Incidence of positive surgical margins after biopsy-selected nerve-sparing radical prostatectomy

Selection of patients for nerve sparing surgery in robot‐assisted radical prostatectomy

Context

Robot‐assisted radical prostatectomy (RARP) has become the standard surgical procedure for localized prostate‐cancer (PCa). Nerve‐sparing surgery (NSS) during RARP has been associated with improved erectile function and continence rates after surgery. However, it remains unclear what are the most appropriate indications for NSS.

Objective

The objective of this study is to systematically review the available parameters for selection of patients for NSS. The weight of different clinical variables, multiparametric magnetic‐resonance‐imaging (mpMRI) findings, and the impact of multiparametric‐nomograms in the decision‐making process on (side‐specific) NSS were assessed.

Evidence acquisition

This systematic review searched relevant databases and included studies performed from January 2000 until December 2020 and recruited a total of 15 840 PCa patients. Studies were assessed that defined criteria for (side‐specific) NSS and associated them with oncological safety and/or functional outcomes. Risk of bias assessment was performed.

Evidence synthesis

Nineteen articles were eligible for full‐text review. NSS is primarily recommended in men with adequate erectile function, and with low‐risk of extracapsular extension (ECE) on the side‐of NSS. Separate clinical and radiological variables have low accuracy for predicting ECE, whereas nomograms optimize the risk‐stratification and decision‐making process to perform or to refrain from NSS when oncological safety (organ‐confined disease, PSM rates) and functional outcomes (erectile function and continence rates) were assessed.

Conclusions

Consensus exists that patients who are at high risk of ECE should refrain from NSS. Several multiparametric preoperative nomograms were developed to predict ECE with increased accuracy compared with single clinical, pathological, or radiological variables, but controversy exists on risk thresholds and decision rules on a conservative versus a less‐conservative surgical approach. An individual clinical judgment on the possibilities of NSS set against the risks of ECE is warranted.

Patient summary

NSS is aimed at sparing the nerves responsible for erection. NSS may lead to unfavorable tumor control if the risk of capsule penetration is high. Nomograms predicting extraprostatic tumor‐growth are probably most helpful.

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.

The Male Lumpectomy: Rationale for a Cancer Targeted Approach for Prostate Cryoablation. A Review

Lumpectomy to treat breast cancer has revolutionized the management of that disease. Lumpectomy showed that the quality of life of the individual patient can successfully be integrated into the equation of cancer treatment, without major loss of cancer treatment efficacy. Prostate cancer raises many of the same issues that breast cancer does in women. Impotence and incontinence, affects the male self image and psyche no less than the loss of a breast does a woman. Management of prostate cancer ranges from no treatment at all (“watchful waiting”) to treatments in which the whole gland is destroyed (radiation therapy, cryosurgery) or removed (radical prostatectomy), with presently no treatment in between these extremes. Pathologic literature indicates, however, that 35% of prostate cancers are solitary and unilateral. In addition, long term studies have confirmed that cryoabltion for prostate cancer is an efficacious treatment. In this paper we will examine the rationale for a “male lumpectomy” using cryoablation and present preliminary data supporting it's role in prostate cancer management.

Discordance between location of positive cores in biopsy and location of positive surgical margin following radical prostatectomy

Purpose

We compared location of positive cores in biopsy and location of positive surgical margin (PSM) following radical prostatectomy.

Materials and Methods

This retrospective analysis included patients who were diagnosed as prostate cancer by standard 12-core transrectal ultrasonography guided prostate biopsy, and who have PSM after radical prostatectomy. After exclusion of number of biopsy cores <12, and lack of biopsy location data, 46 patients with PSM were identified. Locations of PSM in pathologic specimen were reported as 6 difference sites (apex, base and lateral in both sides). Discordance of biopsy result and PSM was defined when no positive cores in biopsy was identified at the location of PSM.

Results

Most common location of PSM were right apex (n=21) and left apex (n=15). Multiple PSM was reported in 21 specimens (45.7%). In 32 specimens (69.6%) with PSM, one or more concordant positive biopsy cores were identified, but 14 specimens (28%) had no concordant biopsy cores at PSM location. When discordant rate was separated by locations of PSM, right apex PSM had highest rate of discordant (38%). The discordant group had significantly lower prostate volume and lower number of positive cores in biopsy than concordant group.

Conclusions

This study showed that one fourth of PSM occurred at location where tumor was not detected at biopsy and that apex PSM had highest rate of discordant. Careful dissection to avoid PSM should be performed in every location, including where tumor was not identified in biopsy.

