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Valentine’s Day PSA

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A few years ago Barrack Obama, the President of the USA, is supposed to have said on Valentine’s Day – “Gentlemen – do not forget!”

He was apparently speaking “from experience”. Not remembering that important day can have catastrophic consequences for many men. On that occasion, PSA stood for public service announcement.

The headline, however, could easily have been mistaken for Prostate Specific Antigen. One could argue whether the PSA test is as important to men as Valentine’s Day. Most men probably do not bother, especially if they are less than 40 years old. The PSA debate swings around like a sine wave. Despite the best possible randomised controlled trials for and against PSA screening, there seem to be no clear answers with deep divisions amongst men and their urologists.

This February, the BJUI adds to the PSA debate by publishing the Melbourne Consensus Statement [1]. It was an attempt to bring some sense to a thorny subject. When published as a blog on www.bjui.org, most of our readers liked it, but certainly not all. The usual heated debate was inevitable. Earlier last summer Bal Carter, one of our BJUI Executive Members, chaired the AUA panel that recommended shared decision making for asymptomatic men between 55–69 years as far as PSA screening was concerned. They carefully analysed over 300 studies to make these recommendations [2]. I congratulated Bal on this milestone on the very morning this made headline news. However, such was the controversy that he had to present the findings twice – one appearance on the AUA podium was just not enough.

In a well-informed man, over diagnosis is not necessarily a problem as long as it does not lead to over treatment. I find myself treating a number of men in their 40s with strong family histories of prostate cancer. It is very difficult to deny them a PSA test when they seek it. This discussion is likely to become redundant in years to come when better risk stratification with genomic tools and improved imaging will complement the PSA test, rather than relying on it alone. In the meantime I leave it to our knowledgeable readers to make up their own minds.

Not everyone is interested in the PSA test in the month of February. If you belong to this category, perhaps we could grab your attention with a multi-institutional collaborative study showing disease free and overall survival rates of over 90% following LESS partial nephrectomy, a challenging procedure, even for technically accomplished surgeons [3]. Khurshid Guru’s group also present data to show that urinary and bowel domains take about 6 months to recover after robotic cystectomy; sexual domains even longer [4].

I have no illusions that none of the above may be of the slightest importance to some readers. In which case you may wish to head to the best florist in town. Forget that at your peril …

Prokar Dasgupta, Editor in Chief, BJUI
Guy’s Hospital, King’s College London

 

References

  1. Murphy DG, Ahlering T, Catalona WJ et al. The Melbourne Consensus Statement on the Early Detection of Prostate Cancer. BJU Int 2014; 113: 186–188
  2. Carter HB. American Urological Association (AUA) Guideline on prostate cancer detection: process and rationale. BJU Int 2013;112: 543–547
  3. Springer C, Greco F, Autorino R et al. Analysis of oncological outcomes and renal function after laparoendoscopic single site partial nephrectomy: a multi-institutional outcome analysis. BJU Int 2014; 113: 266–274
  4. Poch MA, Stegemann AP, Rehman S et al. Short-term patient reported health-related quality of life (HRQL) outcomes after robot-assisted radical cystectomy (RARC). BJU Int 2014; 113: 260–265
 

What gets Indy Gill REALLY excited?

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Dr Indy Gill, as everyone knows, has always been a pioneer of minimally invasive surgery, and has continued to push the boundaries of this over the past 20 years. Some of this progress has been seriously exciting, both for us mere mortals who have visited his operating room or viewed his live surgery, and also for Dr Gill as he has continued to reinvent what is possible.   Tackling a Level II/III caval thrombus using robotic surgery, exploring nephron-sparing surgery with anatomically extreme tumours, and now zero ischaemia – all of this progress has been very thrilling indeed.

But last week, I realised that there is something that is capable of getting the great Dr Gill REALLY excited, and I thought I would share that with you.

It started after Indy accepted an invitation from myself and my colleague, Daniel Moon, to join our international faculty at the National Bladder and Kidney Cancer Symposium which we convene here in Melbourne. Our faculty already included Dr Mike Stifleman (NYU), Dr Colin Dinney (MD Anderson), Dr Simon Horenblas (National Cancer Institute, The Netherlands), Dr Nick James (University of Birmingham), and Dr Maha Hussein (University of Michigan), as well as an excellent faculty from around Australia and New Zealand. This symposium is convened at the world famous Melbourne Cricket Ground (MCG), one of the world’s greatest sporting arenas, and one of the most famous cricket grounds in the world. It recently broke the world record for attendance at an international test cricket match when over 91,000 people attended the Australia versus England “Ashes” match on Boxing Day.

