Laparoscopic radical prostatectomy: Evaluation of specimen pathologic features to critically assess and modify surgical technique

Evaluation of Oncological Outcomes and Data Quality in Studies Assessing Nerve-sparing Versus Non-Nerve-sparing Radical Prostatectomy in Nonmetastatic Prostate Cancer: A Systematic Review

CONTEXT

Surgical techniques aimed at preserving the neurovascular bundles during radical prostatectomy (RP) have been proposed to improve functional outcomes. However, it remains unclear if nerve-sparing (NS) surgery adversely affects oncological metrics.

OBJECTIVE

To explore the oncological safety of NS versus non-NS (NNS) surgery and to identify factors affecting the oncological outcomes of NS surgery.

EVIDENCE ACQUISITION

Relevant databases were searched for English language articles published between January 1, 1990 and May 8, 2020. Comparative studies for patients with nonmetastatic prostate cancer (PCa) treated with primary RP were included. NS and NNS techniques were compared. The main outcomes were side-specific positive surgical margins (ssPSM) and biochemical recurrence (BCR). Risk of bias (RoB) and confounding assessments were performed.

EVIDENCE SYNTHESIS

Out of 1573 articles identified, 18 studies recruiting a total of 21 654 patients were included. The overall RoB and confounding were high across all domains. The most common selection criteria for NS RP identified were characteristic of low-risk disease, including low core-biopsy involvement. Seven studies evaluated the link with ssPSM and showed an increase in ssPSM after adjustment for side-specific confounders, with the relative risk for NS RP ranging from 1.50 to 1.53. Thirteen papers assessing BCR showed no difference in outcomes with at least 12 mo of follow-up. Lack of data prevented any subgroup analysis for potentially important variables. The definitions of NS were heterogeneous and poorly described in most studies.

CONCLUSIONS

Current data revealed an association between NS surgery and an increase in the risk of ssPSM. This did not translate into a negative impact on BCR, although follow-up was short and many men harbored low-risk PCa. There are significant knowledge gaps in terms of how various patient, disease, and surgical factors affect outcomes. Adequately powered and well-designed prospective trials and cohort studies accounting for these issues with long-term follow-up are recommended.

PATIENT SUMMARY

Neurovascular bundles (NVBs) are structures containing nerves and blood vessels. The NVBs close to the prostate are responsible for erections. We reviewed the literature to determine if a technique to preserve the NVBs during removal of the prostate causes worse cancer outcomes. We found that NVB preservation was poorly defined but, if applied, was associated with a higher risk of cancer at the margins of the tissue removed, even in patients with low-risk prostate cancer. The long-term importance of this finding for patients is unclear. More data are needed to provide recommendations.

Benign prostate glandular tissue at radical prostatectomy surgical margins

OBJECTIVE

To determine whether the presence of benign glandular tissue at the radical prostatectomy surgical margin is associated with technique (open radical prostatectomy [ORP] or robotic-assisted laparoscopic radical prostatectomy [RALRP]) and if benign glandular tissue increases the risk of biochemical recurrence.

METHODS

Surgical specimens from men with clinical T1-T2 disease who underwent radical prostatectomy (RP) between 2004 and 2010 were re-reviewed by a single uropathologist, examining all sections from the prostate apex and base for the presence of benign glandular tissue and tumor at the margin. Regression analysis was used to examine associations of benign glandular tissue with surgical approach and biochemical recurrence.

RESULTS

Of 934 cases reviewed, 431 were managed by ORP and 503 by RALRP with a median follow-up of 49 and 28 months, respectively. Overall, benign glandular tissue was found in 274 cases (29%): 98 (36%) at the apex, 138 (50%) at the base, and 38 (14%) at both. Compared with those who underwent ORP, patients who underwent RALRP had 3-fold greater odds of benign glandular tissue at the margin (P <.01), including significantly greater number of cases with benign glandular tissue at the base (P <.01). However, recurrence-free survival rates were similar between patients with and without benign glands at the surgical margin (BGM) regardless of surgical approach and across all clinical risk groups (log-rank P = .20).

CONCLUSION

Patients undergoing RALRP were more likely to have benign glandular tissue at the surgical margin. However, the presence of benign glandular tissue was not an independent risk factor for biochemical recurrence.

