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Dinneen E, Almeida-Magana R, Al-Hammouri T, Fernandes I, Mayor N, Mendes L, Winkler M, Silvanto A, Haider A, Freeman A, Shaw G. Intraoperative margin assessment during radical prostatectomy: is microscopy frozen in time or ready for digital defrost? Histopathology 2024. [PMID: 39104212 DOI: 10.1111/his.15290] [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: 08/07/2024]
Abstract
Intraoperative frozen section (IFS) is used with the intention to improve functional and oncological outcomes for patients undergoing radical prostatectomy (RP). High resource requirements of IFS techniques such as NeuroSAFE may preclude widespread adoption, even if there are benefits to patients. Recent advances in fresh-tissue microscopic digital imaging technologies may offer an attractive alternative, and there is a growing body of evidence regarding these technologies. In this narrative review, we discuss some of the familiar limitations of IFS and compare these to the attractive counterpoints of modern digital imaging technologies such as the speed and ease of image generation, the locality of equipment within (or near) the operating room, the ability to maintain tissue integrity, and digital transfer of images. Confocal laser microscopy (CLM) is the modality most frequently reported in the literature for margin assessment during RP. We discuss several imitations and obstacles to widespread dissemination of digital imaging technologies. Among these, we consider how the 'en-face' margin perspective will challenge urologists and pathologists to understand afresh the meaning of positive margin significance. As a part of this, discussions on how to describe, categorize, react to, and evaluate these technologies are needed to improve patient outcomes. Limitations of this review include its narrative structure and that the evidence base in this field is relatively immature but developing at pace.
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Affiliation(s)
- Eoin Dinneen
- Division of Surgery & Interventional Science, University College London, London, UK
- Department of Urology, Westmoreland Street Hospital, University College Hospital London, London, UK
| | - Ricardo Almeida-Magana
- Division of Surgery & Interventional Science, University College London, London, UK
- Department of Urology, Westmoreland Street Hospital, University College Hospital London, London, UK
| | - Tarek Al-Hammouri
- Division of Surgery & Interventional Science, University College London, London, UK
- Centre for Medical Imaging, University College London, London, UK
| | - Iona Fernandes
- Department of Urology, Westmoreland Street Hospital, University College Hospital London, London, UK
| | - Nikhil Mayor
- Department of Urology, Imperial College NHS Healthcare Trust, Charing Cross Hospital, London, UK
- Imperial Prostate, Division of Surgery, Imperial College London, London, UK
| | - Larissa Mendes
- Department of Histopathology, University College Hospital London, London, UK
| | - Mathias Winkler
- Department of Urology, Imperial College NHS Healthcare Trust, Charing Cross Hospital, London, UK
- Imperial Prostate, Division of Surgery, Imperial College London, London, UK
| | - Anna Silvanto
- Department of Histopathology, University College Hospital London, London, UK
| | - Aiman Haider
- Department of Histopathology, University College Hospital London, London, UK
| | - Alex Freeman
- Department of Histopathology, University College Hospital London, London, UK
| | - Greg Shaw
- Division of Surgery & Interventional Science, University College London, London, UK
- Department of Urology, Westmoreland Street Hospital, University College Hospital London, London, UK
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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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Rodríguez Socarrás M, Gómez Rivas J, Reinoso Elbers J, Espósito F, Llanes Gonzalez L, Monsalve DMC, Fernandez Del Alamo J, Ruiz Graña S, Juarez Varela J, Coria D, Cuadros Rivera V, Gastón R, Gómez Sancha F. Robot-Assisted Radical Prostatectomy by Lateral Approach: Technique, Reproducibility and Outcomes. Cancers (Basel) 2023; 15:5442. [PMID: 38001702 PMCID: PMC10670058 DOI: 10.3390/cancers15225442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/08/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Radical prostatectomy by lateral approach allows performing a prostatectomy through a buttonhole, with direct access to the seminal vesicle and fully sparing the anterior pubovesical complex. Our aim is to show the results of reproducing the technique of robotic radical prostatectomy by lateral approach, in terms of intraoperative, postoperative, oncological and functional parameters. METHODS We analyzed 513 patients submitted to robotic radical prostatectomy by lateral approach from January 2015 to March 2021, operated on by two surgeons in our institution. The oncological and functional results of both surgeons were compared. RESULTS When comparing both surgeons, the rate of positive surgical margins (PSM) was 32.87% and 37.9% and significant surgical margins (PSM > 2 mm) were 5.88% and 7.58% (p = 0.672) for surgeon 1 and surgeon 2, respectively. Immediate continence was 86% and 85% and sexual potency at one year 73% and 72%, with a similar rate of complications for surgeon 1 and 2. CONCLUSIONS Radical prostatectomy by the lateral approach technique with preservation of the anterior pubovesical complex is reproducible and offers good oncological and functional results.
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Affiliation(s)
- Moisés Rodríguez Socarrás
- Instituto de Cirugía Urológica Avanzada (ICUA), Clínica CEMTRO, 28035 Madrid, Spain; (J.G.R.); (J.R.E.); (F.E.); (L.L.G.); (D.M.C.M.); (J.F.D.A.); (S.R.G.); (D.C.); (V.C.R.); (F.G.S.)
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