I was aware that Indy receives about 1000 emails per day and we wanted to catch his eye as we planned the program. I therefore emailed him with the subject heading, “Opening the batting at the MCG?”, in the certain knowledge that as a self-confessed “cricket tragic”, he might just respond! And here is his response:

  

Apologies to those (me included) who do not understand “cricket-speak”! However one can tell that Indy, like everyone else I know from the sub-continent, is a big cricket fan. The stage was therefore set: our Symposium would benefit from Indy presenting a spectacular overview of advances in nephron-sparing surgery with the wonderful backdrop of one of the world’s greatest sporting arenas and a mecca for cricket lovers.

What we did not know was that by chance, one of the greatest cricketers of all time, legendary leg-spin bowler Shane Warne, was hosting a private charity cricket match in aid of The Shane Warne Foundation on the hallowed turf during our Symposium. As soon as we realised, we started plotting to see if we could arrange for the Urology Legend to meet the Cricket Legend. A few phone calls later and it had been agreed- “Warney” would meet Indy at 08:30 the next morning.

Put simply, I have never seen anybody so excited in my entire life. I don’t think Indy slept very much as he looked forward with child-like amazement to his encounter with one of the greatest cricket players of all time. He paced up and down somewhat nervously (I would say considerably more nervous than he would be before performing one of his live surgery spectaculars to a gigantic audience), as we waited for our escort to bring us to the home team changing room at the MCG. He seemed somewhat breathless, he was speaking terribly quickly, his eyes scanning nystagmus-like as he looked like someone having a supraventricular tachycardia.

Meanwhile in the auditorium upstairs, Indy’s colleague Dr Mihir Desai, another cricket tragic, was broadcasting a live robotic cystectomy from the University of Southern California to our auditorium. When we explained that Indy was a little delayed as he was meeting Shane Warne downstairs, this was met with an audible sigh along with some muttering from Dr Desai’s robot console as he clearly would much prefer to have been in Melbourne than in California at that particular moment. “Stop the procedure” he pleaded in vain, “if I leave now I can be there in 15 hours”.

And then the big moment arrived – Shane Warne, cricket legend, taker of over 700 Test wickets, deliverer of the “Ball of the Century”, and one of only five of Wisden’s Cricketers of the 20th Century, walked over to the star-struck urology legend and shook hands.

They chatted for about 10 minutes about various great cricketing moments and about mutual friends in Indian cricket. They both seemed to be thoroughly enjoying themselves and one could tell that Indy was relishing every moment he was spending in the company of true cricket royalty. Shane then happily signed an Australian cricket jersey before we finally dragged Indy back to the Symposium upstairs. I don’t think it is unreasonable to say that he was somewhat starstruck:

  

The moment was shared by Daniel Moon on Twitter using the official meeting hashtag #bkcs14:

Social media metrics supplied by Symplur at that time showed healthy activity for a sub-specialist uro-oncology meeting with about 250 delegates:

However, when Shane Warne re-tweeted us to his 1.46 million followers, the meeting statistics went through the roof! We had gone from 37,000 digital impressions to almost 1,500,000 impressions:

In the twisted world of social media statistics, #bkcs14 has become one of the biggest scientific meetings in the world this year!

Indy then returned to the relatively mundane world he normally inhabits by showing footage of a robotic-assisted partial nephrectomy with zero ischaemia for a 10cm interpolar tumour in a solitary kidney (including vascular reconstruction of a feeding vessel), followed by a super-human robotic resection of a kidney tumour with level II caval thrombus done as part of a live surgery broadcast to 1000 people. Interesting for sure, but not what gets him really excited.

Declan Murphy
Urologist and Associate Editor (Social Media), BJUI
Melbourne, Australia
Twitter: @declangmurphy

 

Will you bury your Bentley for pleasures in your ‘after life’?

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Last year in September, a Brazilian multi-millionaire Count Scarpa, announced to his followers on Facebook that he would bury his most favorite car, a black Flying Spur Bentley costing half a million Dollars, in his backyard! He expressed his intention to be buried next to the Bentley when he died. He explained that this desire arose after he had watched a documentary on the Egyptian Pharaohs and how they buried themselves with their beloved items, so that they can be used during the afterlife. Count Scarpa had stared death in the face on two occasions. He was in a coma after over-whelming sepsis that nearly killed him following an operation to reduce weight. In fact, a priest gave him the last rites on two occasions. However, he recovered to continue with his business. As you would expect, the announcement of the Bentley burial caused uproar in the Brazilian national media and also caught the international media’s attention reported in the UK by Daily Mail and the Metro. His Facebook account was flooded with comments most of which were derogatory and questioning his intentions.

