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Fodor A, Brombin C, Chiti A, Di Muzio NG. Lymph node oligometastases from prostate cancer: extensive or localized treatments - do we have a basis to decide? Eur J Nucl Med Mol Imaging 2024:10.1007/s00259-024-06837-0. [PMID: 38992160 DOI: 10.1007/s00259-024-06837-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Affiliation(s)
- Andrei Fodor
- Department of Radiation Oncology, IRCCS San Raffaele Scientific Institute, 60, Olgettina street, Milan, 20132, Italy.
| | - Chiara Brombin
- University Center for Statistics in the Biomedical Sciences, Vita-Salute San Raffaele University, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Arturo Chiti
- Vita-Salute San Raffaele University, Milan, Italy
- Department of Nuclear Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nadia Gisella Di Muzio
- Department of Radiation Oncology, IRCCS San Raffaele Scientific Institute, 60, Olgettina street, Milan, 20132, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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2
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Patel HD, Okabe Y, Rac G, Pahouja G, Desai S, Shea SM, Gorbonos A, Quek ML, Flanigan RC, Goldberg A, Gupta GN. MRI versus non-MRI diagnostic pathways before radical prostatectomy: Impact on nerve-sparing, positive surgical margins, and biochemical recurrence. Urol Oncol 2023; 41:104.e19-104.e27. [PMID: 36372633 DOI: 10.1016/j.urolonc.2022.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 10/01/2022] [Accepted: 10/13/2022] [Indexed: 11/11/2022]
Abstract
PURPOSE Magnetic resonance imaging (MRI) prior to biopsy has improved detection of clinically significant prostate cancer (CaP), but its impact on surgical outcomes is less well established. We compared MRI vs. non-MRI diagnostic pathways among patients receiving radical prostatectomy (RP) for impact on surgical outcomes. MATERIALS AND METHODS Men diagnosed with CaP and receiving RP at Loyola University Medical Center (2014-2021) were categorized into MRI or non-MRI diagnostic pathways based on receipt of MRI before prostate biopsy. Primary outcomes of interest included positive surgical margin (PSM) rates, the performance of bilateral nerve-sparing, and biochemical recurrence (BCR). Multivariable logistic regression models, Kaplan-Meier curves, and Cox proportional hazards regression were employed. RESULTS Of 609 patients, 281 (46.1%) were in the MRI and 328 (53.9%) in the non-MRI groups. MRI patients had similar PSA, biopsy grade group (GG) distribution, RP GG, pT stage, and RP CaP volume compared to non-MRI patients. PSM rates were not statistically different for the MRI vs. non-MRI groups (22.8% vs. 26.8%, P = 0.25). Bilateral nerve-sparing rates were higher for the MRI vs. non-MRI groups (OR 1.95 (95%CI 1.32-2.88), P = 0.001). The MRI group demonstrated improved BCR (HR 0.64 (95%CI 0.41-0.99), P = 0.04) after adjustment for age, PSA, RP GG, pT, pN, and PSM status. On meta-analysis, a 5.2% PSM reduction was observed but high heterogeneity for use of nerve-sparing. CONCLUSIONS An MRI-based diagnostic approach selected patients for RP with a small reduction in PSM rates, greater utilization of bilateral nerve-sparing, and improved cancer control by BCR compared to a non-MRI approach even after adjustment for known prognostic factors.
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Affiliation(s)
- Hiten D Patel
- Department of Urology, Loyola University Medical Center, Maywood, IL; Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL.
