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Pellegrino F, Falagario UG, Knipper S, Martini A, Akre O, Egevad L, Aly M, Moschovas MC, Bravi CA, Tran J, Heiniger Y, von Kempis A, Schaffar R, Carrieri G, Briganti A, Montorsi F, Rochat CH, Mottrie A, Ahlering TE, John H, Patel V, Graefen M, Wiklund P. Assessing the Impact of Positive Surgical Margins on Mortality in Patients Who Underwent Robotic Radical Prostatectomy: 20 Years' Report from the EAU Robotic Urology Section Scientific Working Group. Eur Urol Oncol 2024; 7:888-896. [PMID: 38155061 DOI: 10.1016/j.euo.2023.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/25/2023] [Accepted: 11/23/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Positive surgical margins (PSMs) are frequent in patients undergoing radical prostatectomy (RP). The impact of PSMs on cancer-specific (CSM) and overall (OM) mortality has not yet been proved definitively. OBJECTIVE To evaluate whether the presence and the features of PSMs were associated with CSM and OM in patients who underwent robotic-assisted RP. DESIGN, SETTING, AND PARTICIPANTS A cohort of 8141 patients underwent robotic-assisted RP with >10 yr of follow-up. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Cox multivariable analyses assessed the impact of margin status (positive vs negative) and PSM features (negative vs <3 mm vs >3 mm vs multifocal) on the risk of CSM, OM, and biochemical recurrence (BCR) after adjusting for potential confounders. We repeated our analyses after stratifying patients according to clinical (Cancer of the Prostate Risk Assessment [CAPRA] categories) and pathological characteristics (adverse: pT 3-4 and/or grade group [GG] 4-5 and/or pN1 and/or prostate-specific antigen [PSA] persistence). RESULTS AND LIMITATIONS PSMs were found in 1348 patients (16%). Among these, 48 (3.6%) patients had multifocal PSMs. Overall, 1550 men experienced BCR and 898 men died, including 130 for prostate cancer. At Cox multivariable analyses, PSMs were associated with CSM in patients with adverse clinical (Intermediate risk: hazard ratio [HR]: 1.71, p = 0.048; high risk: HR: 2.20, p = 0.009) and pathological (HR: 1.79, p = 0.005) characteristics. Only multifocal PSMs were associated with CSM and OM in the whole population (HR for CSM: 4.68, p < 0.001; HR for OM: 1.82, p = 0.037) and in patients with adverse clinical (intermediate risk: HR for CSM: 7.26, p = 0.006; high risk: HR for CSM: 9.26, p < 0.001; HR for OM: 2.97, p = 0.006) and pathological (HR for CSM: 9.50, p < 0.001; HR for OM: 2.59, p = 0.001) characteristics. Potential limitations include a selection bias and a lack of information on the Gleason score at PSM location. CONCLUSIONS We did not find an association between unifocal PSMs and mortality. Conversely, our results underscore the importance of avoiding multifocal PSMs in patients with adverse clinical (intermediate- and high-risk CAPRA score) and pathological (GG ≥4, pT ≥3, pN1, or PSA persistence) characteristics, to enhance overall survival and reduce CSM. PATIENT SUMMARY In this study, we evaluated whether the presence and the characteristics of positive surgical margins were associated with mortality in patients who underwent robotic-assisted radical prostatectomy. We found that the presence of positive surgical margins, particularly multifocal margins, was associated with mortality only in patients with adverse clinical and pathological characteristics.
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Affiliation(s)
- Francesco Pellegrino
- Department of Pelvic Cancer, Karolinska University Hospital, Solna, Sweden; Unit of Urology/Division of Oncology, Soldera Prostate Cancer Lab, Urological Research Institute, IRCCS San Raffaele Hospital, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Ugo Giovanni Falagario
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Department of Urology, University of Foggia, Foggia, Italy.