Count Scarpa even posted photos of him digging the grave and of his favourite Bentley waiting to be buried.

He invited the media for the D-day when the event would take place. The car was being driven into the grave, when Count Scarpa stopped the process and invited the entire media team inside his multi-million Dollar mansion. Once inside, he mentioned that he is not crazy to bury his Bentley but exclaimed ‘everyone thought it was absurd when I said I was going to do that.’ ‘Absurd is bury their organs, which could save many lives. Nothing is more valuable. Be a donor, tell your family.’ (See the video here). The publicity stunt certainly worked. A photo of the Count holding a sign reading “I am an organ donor. Are you?” had spread like wildfire over social media sites, being shared over 40,000 times in just 24 hours! The power of Social Media!

The reason for writing this blog stemmed from reading a very touching article in the UK’s Guardian newspaper. The article quotes that there has been a 30.5% increase in transplants in the past five years, there are still more than 7,000 on the transplant list, and last year more than 1,300 people either died while on the waiting list or became too sick to receive a transplant! There is an urgent need worldwide to raise awareness about organ donation. In the UK, there is a drive by the NHS for organ donation. The organ donations website has very interesting statistics regarding donation as well as that of the recipients. The “Did you Know?” page sheds light on some interesting facts including renal transplantation. It is estimated that 30% of people on the NHS Organ Donor Register are aged between 16-25 when they join. A further 24% are aged between 26-35. Only 9% are 65 or over when they join. More women (54%) than men (46%) have signed up on the NHS Organ Donor Register. There is also a need to raise awareness among the ethnic minorities in the Western World as Black people are three times as likely as the general population to develop kidney failure and the need for organs in the Asian community is three to four times higher than that of Caucasians. 

Government agencies of various countries should take note of the way Count Scarpa took the advantage of the power of Social Media such as Facebook to raise awareness. In fact, an initiative by John’s Hopkins along with Facebook to increase the organ donation was a huge success. The findings were published in the American Journal of Transplantation. On May 1, 2012, Facebook allowed members to specify their organ donor status on their profile. Members were then offered a link to their state registry to complete an official designation, and their “friends” in the network were made aware of the new status as a donor. Those considering the new organ donor status were provided educational links regarding donation. On the first day, astonishingly there were 13,054 new online registrations, representing a 21.1-fold increase over the baseline average of 616 registrations!

Just as BJUI has capitalized social media among the Urologists, we should encourage our respective Governments to use the various channels effectively to spread the word about Organ Donation.  

Amrith Raj Rao is a Consultant Urological and Robotic Surgeon at Wexham Park Hospital, Wexham, UK. Twitter: @urorao

 

Editorial: The evolution of robotic cystectomy

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A decade has passed since the publication of the first series of robot-assisted radical cystectomies in the BJUI by Menon et al. [1]. New technologies are fascinating, and many surgeons who aspire to leave a mark in history take the lead in pioneering new procedures. Others follow without waiting for any evidence to justify the adoption of new procedures. In this race, the opinion of the most important stakeholder, the patient, gets ignored.

Although their study has many methodological flaws, Guru et al. [2] have made the effort to collect data on patients’ health-related quality of life (HRQL) after robot-assisted radical cystectomy for bladder cancer. Radical cystectomy is a morbid procedure with a serious impact on patients’ HRQL, no matter how it is performed. Loosing an organ which is responsible for the storage and evacuation of urine several times a day and replacing it with alternatives of continent or incontinent diversion has a serious impact on quality of life, as is evident from this study.

Robotic cystectomy is still evolving. With more experience, a few experts have ventured to perform intracorporeal reconstruction of the urinary diversion. While we await the long-term functional outcomes of this switch over in surgical approach, Guru et al. report the short-term HQRL outcomes in a series of 43 patients undergoing robot-assisted radical cystectomy and intracorporeal urinary diversion at their institution. Most patients (n = 38) had ileal conduit urinary diversion. The authors went on to compare the postoperative outcomes of this cohort with another group of 70 patients who only completed the questionnaire after having undergone robot-assisted radical cystectomy and extracorporeal urinary diversion.

It is interesting to note that there was no significant difference in HRQL between those undergoing extracorporeal and those undergoing intracorporeal reconstruction. These outcomes reinforce the need to gather robust scientific evidence from properly conducted multi-centre, multinational randomized trials before the introduction of new procedures, instead of evaluation with retrospective studies. The urological community has embraced new technologies and patients have benefited a great deal from these innovative approaches; however, it is incumbent upon us to develop a culture of independent, unbiased data collection on outcomes. In this regard we must make the HQRL one of the most important quality indicators in assessment of the new procedures. Such an approach will enable us to justify the extra cost which society has to bear for our innovative trends in the management of old problems [3].