| | - Yudai Okabe
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Goran Rac
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Gaurav Pahouja
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Shalin Desai
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Steven M Shea
- Department of Radiology, Loyola University Medical Center, Maywood, IL
| | - Alex Gorbonos
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Marcus L Quek
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Robert C Flanigan
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Ari Goldberg
- Department of Radiology, Loyola University Medical Center, Maywood, IL
| | - Gopal N Gupta
- Department of Urology, Loyola University Medical Center, Maywood, IL; Department of Radiology, Loyola University Medical Center, Maywood, IL; Department of Surgery, Loyola University Medical Center, Maywood, IL
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Axén E, Godtman RA, Bjartell A, Carlsson S, Haglind E, Hugosson J, Lantz A, Månsson M, Steineck G, Wiklund P, Stranne J. Degree of Preservation of Neurovascular Bundles in Radical Prostatectomy and Recurrence of Prostate Cancer. EUR UROL SUPPL 2021; 30:25-33. [PMID: 34337544 PMCID: PMC8317882 DOI: 10.1016/j.euros.2021.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Reports on possible benefits for continence with nerve-sparing (NS) radical prostatectomy have expanded the indications beyond preservation of erectile function. It is unclear whether NS surgery affects oncological outcomes. OBJECTIVE To determine whether the degree of NS during radical prostatectomy influences oncological outcomes. DESIGN SETTING AND PARTICIPANTS Of 4003 patients enrolled in a prospective, controlled trial comparing open and robotic radical prostatectomy during 2008-2011, we evaluated 2401 patients who received robotic radical prostatectomy at seven Swedish centres. Patients were followed for 8 yr. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Data for recurrence and positive surgical margin status were assessed using validated patient questionnaires, patient interviews, and clinical record forms before and at 3, 12, and 24 mo and 6 and 8 yr after surgery. Cox and logistic regressions were used to model the effect on recurrence and positive surgical margins (PSM), respectively. RESULTS AND LIMITATIONS A total of 481 men had PSM and 467 experienced recurrence during follow-up. Median follow-up for men without recurrence was 6.6 yr. There were no statistically significant differences in recurrence rate between degrees of NS. The PSM rate was significantly higher with a higher degree of NS: interfascial NS, odds ratio (OR) 2.32 (95% confidence interval [CI] 1.69-3.16); intrafascial NS, OR 3.23 (95% CI 2.17-4.80). Recurrence rates were higher for patients with pT2 disease and PSM (hazard ratio [HR] 3.32, 95% CI 2.43-4.53) than for patients with pT3 disease without PSM (HR 2.08, 95% CI 1.66-2.62). The lack of central review of pathological specimens is a limitation. CONCLUSIONS A higher degree of NS significantly increased the risk of PSM but did not significantly increase the risk of cancer recurrence. Combined with the known functional benefits of NS surgery, these results underscore the need to identify an individualised balance. PATIENT SUMMARY In this report we looked at the effect of a nerve-sparing approach during removal of the prostate on cancer outcomes for patients having robot-assisted surgery at seven Swedish hospitals. We found that a high degree of nerve-sparing increased the rate of cancer positivity at the margins of surgical specimens and that positive surgical margins increased the risk of recurrence of prostate cancer.
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Affiliation(s)
- Elin Axén
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Urology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Rebecka Arnsrud Godtman
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Urology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Anders Bjartell
- Department of Urology, Skåne University Hospital, Malmö, Sweden
| | - Stefan Carlsson
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Haglind
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Scandinavian Surgical Outcomes Research Group, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital/Östra, Region Västra Götaland, Gothenburg, Sweden
| | - Jonas Hugosson
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Urology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Anna Lantz
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Marianne Månsson
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Gunnar Steineck
- Department of Oncology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Peter Wiklund
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden
- Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
| | - Johan Stranne
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Urology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
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4
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Moris L, Gandaglia G, Vilaseca A, Van den Broeck T, Briers E, De Santis M, Gillessen S, Grivas N, O'Hanlon S, Henry A, Lam TB, Lardas M, Mason M, Oprea-Lager D, Ploussard G, Rouviere O, Schoots IG, van der Poel H, Wiegel T, Willemse PP, Yuan CY, Grummet JP, Tilki D, van den Bergh RCN, Cornford P, Mottet N. 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. Eur Urol Focus 2021; 8:690-700. [PMID: 34147405 DOI: 10.1016/j.euf.2021.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/10/2021] [Accepted: 05/25/2021] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Lisa Moris
- Department of Urology, University Hospitals Leuven, Leuven, Belgium.
