Positive surgical margin during radical prostatectomy: overview of sampling methods for frozen sections and techniques for the secondary resection of the neurovascular bundles

101 Background: Prostate multi-parametric magnetic resonance imaging (mpMRI) can precisely depict prostate cancer (PCa) location and adverse pathologic features. Surgeons can utilize this information to maximize sparing of the neurovascular bundles (NVBs) during radical prostatectomy (RP) while avoiding a positive surgical margin (PSM). We detail the technique of using preoperative mpMRI to quantify its effect regarding nerve-sparing and rates of PSMs. Methods: A prospectively maintained database was queried for robotic-assisted RPs (RARPs) with preoperative mpMRI between 2007-2017. Imaging margin risk factors (iMRF) were defined on mpMRI as frank extraprostatic extension (EPE), possible EPE, and capsular irregularity (capsular bulge, lesion-capsule contact, or lesion adjacency to the neurovascular bundles). Surgical adjustments to nerve-sparing technique (full sparing, partial sparing, and wide excision) were made based on these findings. Results: Five hundred thirty-two patients comprising 1041 prostate sides were included for analysis. Overall, PSM rate was found in 80/1041 (7.7%) sides of the prostate. iMRF were seen in 313/1041 (30.1%) prostate sides, for which adjustments were made in 244/313 (78.0%) of these. In the 69/244 (22.0%) cases where full nerve-sparing was performed despite iMRF, PSM rate was 20/69 (29%) compared to 33/244 (13.5%), p = 0.002. MRI-guided surgical adjustments decreased PSM risk by 68% and 15% in pT3 and pT2 cases, respectively. On multivariable analysis, logPSA (odds ratio [OR] 4.06, [95% CI 2.40-12.3], p < 0.001) and iMRF (OR 1.78, [95% CI 1.01-3.16], p = 0.047) were significantly associated with PSM while nerve-sparing adjustment was significantly associated with decreased risk of PSM (OR 0.38 [95% CI 0.22-0.66], p = 0.001). Conclusions: MRI effectively detects risks for PSM and guides surgical adjustments to decrease PSM rates. As prostate MRI is more frequently acquired for PCa screening and biopsy, we show its additional value for RP planning and potentially improved outcomes.

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667: The Positive Surgical Margin (SM) is no Independent Predictor for Biochemical Failure after Radical Prostatectomy (RRP)

The Journal of Urology ◽

10.1016/s0022-5347(18)34907-3 ◽

2005 ◽

Vol 173 (4S) ◽

pp. 182-182

Author(s):

Rein J. Palisaar ◽

Joachim Noldus ◽

Alexander Haese ◽

Markus Graefen ◽

Hartwig Huland

Keyword(s):

Radical Prostatectomy ◽

Independent Predictor ◽

Surgical Margin ◽

Biochemical Failure ◽

Positive Surgical Margin

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Prediction of a positive surgical margin and biochemical recurrence after robot-assisted radical prostatectomy

Scientific Reports ◽

10.1038/s41598-021-93860-y ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Ching-Wei Yang ◽

Hsiao-Hsien Wang ◽

Mohamed Fayez Hassouna ◽

Manish Chand ◽

William J. S. Huang ◽

...

Keyword(s):

Radical Prostatectomy ◽

Biochemical Recurrence ◽

Multivariable Analysis ◽

Specific Antigen ◽

Surgical Margin ◽

Asian Population ◽

Nerve Sparing ◽

Positive Surgical Margin ◽

Robot Assisted ◽

Surgeon Experience

AbstractThe positive surgical margin (PSM) and biochemical recurrence (BCR) are two main factors associated with poor oncotherapeutic outcomes after prostatectomy. This is an Asian population study based on a single-surgeon experience to deeply investigate the predictors for PSM and BCR. We retrospectively included 419 robot-assisted radical prostatectomy cases. The number of PSM cases was 126 (30.1%), stratified as 22 (12.2%) in stage T2 and 103 (43.6%) in stage T3. Preoperative prostate-specific antigen (PSA) > 10 ng/mL (p = 0.047; odds ratio [OR] 1.712), intraoperative blood loss > 200 mL (p = 0.006; OR 4.01), and postoperative pT3 stage (p < 0.001; OR 6.901) were three independent predictors for PSM while PSA > 10 ng/mL (p < 0.015; hazard ratio [HR] 1.8), pT3 stage (p = 0.012; HR 2.264), International Society of Urological Pathology (ISUP) grade > 3 (p = 0.02; HR 1.964), and PSM (p = 0.027; HR 1.725) were four significant predictors for BCR in multivariable analysis. PSMs occurred mostly in the posterolateral regions (73.8%) which were associated with nerve-sparing procedures (p = 0.012) while apical PSMs were correlated intraoperative bleeding (p < 0.001). A high ratio of pT3 stage after RARP in our Asian population-based might surpass the influence of PSM on BCR. PSM was less significant than PSA and ISUP grade for predicting PSA recurrence in pT3 disease. Among PSM cases, unifocal and multifocal positive margins had a similar ratio of the BCR rate (p = 0.172) but ISUP grade > 3 (p = 0.002; HR 2.689) was a significant BCR predictor. These results indicate that PSA and pathological status are key factors influencing PSM and BCR.

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