Bigger challenges, similar outcomes: Robotic prostatectomy in the obese patient

The study aims to review the safety of performing robotic-assisted radical prostatectomy (RARP) in patients with a body mass index (BMI) > 35 kg/m² in a high-volume robotic centre.

A prospective database of all patients who underwent RARP between December 2015 and October 2024 was reviewed. Propensity score matching was done preoperatively on age, prostate-specific antigen, ISUP grade and T stage. Matched cohort analysis was conducted comparing outcomes in 89 patients with BMI ≥ 35 kg/m² and those with BMI 18-25 kg/m². Outcomes included operational time, estimated blood loss (EBL), positive surgical margins (PSM), complications, length of stay, continence and erectile function at 12 months.

Console time was significantly longer in the high-BMI group (146 ± 48 min vs. 129 ± 44 min, p = 0.02). EBL was also greater (median 350 ml vs. 200 ml, p < 0.001). However, there was no significant difference in hospital stay (median 3 days for both groups, p = 0.86), nerve sparing rates or PSM. Patients in the obese cohort experienced more complications although this was not statistically significant. At 12 months post-operatively, continence was comparable between the groups. Median pad use was 1/day (interquartile range [IQR] 0-2) in the obese cohort versus 0/day (IQR 0-1) in the non-obese cohort (p = 0.09). Pad-free status was achieved in 48.3% compared with 61.8% respectively (p = 0.06). Erectile function recovery found 14.8% regaining function in the obese cohort compared with 18.0% in the non-obese cohort (p = 0.82).

This matched cohort analysis demonstrates that obese patients undergoing RARP experience longer operative times and increased EBL. These factors do not adversely impact functional or oncological outcomes. The incidence of post-operative complications remained low and comparable with patients with a normal BMI. With appropriate surgical expertise, high BMI alone should not be considered a contraindication to RARP.