| | - Sophie Knipper
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Alberto Martini
- Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
| | - Olof Akre
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Lars Egevad
- Department of Oncology and Pathology, Karolinska institute, Stockholm, Sweden
| | - Markus Aly
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Departments of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Marcio Covas Moschovas
- AdventHealth Global Robotics Institute, Orlando, FL, USA; University of Central Florida (UCF), Orlando, FL, USA
| | - Carlo Andrea Bravi
- Department of Urology, Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium; ORSI Academy, Ghent, Belgium; Department of Urology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Joshua Tran
- Department of Urology, University of California, Irvine Medical Center, Orange, CA, USA
| | - Yasmin Heiniger
- Department of Urology, Kantonsspital Winterthur, Winterthur, Switzerland
| | | | - Robin Schaffar
- Department of Urology, Clinique Générale Beaulieu, Geneva, Switzerland
| | | | - Alberto Briganti
- Unit of Urology/Division of Oncology, Soldera Prostate Cancer Lab, Urological Research Institute, IRCCS San Raffaele Hospital, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Montorsi
- Unit of Urology/Division of Oncology, Soldera Prostate Cancer Lab, Urological Research Institute, IRCCS San Raffaele Hospital, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | | | - Alexandre Mottrie
- Department of Urology, Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium; ORSI Academy, Ghent, Belgium
| | - Thomas E Ahlering
- Department of Urology, University of California, Irvine Medical Center, Orange, CA, USA
| | - Hubert John
- Department of Urology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Vipul Patel
- AdventHealth Global Robotics Institute, Orlando, FL, USA; University of Central Florida (UCF), Orlando, FL, USA
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Wiklund
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Kinnear N, Fonseca PC, Ogbechie C, Adam S, Haidar O, Jinaraj A, O'Callaghan M, Agarwal S, Lane T, Vasdev N, Adshead J. Impact of frozen section on long-term outcomes in robot-assisted laparoscopic prostatectomy. BJU Int 2024. [PMID: 38961710 DOI: 10.1111/bju.16437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To compare 1-year functional and 5-year oncological outcomes of men undergoing robot-assisted laparoscopic prostatectomy (RALP) with neurovascular structure-adjacent frozen-section examination (NeuroSAFE) with those in men undergoing RALP without NeuroSAFE (standard of care [SOC]). SUBJECTS AND METHODS Men undergoing RALP in our centre between 1 January 2009 and 30 June 2018 were enrolled from a prospectively maintained database. Patients were excluded if they had undergone preoperative therapy or postoperative adjuvant therapy or were enrolled in clinical trials. Patients were grouped based on use of NeuroSAFE. Follow-up was censored at 5 years. The primary outcome was difference in time to biochemical recurrence (BCR) on multivariable analysis, defined as prostate-specific antigen (PSA) >0.2 ng/L on two consecutive measurements. Secondary outcomes were difference in 1-year erectile dysfunction and incontinence. RESULTS In the enrolment period, 1199 consecutive men underwent RALP, of whom 1140 were eligible, including 317 with NeuroSAFE and 823 with SOC. The median PSA follow-up was 60 months in both groups. Rates of 5-year BCR were similar on Kaplan-Meier survival curve analysis (11% vs 11%; P = 0.9), as was time to BCR on multivariable Cox proportional hazards modelling (hazard ratio 1.2; P = 0.6). Compared with the SOC group at 1 year, the NeuroSAFE group had similar unadjusted rates of incontinence (5.1% vs 7.7%) and lower unadjusted impotence (57% vs 80%). On multivariable analysis, NeuroSAFE patients had equivalent risk of incontinence (odds ratio [OR] 0.59, 95% CI 0.17-1.6; P = 0.4) but significantly reduced risk of erectile dysfunction (OR 0.37, 95% CI 0.22-0.60; P < 0.001). CONCLUSIONS For men undergoing RALP, compared with SOC, NeuroSAFE patients had equivalent time to BCR and risk of 1-year incontinence, and significantly lower risk of 1-year erectile dysfunction.
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Affiliation(s)
- Ned Kinnear
- Lister Hospital, Stevenage, UK
- Flinders Medical Centre, Adelaide, SA, Australia
| | | | | | | | | | | | - Michael O'Callaghan
- Flinders Medical Centre, Adelaide, SA, Australia
- Flinders University, Adelaide, SA, Australia
| | - Samita Agarwal
- Department of Histopathology, Lister Hospital, Stevenage, UK
| | | | - Nikhil Vasdev
- Lister Hospital, Stevenage, UK
- University of Hertfordshire, Hatfield, UK
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