.81759%;\"\u003e\n \u003cp\u003eRank\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.5668%;\"\u003e\n \u003cp\u003e13\u003cspan lang=\"ZH-CN\"\u003e（\u003c/span\u003e7.3\u003cspan lang=\"ZH-CN\"\u003e）\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.2638%;\"\u003e\n \u003cp\u003e16\u003cspan lang=\"ZH-CN\"\u003e（\u003c/span\u003e8.4\u003cspan lang=\"ZH-CN\"\u003e）\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.1466%;\"\u003e\n \u003cp\u003e0.327\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41.2052%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;3.Bed Mobility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.81759%;\"\u003e\n \u003cp\u003eRank\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.5668%;\"\u003e\n \u003cp\u003e92\u003cspan lang=\"ZH-CN\"\u003e（\u003c/span\u003e51.4\u003cspan lang=\"ZH-CN\"\u003e）\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.2638%;\"\u003e\n \u003cp\u003e115\u003cspan lang=\"ZH-CN\"\u003e（\u003c/span\u003e60.5\u003cspan lang=\"ZH-CN\"\u003e）\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.1466%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;0.873\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41.2052%;\"\u003e\n \u003cp\u003e4.None mobility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.81759%;\"\u003e\n \u003cp\u003eRank\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.5668%;\"\u003e\n \u003cp\u003e22\u003cspan lang=\"ZH-CN\"\u003e（\u003c/span\u003e12.3\u003cspan lang=\"ZH-CN\"\u003e）\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.2638%;\"\u003e\n \u003cp\u003e21\u003cspan lang=\"ZH-CN\"\u003e（\u003c/span\u003e11.1\u003cspan lang=\"ZH-CN\"\u003e）\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.1466%;\"\u003e\n \u003cp\u003e0.763\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41.2052%;\"\u003e\n \u003cp\u003eNausea \u0026amp; vomiting n (%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.None\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.81759%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRank\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.5668%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e129\u003cspan lang=\"ZH-CN\"\u003e（\u003c/span\u003e72.1\u003cspan lang=\"ZH-CN\"\u003e）\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.2638%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e128\u003cspan lang=\"ZH-CN\"\u003e（\u003c/span\u003e67.0\u003cspan lang=\"ZH-CN\"\u003e）\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.1466%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.043*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41.2052%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;2.Mild \u0026amp; moderate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.81759%;\"\u003e\n \u003cp\u003eRank\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.5668%;\"\u003e\n \u003cp\u003e50\u003cspan lang=\"ZH-CN\"\u003e（\u003c/span\u003e27.9\u003cspan lang=\"ZH-CN\"\u003e）\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.2638%;\"\u003e\n \u003cp\u003e28（29.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.1466%;\"\u003e\n \u003cp\u003e0.651\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 41.2052%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;3. Severe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.81759%;\"\u003e\n \u003cp\u003eRank\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.5668%;\"\u003e\n \u003cp\u003e0\u003cspan lang=\"ZH-CN\"\u003e（\u003c/span\u003e0\u003cspan lang=\"ZH-CN\"\u003e）\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.2638%;\"\u003e\n \u003cp\u003e6（3.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.1466%;\"\u003e\n \u003cp\u003e0.026*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* p\u0026lt;0.05\u003c/p\u003e\n\u003cp\u003eTable 4 The occurrence of other postoperative complications differed between groups after matching\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"554\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 48.0144%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.1625%;\"\u003e\n \u003cp\u003elevel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.4549%;\"\u003e\n \u003cp\u003eCLS\u003c/p\u003e\n \u003cp\u003e(N=252)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.1769%;\"\u003e\n \u003cp\u003eRALS\u003c/p\u003e\n \u003cp\u003e(N=252)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.1913%;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 48.0144%;\"\u003e\n \u003cp\u003ePostoperative oxygen uptake rate (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.1625%;\"\u003e\n \u003cp\u003ecategorical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.4549%;\"\u003e\n \u003cp\u003e14(7.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.1769%;\"\u003e\n \u003cp\u003e10 (5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.1913%;\"\u003e\n \u003cp\u003e0.739\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 48.0144%;\"\u003e\n \u003cp\u003epharyngalgia incidence\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.1625%;\"\u003e\n \u003cp\u003ecategorical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.4549%;\"\u003e\n \u003cp\u003e18(10.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.1769%;\"\u003e\n \u003cp\u003e12 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.1913%;\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 48.0144%;\"\u003e\n \u003cp\u003eAnxiety incidence (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.1625%;\"\u003e\n \u003cp\u003ecategorical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.4549%;\"\u003e\n \u003cp\u003e30(16.