Preoperative Breathing Exercise Training and Postoperative Delirium After Robotic Radical Prostatectomy

Robot-assisted radical prostatectomy (RARP) is a commonly performed minimally invasive surgical procedure for the treatment of prostate cancer. In this population, perioperative factors including advanced age, comorbidities, general anesthesia, pneumoperitoneum, prolonged surgical and anesthetic duration, and steep Trendelenburg positioning may contribute to postoperative respiratory changes and postoperative delirium. Postoperative delirium is characterized by an acute and fluctuating disturbance in attention, awareness, and cognitive function and may be associated with increased complications, prolonged hospitalization, and greater care requirements.

Preoperative breathing exercise training is a noninvasive, nonpharmacological, and low-cost intervention intended to encourage slow, controlled, and deep breathing. Improving patients' familiarity and adherence to breathing exercises before surgery may facilitate postoperative respiratory exercises and may contribute to preservation of oxygenation and reduction of postoperative respiratory complications. These effects may also influence clinical factors associated with postoperative delirium. Evidence regarding the relationship between preoperative breathing exercise training and postoperative delirium specifically in patients undergoing RARP remains limited.

This study is designed as a single-center, prospective, two-arm controlled pilot study and will include 50 male patients aged 40 years or older who are scheduled for elective RARP. Twenty-five patients will be included in the preoperative breathing exercise training group and 25 patients in the control group.

Patients in the intervention group will receive standardized deep breathing exercise training during the preoperative outpatient evaluation, generally approximately one week before surgery. Patients will be instructed to sit in an upright or semi-upright position, relax their shoulders, inhale slowly and deeply through the nose, hold their breath for approximately 2-3 seconds, and then exhale slowly through the mouth. Each session will consist of 10 deep breaths. Patients will be asked to perform the exercises three times daily until the day of surgery. Adherence will be recorded using a home breathing exercise follow-up form and reviewed on the morning of surgery. Patients in the control group will receive routine preoperative information without additional structured breathing exercise training.

Routine perioperative anesthesia and surgical management will not be modified because of study participation. Intraoperative variables including anesthesia and surgical duration, pneumoperitoneum duration, Trendelenburg duration when available, oxygen saturation, end-tidal carbon dioxide, intraoperative hypotension, vasopressor or inotrope requirement, estimated blood loss, fluid administration, transfusion, and perioperative complications will be recorded from routine clinical and anesthesia records.

Postoperative delirium will be evaluated during the first 48 hours after surgery. The 4AT will be administered at approximately 24 and 48 hours after surgery, and the Nursing Delirium Screening Scale (Nu-DESC) will be used during the first 12 postoperative hours and again during the 24-48-hour postoperative period. A 4AT score of 4 or greater and/or a Nu-DESC score of 2 or greater will be considered indicative of delirium for the purposes of the study.

Secondary clinical assessments will include 4AT and Nu-DESC scores, postoperative peripheral oxygen saturation, supplemental oxygen requirement, postoperative hypoxemia, clinically documented pulmonary complications or atelectasis, postoperative pain, nausea and vomiting, additional analgesic requirement, intensive care requirement, and length of hospital stay.

No additional medication, invasive procedure, blood sampling, laboratory testing, imaging, or medical device assessment will be performed solely for research purposes. All anesthesia, surgery, treatment, and postoperative care will follow routine clinical practice.

Inclusion criteria

• Male patients aged 40 years or older.
• Scheduled to undergo elective robot-assisted radical prostatectomy (RARP) at -Akdeniz University Hospital.
• Able to communicate and suitable for preoperative and postoperative -cognitive/delirium assessment using the 4AT and Nu-DESC.
• Able and willing to provide written informed consent.
• Availability of clinical follow-up data during the first 48 postoperative hours.

Exclusion criteria

• Refusal to participate or withdrawal of informed consent.
• History of delirium, severe dementia, severe cognitive impairment, or an active neurological disorder that would interfere with delirium assessment.
• Active psychosis, severe psychiatric disease, or use of psychoactive medication that could substantially affect cognitive assessment.
• Level of consciousness not allowing assessment, or severe hearing or speech impairment preventing adequate communication.
• Emergency surgery or failure to complete the planned procedure as robot-assisted radical prostatectomy.
• Inability to complete the postoperative 4AT and/or Nu-DESC assessments or substantial missing data affecting the primary analysis.
• Inability to tolerate the breathing exercises or insufficient home exercise adherence/follow-up data for the planned analysis.