Obese men undergoing radical prostatectomy: Is robotic or retropubic better to limit positive surgical margins? Results from SEARCH

Abstract

Objectives: To evaluate the association between obesity and positive surgical margins in patients undergoing retropubic radical prostatectomy versus robotic-assisted laparoscopic prostatectomy. Methods: We retrospectively reviewed the data of 3141 men undergoing retropubic radical prostatectomy and 1625 undergoing robotic-assisted laparoscopic prostatectomy between 1988 and 2017 at eight Veterans Health Administration hospitals. The positive surgical margin location (peripheral, apical, bladder neck, overall) was determined from pathology reports. We adjusted for age, race, prostate-specific antigen, surgery year, prostate weight, pathological grade group, extracapsular extension, seminal vesicle invasion, hospital surgical volume and surgical method (in analyses not stratified by surgical method). Interactions between body mass index and surgical approach were tested. Results: Among all patients, higher body mass index was associated with increased odds of overall, peripheral and apical positive surgical margins (OR 1.02-1.03, P ≤ 0.02). Although not statistically significant, there was a trend between higher body mass index and increased odds of bladder neck positive surgical margins (OR 1.03, P = 0.09). Interactions between body mass index and surgical method were significant for peripheral positive surgical margins only (P = 0.024). Specifically, there was an association between body mass index and peripheral positive surgical margins among men undergoing retropubic radical prostatectomy (OR 1.04, P < 0.001), but not roboticassisted laparoscopic prostatectomy (OR 1.00, P = 0.98). Limitations include lacking individual surgeon data and lacking central pathology review. Conclusions: In this multicenter cohort, higher body mass index was associated with increased odds of positive surgical margins at all locations except the bladder neck. Furthermore, there was a significant association between obesity and peripheral positive surgical margins in men undergoing retropubic radical prostatectomy, but not roboticassisted laparoscopic prostatectomy. Long-term clinical significance requires further study.

Effect of obesity on the prognosis and recurrence of prostate cancer after radical prostatectomy: a meta-analysis

“…A total of 14 articles regarding obesity and postoperative recurrence and prognosis were included (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25). As shown in Figure 2, a significant heterogeneity among the studies was identified (I 2 =71.0%, P=0.000), so the REM was used.…”

“…A total of five articles were included to report the PSM condition of patients (12)(13)(14)17,21). Firstly, obvious heterogeneity was identified among the studies (I 2 =50.9%, P<0.001) (Figure 6A), so the REM was used for meta-analysis.…”

Clinical Considerations and Outcomes of Robotic Urologic Surgery in Obese Patients

“…A 2020 multicenter retrospective cohort study by Nik‐Ahd et al 27 investigated the association between obesity and positive surgical margins (PSMs) in patients undergoing RALP versus retropubic RP (RRP). The study found that at all locations except the bladder neck, higher BMI was associated with increased odds of overall, peripheral, and apical PSMs among all patients.…”

“…Higher BMI is a risk factor for PSMs, and the association between obesity and PSMs is slightly stronger for men undergoing RRP than for those undergoing RALP. 27 …”

Editorial Comment to Obese men undergoing radical prostatectomy: Is robotic or retropubic better to limit positive surgical margins? Results from SEARCH

“…The optimal outcome for clinically localized prostate cancer is freedom from the pentafecta: (i) biochemical recurrence; (ii) recovery of continence; (iii) recovery of erectile function; (iv) no perioperative complications; and (v) the absence of positive surgical margins 1 . In the present article, Nik‐Ahd et al retrospectively investigated the SEARCH database, so they could stratify patients with localized prostate cancer according to body mass index (BMI) category who underwent retropubic radical prostatectomy versus robot‐assisted laparoscopic prostatectomy 2 . As expected, higher BMI was associated with a higher rate of whole positive surgical margins (PSMs).…”