Predictive Factors for Positive Surgical Margins in Patients With Prostate Cancer After Radical Prostatectomy: A Systematic Review and Meta-Analysis

Background and Objectives

Previous studies have demonstrated that positive surgical margins (PSMs) were independent predictive factors for biochemical and oncologic outcomes in patients with prostate cancer (PCa). This study aimed to conduct a meta-analysis to identify the predictive factors for PSMs after radical prostatectomy (RP).

Methods

We selected eligible studies via the electronic databases, such as PubMed, Web of Science, and EMBASE, from inception to December 2020. The risk factors for PSMs following RP were identified. The pooled estimates of standardized mean differences (SMDs)/odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. A fixed effect or random effect was used to pool the estimates. Subgroup analyses were performed to explore the reasons for heterogeneity.

Results

Twenty-seven studies including 50,014 patients with PCa were eligible for further analysis. The results showed that PSMs were significantly associated with preoperative prostate-specific antigen (PSA) (pooled SMD = 0.37; 95% CI: 0.31–0.43; P < 0.001), biopsy Gleason Score (<6/≥7) (pooled OR = 1.53; 95% CI:1.31–1.79; P < 0.001), pathological Gleason Score (<6/≥7) (pooled OR = 2.49; 95% CI: 2.19–2.83; P < 0.001), pathological stage (<T2/≥T3) (pooled OR = 3.90; 95% CI: 3.18–4.79; P < 0.001), positive lymph node (PLN) (pooled OR = 3.12; 95% CI: 2.28–4.27; P < 0.001), extraprostatic extension (EPE) (pooled OR = 4.44; 95% CI: 3.25–6.09; P < 0.001), and seminal vesicle invasion (SVI) (pooled OR = 4.19; 95% CI: 2,87–6.13; P < 0.001). However, we found that age (pooled SMD = 0.01; 95% CI: −0.07–0.10; P = 0.735), body mass index (BMI) (pooled SMD = 0.12; 95% CI: −0.05–0.30; P = 0.162), prostate volume (pooled SMD = −0.28; 95% CI: −0.62–0.05; P = 0.097), and nerve sparing (pooled OR = 0.90; 95% CI: 0.71–1.14; P = 0.388) had no effect on PSMs after RP. Besides, the findings in this study were found to be reliable by our sensitivity and subgroup analyses.

Conclusions

Preoperative PSA, biopsy Gleason Score, pathological Gleason Score, pathological stage, positive lymph node, extraprostatic extension, and seminal vesicle invasion are independent predictors of PSMs after RP. These results may helpful for risk stratification and individualized therapy in PCa patients.

Development and validation of a preoperative nomogram for predicting positive surgical margins after laparoscopic radical prostatectomy

BACKGROUND

Positive surgical margins are independent risk factor for biochemical recurrence, local recurrence, and distant metastasis after radical prostatectomy. However, limited predictive tools are available. This study aimed to develop and validate a preoperative nomogram for predicting positive surgical margins after laparoscopic radical prostatectomy (LRP).

METHODS

From January 2010 to March 2016, a total of 418 patients who underwent LRP without receiving neoadjuvant therapy at Peking University Third Hospital were retrospectively involved in this study. Clinical and pathological results of each patient were collected for further analysis. Univariable and multivariable logistic regression (backward stepwise method) were used for the nomogram development. The concordance index (CI), calibration curve analysis and decision curve analysis were used to evaluate the performance of our model.

RESULTS

Of 418 patients involved in this study, 142 patients (34.0%) had a positive surgical margin on final pathology. Based on the backward selection, four variables were included in the final multivariable regression model, including the percentage of positive cores in preoperative biopsy, clinical stage, free prostate specific antigen (fPSA)/total PSA (tPSA), and age. A nomogram was developed using these four variables. The concordance index (C-index) of the nomogram was 0.722 in the development cohort and 0.700 in the bootstrap validations. The bias-corrected calibration plot showed a limited departure from the ideal line with a mean absolute error of 2.0%. In decision curve analyses, the nomogram showed net benefits in the range from 0.2 to 0.7.

CONCLUSION

A nomogram to predict positive surgical margins after LRP was developed and validated, which could help urologists plan surgical procedures.

Clinical effect of a positive surgical margin without extraprostatic extension after robot-assisted radical prostatectomy

OBJECTIVES

The aim of this study was to investigate the effect of positive surgical margin (PSM) without extraprostatic extension after robot-assisted radical prostatectomy (RARP).

MATERIALS AND METHODS

We retrospectively reviewed 837 patients who underwent RARP for clinically localized prostate cancer without neoadjuvant endocrine therapy. The pT2+category lesions were defined according to World Health Organization classification. The actuarial probabilities of biochemical recurrence-free survival (BCR-FS) were determined using Kaplan-Meier analysis. Univariate and multivariate Cox proportional hazards regression analyses were also used to identify independent predictors for BCR.

RESULTS

Of the 837 patients, 102 (12.2%) experienced BCR during the follow-up period. The BCR-FS rate was significantly higher in patients with pT2+category tumors than in those with pT3a category tumors, and significantly lower in patients with pT2+category tumors than that in those with pT2 category tumors without PSM. The BCR-FS rate of patients with pT2+category tumors was significantly higher than that with pT3a category tumors with PSM but not significantly different from that with pT3a category tumors without PSM. In a multivariate analysis, the pathological T category considering pT2+category was one of independent predictive factors for BCR.

CONCLUSIONS

This study support the hypothesis that the pT2+category disease is associated with a significantly increased risk of BCR in patients with organ-confined prostate cancer after RARP. As PSM can be avoided in some cases, urologists should continually seek to improve their operative skills and to reduce the rate of PSM, especially in patients with organ-confined prostate cancer.