An evaluation of the decreasing incidence of positive surgical margins in a large retropubic prostatectomy series

Imaging classification of prostate cancer with extracapsular extension and its impact on positive surgical margins after laparoscopic radical prostatectomy

Abstract

To explore the impact of different imaging classifications of prostate cancer (PCa) with extracapsular extension (EPE) on positive surgical margins (PSM) after laparoscopic radical prostatectomy.

Methods

Clinical data were collected for 114 patients with stage PT3a PCa admitted to Ningbo Yinzhou No. 2 Hospital from September 2019 to August 2023. Radiologists classified the EPE imaging of PCa into Type I, Type II, and Type III. A chi-square test or t-test was employed to analyze the factors related to PSM. Multivariate regression analysis was conducted to determine the factors associated with PSM. Receiver operating characteristic curve analysis was used to calculate the area under the curve and evaluate the diagnostic performance of our model. Clinical decision curve analysis was performed to assess the clinical net benefit of EPE imaging classification, biopsy grade group (GG), and combined model.

Results

Among the 114 patients, 58 had PSM, and 56 had negative surgical margins. Multivariate analysis showed that EPE imaging classification and biopsy GG were risk factors for PSM after laparoscopic radical prostatectomy. The areas under the curve for EPE imaging classification and biopsy GG were 0.677 and 0.712, respectively. The difference in predicting PSM between EPE imaging classification and biopsy GG was not statistically significant (P>0.05). However, when used in combination, the diagnostic efficiency significantly improved, with an increase in the area under the curve to 0.795 (P<0.05). The clinical decision curve analysis revealed that the clinical net benefit of the combined model was significantly higher than that of EPE imaging classification and biopsy GG.

Conclusions

EPE imaging classification and biopsy GG were associated with PSM after laparoscopic radical prostatectomy, and their combination can significantly improve the accuracy of predicting PSM.

Clinicopathological implications of histological mapping in radical prostatectomy specimens

OBJECTIVE

The present study aims to elucidate the clinicopathological implications of histological mapping in radical prostatectomy specimens.

METHODS

This study included 76 prostatic cancers with histological mapping. The examined characteristics from the histological mappings were the largest tumor dimension, distance from the tumor core to resection margin, tumor dimension from the apex to base, tumor volume, tumor surface area, and proportion of the tumor. In addition, these histological parameters from the histological mapping were compared between patients with positive surgical margin (PSM) and negative surgical margin (NSM).

RESULTS

Patients with PSM were significantly correlated with a higher Gleason score and pT stage than those with NSM. Among the histological characteristics from mappings, there were significant correlations between PSM and the largest tumor dimension, tumor volume, tumor surface area, and proportion of tumor (P < 0.001, P < 0.001, P < 0.001, and P = 0.017, respectively). The distance from the tumor core to the resection margin was significantly longer with PSM than with NSM (P = 0.024). According to the linear regression test, the tumor volume, tumor surface area, and largest tumor dimension were significantly correlated with Gleason score and grade (P = 0.019, P = 0.036, and P = 0.016, respectively). There were no significant differences in the histological factors between the apical and non-apical involved subgroups.

CONCLUSION

Various clinicopathological characteristics assessed from the histological mappings, such as the tumor volume, tumor surface area, and proportion of the tumor, can be useful for interpreting PSM after radical prostatectomy.

Comparison of early oncologic and functional results of open and robot-assisted laparoscopic radical prostatectomy

Aim: Radical prostatectomy (RP) has undergone a remarkable transformation from open surgery to minimally invasive surgery over the past two decades. In our study, we aimed to compare patients who underwent open (ORRP) and robot-assisted laparoscopic radical prostatectomy (RARP) for localized prostate cancer in terms of early oncological and functional outcomes. Material and Methods: Our study included 537 patients who were diagnosed with prostate cancer and underwent RP between January 2009 and January 2014. (Open retropubic radical prostatectomy (ORRP)=387, robot-assisted laparoscopic radical prostatectomy (RARP)=150). Demographic data, perioperative and postoperative results of the patients were compared between the two groups. Results: The mean age of the patients was 62.9 (46-76) in the ORRP group and 61.1 (42-76) years in the RARP group. It was observed that the mean hospital stay, urethral catheterization time, and blood transfusion requirement were significantly shorter in the RARP group. Surgical margin positivity rates were 16.3% and 20% (p=0.412) for the ORRP and RARP groups, respectively, in those with pT2 stage, and 40.9% and 68.8% in the ORRP and RARP groups, respectively, in patients with pT3 stage (p= 0.05). The mean follow-up period was 30.6 (3-64) months in the ORRP group and 11.3 (1-24) months in the RARP group. At follow-up, anastomotic stricture and biochemical recurrence were observed to be less in the RARP group (3.9% vs. 29.9% p