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.1769%;\"\u003e\n \u003cp\u003e24 (12.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.1913%;\"\u003e\n \u003cp\u003e0.048*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 48.0144%;\"\u003e\n \u003cp\u003eIncidence of respiratory depression (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.1625%;\"\u003e\n \u003cp\u003ecategorical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.4549%;\"\u003e\n \u003cp\u003e3 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.1769%;\"\u003e\n \u003cp\u003e1(0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.1913%;\"\u003e\n \u003cp\u003e0.144\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 48.0144%;\"\u003e\n \u003cp\u003eIncidence of dizziness (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.1625%;\"\u003e\n \u003cp\u003ecategorical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.4549%;\"\u003e\n \u003cp\u003e32(18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.1769%;\"\u003e\n \u003cp\u003e47(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.1913%;\"\u003e\n \u003cp\u003e\u0026nbsp;0.032*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* p\u0026lt;0.05\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eConsensus in the comparison of anesthesia recovery between RALS and CLS has not been reached. A study on endometrial cancer found no differences in complications and hospital stay between the two surgical methods, though RALS had a longer operating time, which also largely depends on the proficiency and experience of the surgeons\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e.Our study revealed that preparation time was longer in RALS group, leading to a significantly prolonged operation and anesthesia times compared to those in CLS group, which is consistent with previous findings\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e][\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e.We anticipated that this might affect recovery, but the results indicated no notable differences in recovery time; this result is consistent with a randomized controlled trial where no significant variations in post-anesthesia care unit (PACU) time were found between the two methods\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e..In the aforementioned endometrial cancer study, the correlation between perioperative anesthetic dose and extended recovery times after RALS was observed, with the multivariate analysis suggesting that the dependency of recovery time rest upon the total anesthetic dose and surgical technique\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e.The length of emergence period is believed to be largely dependent on intrinsic disturbances such as the accumulation of anesthetic drugs, blood loss, carbon dioxide retention, or hyperventilation, though we assume prolonged surgery and anesthesia may also influence the emergence postoperatively. In this study, short-acting anesthetics like remifentanil and propofol were administered to maintain anesthesia; deep muscle relaxation technology was used to reduce the higher pneumoperitoneum pressure required for RALS; and in the end of surgeries, antagonism with Sugammadex was infused. The perioperative management team consisted of fixed urology specialists in anesthesia and surgery. Given the consistency in anesthetic regimen, perioperative management, and surgical protocol, differences in intraoperative blood loss were minimized. Furthermore, the propensity score matching performed in this study minimized bias from potential errors, such as age, BMI, preoperative comorbidities, and type of surgery. Thus, under standard anesthesia protocols, no differences in postoperative recovery time was appreciated, comparing CLS and RALS.\u003c/p\u003e \u003cp\u003eMinimally invasive surgery has proven to reduce the use of postoperative analgesics, promote earlier recovery of bowel function, decrease postoperative complications, and shorten hospital stays\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e][\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e.Regarding postoperative pain management, some studies suggest that RALS results in less pain and faster recovery\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e][\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e.However, comparative studies on postoperative pain between laparoscopic and robotic surgeries are limited. Tewari et al reported a significant reduction in VAS on day one post operatively (POD 1) for patients undergoing RALS\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e.Conversely, Webster\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e et al observed a statistical difference only in the early postoperative period, with no significant differences in pain scores on POD 1 or POD 14 and only a slight difference in morphine demand. In our study, when utilizing PCA (patient-controlled analgesia) pumps, there was no difference in resting-VAS between the two groups; however, the RALS group had significantly higher VAS scores during mobilization, which may be attributed to the higher number of trocar incisions and port sites required by RALS. Some studies\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e][\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003eproposed that the primary source of postoperative pain after RALS is from the incision site; this limits the patient\u0026rsquo;s early mobilization, which leads to a lower occurrence of autonomous movement in the RALS group. In terms of other comparable parameters, Boo-young\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e et al studied 57 prostate cancer patients and found no significant advantages in blood loss, PACU time, and hospital stay for RALS compared to CLS; on the contrary, the longer operative time for RALS increased the dosage of anesthetics and analgesics used.