| | - Giorgio Gandaglia
- Unit of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Antoni Vilaseca
- Uro-Oncology Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | | | - Maria De Santis
- Department of Urology, Charité University Hospital Berlin, Berlin, Germany; Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Silke Gillessen
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Università della Svizzera Italiana, Lugano, Switzerland
| | - Nikos Grivas
- Department of Urology, Hatzikosta General Hospital, Ioannina, Greece
| | - Shane O'Hanlon
- Medicine for Older People, Saint Vincent's University Hospital, Dublin, Ireland
| | - Ann Henry
- Leeds Cancer Centre, St. James's University Hospital and University of Leeds, Leeds, UK
| | - Thomas B Lam
- Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Michael Lardas
- Department of Urology, Metropolitan General Hospital, Athens, Greece
| | - Malcolm Mason
- Division of Cancer & Genetics, School of Medicine Cardiff University, UK
| | - Daniela Oprea-Lager
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, VU University, Amsterdam, The Netherlands
| | | | - Olivier Rouviere
- Department of Urinary and Vascular Imaging, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Ivo G Schoots
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands; Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Henk van der Poel
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
| | - Peter-Paul Willemse
- Department of Oncological Urology, Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Cathy Y Yuan
- Department of Medicine, Health Science Centre, McMaster University, Hamilton, ON, Canada
| | - Jeremy P Grummet
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center and Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Philip Cornford
- Department of Urology, Liverpool University Hospitals NHS Trust, Liverpool, UK
| | - Nicolas Mottet
- Department of Urology, University Hospital, St. Etienne, France
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5
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Çelik S, Aslan G, Sözen S, Özen H, Akdoğan B, Baltaci S, İzol V, Tansuğ Z, Türkeri L. Factors Affecting Surgical Margin Positivity after Radical Prostatectomy in the Turkish Population: A Multicenter Study of the Urooncology Association. Urol Int 2020; 104:724-730. [PMID: 32353851 DOI: 10.1159/000507268] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 03/13/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The prediction of positive surgical margins (SM) after radical prostatectomy (RP) is important for planning the surgical modality and adjuvant therapy in patients with prostate cancer (PCa). OBJECTIVES To investigate factors affecting SM positivity in patients diagnosed with PCa who underwent RP using the PCa database of the Urooncology Association (Turkey). METHODS Patients who underwent RP due to clinically T1c-T3 PCa and who had detailed SM data for the RP specimen were included in the study. Pathological data of 12 core transrectal ultrasound prostate biopsies and RP were evaluated. Patients were divided into 2 groups (SM positive and SM negative) according to SM status after RP. Data were compared between the groups. Factors affecting SM positivity, the number of positive SM sites, and the location of positive SM were separately evaluated with regression models. RESULTS A total of 2,643 patients from 6 different centers (median age: 63 years) with a prostate-specific antigen (PSA) level of 7.3 ng/mL were investigated in the study. BMI, PSA, biopsy Gleason score (GS), and perineural invasion (PNI) were found to be independent predictive factors for SM positivity and the number of positive SM locations, respectively (p < 0.05). According to the positive SM location, PSA was found to be associated with positive SM in apex, anterior prostate, and bladder neck locations. Also, according to posterolateral SM status, PNI and nerve-sparing RP (nsRP) rates were 21.3 and 44% for patients with negative posterolateral SM, and rates were 35.4 and 50.6% for patients with positive posterolateral SM, respectively (p < 0.05). In patients who underwent nsRP, positive SM was present in 22.2% of patients who did not have PNI on prostate biopsy, whereas positive SM was present in 40.6% of patients with PNI (p < 0.001). Similarly, 10.9% of patients without PNI had positive posterolateral SM, whereas 17.3% of patients with PNI had positive posterolateral SM (p = 0.031). CONCLUSIONS BMI, PSA, biopsy GS, and biopsy PNI positivity were found to be predictive factors affecting SM positivity. The most important factors affecting posterolateral positive SM were biopsy PNI and nsRP, indicating that the nsRP approach may cause positive SM in the posterolateral margin of the prostate (neurovascular bundle location) in patients with positive PNI on biopsy.