Comparative effectiveness of robotic and open radical prostatectomy

Radical prostatectomy (RP) has undergone a remarkable transformation from open to minimally-invasive surgery over the last two decades. However, it is important to recognize there is still conflicting evidence regarding key outcomes. We aimed to summarize current literature on comparative effectiveness of robotic and open RP for key outcomes including oncologic results, health-related quality of life (HRQOL) measures, safety and postoperative complications, and healthcare costs. The bulk of the paper will discuss and interpret limitations of current data. Finally, we will also highlight future directions of both surgical approaches and its potential impact on health care delivery.

Impact of positive surgical margin length and Gleason grade at the margin on biochemical recurrence in patients with organ-confined prostate cancer

BACKGROUND

Positive surgical margins (PSMs) represent a poor prognostic factor at radical prostatectomy (RP). To investigate the impact of PSM, its length, the focality, and the PSM Gleason, on biochemical recurrence (BCR) in organ-confined RP patients.

METHODS

Within a high-volume center database, we identified patients who harbored organ-confined (pathologic stage T2 disease) prostate cancer (PCa) at RP (2010-2016). Kaplan-Meier analyses and multivariable Cox regression models were used to test the effect of the PSM on the BCR risk.

RESULTS

Overall, 8770 patients were identified. Of those, 6.6% (n = 579) harbored PSM. BCR-free survival at 72 months after RP was 77.7% vs 89.0% for patients with vs without PSM (P < .001). BCR-free survival rates at 72 months were 77.4% vs 73.6% (P = .1) for unifocal vs multifocal PSM, 77.2% vs 71.8% (P = .03) for Gleason pattern 3 vs ≥4 at the margin and 88.4% vs 66.3% (P < .001) for <3 vs ≥3 mm length of margin. In multivariable Cox models PSM was an independent predictor for BCR (hazard ratio [HR] = 2.40, P < .001). However, in subgroups with PSM, only ≥3 mm PSM represented an independent predictor (HR = 1.93, P = .04), while focality and Gleason at the margin were no significant predictors.

CONCLUSION

PSM represents an independent predictor for BCR in organ-confined PCa at RP. Moreover, Gleason ≥4 at the margin and ≥3 mm PSM length were associated with worse BCR-free survival. Closer surveillance of patients with organ-confined PCa at RP and PSM can help to identify those who qualify for early salvage radiotherapy.

Extent of positive surgical margins following radical prostatectomy: impact on biochemical recurrence with long-term follow-up

Background

To assess the prognostic value of the extent of positive surgical margins (PSM) following radical prostatectomy (RP) on biochemical recurrence (BR) with long-term follow-up.

Methods

This retrospective study analyzed 1275 RPs performed between January 1992 and December 2013 in two university centers in Marseille (France). The inclusion criteria were: follow-up > 24 months, undetectable postoperative prostate-specific antigen (PSA), no seminal vesicle (SV) invasion, no lymph node invasion confirmed by surgery (pN0) or imaging (pNx), and no neoadjuvant or adjuvant treatment. BR was defined by PSA level ≥ 0.2 ng/mL on two successive samples. We included 189 patients, divided into two groups:

- Focal PSM (fPSM): single PSM (sPSM) ≤3 mm;

- Extensive PSM (ePSM): sPSM with linear length > 3 mm or several margins regardless of the length.

Results

The median follow-up was 101 months (18–283) and the median age was 63 years (46–76). BR occurred in only 12.1% (14/115) of cases involving fPSM and in 54.1% (40/74) of cases involving ePSM. In the multivariate model, ePSM patients were significantly associated with increased BR compared to fPSM (hazard ratio [HR] = 6.11; 95% confidence interval [CI] = 3.25–11.49). The ePSM significantly decreased BR-free survival (p < 0.001) for every patient and every subgroup (pT2, pT3a, pG ≤6, and pG ≥7). The median BR time following RP was significantly shorter for ePSM patients than fPSM (57.2 vs. 89.2 months p < 0.001).