\u003c/p\u003e \u003cp\u003eThe incidence rate and severity of nausea and vomiting were higher in RALS group, potentially related to the longer pneumoperitoneum duration and the steep Trendelenburg position. Previous studies\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e have reported a propensity for laryngeal edema and pharyngeal pain following RALS. However, significant pharyngeal pain in the RALS group was not exhibited possibly due to the use of deep muscle relaxation to relax pharyngeal muscles and to reduce mucosal edema. There was no difference in oxygen uptake or incidence of respiratory depression between the two groups, indicating absence of residual anesthetic effects and optimal muscle relaxation antagonism. The lower postoperative anxiety in the RALS group may be attributed to the placebo effect linked to preoperative education. Conversely, the higher incidence of dizziness could be linked to increased intracranial pressure caused by prolonged steep Trendelenburg positioning.\u003c/p\u003e \u003cp\u003eThis study, focusing on the anesthesia related parameters of urological surgeries, evaluated and compared RALS and CLS; Superiority of the RALS across all aspects examined was not appreciated. Therefore, we suggest that surgical decisions should be based on a patient\u0026rsquo;s concurrent health status; this necessitates rigorous risk assessments, screenings, and pertinent pre-treatments to be carried out before operation. This is particularly important when facing prolonged pneumoperitoneum and steep Trendelenburg positions during RALS, both of which can negatively impact patients with serious cardiopulmonary dysfunction\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e .It is also important to factor in intraoperative emergency protocols. Due to the bulky robotic apparatuses, establishing resuscitation or other necessary measures is significantly more difficult and time consuming\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e.Additionally, considering the higher cost associated with robotic assisted surgeries, medical disputes may be more prone to arise in a failed scenario.\u003c/p\u003e \u003cp\u003eThe highlights of this study: it is amongst the few that dissect differences in postoperative recovery between laparoscopic and robotic surgeries from the perspective of anesthesiologists. Despite it being a retrospective study, the use of PSM effectively mitigated confounding factors such as age, gender, and surgical methodology. However, this study has also some certain limitations: although the initial dataset was large, the sample size is significantly reduced after matching. Moreover, due to the inherent limitations of a retrospective study design, the accuracy of results may not be superior to that of a randomized controlled trial (RCT) and as a single-center study, some of the observed indicators may be affected, necessitating further validation. Furthermore, we primary survey the recovery conditions from anesthesia aspect without the indicator about the operation such as blood loss intraoperative, warm ischemia time of partial nephrectomy, incidence of open transfer surgery, serious postoperative operation related complications, length of stay and total expenses. The variations trend of cardiopulmonary function index perioperative were lack, and these parts would be studied in the RCT in the future.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study compares the recovery indexes of CLS and RALS of urology surgery in terms of anesthesia, with results showing that CLS had both advantages and disadvantages. Anesthesiologist\u0026rsquo; involvement in RALS can optimize various indicators such as reduced postoperative pain and anesthesia recovery time. However, it is important to note that the extreme steep Trendelenburg position as well as prolonged pneumoperitoneum associated with RALS may exacerbate postoperative complications like dizziness, nausea, vomiting, thereby increasing overall perioperative risk for patients with cardiopulmonary dysfunction. Therefore, preoperative high-risk screening and stringent preoperative evaluations are crucial for special individuals undergoing RALS. When necessary, establishing a preoperative high-risk clinic led by anesthesiologists, facilitating MDT (Multidisciplinary Team) approach with urologists, may further minimize operating risks.\u003c/p\u003e"},{"header":"Declarations","content":" \u003ch2\u003eConflict of interest\u003c/strong\u003e \u003cp\u003e \u003cem\u003eThe authors declare that there are no competing interests.