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Affiliation(s)
- Serdar Çelik
- Department of Urology, Izmir Bozyaka Training and Research Hospital, Health Sciences University, Izmir, Turkey, .,Department of Basic Oncology, Institute of Oncology, Dokuz Eylul University, Izmir, Turkey,
| | - Güven Aslan
- Department of Urology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Sinan Sözen
- Department of Urology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Haluk Özen
- Department of Urology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Bülent Akdoğan
- Department of Urology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Sümer Baltaci
- Department of Urology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Volkan İzol
- Department of Urology, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Zühtü Tansuğ
- Department of Urology, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Levent Türkeri
- Department of Urology, Acibadem Altunizade Hospital, Mehmet Ali Aydınlar University, Istanbul, Turkey
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6
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Nguyen LN, Head L, Witiuk K, Punjani N, Mallick R, Cnossen S, Fergusson DA, Cagiannos I, Lavallée LT, Morash C, Breau RH. The Risks and Benefits of Cavernous Neurovascular Bundle Sparing during Radical Prostatectomy: A Systematic Review and Meta-Analysis. J Urol 2017; 198:760-769. [DOI: 10.1016/j.juro.2017.02.3344] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Laura N. Nguyen
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Linden Head
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kelsey Witiuk
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Nahid Punjani
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Sonya Cnossen
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Ilias Cagiannos
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Luke T. Lavallée
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Christopher Morash
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Rodney H. Breau
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Tatsugami K, Yoshioka K, Shiroki R, Eto M, Yoshino Y, Tozawa K, Fukasawa S, Fujisawa M, Takenaka A, Nasu Y, Kashiwagi A, Gotoh M, Terachi T. Reality of nerve sparing and surgical margins in surgeons’ early experience with robot-assisted radical prostatectomy in Japan. Int J Urol 2017; 24:191-196. [DOI: 10.1111/iju.13281] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 11/24/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Katsunori Tatsugami
- Department of Urology; Graduate School of Medical Sciences; Kyushu University; Fukuoka Japan
| | | | - Ryoichi Shiroki
- Department of Urology; Fujita Health University School of Medicine; Aichi Japan
| | - Masatoshi Eto
- Department of Urology; Graduate School of Medical Sciences; Kyushu University; Fukuoka Japan
| | - Yasushi Yoshino
- Department of Urology; Nagoya University Graduate School of Medicine; Aichi Japan
| | - Keiichi Tozawa
- Department of Nephro-Urology; Nagoya City University Graduate School of Medical Sciences; Aichi Japan
| | | | - Masato Fujisawa
- Division of Urology; Department of Surgery Related; Kobe University Graduate School of Medicine; Hyogo Japan
| | - Atsushi Takenaka
- Division of Urology; Department of Surgery; Tottori University Faculty of Medicine; Tottori Japan
| | - Yasutomo Nasu
- Department of Urology; Okayama University Graduate School of Medicine; Dentistry and Pharmaceutical Sciences; Okayama Japan
| | - Akira Kashiwagi
- Department of Urology; Teine Keijinkai Medical Center; Hokkaido Japan
| | - Momokazu Gotoh
- Department of Urology; Nagoya University Graduate School of Medicine; Aichi Japan
| | - Toshiro Terachi
- Department of Urology; Tokai University School of Medicine; Kanagawa Japan
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Kang YJ, Abalajon MJ, Jang WS, Kwon JK, Yoon CY, Lee JY, Cho KS, Ham WS, Choi YD. Association of Anterior and Lateral Extraprostatic Extensions with Base-Positive Resection Margins in Prostate Cancer. PLoS One 2016; 11:e0158922. [PMID: 27391650 PMCID: PMC4938503 DOI: 10.1371/journal.pone.0158922] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 06/23/2016] [Indexed: 12/01/2022] Open
Abstract
Introduction Positive surgical margins (PSM) detected in the radical prostatectomy specimen increase the risk of biochemical recurrence (BCR). Still, with formidable number of patients never experiencing BCR in their life, the reason for this inconsistency has been attributed to the artifacts and to the spontaneous regression of micrometastatic site. To investigate the origin of margin positive cancers, we have looked into the influence of extraprostatic extension location on the resection margin positive site and its implications on BCR risk. Materials & Methods The clinical information and follow-up data of 612 patients who had extraprostatic extension and positive surgical margin at the time of robot assisted radical prostatectomy (RARP) in the single center between 2005 and 2014 were modeled using Fine and Gray’s competing risk regression analysis for BCR. Extraprostatic extensions were divided into categories according to location as apex, base, anterior, posterior, lateral, and posterolateral. Extraprostatic extensions were defined as presence of tumor beyond the borders of the gland in the posterior and posterolateral regions. Tumor admixed with periprostatic fat was additionally considered as having extraprostatic extension if capsule was vague in the anterior, apex, and base regions. Positive surgical margins were defined as the presence of tumor cells at the inked margin on the inspection under microscopy. Association of these classifications with the site of PSM was evaluated by Cohen’s Kappa analysis for concordance and logistic regression for the odds of apical and base PSMs. Results Median follow-up duration was 36.5 months (interquartile range[IQR] 20.1–36.5). Apex involvement was found in 158 (25.8%) patients and base in 110 (18.0%) patients. PSMs generally were found to be associated with increased risk of BCR regardless of location, with BCR risk highest for base PSM (HR 1.94, 95% CI 1.40–2.68, p<0.001) after adjusting for age, initial prostate-specific antigen, pathologic Gleason score, and pathologic T stage in the multivariate model. Logistic regression for PSM site revealed no significant correlation of apex PSM with extraprostatic extension location, while base PSM was associated with increased odds of anterior (OR 2.513, 95% CI 1.425–4.430, p = 0.001) and lateral (OR 2.715, 95% CI 1.735–4.250, p<0.001) extraprostatic extension. Conclusion Extension into the extraprostatic tissue on some specific locations do not share the same recur risk due to the different anatomical structures surrounding the organ. Anterior and lateral EPEs are prone to leave PSM on the base of the prostate, probably because of the lack of anatomical barricades slowing down the direct invasion process. More study on the pattern of spread of the tumors found to have extraprostatic extension is suggested for optimal planning of the operation extent and of the adjuvant radiotherapy.