Prevention and management of postprostatectomy sexual dysfunctions. Part 1: choosing the right patient at the right time for the right surgery

CONTEXT

Sexual dysfunction is common in patients following radical prostatectomy (RP) for prostate cancer (PCa).

OBJECTIVE

To review the available literature concerning prevention and management strategies for post-RP erectile function (EF) impairment in terms of preoperative patient characteristics and intra- and postoperative factors that may influence EF recovery.

EVIDENCE ACQUISITION

A literature search was performed using Google and PubMed database for English-language original and review articles either published or e-published up to November 2011.

EVIDENCE SYNTHESIS

The literature demonstrates great inconsistency in what constitutes normal EF before surgery and what a man may consider a normal erection after RP. The use of validated psychometric instruments with recognised cut-offs for normalcy and severity during the pre- and postoperative evaluation should be routinely considered. Therefore, a comprehensive discussion with the patient about the true prevalence of postoperative erectile dysfunction (ED), the concept of spontaneous or pharmacologically assisted erections, and the difference between "back to baseline" EF and "erections adequate enough to have successful intercourse" clearly emerge as key issues in the eventual understanding of the prevention of ED and promotion of satisfactory EF recovery post-RP. Patient factors (including age, baseline EF, and status of comorbid conditions), cancer selection (unilateral vs bilateral nerve sparing), type of surgery (ie, intra- vs inter- vs extrafascial surgeries), surgical techniques (ie, open, laparoscopic, and robot-assisted RP), and surgeon factors (ie, surgical volume and surgical skill) represent the key significant contributors to EF recovery.

CONCLUSIONS

The complexity of the issues discussed throughout this review culminates in the simple concept that optimal outcomes are achieved by the careful choice of the correct patient for the correct type of surgery.

Guideline for optimization of surgical and pathological quality performance for radical prostatectomy in prostate cancer management: evidentiary base

BACKGROUND

The objective is to provide surgical and pathological guidelines for radical prostatectomy (RP) with or without concurrent pelvic lymph node dissection (PLND) to achieve optimal benefit for patients, with minimal risk of harm.

METHODS

For surgical questions, a literature search of MEDLINE, EMBASE and the Cochrane database was performed. A literature search for the pathological questions was not conducted since the protocol for invasive carcinomas of the prostate gland developed by the College of American Pathologists (CAP) was endorsed. Urologists and pathologists were consulted for their assessment of the surgical and pathological recommendations.

RESULTS

Limited high-quality evidence from 95 primary studies was available and, therefore, the expert panel developed recommendations on the basis of a consensus of the expert opinion of the working group and through a consultation with urologists and pathologists. In addition to the CAP protocol, some technical recommendations related to the handling and processing of the specimen were made.

CONCLUSION

Radical prostatectomy is recommended for the surgical treatment of prostate cancer, depending on a patient's preoperative risk profile. The panel unanimously determined that the goals for RP are to attain a positive margin rate of <25% for pT2 disease, a mortality rate of <1%, rates of rectal injury of <1% and blood transfusion rates of <10% in non-anemic patients. Standard PLND should be mandatory in high-risk patients, should be recommended for intermediate-risk patients and should be optional for low-risk patients. The quality and effectiveness of this treatment and of subsequent patient care depend on good management, effective communication and reporting between surgeons and pathologists working together as part of a multidisciplinary team. The complete guideline document is posted on the Cancer Care Ontario website (www.cancercare.on.ca); search in their Toolbox, Quality Guidelines & Standards, Clinical Program category under "surgery."

Can we predict real T3 stage prostate cancer in patients with clinical T3 (cT3) disease before radical prostatectomy?

PURPOSE

Down-staging of clinical T3 (cT3) prostate cancer after radical prostatectomy (RP) is not uncommon due to the inaccuracy of the currently available staging modalities, although selected down-staged cT3 patients can be a candidate for definitive RP. We identified the significant predictors for down-staging of cT3 after RP.

MATERIALS AND METHODS

We included 67 patients with cT3 stage prostate cancer treated with radical perineal prostatectomy (RPP) between 1998 and 2006 and reviewed their medical records retrospectively. The clinical stage was obtained according to the DRE, the prostate biopsy findings, and the prostate MRI.