Conclusion

With a median 8-year follow-up, ePSM was strongly associated with BR compared to fPSM. Therefore, it seems legitimate to monitor patients with fPSM. In cases of ePSM, adjuvant treatment appears effective.

Minimal residual disease in prostate cancer patients after primary treatment: theoretical considerations, evidence and possible use in clinical management

Minimal residual disease is that not detected by conventional imaging studies and clinically the patient remains disease free. However, with time these dormant cells will awaken and disease progression occurs, resulting in clinically and radiological detectable metastatic disease. This review addresses the concept of tumor cell dissemination from the primary tumor, the micrometastatic niche and tumor cell survival and finally the clinical utility of detecting and characterizing these tumor cells in order to guide management decisions in treating patients with prostate cancer.

Improving postoperative radiotherapy following radical prostatectomy

INTRODUCTION

Prostate cancer has one of the highest incidences in the world, with good curative treatment options like radiotherapy and radical prostatectomy. Unfortunately, about 30% of the patients initially treated with curative intent will develop a recurrence and need adjuvant treatment. Five randomized trials covered the role of postoperative radiotherapy after radical prostatectomy, but there is still a lot of debate about which patients should receive postoperative radiotherapy. Areas covered: This review will give an overview on the available literature concerning post-operative radiotherapy following radical prostatectomy with an emphasis on the five randomized trials. Also, new imaging techniques like prostate-specific membrane antigen positron emission tomography (PSMA-PET) and multiparametric magnetic resonance imaging (mp-MRI) and the development of biomarkers like genomic classifiers will be discussed in the search for an improved selection of patients who will benefit from postoperative radiotherapy following radical prostatectomy. With new treatment techniques like Intensity Modulated Radiotherapy, toxicity profiles will be kept low. Expert commentary: Patients with biochemical recurrence following radical prostatectomy with an early rise in prostate-specific antigen (PSA) will benefit most from postoperative radiotherapy. In this way, patients with only high risk pathological features can avoid unnecessary treatment and toxicity, and early intervention in progressing patients would not compromise the outcome.

Influence of pathologist experience on positive surgical margins following radical prostatectomy

BACKGROUND

A positive surgical margin (PSM) following radical prostatectomy (RP) for prostate cancer is associated with increased risk of biochemical recurrence. We sought to examine whether the pathologist is an independent predictor of PSMs.

METHODS

We performed a retrospective review of 3,557 men who underwent RP for localized prostate cancer at our institution from 2003 to 2015. We evaluated 29 separate pathologists. Univariate and multivariable logistic regression were used to test variables previously shown to influence PSM rates.

RESULTS

Overall rate of PSM was 18.9%. Compared with patients without PSM, patients with PSM had higher body mass index (mean: 28.8 vs. 28.3), Gleason score≥7 (84% vs. 66%), extracapsular extension (51% vs. 20%), and median prostate-specific antigen (5.9 vs. 5.1ng/ml) (all P<0.05). Univariate logistic regression showed that surgeon experience, pathologist experience, and pathologist genitourinary fellowship training were all predictors of PSMs (all P<0.05). Multivariable regression analysis confirmed that decreased surgeon experience, increased pathologist experience, higher pathologic Gleason score, higher pathologic stage, and higher prostate-specific antigen were significant predictors of PSMs. Increasing surgeon experience was associated with decreased odds of PSM (odds ratio = 0.79 per 1 standard deviation increase, 95% CI [0.70-0.89]). In contrast, increasing pathologist experience was associated with increased odds of PSM (odds ratio = 1.11 per 1 standard deviation increase, 95% CI [1.03-1.19]). The relationship between pathologist experience and PSM appeared to be nonlinear (Fig. 2).

CONCLUSIONS

Greater pathologist experience appears to be associated with greater odds of PSMs following radical prostatectomy, even after controlling for case mix, pathologist fellowship training, and surgeon experience. Based on these findings, pathologists with less experience reviewing RP specimens may consider requesting rereview by a dedicated genitourinary pathologist.

Determinants and effects of positive surgical margins after prostatectomy on prostate cancer mortality: a population-based study

BACKGROUND

The objective of this population-based study was to assess patient, physician and tumour determinants associated with positive surgical margins after prostatectomy, and to assess the effects of positive surgical margins on prostate cancer-specific survival.