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Affiliation(s)
- Yong Jin Kang
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Mark Joseph Abalajon
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Won Sik Jang
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Kyou Kwon
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Cheol Yong Yoon
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joo Yong Lee
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kang Su Cho
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Won Sik Ham
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Deuk Choi
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
- * E-mail:
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9
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Vasdev N, Agarwal S, Rai BP, Soosainathan A, Shaw G, Chang S, Prasad V, Mohan-S G, Adshead JM. Intraoperative Frozen Section of the Prostate Reduces the Risk of Positive Margin Whilst Ensuring Nerve Sparing in Patients with Intermediate and High-Risk Prostate Cancer Undergoing Robotic Radical Prostatectomy: First Reported UK Series. Curr Urol 2016; 9:93-103. [PMID: 27390582 DOI: 10.1159/000442860] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 11/24/2015] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Nerve sparing during robotic radical prostatectomy (RRP) considerably improves post-operative potency and urinary continence as long as it does not compromise oncological outcome. Excision of the neurovascular bundle (NVB) is often performed in patients with intermediate and high risk prostate cancer to reduce the risk of positive surgical margin raising the risk of urinary incontinence and impotence. We present the first UK series outcomes of such patients who underwent an intra-operative frozen section (IOFS) analysis of the prostate during RRP allowing nerve sparing. PATIENTS AND METHODS We prospectively analysed the data of 40 patients who underwent an IOFS during RRP at our centre from November 2012 until November 2014. Our IOFS technique involved whole lateral circumferential analysis of the prostate during RRP with the corresponding neurovascular tissue. An intrafascial nerve spare was performed and the specimen was removed intra-operatively via an extension of the 12 mm Autosuture™ camera port without undocking robotic arms. It was then painted by the surgeon and sprayed with "Ink Aid" prior to frozen section analysis. The corresponding NVB was excised if the histopathologist found a positive surgical margin on frozen section. RESULTS Median time to extract the specimen, wound closure and re-establishment of pneumoperitoneum increased the operative time by 8 min. Median blood loss for IOFS was 130 ± 97 ml vs. 90 ± 72 ml (p = NS). IOFS was not associated with major complications or with blood transfusion. PSM decreased significantly from non-IOFS RRP series of 28.7 to 7.8% (p < 0.05). Intra-operative PSM on the prostate specimen was seen in 8/40 margin analysis (20%) leading to an excision of the contra-lateral nerve bundle. On analysis of the nerve bundle on a paraffin embedded block, 6 nerve bundle matched tumor on the specimen whereas 2 NVB were retrospectively removed unnecessarily in our series. All 40 patients have undetectable PSA at a mean follow up of 21.2 months (SD 7.79). Functional data at 18 months confirms a reduction in the urinary incontinence from 37% in the IOFS group vs 57% in the non-IOFS group (p = NS). IOFS technique has resulted in a significant increase in intravesical nerve sparing in both T2/T3 patients with intermediate and high risk prostate cancer when appropriately counselled and selected (T2 from 100% in the IOFS group versus 67% and T3 from 100% in the IOFS group to 42%) (p < 0.05). CONCLUSION Introduction of the IOFS analysis during intrafascial nerve spare RRP has reduced PSM and the rate of urinary incontinence.