Read the full article

Muhammad Shamim Khan
Guy’s and St Thomas’s Hospital and King’s College London, London, UK

References

  1. Menon M, Hemal AK, Tewari A et al. Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion. BJU Int 2003; 92: 232–236
  2. Poch MA, Stegemann AP, Rehman S et al. Short-term patient reported health-related quality of life (HRQL) outcomes after robot-assisted radical cystectomy (RARC). BJU Int 2014; 113: 260–265
  3. Wang TT, Ahmed KA, Khan MS et al. Quality-of-care framework in urological cancers: where do we stand? BJU Int 2011; 109: 1436–1443

 

February #urojc summary: complications arising from radical treatment of prostate cancer

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February 2014 twitter-based international urology journal club #urojc continued with the theme of prostate cancer. This time the discussion was based around the complications arising from radical treatment, and the paper was available open access courtesy of Lancet Oncology. Nam et al [1]
reported on a population based retrospective cohort study of men who underwent surgery or radiotherapy alone for prostate cancer in Ontario, Canada between 2002 to 2009. Instead of the traditional outcomes that usually include urinary incontinence and erectile dysfunction, they evaluated five other treatment related complications, hospital admissions; urological, rectal or anal procedures, open surgical procedures and secondary malignancies.

First author of the manuscript Rob Nam joined the discussion using the urojcguest twitter account. The journal club kicked off on Sunday 2nd February at 8pm GMT time, quick off the mark was the ‘Queen of uro-twitter’.

There was quick agreement.

Patients who underwent surgery were more likely to undergo minimally invasive urological procedures, most commonly diagnostic cystoscopy, was this due to easy access to it for urologists?

However, there was comment from Canada where the study was performed that this may not necessarily be the case.

One of the limitations of the study was noted,

Stacy Loeb commented

and the lead author Robert Nam explained

The question was posed how much emphasis was placed on non ED, non urinary incontinence adverse events when counseling patients regarding prostate cancer treatment.

Ben Davies (the self-proclaimed King of uro-twitter) commented that bladder neck contracture was rare in the robotic prostatectomy era, which was the experience of others.

It was noted that the risk of secondary malignancy is probably underplayed due to the relatively short follow up in the study,

and secondary malignancies may sway the decision-making balance towards surgery

Stacy Loeb changed her avatar and commented that the study may not be generalizable to patients treated in the active surveillance era

The timing and severity of complications post treatment was discussed

It was commented that this is likely ‘real world’ data.

The side effects and their likely effects on quality of life were commented on, (from a surgical perspective).

In the same way that surgeons get different results for the same procedure, do radiation oncologists results differ.

A radiation oncologist joined in the discussion.

There was discussion regarding the mode of radiotherapy and variability in outcomes.

We were reminded that not all prostate cancer requires radical treatment.

Final thoughts in the last few minutes of the journal club came from Stacy Loeb.

Thanks to all who participated, looking forward to next months #urojc. Best tweet prize was won by @VMisrai and is complimentary registration to #WCE14 courtesy of @EndourolSoc. His tweet provided a particularly useful link alerted us to an article published on line ahead of print in the ESTRO Green Journal within hours of his tweet. Special acknowledgement again to Rob Nam who contributed as an author and also to brave attendance by Matt Katz whose insightful tweets gave us urologists much to think about.

 

Kate. D. Linton is a consultant urological surgeon at Sheffield Teaching Hospitals/Barnsley Hospital, UK. Twitter @linton_kate

 

Reference

  1. Nam RK, Cheung P, Herschorn S, et al. Incidence of complications other than urinary incontinence or erectile dysfunction after radical prostatectomy or radiotherapy for prostate cancer: a population-based cohort study. Lancet Oncol 2014; 15: 223-31

 

What’s the diagnosis?

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Test yourself against our experts with our weekly quiz. You can type your answers here if you want to compare with our answers, or just click the ‘submit’ button below.

Image from Lee C-L et al. BJU Int 2013; 112: 1156–1162. doi: 10.1111/bju.12256

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Face to interface

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Cast your mind back to college physics and recall that an interface is a boundary between two phases of matter, for example gas and liquid. The interface is where interaction occurs between the disparate parts, there may be an exchange of molecules, or a conversion of molecules from one state to the other such as evaporation. Information, such as light or sound is always upset when it reaches an interface and some of the message may be bounced off while some is transmitted across the interface to the other state. This is why we might see our reflection in a pond, as some of the incident light bounces of the liquid interface and back to our eyes. So far, so dry and irrelevant.