RESULTS

Fifty three (79%) patients with cT3 prostate cancer were down-staged to pT2 after RP. The percent of positive cores had the strongest association with down-staging of cT3 [p = 0.01, odds ratio (OR) = 6.3], followed by baseline prostate specific antigen (PSA) (p = 0.03, OR = 5.0), the biopsy Gleason sum (GS) (p = 0.03, OR = 4.7), and the maximum tumor volume of the positive cores (p = 0.05, OR = 4.0). When the cut-off points of significant parameters which were a PSA < 10 ng/mL, a percent of positive cores < or = 30%, a maximum tumor volume of the positive cores < or = 75% and GS < or = 7 were combined, the sensitivity, specificity, and positive predictive value were 0.25%, 1.00%, and 100%, respectively.

CONCLUSION

The percent of positive cores < or = 30%, serum PSA < 10 ng/mL, the biopsy GS < or = 7, and the maximum tumor volume of the positive cores < or = 75% were the significant predictors of down-staging cT3 disease after RP.

Can prostate biopsies predict suitability for nerve‐sparing radical prostatectomy?

OBJECTIVE

The process for selecting patients suitable for nerve-sparing radical prostatectomy (NSRP) has been the source of much debate. In this study we analysed the use of prostate biopsies as the principal selection tool.

MATERIAL AND METHODS

Patients undergoing radical retropubic prostatectomy (n = 133) were retrospectively categorized as having "unilateral" (biopsy demonstrated malignancy confined to one side of the gland) or "bilateral" carcinoma. The accuracy and reliability of this categorization were determined by correlation with the final histopathology of the resected radical prostatectomy specimen.

RESULTS

Prostate biopsy suggested "unilateral" carcinoma in 30/58 (52%) and 45/75 (60%) patients diagnosed using transrectal ultrasound-guided (TRUS) and transperineal digital-guided (TP) routes, respectively. Subsequent analysis of the resected specimen, however, revealed "bilateral" malignancy in 50 patients (86%) in the TRUS group and in 63 (84%) in the TP group. Furthermore, positive surgical margins were identified on the "benign" side (by preoperative biopsy) in 6 (20%) patients in the TRUS subgroup whose biopsy had suggested "unilateral" carcinoma, and in 12 (27%) of the comparative TP subgroup.

CONCLUSIONS

Biopsy-suggested "unilateral" carcinoma was associated with both a high incidence of "bilateral" disease on final histology following radical prostatectomy and an alarming incidence (24%) of positive surgical margins on the "benign" side where NSRP might be advocated.

The "male lumpectomy": focal therapy for prostate cancer using cryoablation results in 48 patients with at least 2-year follow-up

BACKGROUND

The use of breast sparing surgery, i.e., "lumpectomy", revolutionized management of breast cancer. Lumpectomy confirmed that quality of life issues can successfully be addressed without compromising treatment efficacy. Complications of prostate cancer treatment, including impotence and incontinence, affect the male self image no less than the loss of a breast does a woman. Traditional thinking held that prostate cancer was multifocal and therefore not amenable to a focal treatment approach. Recent pathology literature indicates, however, that up to 25% of prostate cancers are solitary and unilateral. This raises the question of whether these patients can be identified and treated with a limited "lumpectomy" or focal cancer treatment.

METHODS

Focal cryoablation was planned to encompass the area of known tumor based on staging biopsies. PSAs were obtained every 3 months for 2 years and then every 6 months thereafter.

RESULTS

Forty-eight patients with at least 2-year follow-up had focal cryoablation. Follow-up ranged from 2 years 10 years with a mean of 4.5 years; 45 of 48 patients (94%) have stable PSAs [American Society of Therapeutic Radiology and Oncology (ASTRO) criteria] with no evidence for cancer, despite 25 patients being medium to high risk for recurrence. Of the 24 patients with stable PSAs who were routinely biopsied (n = 24) all were negative. No local recurrences were noted in areas treated. Potency was maintained to the satisfaction of the patient in of 36 of 40 patients who were potent preoperatively. Of the 48, all were continent.

CONCLUSION

These preliminary results indicate a "male lumpectomy" in which the prostate tumor region itself is destroyed, appears to preserve potency in a majority of patients and limits other complications (particularly incontinence), without compromising cancer control. If confirmed by further studies and long-term follow-up, this treatment approach could have a profound effect on prostate cancer management.

Rationale for a "male lumpectomy," a prostate cancer targeted approach using cryoablation: results in 21 patients with at least 2 years of follow-up

BACKGROUND

Prostate cancer in men raises many of the same issues that breast cancer does in women. Complications of prostate cancer treatment, including impotence and incontinence, affect the self-image and psyche of a man no less than does the loss of a breast in a woman. We present a pilot study in which 21 patients were treated with a focal cryoablation procedure.

