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Article of the week: Obese patients should not be denied RARP

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Perioperative and early oncological outcomes after robot-assisted radical prostatectomy (RARP) in morbidly obese patients: a propensity score-matched study

Haidar Abdul-Muhsin, Camilo Giedelman, Srinivas Samavedi, Oscar Schatloff, Rafael Coelho, Bernardo Rocco, Kenneth Palmer, George Ebra and Vipul Patel

Global Robotics Institute, Florida Hospital Celebration Health, Celebration, FL, USA

OBJECTIVE

• To evaluate the perioperative and pathological outcomes associated with robot-assisted radical prostatectomy (RARP) in morbidly obese men.

PATIENTS AND METHODS

• Between January 2008 and March 2012, 3041 patients underwent RARP at our institution by a single surgeon (V.P.).

• In all, 44 patients were considered morbidly obese with a body mass index (BMI) of ≥40 kg/m2.

• A propensity score-matched analysis was conducted using multivariable analysis to identify comparable groups of patients with a BMI of ≥40 and <40 kg/m2.

• Perioperative, pathological outcomes and complications were compared between the two matched groups.

RESULTS

• There was no significant difference in operative time. However, the mean estimated blood loss was higher in morbidly obese patients, at a mean (sd) of 113 (41) vs 130 (27) mL (P = 0.049).

• Anastomosis was more difficult in morbidly obese patients (P = 0.001).

• There were no significant differences in laterality, ease of nerve sparing, or transfusion rate between the groups.

• There were no intraoperative complications in either group. Postoperative pathological outcomes were similar between the groups.

• Differences in positive surgical margins and ease of nerve sparing approached statistical significance (P = 0.097, P = 0.075 respectively). Postoperative complication rates, pain scores, length of stay and indwelling catheter duration were similar in the groups.

CONCLUSIONS

• RARP in morbidly obese patients is technically demanding. However, it can be accomplished with acceptable morbidity and resource use.

• In the hands of an experienced surgeon, it is a safe procedure and offers beneficial clinical outcomes.

 

Read Previous Articles of the Week

 

 

Editorial: How should we best manage obesity in urology?

Abdul-Muhsin et al. [1] are to be congratulated on an excellent study involving >3000 patients undergoing robot-assisted radical prostatectomy over a 4-year period. In their study they demonstrate that the morbidly obese patient can be managed in a just about equal way to the non-morbidly obese patient for removal of the prostate. The complications and recovery characteristics in morbidly obese patients are reviewed and it is concluded that, in this single-operator single-centre study, the morbidly obese male with prostate cancer should not be overlooked as a candidate for radical surgery.

We are all faced with more obese patients presenting to our clinical care; in the UK 20% of the adult population are obese and >3% are morbidly obese. There are an increasing number of studies looking at the outcome of surgery in the obese and morbidly obese populations. These studies have drawn mixed conclusions, with some suggesting an increased risk and morbidity and others suggesting no difference when compared with a non-obese population. This is confusing: perhaps the use of body mass index alone to assess obesity is limited and misleading [2]. This is because the distribution of fat varies considerably among individuals, with the most at-risk patients being those with a centripetal fat distribution producing a large abdominal girth. In middle-aged men, a waist size of >102 cm is the best predictor of metabolic syndrome with all its concomitant risk factors [3]. It is these patients who represent the greatest risk for surgery and it is these same patients who urgently need to improve their lifestyle and shed weight in order to achieve a normal life expectancy both to aid surgery and thereafter. Factors such as hypoventilation, hypertension and the risk of thromboembolism are greatly increased in this group. Diabetes, abnormal lipids, bone and joint diseases and reflux are common. These factors will probably contribute to multiple potential peri-operative complications. Cardiopulmonary exercise testing is very useful in detecting the patients most at risk and likely to require most intensive care postoperatively. There are too few studies to date that include this test and that specifically looking at the morbidly obese population, but results are encouraging and will very probably detect those patients most likely to require critical care facilities [4].

While the surgical results in the Abdul-Muhsin et al. study are excellent, one would not wish to dilute the key message to our patients that preparation for major surgery with weight loss is vital. Addressing nutrition and exercise activity in the preoperative period is extremely beneficial and highly successful. Achieving a 10% weight loss within weeks before surgery is entirely achievable with significant benefits to the medical comorbidities and, in particular, breathing and muscle activity [5]. One great advantage of prostate cancer surgery is the often slow-growing nature of the tumour and we can, therefore, often take the opportunity to postpone major surgery for just a matter of weeks to improve fitness and nutrition. This window of opportunity is more than enough to transform a high-risk patient to one with a much lower risk profile.

If we inspire our patients to join in the aim of the whole surgical team to safely cure prostate cancer using weight reduction and improved fitness then long-term life benefits will surely follow in addition to the immediate gains for surgery and anaesthesia.

Peter Amoroso
The London Clinic, 20 Devonshire Place, London W1G 6BW

Read the full article

References

  1. Abdul-Muhsin H, Giedelman C, Samavedi S et al. Perioperative and early oncological outcomes after robot-assisted radical prostatectomy (RARP) in morbidly obese patients: a propensity score-matched studyBJU Int 2014; 113: 84–91
  2. Mullen JT, Moorman DW, Davenport DL. The obesity paradox body mass index and outcomes in patients undergoing non-bariatric general surgeryAnn Surg 2009; 250: 166–172
  3. Balentine CJ, RobInson CN, Marshall CR et al. Waist circumference predicts increased complications in rectal cancer surgeryJ Gastrointest Surg 2010; 14: 1669–1679
  4. Hennis PJ, Meale PM, Hurst RA et al. Cardiopulmonary exercise testing predicts post operative outcome in patients undergoing gastric bypass surgeryBr J Anaesth 2012; 109: 566–571
  5. Benotti PN, Still CD, Wood GC et al. Preoperative weight loss before bariatric surgeryArch Surg 2009; 44: 1150–1155

 

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