Optimal Surgical Management of the Obese Man With Prostate Cancer: Laproscopic or Perineal Radical Prostatectomy

POINT-COUNTERPOINT Optimal Surgical Management of the Obese Man With Prostate Cancer: Laparoscopic or Perineal Radical Prostatectomy Stephen J. Freedland, MD, Alan W. Partin, MD, PhD The James Buchanan Brady Urological Institute, and Departments of Urology and Pathology, The Johns Hopkins Medical Institutions, Baltimore, MD [Rev Urol. 2005;7(1):46-47] © 2005 MedReviews, LLC adical prostatectomy is one of the most common treatments for prostate cancer. It was originally described via a perineal approach over 100 years ago by Hugh Hampton Young.1 However, it was not until the 1970s and early 1980s, with new detailed anatomic descriptions,2, 3 that radical prostatectomy became a common treatment for prostate cancer. Prostate-specific antigen–based screening, which began in the late 1980s and early 1990s, resulted in a large pool of men with clinically localized disease who were candidates for surgical treatment. Together, these events resulted in a dramatic rise in the number of radical prostatectomies performed annually.4 In the 1990s, laparoscopic surgical approaches became more common in urological practice, particularly for renal surgery.5 Over time, it became increasingly clear that it was possible to reduce morbidity without impacting on oncological success.6 Not long thereafter the first laparoscopic radical prostatectomy was performed.7 This, in turn, heightened awareness of the need to minimize morbidity and resulted in a renewed interest in perineal prostatectomy. Obesity is a growing problem in the United States. Currently, over 30% of the adult population is obese.8 Given that it is estimated that there will be 230,100 new cases of prostate cancer diagnosed in 2004, nearly 70,000 obese men will have received this diagnosis in that year (assuming there is no association between obesity and risk of developing prostate cancer, which is a matter of debate).9 There is a clear dearth in the literature as to the best treatment approach for the obese man. Therefore, in this Point-Counterpoint we have drawn on the opinions and personal experience of 3 experts in the field—Drs. Albert Leung and Arnold Melman in perineal prostatectomy and Dr. Richard Link in laparoscopic prostatectomy—to guide R 46 VOL. 7 NO. 1 2005 REVIEWS IN UROLOGY Surgical Choice for Prostate Cancer with Obesity us as to how best to surgically treat the obese patient. Though no clear conclusion can be drawn on which is the optimal treatment approach, it is evident that with careful planning and attention to detail most obese men who are reasonable surgical candidates can have a safely performed prostatectomy. We hope this discussion will spur further debate and interest in the treatment of obese men with prostate cancer. References 1. 2. 3. 4. 5. Young HH. The early diagnosis and radical cure of carcinoma of the prostate. Being a study of 40 cases and presentation of a radical operation which was carried out in four cases. 1905. J Urol. 2002;167:939-946; discussion 947. Walsh PC, Donker PJ. Impotence following radical prostatectomy: insight into etiology and prevention. J Urol. 1982;128:492-497. Reiner WG, Walsh PC. An anatomical approach to the surgical management of the dorsal vein and Santorini's plexus during radical retropubic surgery. J Urol. 1979;121:198-200. Shaw M, Elterman L, Rubenstein M, et al. Changes in radical prostatectomy and radiation therapy rates for African Americans and whites. J Natl Med Assoc. 2000;92:281-284. Ratner LE, Montgomery RA, Kavoussi LR. 6. 7. 8. 9. Laparoscopic live donor nephrectomy. A review of the first 5 years. Urol Clin North Am. 2001; 28:709-719. Bhayani SB, Clayman RV, Sundaram CP, et al. Surgical treatment of renal neoplasia: evolving toward a laparoscopic standard of care. Urology. 2003;62:821-826. Schuessler WW, Schulam PG, Clayman RV, et al. Laparoscopic radical prostatectomy: initial shortterm experience. Urology. 1997;50:854-857. Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and trends in obesity among US adults, 1999-2000. JAMA. 2002;288:1723-1727. Jemal A, Tiwari RC, Murray T, et al. Cancer statistics, 2004. CA Cancer J Clin. 2004;54:8-29. VOL. 7 NO. 1 2005 REVIEWS IN UROLOGY 47