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Affiliation(s)
- Nikhil Vasdev
- Hertfordshire and South Bedfordshire Robotic Urological Cancer Centre, Department of Urology, Lister Hospital, Stevenage, UK; School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Samita Agarwal
- Department of Histopathology, Lister Hospital, Stevenage, UK
| | - Bhavan P Rai
- Hertfordshire and South Bedfordshire Robotic Urological Cancer Centre, Department of Urology, Lister Hospital, Stevenage, UK
| | - Arany Soosainathan
- Hertfordshire and South Bedfordshire Robotic Urological Cancer Centre, Department of Urology, Lister Hospital, Stevenage, UK
| | - Gregory Shaw
- Hertfordshire and South Bedfordshire Robotic Urological Cancer Centre, Department of Urology, Lister Hospital, Stevenage, UK
| | | | - Venkat Prasad
- Department of Anaesthetics, Lister Hospital, Stevenage, UK
| | - Gowrie Mohan-S
- Department of Anaesthetics, Lister Hospital, Stevenage, UK
| | - James M Adshead
- Hertfordshire and South Bedfordshire Robotic Urological Cancer Centre, Department of Urology, Lister Hospital, Stevenage, UK
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Lavallée LT, Stokl A, Cnossen S, Mallick R, Morash C, Cagiannos I, Breau RH. The effect of wide resection during radical prostatectomy on surgical margins. Can Urol Assoc J 2016; 10:14-7. [PMID: 26977200 DOI: 10.5489/cuaj.3326] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION The impact of nerve-sparing on positive surgical margins during radical prostatectomy (RP) remains unclear. The objective of this study was to determine the incidence of positive surgical margins with a wide resection compared to a nerve-sparing technique. METHODS A consecutive, single-surgeon patient cohort treated between August 2010 and November 2014 was reviewed. A standardized surgical approach of lobe-specific nerve-spare or wide resection was performed. Lobe-specific margin status and tumour stage were obtained from pathology reports. Univariable and multivariable associations between nerve management technique and lobe-specific positive surgical margin were determined. RESULTS Of 388 prostate lobes, wide resection was performed in 105 (27%) and nerve-sparing in 283 (73%). In 273 lobes without extra-prostatic extension (EPE), 0 of 52 (0%) had a positive margin when wide resection was performed compared to 20 of 221 (9%) if nerve-sparing was performed (p=0.02). In 115 lobes with EPE, 11 of 53 (21%) had a positive margin if wide resection was performed compared to 28 of 62 (45%) if nerve-sparing was performed (p=0.006). In multivariable analysis, the risk of a positive margin was decreased among patients who received wide resection as compared to nerve-spare (RR 0.43, 95% CI 0.26-0.71; p=0.001). CONCLUSIONS Surgical techniques to reduce positive surgical margins have become increasingly important as more patients with high-risk cancer are selecting surgery. The risk of a positive margin was greatly reduced using a standardized wide resection technique compared to nerve-sparing.
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Affiliation(s)
- Luke T Lavallée
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada;; University of Ottawa, ON, Canada;; Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Andrew Stokl
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sonya Cnossen
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Chris Morash
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada;; University of Ottawa, ON, Canada
| | - Ilias Cagiannos
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada;; University of Ottawa, ON, Canada
| | - Rodney H Breau
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada;; University of Ottawa, ON, Canada;; Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Gómez Caamaño A, Zapatero A, López Torrecilla J, Maldonado X. Management of prostate cancer patients following radiation therapy after radical surgery referred from urology to radiation oncology departments in Spain. Clin Transl Oncol 2015; 18:884-92. [PMID: 26621508 DOI: 10.1007/s12094-015-1454-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/12/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE To define usual clinical management of prostate cancer (PCa) patients following postoperative radiation therapy (RT) (adjuvant or salvage) and its evolution over time in radiation oncology (RO) departments in Spain. METHODS An epidemiological, cross-sectional, multicentre study was conducted. 567 PCa patients that had undergone radical prostatectomy (RP) and received postoperative RT between February and December of both 2006 and 2011 participated in the study. In patients from 2006, health-related quality of life (HRQoL) was assessed using the EPIC questionnaire. Investigators completed a specific survey on two clinical cases of adjuvant and salvage RT. RESULTS 70.6 % of patients received salvage RT versus 29.4 % who received adjuvant RT; no significant differences were found in terms of frequency for each procedure between both the years. Regarding the survey, a positive surgical margin was the main criteria used in adjuvant RT decision making. In terms of salvage RT scenario, 85.7 % of the investigators stated that adjuvant RT should have been offered instead, 81.4 % of the investigators agreed on a PSA score >0.2 ng/mL as the main criteria for identifying biochemical recurrence after RP, and 67.4 % of investigators did not consider any PSA score for ruling out salvage RT treatment. CONCLUSIONS Most patients are referred to RO departments to receive salvage RT. Despite the publication of three IA evidence level randomized clinical trials, the patterns for using adjuvant and salvage RT did not change from 2006 to 2011, although patients' profile did. A consensus regarding postoperative RT indications should be reached in order to correct this controversial situation.