METHODS

Focal cryoablation was performed using biplane transrectal ultrasound if the tumor was confined to only one prostate lobe. Preoperative PSA values were recorded. Cryoablation was planned to encompass the area of known tumor. PSA values were obtained every 3 months for 2 years and every 6 months thereafter. Potency and continence status was obtained at the same intervals. Routine biopsy was obtained at 1 year.

RESULTS

Twenty-one patients had focal cryoablation. Follow-up ranged from 24 to 105 months with a mean of 50 months. Twenty of 21 (95%) patients have stable PSA values with no evidence for cancer, despite 10 patients being at medium to high risk for recurrence. All patients biopsied (n = 19) were negative for tumor. Potency was maintained in 17 of 21 patients (80%). No other complications, including incontinence or fistula formation, were noted.

CONCLUSION

These preliminary results indicate a "male lumpectomy," in which the prostate tumor region itself is destroyed, appears to preserve potency in a majority of patients and limits other complications, without compromising cancer control. If these results are confirmed by further studies and long-term follow-up, this treatment approach could have a profound effect on prostate cancer management.

"Male lumpectomy": focal therapy for prostate cancer using cryoablation

The introduction of breast-sparing surgery (ie, "lumpectomy") revolutionized the management of breast cancer. The use of lumpectomy showed that quality of life could be optimized without compromising treatment efficacy. Complications of prostate cancer treatment, including impotence and incontinence, adversely alter the male self-image similarly to the way the loss of a breast does for a woman. Traditional thinking holds that prostate cancer is multifocal and therefore is not amenable to focal treatment. However, histopathologic findings from published data have indicated that up to 25% of prostate cancers are solitary and unilateral. Furthermore, the significance of minute secondary cancers might be minimal. These observations raise the question of whether certain patients can be identified and treated with a limited "lumpectomy." In this study, focal cryoablation has been used to ablate the area of known cancer as determined by staging biopsies. The serum prostate-specific antigen (PSA) concentration was obtained every 3 months for 2 years and every 6 months thereafter. American Society for Therapeutic Radiology Oncology (ASTRO) criteria for PSA recurrence were used. A total of 55 patients with > or = 1 year of follow-up had undergone focal cryoablation. Follow-up ranged from 1 to 10 years (mean, 3.6 years). At the original transrectal ultrasound biopsy, the mean and median numbers of cores taken were 9.9 and 10 (SD, +/- 3.5), respectively. Mean and median numbers of positive cores were 1.8 and 1 (SD, +/- 1.3), respectively. Of the 55 study patients, 52 (95%) had stable PSA levels with no evidence of cancer despite a medium to high risk for recurrence in 29 patients. All biopsy findings were negative among the 26 patients with a stable PSA level who had undergone routine biopsy at 1 year. No local recurrence was noted in treated areas. Potency was maintained in 44 (86%) of 51 patients. Of the 54 patients without previous prostate surgery or radiotherapy, all were continent. These preliminary results indicate that "male lumpectomy"--in which the prostate tumor region itself is destroyed--preserves potency in most patients and limits other complications (particularly incontinence) without compromising cancer control. Additional studies and long-term follow-up are needed to confirm that this treatment approach could have a profound effect on prostate cancer management.

[The treatments of localized prostate cancer: the impact on sexuality]

Nowadays, taking into account the sexuality is an essential component of the management of prostate cancer patients. This implies the necessity for providing accurate, clear and transparent information about the potential adverse effects on the sexual functioning for each proposed treatment. This information is not only given to the patient, but also to his female partner. The association of extended radical prostatectomy (without preservation of neurovascular bundles) and androgen suppression therapy will be proposed for men with locally advanced prostate cancer at high-risk for recurrence. The impact of such combined management regarding sexual functioning is high in terms of erection and sexual interest. Early pharmacological treatment of erectile dysfunction (within the three months following surgical treatment) with phosphodiesterase 5 inhibitors or intracavernous injections will allow an optimal recovery of a certain quality of erection. Moreover, monotherapy with bicalutamide will be associated with significant advantage in terms of sexual interest. The sexuality after treatment will certainly be different but will be accomplished.