METHODS

We included 1'254 prostate cancer patients recorded at the Geneva Cancer Registry who had radical prostatectomy during 1990-2008. To assess factors associated with positive margins, we used logistic regression. We assessed the effects of positive margins on prostate cancer-specific survival by Cox proportional hazard models accounting for numerous other prognostics factors including prostate and tumour volume, the total percentage of tumour, radiotherapy, surgical approach and surgeon's caseload.

RESULTS

Among men undergoing prostatectomy, 479 (38%) had positive margins. In the multivariate logistic regression analysis, period, clinical- and pathological T stage, Prostate Specific Antigen (PSA) level, Gleason score and percentage of tumour in the prostate were significantly associated to positive margins. Ten-year prostate cancer-specific survival was 96.6% for the negative margins group and 92.0% for the positive margins group (log rank p = 0.008). In the Cox survival analysis adjusted for tumour characteristics, surgical margin status per se was not an independent prognostic factor while age, pathological T, PSA level and Gleason score remained associated with prostate cancer-specific survival.

CONCLUSIONS

More aggressive tumour characteristics were strong determinants for positive margins. Furthermore, surgical margin status per se was not an independent prognostic factor for prostate cancer-specific survival after adjusting by the gravity of the disease in the multivariate analysis.

Efficiency of pretreatment risk stratification systems for prostate cancer in a Japanese population treated with radical prostatectomy

OBJECTIVE

To determine whether the currently available pretreatment risk classification systems are applicable in Japanese prostate cancer patients.

METHODS

Using data obtained from 1264 consecutive patients with prostate cancer treated with radical prostatectomy at four hospitals in Japan, biochemical recurrence-free survival rates were estimated and compared between the D'Amico, the National Institute for Health and Clinical Excellence, the Cancer of the Prostate Strategic Urological Research Endeavor, the National Comprehensive Cancer Network, and the European Society of Medical Oncology risk groups by using the Kaplan-Meier method and log-rank test.

RESULTS

The 5-year biochemical recurrence-free survival rates in the D'Amico low-, intermediate-, and high-risk groups were 88.3%, 84.7% and 66.9%, respectively (low and intermediate risk vs high risk, P < 0.001). The 5-year biochemical recurrence-free survival rates in the National Institute for Health and Clinical Excellence, National Comprehensive Cancer Network, and European Society of Medical Oncology low-, intermediate- and high-risk groups were 88.3%, 84.3%, and 60.3%, respectively (low and intermediate risk vs high risk, P < 0.001). The 5-year biochemical recurrence-free survival rates in the Cancer of the Prostate Strategic Urological Research Endeavor low-, intermediate-, and high-risk groups were 90%, 83.5% and 60.3%, respectively (low and intermediate risk vs high risk, P < 0.001). Low- and intermediate-risk groups according to any of the risk stratification systems did not show significant differences in biochemical recurrence-free survival.

CONCLUSION

Current risk stratification systems do not discriminate between low- and intermediate-risk groups in the Japanese population. A novel, pretreatment risk stratification system including other prognostic factors is necessary for an adequate prostate cancer risk assessment in the Japanese population.

Robotic-assisted laparoscopic radical prostatectomy: a report of the current state

Cancer of the prostate is the most common malignancy diagnosed in the male genitourinary tract. Although a number of treatment options are available for early prostate cancer, the gold standard of treatment remains retropubic radical prostatectomy. However, robotic-assisted laparoscopic radical prostatectomy (RALP) has become a forerunner in treatment options, yielding comparable medium-term perioperative and functional outcomes. For this our team utilized MEDLINE, searching for publications on perioperative and functional outcomes related to robotic prostatectomy. Robotic-assisted prostatectomy has allowed urologists to enter the realm of minimally invasive surgery by incorporating open surgery maneuvers into a laparoscopic environment. To date, RALP perioperative and functional outcomes are comparable to the gold standard; the collection of long-term data is needed in order to establish its true efficacy.

Open radical retropubic prostatectomy 2007: the true minimally invasive surgery for localized prostate cancer?