Cancer Care Ontario Guidelines for radical prostatectomy: striving for continuous quality improvement in community practice

OBJECTIVE

: Cancer Care Ontario has published an evidence-based guideline on their website "Guideline for Optimization of Surgical and Pathological Quality Performance for Radical Prostatectomy in Prostate Cancer Management: Surgical and Pathological Guidelines." The evidentiary base for this guideline was recently published in CUAJ. The CCO guideline proposes the following: a positive surgical margin (PSM) rate of <25% for organ-confined disease (pT2), a perioperative mortality of <1%, a rate of rectal injury <1%, and a blood transfusion rate <10% in non-anemic patients. The objective of this study was to review the radical prostatectomy practice at the Grey Bruce Health Services, an Ontario community hospital, and to compare our performance in relation to the Cancer Care Ontario guideline and the literature.

METHODS

: We conducted a retrospective review of all radical prostatectomies performed at the Grey Bruce Health Services from January 1, 2006 to December 31, 2007. The following data were obtained from clinical records and pathology reports: patient age, pre-biopsy prostate-specific antigen, biopsy Gleason score, resected prostate gland weight, radical prostatectomy Gleason score, surgical margin status, pathological tumour stage (pT), lymph node dissection status, perioperative incidence of transfusion of blood products and if the patient was anemic (hemoglobin <140 g/L) preoperatively, incidence of rectal injury, and perioperative mortality within 30 days following surgery.

RESULTS

: Using the method proposed by D'Amico, most patients undergoing radical prostatectomy were intermediate risk (62%), with a minority of low-risk (24%) and high-risk (14%) patients. The overall PSM rate was 37%. The rate of PSMs in organ-confined disease (pT2) was 26%. There was a statistically significant trend between increasing D'Amico risk category and increasing rate of PSM (Cochran-Armitage trend test, p = 0.023). There was a strong correlation between the pathological tumour stage and the rate of PSM (Cochran-Armitage trend test, p = 0.0003). The rate of blood transfusion in non-anemic patients was 6%. There was 1 patient (0.8%) who experienced a rectal injury. There were no perioperative deaths in our study group.

CONCLUSION

: Our results show that a community hospital group can appropriately select patients to undergo radical prostatectomy, as well as achieve an acceptable rate of PSMs. We believe that ongoing critical appraisal and reflective practice are essential to improving surgical outcomes and providing quality care.

Radical prostatectomy: does surgical technique influence margin control?

The goal of radical prostatectomy (RP) is complete removal of the prostate and seminal vesicles with negative surgical margins. Regardless of approach, the occurrence of positive surgical margins (PSMs) remains a risk associated with RP. In addition, PSMs can adversely affect biochemical and cause-specific survival. With the advent of PSA screening and introduction of new RP approaches, surgical technique has become increasingly debated in relationship to margin positivity. The issue, however, is controversial, as underlying clinical and pathologic characteristics of prostate cancer also influence margin control. This article evaluates the impact of surgical technique on margin control during RP. In addition, we evaluate the influence that stage migration, the individual surgeon, new technologic adjuncts, and specimen handling have had on margin control.

Laparoscopic radical prostatectomy: oncological and functional results of 126 patients with a minimum 3-year follow-up at a single Chinese institute

In this study we evaluate the oncological and functional results of the largest cohort of patients in China treated by laparoscopic radical prostatectomy (LRP) and with at least 3 years of follow-up. 126 inconsecutive patients (range 56-78 years, median 62.5) who had an LRP were retrospectively analyzed. The mean prostate specific antigen level and Gleason score was 13.4 ng mL(-1) and 6.4, respectively. Twenty-seven patients had unilateral or bilateral nerve preservation and 29 had pelvic lymphadenectomy. Multivariate analysis was used to adjust for differences in clinical and pathological features when comparing the risk for biochemical progression-free survival (bPFS). Urinary continence was assessed by incontinence questionnaire and erectile function by the Sexual Health Inventory for Men score. The mean operative duration was 250 min and blood loss 354 mL. Five patients received blood transfusion and nine had complications, including rectal injury (two), ureteral injury (one), active bleeding (one), bladder neck stenosis (two), paralytic ileus (one), subcutaneous hematoma (one) and port-site hernia (one). The overall positive surgical margin rate was 20.6% and correlated with pathological stage and Gleason score respectively (P = 0.03, P < 0.001 respectively). All patients had >or= 3 years of follow-up (range 3-6.75 years, mean 4.6, median 4.75). At 3 years of follow-up, the overall survival rate was 100% and the bPFS was 81.0% in all patients; 124 patients (98.4%) were continent; 22 of 27 patients (81.5%) who underwent nerve preservation retained erectile function. Our series confirms that LRP is an effective, safe and precise technique at Chinese institution.