Prognostic factors and reporting of prostate carcinoma in radical prostatectomy and pelvic lymphadenectomy specimens

This paper, based on the activity of the Morphology-Based Prognostic Factors Committee of the 2004 World Health Organization-sponsored International Consultation, describes various methods of handling radical prostatectomy specimens for both routine clinical use and research purposes. The correlation between radical prostatectomy findings and postoperative failure is discussed in detail. This includes issues relating to pelvic lymph node involvement, detected both at the time of frozen section and in permanent sections. Issues of seminal vesicle invasion, including its definition, routes of invasion and relationship to prognosis, are covered in detail. The definition, terminology and incidence of extra-prostatic extension are elucidated, along with its prognostic significance relating to location and extent. Margins of resection are covered in terms of their definition, the etiology, incidence and sites of positive margins, the use of frozen sections to assess the margins and the relationship between margin positivity and prognosis. Issues relating to grade within the radical prostatectomy specimen are covered in depth, including novel ways of reporting Gleason grade and the concept of tertiary Gleason patterns. Tumor volume, tumor location, vascular invasion and perineural invasion are the final variables discussed relating to the prognosis of radical prostatectomy specimens. The use of multivariate analysis to predict progression is discussed, together with proposed modifications to the TNM system. Finally, biomarkers to predict progression following radical prostatectomy are described, including DNA ploidy, microvessel density, Ki-67, neuroendocrine differentiation, p53, p21, p27, Bcl-2, Her-2/neu, E-cadherin, CD44, retinoblastoma proteins, apoptotic index, androgen receptor status, expression of prostate-specific antigen and prostatic-specific acid phosphatase and nuclear morphometry.

Validation of criteria used to predict extraprostatic cancer extension: a tool for use in selecting patients for nerve sparing radical prostatectomy

PURPOSE

We have previously reported that a prostate biopsy core specimen with a tumor length of at least 7 mm plus any positive basal biopsy core is the best predictor of extraprostatic extension (EPE) in radical prostatectomy (RP) specimens. We present prospectively collected data to validate our results.

MATERIALS AND METHODS

The study included 270 patients who underwent RP for localized prostate cancer between January 2002 and December 2003 by a single surgeon. We correlated side specific biopsy data, pretreatment prostate specific antigen, clinical stage and RP type using pathological specimen data.

RESULTS

Mean patient age was 59.6 years and median prostate specific antigen was 8.24 ng/ml. Of the patients 94 (35%) underwent unilateral and 114 (42%) underwent bilateral nerve sparing RP. The overall incidence of EPE was 16%. The incidence of EPE was 33% in patients who met our criteria vs 4.6% in those who did not. Of 538 evaluable sides 7.2% were positive at the surgical margin. The incidence of ipsilateral positive margins was 2.5% when the neurovascular bundle was spared according to our criteria vs 11.8% when the bundle was resected according to criteria.

CONCLUSIONS

This series validates our finding that a prostate biopsy core with a tumor length of at least 7 mm plus a positive basal biopsy core of any length and tumor grade is predictive of ipsilateral EPE. In the absence of these criteria the incidence of ipsilateral positive margins is low. Thus, these criteria are valuable for predicting EPE and selecting patients for nerve sparing RP.

Tumor length and location of cancer on biopsy predict for side specific extraprostatic cancer extension

PURPOSE

We studied preoperative variables in a contemporary series of men who underwent nonnerve sparing radical prostatectomy in an effort to establish criteria that would predict side specific extraprostatic extension (EPE) of cancer.

MATERIALS AND METHODS

We reviewed the records of 430 patients who underwent radical prostatectomy for localized prostate cancer with no prior therapy between 1996 and 1998, and for whom we had at least sextant biopsy information. We evaluated biopsy data (Gleason score, maximum length of cancer in positive cores, percent of cancer per involved core, proportion of positive biopsy cores, tumor location and number of positive biopsy cores) and correlated these findings with EPE at the neurovascular bundle and posterior lateral (NVB/PL) region.

RESULTS

We found that a higher number of positive cores, a higher biopsy Gleason score on a side, a positive core at the basal region, 50% or greater tumor in the core or a maximum tumor length of 7 mm or greater increased the likelihood that EPE was present at the NVB/PL region on the corresponding side of the prostate. On multivariate analysis maximum tumor length 7 mm or greater and positive basal core location were the strongest independent predictors of EPE at the NVB/PL region on a given side (p <0.0001 and 0.002, respectively).

CONCLUSIONS

Excluding any patient with 1 positive biopsy core with a maximum tumor length of 7 mm or greater plus a positive basal core of any tumor length and grade can decrease the risk of EPE at the NVB/PL region to approximately 10%.

