Surgery is an essential and often life-saving treatment for most solid organ cancers. Major urologic oncologic surgeries include radical prostatectomy, radical and partial nephrectomy, and radical cystectomy with reconstruction of the urinary tract. In recent years, the use of laparoscopic surgery in urologic oncology has increased significantly, supplanting open surgery in favor of a less invasive technique. The increased number of surgical robots, improved surgical vision, and reduced costs, which were initially high, has allowed most laparoscopic surgeries to be performed by robotic assistance. The surgeon, physically away from the operating field and seated at a nonsterile workstation equipped with monitors and controls, moves the robot arms and can analyses the operating field, projected three-dimensionally, with very high-resolution images. On the one hand robotic surgery has several advantages such as small incisions with reduction of tissue trauma, less bleeding and less need for transfusions, reduction of length of stay or reduction of hospitalization and post-operative pain, reduction of recovery times, faster return in carrying out daily activities, greater ease in performing complex surgical maneuvers and greater safety for the patient [[1], [2], [3], [4], [5]]. On the other hand, robot-assisted surgery also has some disadvantages. Prolonged Trendelenburg position (Fig. 1), necessary to allow a better visualization of the pelvis, causes high intraocular pressure predisposing to ocular injuries such as ischemic optic neuropathy [6,7]. The high intra-abdominal pressure and the head-down position predisposes to laryngeal and face edema and reduces pulmonary compliance [8]. Furthermore, this extreme position could cause neurophysiological damage such as cerebral edema and increased intracranial pressure [8]. Finally, the direct compression of the venous vessels as well as the renal parenchima reduces the renal blood flow worsening the glomerular filtration rate [9]. The difficulties related to robotic instrumentarium, the respiratory or haemodynamic effects and the possible complications related to pneumoperitoneum and to the patient positioning are better specified in box 1.

The diffusion of robot-assisted laparoscopic surgery in the urological field has required the modulation of intraoperative anesthetic approach. The purpose of this review is to provide topics and indications for the anesthetic management in patients undergoing oncological major robotic uro-surgery.