[Comparative study of surgical efficacy in open versus laparoscopic prostatectomy: virtual prostate reconstruction and periprostatic tissue quantification]

INTRODUCTION

The introduction of laparoscopic surgery as a procedure to perform radical prostatectomy needs an objective method to evaluate the suitability of this new surgical procedure. The traditional parameters, including the incidence of positive surgical margins, are useful, but not sufficiently objective. Different authors publish different criteria to define positive surgical margins. In addition, there are some technical problems that may ocur during the processing of the surgical specimen by the pathologist, which can give false positive margins. We have used a computer modeling software in connection to scanned images from serial sections of the whole gland, to determine the percentage of extracapsular tissue that surrounds the prostate glands, removed by both, open retropubic and laparoscopic procedures. This percentage can be considered as an objective parameter which can potentially predict the benefit of surgery in predicting cancer control, as well as the clinical success of the surgical procedure. The correlation with the clinical results in the long term--survival and bioche--mical recurrence--will be useful to validate as a last resort the clinical utility of this parameter in the coming years.

MATERIALS AND METHODS

We had a total of 32 prostate surgical specimens, 15 from patients who underwent open retropubic prostatectomy and 17 from patients who underwent laparoscopic prostatectomy for this study. After surgery and 24 hours formol fixation, serial cuts were taken at 5 mm thickness intervals to make complete sections ("whole mount") of the prostate. An expert uropathologist reviewed all the surgical sections and drew in each tissue cut the prostatic capsule and tumor contours. The serial images of the whole gland and surrounding prostate tissue were scanned to produce digital images, using a computer software to create a file with capsule information and a file with information on the surrounding fibroadipose tissue (extraprostatic). These procedures allowed the reconstruction of a three dimensional tissue model of the prostatic capsule and the surrounding extraprostatic tissue. Two separate point clouds files were generated, with the purpose of representing capsule and extraprostatic tissue models and software algorithms were used to generate differences in point clouds and thereby quantifying the extracapsular tissue coverage dimension, a parameter that we considered indicative of the adequeacy and feasibility of the surgical procedure.

RESULTS

The global percentage of prostate gland surface covered by extracapsular fibroadipose tissue was statistically higher in specimens removed by a laparoscopic procedure when compared to the open retropubic procedure. When a segmental analysis of the gland percentage of coverage was evaluated, it was found this percentage was significantly higher in the apical and inferolateral segments of those glands removed without nerves preservation and in the apical segments of those glands removed with nerves preservation for the laparoscopic prostatectomy.

CONCLUSIONS

In our series. laparoscopic prostatectomy contributed superior extracapsular tissue coverage than retropubic prostatectomy. Similarly laparoscopic prostatectomy produced a superior tissue coverage in inferolateral and apical regions on those glands removed without nerve preservation and in the apical regions of those glands removed with nerve preservation. Therefore, the surgical suitability of this technique, when compared to the retropubic, seems to be higher

Computer modeling technology to assess extracapsular tissue coverage of whole mount sections after retropubic and laparoscopic radical prostatectomy

PURPOSE

The introduction of new surgical approaches to radical prostatectomy requires methodologies that permit valid comparison that are more expedient than long-term outcomes of biochemical local and distant failure and survival. We used a computer modeling program to assess the percent of extracapsular tissue coverage of prostate glands removed by the open retropubic and laparoscopic approaches.

MATERIALS AND METHODS

Specimens were available for 15 and 17 patients who underwent open and laparoscopic radical prostatectomy, respectively. Serial whole mount sections were taken at 5 mm intervals. A genitourinary pathologist drew the contours of the prostate capsule on each tissue section. The whole mount was scanned to produce digital images. A software program was used to create a file with capsule information and a file with extraprostatic fibroadipose tissue information. Two separate point cloud files were generated to represent the capsule and extraprostatic models, and software algorithms were used to generate differences in the point clouds to quantify the extent of extracapsular tissue coverage.

RESULTS

When separated into sides dissected by a nerve or nonnerve sparing technique, the overall percent of gland surface coverage by extracapsular fibroadipose tissue was statistically greater with laparoscopic dissection than with the open approach. When a segmental analysis of gland coverage was evaluated, a statistically greater percent of fibroadipose coverage was associated with laparoscopic dissection in the apical and inferolateral segments with nonnerve sparing, and in the apical segment with nerve sparing.

CONCLUSIONS

This small radical prostatectomy series, analyzed by computer reconstruction as described, provides information suggesting that overall extracapsular tissue coverage is at least equal if not superior using the laparoscopic vs the open approach. This was specifically the case in areas of inferolateral and apical dissection with nonnerve sparing procedures and in areas of the apical dissection with nerve sparing procedures.

Oncological outcome of laparoscopic prostatectomy

AIM

Oncological outcomes including surgical margin status and biological progression-free survival (bPFS) were analyzed in patients who underwent laparoscopic prostatectomy (LRP) only.