Avoidance and management of positive surgical margins before, during and after radical prostatectomy

Positive surgical margins after radical prostatectomy lead to an increased risk of progression and reduced disease free survival. Earlier detection of prostate cancer, appropriate patient selection and improved operative techniques can reduce the incidence of positive margins, though the risk can not be eliminated as pre-operative staging techniques are not sufficiently sensitive. Nerve sparing and bladder neck sparing do not adversely affect margin status in appropriately selected men. Once positive margins have been diagnosed the optimal management and the timing of treatment remains controversial. Adjuvant radiotherapy or salvage radiotherapy in men with a low PSA may improve local control and PSA free survival in some individuals, a survival benefit has not yet been established.

Focal "nerve-sparing" cryosurgery for treatment of primary prostate cancer: a new approach to preserving potency

OBJECTIVES

To present a pilot study in which 9 patients treated with focal, unilateral nerve-sparing cryosurgery were followed for up to 6 years. Cryosurgery, in which the whole gland is frozen, has a high rate of impotence, similar to non-nerve-sparing radical prostatectomy.

METHODS

Before focal nerve-sparing cryosurgery, all patients underwent repeated biopsy on the side opposite the previous positive biopsy. One neurovascular bundle was spared on the side opposite the positive biopsy. Just before the start of freezing, a 22-gauge spinal needle was placed into Denonvilliers fascia using a transperineal route, and saline was injected to separate the rectum from the prostate. Combined hormone therapy was stopped in all patients postoperatively. The prostate-specific antigen (PSA) level was obtained every 3 months for the first 2 years and then every 6 months thereafter. Patients were considered to have a stable PSA if they had two consecutive PSA measurements without a rise. All patients were strongly encouraged to undergo routine biopsies despite a stable PSA level.

RESULTS

Between June 1995 and November 2000, 9 patients underwent focal, nerve-sparing cryosurgery. The follow-up ranged from 6 to 72 months (mean 36). All patients had stable PSA levels at last follow-up. Six patients routinely biopsied had negative biopsies. Potency (defined as an erection sufficient to complete intercourse to the satisfaction of the patient) was maintained in 7 of 9 patients.

CONCLUSIONS

Focal nerve-sparing cryosurgery, in which one neurovascular bundle is spared, appears to preserve potency in most patients without compromising cancer control. These preliminary results warrant further study.

Preoperative predictors of cancerous involvement of the neurovascular bundles in patients with localized prostate cancer

BACKGROUND

The purpose of this study was to identify preoperative variables that would be useful in objectively selecting prostate cancer patients for nerve-sparing prostatectomy.

METHODS

Twenty-six patients with clinical T1c-T2c cancers were evaluated for cancerous involvement in the region of the neurovascular bundles (NVB) from prostatectomy specimens. Preoperative prostate-specific antigen (PSA) and pathologic features in systematic biopsy specimens also were reviewed.

RESULTS

A total of eight (31%) patients had cancerous involvement in the region of the NVB, including four on the right side, three on the left side and one on both sides. The percentage of each biopsy specimen occupied by the cancer was scored from zero to four and defined as the positive biopsy score. Preoperative PSA (P = 0.046), mean positive biopsy score (total sum of positive biopsy score divided by number of biopsy specimens; P = 0.001), number of cores containing cancer (P = 0.011), percentage of cores involved (P = 0.036) and maximum positive biopsy score (P < 0.001) were significant for predicting cancerous involvement in the NVB region using univariate analysis. However, only the mean positive biopsy score was independently significant according to multivariate analysis. To predict cancerous involvement in the region of each NVB, we found that ipsilateral mean positive biopsy score (total sum of corresponding positive biopsy score divided by number of ipsilateral biopsy specimens), number of cores involved on the ipsilateral side, percentage of cores involved on the ipsilateral side and maximum positive biopsy score on the ipsilateral side were significant predictive variables: the ipsilateral mean positive biopsy score being most appropriate for clinical practice.

CONCLUSION

Ipsilateral mean positive biopsy score in systematic biopsy specimens can be an appropriate variable for selecting patients with localized prostate cancer for nerve-sparing prostatectomy.

Pathologic assessment of the surgical specimen

Despite the wealth of information obtained by conventional histology, long-term studies are needed to provide novel information on the correlation of pathologic findings with prognosis. Findings need to be correlated not only with PSA progression but with the more clinically important parameters of distant metastases and survival. Although conventional histology still will have a role in the evaluation of prostate cancer at radical prostatectomy and its correlation with outcome, it undoubtedly will be augmented by newer techniques. These developments must be approached critically and rationally to determine whether they provide additional prognostic information beyond that currently available using more conventional parameters.

Intraoperative T staging in radical retropubic prostatectomy: is it reliable?

