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Does Obesity Affect Intraoperative, Pathological Outcomes and Approach Chosen In Patients Undergoing Robot-Assisted Radical Prostatectomy (RARP)? Comparative Analysis of Extra-Peritoneal Vs Trans- Peritoneal Approaches - A Single Institution Experience.
Jessica Kreshover, M.D., Satya Allaparthi, MRCS,MD, Thomas Hoang, MD, Nadeem N. Dhanani, MD, MPH Ingolf A. Tuerk, MD,PhD.
Caritas St Elizabeth Hospital, Boston, MA, USA.

BACKGROUND:
It is well known in previous studies that obesity has an overall impact on perioperative and intra operative outcomes of robotic assisted radical prostatectomy (RARP). Herein, we have reported our experience and impact of obesity on approach chosen, intra-operative factors and pathological outcomes in-patient undergoing extra-peritoneal (EP) vs. transperitoneal (TP) RARP.
METHODS:
After institutional review board approval, a retrospective review of our database was performed. All patients underwent RARP as performed by a single surgeon (IT) at our institution in between November 2008 and February 2010. We stratified patient into group-I EP-BMI >30 (kg/m²) and group-II TP-BMI >30 (kg/m²). Demographic data, operative time, intra-operative blood loss, pathological grade, surgical positive margins were compared. Statistical analysis was performed using the SYSTAT 13 ® statistical package. Student t-test, with P < 0.05 considered statistically significant for normally distributed continuous data and Chi-square and Fisher’s exact tests were used to compare categorical outcome variables
RESULTS:
A total of 351 consecutive patients underwent RARP at our institution , of which 115 patients had BMI >30 kg/m², EP n=73, TP n= 42 . Patients with BMI <30 kg/m² were excluded from our study. There were zero conversions from RARP to laparoscopic or open. The mean ± SD for age , BMI , PSA and volume of prostate in EP and TP groups were 58 ± 6.7 vs 59.4±7.6 years (p=0.336); 31.9±1.4 vs 35.3±3.3 kg/m² (p<0.001) ; 5.5±3.2 vs 7.2 ± 6.3 ng/ml (p=0.118) and 49.5± 17.5 vs 53.3±19.2 ml(p= 0.275). There was no significant difference in the operative time (minutes) between the two groups 129.6±20.4 vs130.7±23.2 (p=0.792). However, there was a statistically significant difference in EBL (ml) noticed in the EP vs. TP group 238.7±171.9 vs 145.1 ± 98.3 (p=0.002). Pathological staging distribution was T2c in 57.5% vs. 69.2% and T3a 31.3% vs. 20.4% respectively. Surgical positive margin rates in both groups when stratified to T2c and T3a pathological stages were 10.3% vs. 9.5% and 16.8% vs. 14.7% respectively .
CONCLUSIONS:
In our series, we noticed statistically significant differences for BMI and estimated blood loss in between the two approaches. We have not seen any association with positive margins in either approach. Overall, RARP is an effective and efficient means of prostate cancer treatment in the obese population, although the choice of approach EP vs. TP depends on surgeons experience and preference.


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