METHODS

A total of 136 patients who underwent LRP only without lymph node metastasis or perioperative supportive therapy between April 2000 and October 2005 were analyzed. All patients received > or =6 months postoperative follow-up. Biological progression was defined as elevation of prostate-specific antigen by >0.2 ng/mL.

RESULTS

The positive margin (ew+) rate was 36.8% and the 3-year bPFS was 72.6% for all patients. Positive margin rates in pT2a-b, pT2c, pT3a and pT3b were 10.0%, 27.5%, 77.3% and 53.8%, respectively. Three-year bPFS rates in pT2, pT3a and pT3b were 91.8%, 66.8% and 44.9%, respectively. Although the positive margin rate at posterior and anterior sites decreased as more patients were recruited, no significant improvements were observed at apex and base sites. Three-year bPFS rates in pT2 ew-, pT2 ew+, pT3 ew- and pT3 ew+ were 95.8%, 85.7%, 81% and 48.5%, respectively, indicating that positive margins exert a greater impact in pT3 disease than in pT2 disease.

CONCLUSIONS

Although 3-year bPFS results were almost identical to previous reports of LRP and retropubic radical prostatectomy, the positive margin rate in pT3a disease was particularly high, probably due to immature surgical skill. Although positive margins at posterior and anterior sites decreased with the leaning curve, improvements are needed to reduce positive margin rates at the apex. Positive margins exert greater impact in pT3 disease than in pT2 disease.

Contemporary Laparoscopic and Open Radical Retropubic Prostatectomy: Pathologic Outcomes and Kattan Postoperative Nomograms Are Equivalent

OBJECTIVES

Although contemporary cohort comparisons are lacking, open surgeons have questioned the oncologic efficacy of laparoscopic radical prostatectomy (LRP) owing to the lack of haptic feedback. As such, we compared the pathologic outcomes and predicted the progression-free survival after open radical prostatectomy (ORP) and LRP in a single referral setting within a defined period, thereby isolating the effect of the surgical technique alone.

METHODS

Data were collected on 169 ORPs and 111 LRPs performed at our institution from May 2003 to May 2005. The surgical pathologic outcomes were compared, and the Kattan postoperative nomogram was used to calculate the 5 and 7-year progression-free probabilities after ORP and LRP.

RESULTS

On univariate analysis, no differences were found in age, Gleason sum, stage, margin status, extracapsular extension, and seminal vesicle invasion. The positive margin rate was 29% for LRP and 35% for ORP (P = 0.29), and no difference was found even after stratifying by pathologic stage. After controlling for Gleason sum, extracapsular extension, seminal vesicle invasion, nodal involvement, margin status, and preoperative prostate-specific antigen, no difference was found in detectable prostate-specific antigen after ORP and LRP (P = 0.73). When the Kattan postoperative nomogram was used to compute the biochemical progression-free probabilities, no differences were found at 5 (P = 0.51) and 7 years (P = 0.50).

CONCLUSIONS

In this contemporary series without the confounding effects of stage migration, regional practice variation, or the use of historical controls, the pathologic outcome after conventional LRP was similar to that after ORP. Biochemical progression-free survival was also similar using a validated multivariate predictive model.

Pathologic outcome of laparoscopic and open radical prostatectomy

OBJECTIVES

To compare the clinicopathologic data of 286 laparoscopic radical prostatectomies (LRPs) and 714 open radical prostatectomies (RRPs) performed at the Massachusetts General Hospital from 2001 to 2005.

METHODS

A total of 1000 radical prostatectomy procedures were analyzed for prostate weight, pathologic stage, Gleason score, surgical margin status, and positive margin location.

RESULTS

The mean patient age was 58.6 and 59.1 years for the LRP and RRP groups, respectively. The mean preoperative prostate-specific antigen level was 5.96 and 6.00 ng/mL, respectively. Clinical Stage T1c cancer was seen in 86.4% of the LRP and 90.5% of the RRP patients. Gleason score 7 or less disease was seen on biopsy in 97.5% of the LRP and 96.9% of the RRP patients. The average prostate weight was 46.8 g for LRP and 46.0 g for RRP. In the radical prostatectomy specimens, 94.4% of LRP and 93.3% of RRP patients had Gleason score 7 or less disease and 86.0% of LRP and 81.7% of RRP patients had pathologic Stage pT2 cancer. The rate of positive surgical margins was 15.0% and 17.4% for the LRP and RRP groups, respectively. The positive margins occurred mainly at the peripheral and apical regions in both groups. No significant difference was found in the preoperative variables or final pathologic findings between the two surgical groups.

CONCLUSIONS

With similar case selection, LRP and RRP achieve similar pathologic outcomes.