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Affiliation(s)
- A Gómez Caamaño
- Servicio de Oncología Radioterápica Hospital Universitario de Santiago de Compostela, Tr. Choupana s/n, Compostela, Spain.
| | - A Zapatero
- H. Universitario de La Princesa de Madrid, Madrid, Spain
| | | | - X Maldonado
- H. Universitari Vall d'Hebron de Barcelona, Barcelona, Spain
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Salomon L, Rozet F, Soulié M. La chirurgie du cancer de la prostate : principes techniques et complications péri-opératoires. Prog Urol 2015; 25:966-98. [DOI: 10.1016/j.purol.2015.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 08/06/2015] [Indexed: 11/25/2022]
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13
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[Positive surgical margin status after minimally invasive radical prostatectomy: a multicenter study]. Urologia 2015; 82:229-37. [PMID: 26429390 DOI: 10.5301/uro.5000125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2015] [Indexed: 11/20/2022]
Abstract
UNLABELLED UNLABELLED: The aim of our study is to evaluate the status of positive margins (PSMs) comparing their incidence between aparoscopic radical prostatectomy (LRP) and robot assisted radical prostatectomy (RARP) in centers with medium case-load (50-150 cases/year). We also analyzed the correlations between surgical technique, nerve-sparing approach (NS), and incidence of PSMs, stratifying our results by pathological stage. MATERIALS AND METHODS We analyzed 1992 patients who underwent RP in various urologic centers. We evaluated the incidence of PSMs, and then we compared the stage-related incidence of PSMs, for both the techniques. RESULTS We did not find a statistically significant difference between the two surgical modalities in the study regarding the overall incidence of PSMs. CONCLUSIONS In our retrospective study, we did not find any difference in terms of PSMs in RARP versus LRP. Our PSMs were not negligible, particularly in pT3 stages, compared with high-volume centers; surgical experience and patients' selection can be a possible explanation.
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[MODIFICATIONS FOR CONTROLLING THE DORSAL VEIN COMPLEX IN ROBOTIC-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY]. Nihon Hinyokika Gakkai Zasshi 2015; 106:7-11. [PMID: 26399124 DOI: 10.5980/jpnjurol.106.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To investigate a superior method for controlling the dorsal vein complex (DVC) in robotic-assisted laparoscopic radical prostatectomy at Nagakubo hospital. PATIENTS AND METHODS DVC control was altered from suture ligation followed by DVC division (SL group, n = 115) to preceding division followed by suture (PD group, n = 62). Surgical margin status and functional outcomes were investigated. RESULTS No notable surgical complications were found in the PD group. Operation time and estimated blood loss were significantly less in the PD group; however, changes to serum hemoglobin before and after surgery showed no significant difference. The rates of positive surgical margin were 26.1% and 11.3% in the SL and PD groups, respectively (p = 0.021). Apical margin positivity was 9.6% and 3.2% in the SL and PD groups, respectively (p = 0.12). Urinary continence outcomes of within one pad/day and pad free in the SL and PD groups until 6 mo after surgery were 93.6% and 89.1% (P = 0.21), and 67.3% and 67.5% (p = 0.96), respectively. Erection recovery within 6 mo was 43.6% and 41.7% in the SL and PD groups (p = 0.91). CONCLUSION Preceding division followed by suture method decreased apical margin positivity and provided superior cancer control in comparison with suture ligation followed by DVC division, although, it was probably influenced by the learning curve. Functional outcomes were not significantly different with either method.