OBJECTIVES

During radical prostatectomy, wide local excision of the lateral prostatic fascia and neurovascular bundle on the ipsilateral side of the tumor is advocated if nerve sparing is likely to result in a positive surgical margin. Our intent was to validate whether intraoperative T staging can predict the presence of positive surgical margins and aid in the decision of whether to perform nerve-sparing prostatectomy.

METHODS

One surgeon performed 100 consecutive radical prostatectomies, and one pathologist interpreted the pathologic findings. Topographic distribution of tumor within the specimen was assessed intraoperatively by palpation. The margin status was similarly assessed. This tactile clinical impression was compared with the final pathologic findings.

RESULTS

The surgical margins were positive in 39 (39%) of 100 cases. The intraoperative assessment of the margin status had a high false-negative rate and a sensitivity of only 7%. However, the specificity was 96%, because few margins were falsely positive. The overall accuracy was 62%, with a negative predictive value of 62%. The sensitivity of the intraoperative assessment of tumor location was 73%, and the positive predictive value was 65%.

CONCLUSIONS

The results of our study indicate that the intraoperative assessment of the margin status is not accurate and thus cannot help determine which patients require excision of the neurovascular bundle. We believe the decision to preserve the neurovascular bundle should be based on the preoperative prognostic factors and the presence of an intact capsule covering the region of the gland adjacent to this structure.

Dynamic endorectal magnetic resonance imaging for local staging and detection of neurovascular bundle involvement of prostate cancer: correlation with histopathologic results

OBJECTIVES

To assess the staging accuracy and detection of neurovascular bundle involvement by dynamic subtraction contrast-enhanced endorectal magnetic resonance imaging (MRI) in patients with localized prostate cancer.

METHODS

In 38 patients with biopsy-proven prostate cancer, endorectal MRI was performed on a 1.5-Tesla magnetic resonance system using the dynamic technique with gadolinium-diethylenetriaminepentaacetic acid bolus enhancement. Two radiologists prospectively assessed the tumor involvement, localization, capsular penetration, seminal vesicle invasion, and neurovascular bundle involvement. All patients subsequently underwent radical prostatectomy, and the MRI findings were correlated with the histopathologic results.

RESULTS

The overall accuracy of detecting cancer localization in the prostate was 72%. The detection of involvement in the peripheral zone had an 80% accuracy rate, but for lesions in the transition zone, the rate was 63%. The sensitivity and specificity of tumor detection was 81% and 79% for peripheral zone cancers and 37% and 97% for transition zone cancers, respectively. The accuracy rate, was 84%, 97%, and 97% for the detection of capsular penetration, seminal vesicle invasion, and neurovascular bundle involvement, respectively.

CONCLUSIONS

Prostatic MRI with an endorectal surface coil using the dynamic technique more accurately detected tumor localization, capsular penetration, seminal vesicle invasion, and neurovascular bundle involvement than previously reported methods. The detection of tumor localization was more accurate in the peripheral zone than in the transition zone. This technique may be useful for the selection of patients for radical prostatectomy and, particularly, for identifying candidates for nerve-sparing surgery.

Radical prostatectomy: the value of preoperative, individually labeled apical biopsies

PURPOSE

Involvement of the prostatic apex with adenocarcinoma is a relatively common finding, as is a positive surgical margin at this location. We evaluated whether a positive apical core biopsy provides preoperative information that may be used as a basis for the subsequent surgical approach in individuals.

MATERIALS AND METHODS

We evaluated apical prostate cancer in 240 individually labeled, preoperative apical core biopsies and the corresponding prostatectomy specimen in 120 patients who underwent radical prostatectomy for clinically localized prostate cancer. Sensitivity, specificity, and positive and negative predictive values were calculated for the ability of an individual apical core to predict the side of tumor in the surgical specimen using 2 x 2 contingency tables. Moreover, univariate subset analysis was done for positive biopsies to assess the ability of histopathological characteristics, including Gleason score, cancer length, percent of cancer in the core and distance of cancer from the inked rectal core end, to predict a positive surgical margin at the apex.

RESULTS

The positive predictive value of a single positive apical core for identifying tumor location correctly in the prostatectomy specimen was 71.1%, while absent cancer in the apical biopsy had a negative predictive value of 75.5%. Sensitivity was 44.5% for a positive biopsy core. In this context the predictive value of an individual positive apical core biopsy was only 28.8% for predicting surgical margin positivity at the apex.

CONCLUSIONS

Cancer and its histopathological characteristics in an individual core biopsy failed to predict apical tumor involvement as well as a positive apical margin at subsequent radical prostatectomy.

