| Summary: | Individualized positive end-expiratory pressure (PEEP) combined with recruitment maneuvers improves intraoperative oxygenation in individuals undergoing robot-assisted prostatectomy. However, whether electrical impedance tomography (EIT)-guided individualized PEEP without recruitment maneuvers can also improve intraoperative oxygenation is unknown. To test this, fifty-six male patients undergoing elective robot-assisted laparoscopic prostatectomy were randomly assigned to either individualized PEEP (Group PEEP<sub>IND</sub>, <i>n</i> = 28) or a control with a fixed PEEP of 5 cm H<sub>2</sub>O (Group PEEP<sub>5</sub>, <i>n</i> = 28). Individualized PEEP was guided by EIT after placing the patients in the Trendelenburg position and performing intraperitoneal insufflation. Patients in Group PEEP<sub>IND</sub> maintained individualized PEEP without intermittent recruitment maneuvers, and those in Group PEEP<sub>5</sub> maintained a PEEP of 5 cm H<sub>2</sub>O intraoperatively. Both groups were extubated in a semi-sitting position once the extubation criteria were met. The primary outcome was arterial oxygen partial pressure (PaO<sub>2</sub>)/inspiratory oxygen fraction (FiO<sub>2</sub>) prior to extubation. Other outcomes included intraoperative driving pressure, plateau pressure and dynamic, respiratory system compliance, and the incidence of postoperative hypoxemia in the post-operative care unit (PACU). Our results showed that the intraoperative median for PEEP<sub>IND</sub> was 16 cm H<sub>2</sub>O (ranging from 12 to 18 cm H<sub>2</sub>O). EIT-guided PEEP<sub>IND</sub> was associated with higher PaO<sub>2</sub>/FiO<sub>2</sub> before extubation compared to PEEP<sub>5</sub> (71.6 ± 10.7 vs. 56.8 ± 14.1 kPa, <i>p</i> = 0.003). Improved oxygenation extended into the PACU with a lower incidence of postoperative hypoxemia (3.8% vs. 26.9%, <i>p</i> = 0.021). Additionally, PEEP<sub>IND</sub> was associated with lower driving pressures (12.0 ± 3.0 vs. 15.0 ± 4.4 cm H<sub>2</sub>O, <i>p</i> = 0.044) and better compliance (44.5 ± 12.8 vs. 33.6 ± 9.1 mL/cm H<sub>2</sub>O, <i>p</i> = 0.017). Our data indicated that individualized PEEP guided by EIT without intraoperative recruitment maneuvers also improved perioperative oxygenation in patients undergoing robot-assisted laparoscopic radical prostatectomy, which could benefit patients with the risk of intraoperative hemodynamic instability caused by recruitment maneuvers. Trial registration: China Clinical Trial Registration Center Identifier: ChiCTR2100053839. This study was registered on 1 December 2021. The first patient was recruited on 15 December 2021.
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