The introduction of robotic laparoscopic assisted prostatectomy at our institution and nationwide has been a great advancement and has caused us to focus and fine-tune our goal for improvements in prostate cancer outcomes whether the patient elects for robotic laparoscopic assisted prostatectomy or open minimally invasive radical retropubic prostatectomy. While these authors favor the open technique performed by highly skilled urologic surgical oncologists, the lessons we have learned to date suggest that it is the skill of the surgeon that determines outcome, regardless of whether or not the operation is performed by an open or robotic laparoscopic technique. The concepts we have articulated here are related to resection and avoidance of positive margins, limited intraoperative blood loss and pain control, which allow equivalence in these outcome areas, regardless of technique.

Positive surgical margins at radical prostatectomy: Population-based averages within PSA and Gleason strata

BACKGROUND

Positive surgical margins (PSM) are an important determinant of biochemical recurrence after radical prostatectomy (RP). We use a population-based cancer registry to evaluate PSM by stage, Gleason and prostate-specific antigen (PSA).

METHODS

We identified men undergoing RP from the Surveillance, Epidemiology and End Results (SEER) database between 2004 and 2007. Differences between those with and without PSM were compared with chi-squared tests. The proportion of cases with PSM were stratified by PSA and Gleason sum for both pT2 and pT3a tumours. Factors associated with PSM were analyzed using chi square and multivariate logistic regression analysis. A composite variable was used in a second multivariate analysis to display the odds ratio (OR) for a PSM for each discrete combination of PSA, Gleason score and pT stage.

RESULTS

In total, 28 461 RP patients were identified and a PSM was present in 19.5%. PSM were 42% in pT3a and 16% in pT2 cases. Higher PSAs (<4.0, 4-9.9, >10) were associated with higher proportions of PSM (12%, 20% and 28%, p < 0.001). Similarly, higher Gleason scores (≤6, 3+4, 4+3, ≥8) were associated with higher PSM (12%, 22%, 27% and 33%, p < 0.001). For pT2 tumours, the proportion of PSM ranged from 8% (Gleason ≤6, PSA <4.0) to 28% (Gleason 8-10, PSA ≥10). For pT3a tumours, the PSM was higher in each Gleason/PSA strata compared to those with pT2 tumours, reaching 63% for those with pT3a, Gleason 8-10, PSA >10 disease. On multivariate analysis, stage was the largest predictor for PSM (OR 3.05, 95% confidence interval 2.81-3.30), although Gleason score and PSA remained statistically significant.

CONCLUSION

In this population-based study of PSM after RP, the proportion of PSM vary significantly within different PSA and Gleason strata for organ-confined and extracapsular disease. These data can be used as a reference for urologist self-assessment.

Detection of prostate cancer by radio-frequency near-field spectroscopy in radical prostatectomy ex vivo specimens

BACKGROUND

The aim of radical prostatectomy (RP) is the complete removal of the prostate gland with negative surgical margins. The presence of cancer at the surgical margin is associated with higher probability of disease progression. Current methods of intraoperative margin assessment are inaccurate or time-consuming.The study goal was to evaluate the ability of a novel device (Dune Medical Devices) to differentiate between cancer and BPH.

METHODS

A total of 49 patients undergoing RP in four medical centers between November 2007 and May 2008 were enrolled in this study.The device was applied to numerous intra- and extra-capsular sites of freshly excised RP specimens. Measurement sites were accurately marked and analyzed histologically. The ability of the device to differentiate between malignant and nonmalignant sites was assessed.

RESULTS

A total of 15,156 measurements from 45 patients were analyzed. Differentiation of the intra-capsular malignant sites from extra-capsular nonmalignant sites (bladder neck and apex regions) depends on the cancer feature size. Differentiation was achieved with sensitivity and specificity of 93.6 (95% confidence interval (CI): 88-98) and 94.1 (95% CI: 93-95), respectively, at feature sizes at or >0.8 mm in diameter. The device was able to discriminate between all intra-capsular malignant (with feature sizes down to a few cells) and nonmalignant measurement sites, with sensitivity and specificity of 80.8 (95% CI: 73-87) and 68.4 (95% CI: 67-69), respectively.

CONCLUSIONS

First results from a radio-frequency near-field spectroscopy sensor look promising for differentiation between cancer and benign prostate tissue. The sensor's dimensions (radius of ~ 1 mm) and design enable use in open, laparoscopic and robotic RP to evaluate the surgical margins intraoperatively.