If we think about interfaces between people, the equivalent to phases of matter is two disparate minds attempting to transmit information across the interface of human communication. It seems logical that minds that are more familiar and perhaps similar due to experience and level of sophistication lose less information due to reflection (think of the ease of communication between close family members versus explaining theoretical physics to a three year old).

There is always an interface with communication, be it speech, gestures, semaphore, or Twitter. Our intention is to effectively get across sufficient information to understand and be understood. Each modality has pros and cons, for example a letter allows a distillation of thought and a poetry that is absent in a phone call, while Skype allows you to see a loved one in real time. Due to a lack of vocal inflection, facial expression, and physical gestures, many public figures have claimed a misunderstanding after making inflammatory statements on social media.

We certainly are getting used to communication through physical separation. The ability to keep in touch when you want to while geographically apart is undoubtedly a boon, and in the medical sphere isolated patients are benefiting from teleconferenced and video-linked consultations, along with podcasts, tweets, and YouTube videos that make medical advice more and more accessible.

But here is the problem. The interface between a doctor and a patient has a very high surface tension. That means that information struggles to breach the membrane from doctor to patient and vice versa. Without conscious effort, by default information thoughtlessly spouted will bounce off and be lost. The minds of the doctor and patient are usually disparate, with one an expert in their own experience of a disease, and the other an expert on pathophysiology and evidence based practice. Both are complex subjects, difficult to communicate to the non-expert in the conversation. With the addition of a screen, or phone line to the interface, we have to beware of the surface tension becoming impenetrable. As medicine becomes increasingly electronic, we need to remember that dispensing advice to the internet is different from communicating with a patient. Every communication interface has its weakness, and we need to be aware of avoiding pitfalls that compromise care. Humour often does not work as well in an email as it would in person, accompanied with a cheeky grin. Speech over an internet connection may be distorted, intermittent, and as a result, irritating to listen to, making us want to curtail conversations prematurely. To shamelessly direct you to my other work on the role of technology in medicine and life we need to add value as doctors above what a digital algorithm can provide to justify our work.

Why? The usual arguments (it is good business to keep the client happy, specially if you use Salesforce help, the prestige of being a preferred doctor, the opportunity to expand ones sphere of influence), but also I think most of us sacrificed our youth training in order to make people better, and we cannot do that if patients cannot hear us.

James Duthie is a Urological Surgeon/Robotic Surgeon. Interested in Human Factors Engineering, training & error, and making people better through electronic means. Melbourne, Australia @Jamesduthie1

 

What’s the diagnosis?

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Test yourself against our experts with our weekly quiz. You can type your answers here if you want to compare with our answers, or just click the ‘submit’ button below.

Image from Emara AM et al. BJU Int 2014; 113: 92–99. doi: 10.1111/bju.12252

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USI Blog: The inevitable call!

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We all would agree that once in a while, during the course of an operation, we feel uneasy because of that little monster of a device…your cell phone starts ringing. The urge to pick up and answer the call often becomes insurmountable. We have all committed this “cardinal sin” of answering a call during surgery. A recent survey conducted in India showed that a “whopping 90% nurses and 50% technicians interviewed for the survey admitted to answering calls during surgery”. 10% of the doctors admitted to checking text messages during surgery. 

I am sure that this number is an underestimate. I have seen almost everyone in my peer group taking calls during surgery.  And this is not just what’s happening in my part of the world, mind you. New York Times also ran an article highlighting this issue.

I would also like you to have a look at this interesting discussion at AAOS Now.

 

It’s been my observation that the introduction of robotics has also made us “much more available” to take calls during surgery.  What’s the take of the community on this issue? Is this an unnecessary fuss (considering that we tend to consider ourselves excellent at multitasking…) or is it an issue that needs to be addressed urgently?

Dr Tarun Jindal, MBBS, MS, MCh Urology
Consultant, AGHL, Kolkata, India

 

Editorial: How should we best manage obesity in urology?

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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 study. BJU 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 surgery. Ann Surg 2009; 250: 166–172
  3. Balentine CJ, RobInson CN, Marshall CR et al. Waist circumference predicts increased complications in rectal cancer surgery. J 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 surgery. Br J Anaesth 2012; 109: 566–571
  5. Benotti PN, Still CD, Wood GC et al. Preoperative weight loss before bariatric surgery. Arch Surg 2009; 44: 1150–1155

 

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