Prognostic factors in prostate cancer. College of American Pathologists Consensus Statement 1999

BACKGROUND

Under the auspices of the College of American Pathologists, a multidisciplinary group of clinicians, pathologists, and statisticians considered prognostic and predictive factors in prostate cancer and stratified them into categories reflecting the strength of published evidence and taking into account the expert opinions of the Prostate Working Group members.

MATERIALS AND METHODS

Factors were ranked according to the previous College of American Pathologists categorical rankings: category I, factors proven to be of prognostic importance and useful in clinical patient management; category II, factors that have been extensively studied biologically and clinically but whose importance remains to be validated in statistically robust studies; and category III, all other factors not sufficiently studied to demonstrate their prognostic value. Factors in categories I and II were considered with respect to variations in methods of analysis, interpretation of findings, reporting of data, and statistical evaluation. For each factor, detailed recommendations for improvement were made. Recommendations were based on the following aims: (1) increasing uniformity and completeness of pathologic evaluation of tumor specimens, (2) enhancing the quality of data collected pertaining to existing prognostic factors, and (3) improving patient care.

RESULTS AND CONCLUSIONS

Factors ranked in category I included preoperative serum prostate-specific antigen level, TNM stage grouping, histologic grade as Gleason score, and surgical margin status. Category II factors included tumor volume, histologic type, and DNA ploidy. Factors in category III included perineural invasion, neuroendocrine differentiation, microvessel density, nuclear roundness, chromatin texture, other karyometric factors, proliferation markers, prostate-specific antigen derivatives, and other factors (oncogenes, tumor suppressor genes, apoptosis genes, etc).

Diagnosis of localized prostate cancer: 10 years of progress

Advances in the diagnosis of early stage disease, and particularly the introduction of prostate-specific antigen (PSA) testing, have had a dramatic effect on the presentation and clinical management of prostate cancer during the past ten years. As a result, there have been significant epidemiological changes in countries where early diagnosis is recommended. The importance of PSA testing for the diagnosis of localized prostate cancer has become well established in clinical practice and this is reflected by improved outcomes from definitive treatment. The contribution of PSA-related parameters and molecular forms of PSA both to cancer detection and prediction of pathological stage continue to be explored. Concerns about the reliability of the standard sextant biopsy technique for cancer detection relate to the need for re-biopsy in a growing number of patients with negative biopsies and an increasing proportion of patients with low volume, multifocal disease. In men with cancer, additional prognostic information can be derived from biopsy findings, with important therapeutic implications. This relates also to the need for reliable markers indicating pathological stage and risk of progression. The opportunities for the prevention of prostate cancer have grown with improved understanding of its biology and the genetic basis of the early steps associated with malignant transformation. In the future, the need for therapeutic intervention is likely to be most influenced by successful prevention strategies.

Bladder neck-sparing modification of radical prostatectomy adversely affects surgical margins in pathologic T3a prostate cancer

OBJECTIVES

To determine whether the bladder neck-sparing (BNS) modification of radical retropubic prostatectomy (RRP) alters the likelihood of positive surgical margins and postsurgical prostate cancer recurrence.

METHODS

Surgical outcomes, as measured by pathologic margin status and progression-free survival, were evaluated in 751 consecutive RRP cases, among whom 222 underwent BNS technique. To reduce selection bias, comparison of positive margin rates between BNS and standard RRP was stratified by pathologic stage. Differences in surgical margin rates were assessed using the chi-square test, and effects of bladder neck preservation on prostate-specific antigen (PSA)-free survival were assessed, using multivariable Cox proportional hazards analysis.

RESULTS

The clinical stage, Gleason score, and preoperative serum PSA profiles were similarly distributed between patients undergoing standard RRP and those undergoing the BNS modification. Surgical margins in the unstratified entire cohort were positive at rates similar to prior reports (28% BNS, 27% standard RRP). However, stratification by pathologic stage revealed that among pT3a cancers, BNS surgery was associated with significantly higher rates of positive surgical margins than was standard RRP (47% versus 20%; chi- square = 6.32, P = 0.01). Differences in positive margin rates were not seen between the two groups at other pathologic stages. The adverse effect of BNS technique on pT3a surgical margins was associated with a trend toward an adverse effect on PSA-free survival (Cox proportional hazards P = 0.016).

CONCLUSIONS

The BNS modification of RRP can be associated with an increased rate of positive surgical margins specifically in cancers that have focally penetrated through the prostatic capsule (pT3a), with an associated trend toward decreased PSA-free survival in this group. BNS surgery may, therefore, compromise the ability to completely remove a subset of cancers focally penetrating the prostatic capsule.