Adjuvant radiotherapy following radical prostatectomy: Genito-Urinary Radiation Oncologists of Canada Consensus Statement

Until the results of 3 randomized trials became known in 2005, the role of adjuvant postoperative radiation therapy following radical prostatectomy was poorly defined. After the publication of these trials, the Genito-Urinary Radiation Oncologists of Canada (GUROC) met and crafted a consensus statement regarding the current place of adjuvant radiation therapy. GUROC also identified gaps in current knowledge and strongly supports ongoing study protocols to further quantify the benefit of postoperative radiotherapy.This report summarizes the main trial findings and the commentary provided during the consensus-building process. It also outlines the subsequent consensus statement.

[Oncological and functional results of open intrafascial radical prostatectomy]

BACKGROUND

According to the recently published German-language S3 guidelines, various treatment options such as surgical management or radiation therapy are available to patients with locally advanced prostate cancer.

METHODS

Particularly the establishment of minimally invasive endoscopic surgical techniques, which provide better optical images, has made it possible to visualize tissue layers that are usually difficult to identify with the open surgical technique. This contribution describes a pilot study on the establishment of open intrafascial radical prostatectomy.

AIM

The goal of the study is to critically analyze both the functional and especially the oncological results, which should not be compromised by the nerve-sparing approach.

Contemporary radical prostatectomy

Purpose. Patients diagnosed with clinically localized prostate cancer have more surgical treatment options than in the past. This paper focuses on the procedures' oncological or functional outcomes and perioperative morbidities of radical retropubic prostatectomy, radical perineal prostatectomy, and robotic-assisted laparoscopic radical prostatectomy. Materials and Methods. A MEDLINE/PubMed search of the literature on radical prostatectomy and other new management options was performed. Results. Compared to the open procedures, robotic-assisted radical prostatectomy has no confirmed significant difference in most literatures besides less blood loss and blood transfusion. Nerve sparing is a safe means of preserving potency on well-selected patients undergoing radical prostatectomy. Positive surgical margin rates of radical prostatectomy affect the recurrence and survival of prostate cancer. The urinary and sexual function outcomes have been vastly improved. Neoadjuvant treatment only affects the rate of positive surgical margin. Adjuvant therapy can delay and reduce the risk of recurrence and improve the survival of the high risk prostate cancer. Conclusions. For the majority of patients with organ-confined prostate cancer, radical prostatectomy remains a most effective approach. Radical perineal prostatectomy remains a viable approach for patients with morbid obesity, prior pelvic surgery, or prior pelvic radiation. Robot-assisted laparoscopic prostatectomy (RALP) has become popular among surgeons but has not yet become the firmly established standard of care. Long-term data have confirmed the efficacy of radical retropubic prostatectomy with disease control rates and cancer-specific survival rates.

The triple clinicopathologic features to seminal vesicle-sparing radical prostatectomy

BACKGROUND AND PURPOSE

With the widespread early detection programs for prostate cancer, there has been a downward stage migration and a marked decrease in the percentage of men with seminal vesicle invasion (SVI) compared with previous data. We evaluated clinicopathologic findings that are associated with SVI to select patients for potential seminal vesicle-sparing surgery.

PATIENTS AND METHODS

We reviewed our radical prostatectomy database from 1997 to 2006 to evaluate the incidence and clinical correlates of SVI. Variables analyzed included serum prostate-specific antigen (PSA) level, clinical stage, percentage of positive cores with cancer, Gleason score on biopsy, age, prostate weight, and urethral and vesical surgical margins. Statistical analysis included univariate and multivariate logistic regressions.

RESULTS

Of 267 patients, 32 (12%) had SVI. Preoperative PSA level, biopsy Gleason score, and percentage of positive cores were highly predictive of SVI on multivariate analysis. SVI was present in only 1/98 patients (1.02 %) with biopsy Gleason score ≤6, 0/23 patients (0%) with serum PSA level <4 ng/mL, and only 1 patient with ≤12.8% of positive cores on biopsy. In all cases of distal SVI, there was proximal involvement.

CONCLUSION

Serum PSA level, Gleason score, and percentage of positive cores on biopsy are statistically significant predictors of SVI on multivariate analysis. Seminal vesiculectomy does not benefit almost 99% of patients with biopsy Gleason score ≤6, PSA level <4 ng/mL, and with <12% cores with cancer. In cases of seminal vesicle-sparing surgery, frozen section of the proximal portion may be of adjunct usefulness for the triple.