\u003c/em\u003e \u003c/p\u003e \u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe authors have not disclosed any funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMei-yu Wei wrote the main manuscript text and Bo Yang reviewed and edited the text. Mei-yu Wei collected the data, and Ce Zhang conducted statistical analysis, and Li-jie Wen investigated it, Dong-nan Hou was in charge or supervision. All authors reviewed the manuscript.Conceptualization: Mei-yu Wei, Bo Yang. Methodology: Mei-yu Wei, Bo Yang. Formal analysis and investigation: Ce Zhang, Li-jie Wen. Writing: Mei-yu Wei. Writing\u0026mdash;review and editing: Bo Yang. Supervision: Dong-nan Hou.\u003c/p\u003e\u003ch2\u003eData availability\u003c/h2\u003e \u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAron M, Koenig P, Kaouk J H, et al. Robotic and laparoscopic partial nephrectomy: a matched-pair comparison from a high‐volume centre[J]. BJU international, 2008, 102(1): 86\u0026ndash;92. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1464-410X.2008.07580.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1464-410X.2008.07580.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNovara G, Ficarra V. Robotic-assisted laparoscopic radical cystectomy: where do we stand? [J]. 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Journal of Laparoendoscopic \u0026amp; Advanced Surgical Techniques, 2015, 25(9): 724\u0026ndash;729 \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/lap.2015.0152\u003c/span\u003e\u003cspan address=\"10.1089/lap.2015.0152\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGainsburg D M. Anesthetic concerns for robotic-assisted laparoscopic radical prostatectomy[J]. Minerva anestesiologica, 2012, 78(5): 596.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHafiani H, Choubhi M, Ameur A, et al. Anesthetic considerations in robotic surgery: a comprehensive review[J]. Journal of Robotic Surgery, 2024, 18(1): 220 \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11701-024-01974-y\u003c/span\u003e\u003cspan address=\"10.1007/s11701-024-01974-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Robotic-Assisted Laparoscopic Surgery (RALS), Conventional Laparoscopic Surgery (CLS), Anesthesia, Decision-making, Urological Surgery, Postoperative Recovery","lastPublishedDoi":"10.21203/rs.3.rs-5324394/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5324394/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComparative studies between robotic and laparoscopic surgeries primarily focus on surgical aspects, with less emphasis on anesthesia. This study explores the role of the anesthesia team in making complex decisions between robotic-assisted laparoscopic surgery (RALS) and conventional laparoscopic surgery (CLS) by comparing postoperative indicators from Enhanced Recovery After Surgery (ERAS).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: This retrospective analysis included patients who underwent partial nephrectomy and radical prostatectomy for prostate and renal cancer at the Urological Surgery Department of the Second Affiliated Hospital of Dalian Medical University from 2021 to 2023. Propensity score matching (PSM) with a 1:1 ratio was used, considering variables such as age, gender, BMI, operation type, and preoperative comorbidities. Primary outcomes included anesthesia, surgery, and recovery times. Secondary outcomes included resting and activity Visual Analog Scale (VAS) scores, voluntary activities, and the incidence of nausea/vomiting, dizziness, surgical site pain, respiratory depression, and anxiety on postoperative day one (POD1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: A total of 252 cases were assigned to experienced RALS and CLS groups. The anesthesia and surgery times for RALS were 158.52 and 140.15 minutes, respectively, significantly longer than those for CLS (136.56 and 125.34 minutes) (P \u0026lt; 0.05). However, there were no differences in PACU recovery times (24.63 vs. 26.51 minutes) or rest-VAS scores (0.96 vs. 1.06) between the RALS and CLS groups. Activity-VAS scores showed a statistically significant difference between RALS (2.19) and CLS (1.86) (P \u0026lt; 0.05). The occurrence rates of voluntary activity, nausea/vomiting, dizziness, and anxiety were 19.5% vs. 29.1% (P \u0026lt; 0.01), 33% vs. 27.9% (P \u0026lt; 0.05), 25% vs. 18% (P \u0026lt; 0.05), and 12.6% vs. 16.8% (P \u0026lt; 0.05) for the RALS and CLS groups, respectively. No significant differences were observed in pharyngeal pain (6.3% vs. 10.1%), respiratory depression (0.5% vs. 1.7%), or oxygen requirement (5.2% vs. 7.8%) between groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: From the anesthetist’s perspective, RALS extends surgery and anesthesia durations, increasing the potential risks to respiratory, circulatory, and central nervous systems during the perioperative period. RALS also increases the patient's financial burden. Therefore, it is crucial to consider the patient’s physical condition when selecting the surgical approach, alongside tumor prognosis and economic costs in clinical decision-making.\u003c/p\u003e","manuscriptTitle":"The Role of Anesthesia in Decision-making for Robotic/Laparoscopic Urological Surgery: A Propensity Score Matching Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-05 10:48:58","doi":"10.21203/rs.3.rs-5324394/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b5278aa4-ae2b-4640-afdf-b58a6067b56a","owner":[],"postedDate":"November 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-13T15:38:47+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-05 10:48:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5324394","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5324394","identity":"rs-5324394","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}