Impact of surgical technique (open vs laparoscopic vs robotic-assisted) on pathological and biochemical outcomes following radical prostatectomy: an analysis using propensity score matching

OBJECTIVE

• To investigate a single institution experience with radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robot-assisted radical prostatectomy (RARP) with respect to pathological and biochemical outcomes.

PATIENTS AND METHODS

• A group of 522 consecutive patients who underwent RARP between 2003 and 2008 were matched by propensity scoring on the basis of patient age, race, preoperative prostate-specific antigen (PSA), biopsy Gleason score and clinical stage with an equal number of patients who underwent LRP and RRP at our institution. • Pathological and biochemical outcomes of the three cohorts were examined.

RESULTS

• Overall positive surgical margin rates were lower among patients who underwent RRP (14.4%) and LRP (13.0%) compared to patients who underwent RARP (19.5%) (P= 0.010). There were no statistically significant differences in positive margin rates between the three surgical techniques for pT2 disease (P= 0.264). • In multivariate logistic regression analysis, surgical technique (P= 0.016), biopsy Gleason score (P < 0.001) and preoperative PSA (P < 0.001) were predictors of positive surgical margins. • Kaplan-Meier analysis did not show any statistically significant differences with respect to biochemical recurrence for the three surgical groups.

CONCLUSIONS

• RRP, LRP and RARP represent effective surgical approaches for the treatment for clinically localized prostate cancer. A higher overall positive SM rate was observed for the RARP group compared to RRP and LRP; however, there was no difference with respect to biochemical recurrence-free survival between groups. • Further prospective studies are warranted to determine whether any particular technique is superior with regard to long-term clinical outcomes.

Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a critical review of outcomes reported by high-volume centers

PURPOSE

To critically review perioperative outcomes, positive surgical margin (PSM) rates, and functional outcomes of several large series of retropubic radical prostatectomy (RRP), laparoscopic RP (LRP), and robot-assisted radical prostatectomy (RARP) currently available in the literature.

METHODS

A Medline database search was performed from November 1994 to May 2009, using medical subject heading search terms "prostatectomy" and "Outcome Assessment (Health Care)" and text words "retropubic," "robotic," and "laparoscopic." Only studies with a sample size of 250 or more patients were considered. Weighted means were calculated for all outcomes using the number of patients included in each study as the weighing factor.

RESULTS

We identified 30 articles for RRP, 14 for LRP, and 14 for RARP. The mean intraoperative and postoperative RRP transfusion rates for RRP, LRP, and RARP were 20.1%, 3.5%, and 1.4%, respectively. The weighted mean postoperative complication rates for RRP, LRP, and RARP were 10.3% (4.8% to 26.9%), 10.98% (8.9 to 27.7%), and 10.3% (4.3% to 15.7%), respectively. RARP revealed a mean overall PSM rate of 13.6%, whereas LRP and RRP yielded a PSM of 21.3% and 24%, respectively. The weighted mean continence rates at 12 month follow-up for RRP, LRP, and RARP were 79%, 84.8%, and 92%, respectively. The weighted mean potency rates for patients who underwent unilateral or bilateral nerve sparing, at 12 month follow-up, were 43.1% and 60.6% for RRP, 31.1% and 54% for LRP, and 59.9% and 93.5% for RARP.

CONCLUSION

RRP, LRP, and RARP performed in high-volume centers are safe options for treatment of patients with localized prostate cancer, presenting similar overall complication rates. LRP and RARP, however, are associated with decreased operative blood loss and decreased risk of transfusion when compared with RRP. Our analysis including high-volume centers also showed lower weighted mean PSM rates and higher continence and potency rates after RARP compared with RRP and LRP. However, the lack of randomized trials precludes definitive conclusions.

Novel diagnostic biomarkers for prostate cancer

Prostate cancer is the most frequently diagnosed malignancy in American men, and a more aggressive form of the disease is particularly prevalent among African Americans. The therapeutic success rate for prostate cancer can be tremendously improved if the disease is diagnosed early. Thus, a successful therapy for this disease depends heavily on the clinical indicators (biomarkers) for early detection of the presence and progression of the disease, as well as the prediction after the clinical intervention. However, the current clinical biomarkers for prostate cancer are not ideal as there remains a lack of reliable biomarkers that can specifically distinguish between those patients who should be treated adequately to stop the aggressive form of the disease and those who should avoid overtreatment of the indolent form.

A biomarker is a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention. A biomarker reveals further information to presently existing clinical and pathological analysis. It facilitates screening and detecting the cancer, monitoring the progression of the disease, and predicting the prognosis and survival after clinical intervention. A biomarker can also be used to evaluate the process of drug development, and, optimally, to improve the efficacy and safety of cancer treatment by enabling physicians to tailor treatment for individual patients. The form of the prostate cancer biomarkers can vary from metabolites and chemical products present in body fluid to genes and proteins in the prostate tissues.

Current advances in molecular techniques have provided new tools facilitating the discovery of new biomarkers for prostate cancer. These emerging biomarkers will be beneficial and critical in developing new and clinically reliable indicators that will have a high specificity for the diagnosis and prognosis of prostate cancer. The purpose of this review is to examine the current status of prostate cancer biomarkers, with special emphasis on emerging markers, by evaluating their diagnostic and prognostic potentials. Both genes and proteins that reveal loss, mutation, or variation in expression between normal prostate and cancerous prostate tissues will be covered in this article. Along with the discovery of prostate cancer biomarkers, we will describe the criteria used when selecting potential biomarkers for further development towards clinical use. In addition, we will address how to appraise and validate candidate markers for prostate cancer and some relevant issues involved in these processes. We will also discuss the new concept of the biomarkers, existing challenges, and perspectives of biomarker development.

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.

Predictive factors for positive surgical margins and their locations after robot-assisted laparoscopic radical prostatectomy

BACKGROUND

Positive surgical margin (PSM) after radical prostatectomy (RP) has been shown to be an independent predictive factor for cancer recurrence. Several investigations have correlated clinical and histopathologic findings with surgical margin status after open RP. However, few studies have addressed the predictive factors for PSM after robot-assisted laparoscopic RP (RARP).

OBJECTIVE

We sought to identify predictive factors for PSMs and their locations after RARP.

DESIGN, SETTING, AND PARTICIPANTS

We prospectively analyzed 876 consecutive patients who underwent RARP from January 2008 to May 2009.

INTERVENTION

All patients underwent RARP performed by a single surgeon with previous experience of >1500 cases.

MEASUREMENTS

Stepwise logistic regression was used to identify potential predictive factors for PSM. Three logistic regression models were built: (1) one using preoperative variables only, (2) another using all variables (preoperative, intraoperative, and postoperative) combined, and (3) one created to identify potential predictive factors for PSM location. Preoperative variables entered into the models included age, body mass index (BMI), prostate-specific antigen, clinical stage, number of positive cores, percentage of positive cores, and American Urological Association symptom score. Intra- and postoperative variables analyzed were type of nerve sparing, presence of median lobe, percentage of tumor in the surgical specimen, gland size, histopathologic findings, pathologic stage, and pathologic Gleason grade.

RESULTS AND LIMITATIONS

In the multivariable analysis including preoperative variables, clinical stage was the only independent predictive factor for PSM, with a higher PSM rate for T3 versus T1c (odds ratio [OR]: 10.7; 95% confidence interval [CI], 2.6-43.8) and for T2 versus T1c (OR: 2.9; 95% CI, 1.9-4.6). Considering pre-, intra-, and postoperative variables combined, percentage of tumor, pathologic stage, and pathologic Gleason score were associated with increased risk of PSM in the univariable analysis (p<0.001 for all variables). However, in the multivariable analysis, pathologic stage (pT2 vs pT1; OR: 2.9; 95% CI, 1.9-4.6) and percentage of tumor in the surgical specimen (OR: 8.7; 95% CI, 2.2-34.5; p=0.0022) were the only independent predictive factors for PSM. Finally, BMI was shown to be an independent predictive factor (OR: 1.1; 95% CI, 1.0-1.3; p=0.0119) for apical PSMs, with increasing BMI predicting higher incidence of apex location. Because most of our patients were referred from other centers, the biopsy technique and the number of cores were not standardized in our series.

CONCLUSIONS

Clinical stage was the only preoperative variable independently associated with PSM after RARP. Pathologic stage and percentage of tumor in the surgical specimen were identified as independent predictive factors for PSMs when analyzing pre-, intra-, and postoperative variables combined. BMI was shown to be an independent predictive factor for apical PSMs.