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Preston MA, Breau RH, Lantz AG, Morash C, Gerridzen RG, Doucette S, Mallick R, Eastham JA, Cagiannos I. The association between nerve sparing and a positive surgical margin during radical prostatectomy. Urol Oncol 2014; 33:18.e1-18.e6. [PMID: 25308562 DOI: 10.1016/j.urolonc.2014.09.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 09/05/2014] [Accepted: 09/07/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE A positive surgical margin (SM) during radical prostatectomy (RP) increases risk of biochemical recurrence. We evaluated the effect of nerve-sparing procedures on risk of positive SM for pT2- and pT3-category tumors. We hypothesized that nerve sparing would increase rates of pT2 positive margins. METHODS We evaluated a historical cohort of 9,915 consecutive RP patients treated at The Ottawa Hospital or Memorial Sloan-Kettering Cancer Center from 2000 to 2010. Patients underwent open, laparoscopic, or robotic RP. The primary outcome was presence of a positive SM stratified by pathologic pT2 and pT3 categories. The association between nerve sparing and positive margin was adjusted for prostate-specific antigen, RP Gleason sum, surgical modality, surgical date, and location in the multivariable model. RESULTS Of 6,120 eligible patients, 3,958 (64.7%) had open RP, 1,566 (25.6%) had laparoscopic RP, and 596 (9.7%) had robotic RP. Approximately 8.6% (363/4,199) of patients with pT2-category disease and 25.2% (485/1,921) of patients with pT3-category disease had a positive margin. Patients with pT2-category disease who underwent a bilateral nerve-sparing procedure were more likely to have a positive margin when compared with those who underwent nerve resection on multivariable analysis (relative risk [RR] = 1.52, 95% CI: 0.97-2.39) after adjusting for confounders. Patients with pT3-category disease who underwent a bilateral nerve-sparing procedure had no associated increase in risk of positive margin after adjustment for other variables (RR = 0.96, 95% CI: 0.80-1.16). Prostate incision into tumor (pT2R1) was significantly more likely in patients treated with robotic surgery (RR = 1.76, 95% CI: 1.25-2.48) than in those with open surgery. There was no difference between laparoscopic and open RP (RR = 0.86, 95% CI: 0.65-1.12). CONCLUSIONS Bilateral nerve sparing is associated with increased risk of positive SMs in patients with pathologic T2-category disease during RP.
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Affiliation(s)
- Mark A Preston
- Department of Urology, Brigham and Women's Hospital, Boston, MA
| | - Rodney H Breau
- Department of Surgery, The Ottawa Hospital, General Campus, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Andrea G Lantz
- Department of Urology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Christopher Morash
- Department of Surgery, The Ottawa Hospital, General Campus, University of Ottawa, Ottawa, Ontario, Canada
| | - Ronald G Gerridzen
- Department of Surgery, The Ottawa Hospital, General Campus, University of Ottawa, Ottawa, Ontario, Canada
| | - Steve Doucette
- Research Methods Unit, Capital Health Authority, Halifax, Nova Scotia, Canada
| | | | - James A Eastham
- Department of Urology, Urology Service, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Ilias Cagiannos
- Department of Surgery, The Ottawa Hospital, General Campus, University of Ottawa, Ottawa, Ontario, Canada.
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Evaluating the Impact of PSA as a Selection Criteria for Nerve Sparing Radical Prostatectomy in a Screened Cohort. Prostate Cancer 2014; 2014:395078. [PMID: 24829803 PMCID: PMC4009223 DOI: 10.1155/2014/395078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 03/18/2014] [Accepted: 03/19/2014] [Indexed: 11/17/2022] Open
Abstract
Purpose. We investigated whether NS-RP increased risk of PSA failure and whether PSA should be included as a selection criterion for NS. Methods. We evaluated 357 consecutive men with screen-detected PC who underwent open RP without adjuvant radiotherapy between 9/11/2001 and 12/30/2008. Criteria for NS included Gleason score ≤3 + 4, percentage of positive biopsies (PPB) ≤50%, percentage of core involvement ≤50%, nonapical location, no perineural invasion, and no palpable disease on pre- or intraoperative exam but did not include a PSA threshold. Cox multivariable regression assessed whether increasing PSA or unilateral- or bilateral-NS versus non-NS-RP was associated with PSA failure adjusting for prognostic factors. Results. After a median follow-up of 3.96 years, 34 men sustained PSA failure (9.5%). Increasing PSA was significantly associated with increased risk of PSA failure in the interaction model (adjusted hazard ratio (AHR): 1.09 [95% CI: 1.03-1.16]; P = 0.005), whereas unilateral (AHR: 1.24 [95% CI: 0.36-4.34]; P = 0.73) or bilateral NS (AHR: 0.41 [95% CI: 0.06-2.59]; P = 0.34) versus non-NS RP was not. Conclusion. NS-RP in a screened cohort did not increase risk of PSA failure using NS criteria not including PSA.
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[Comparison of initial results with robotic-assisted laparoscopic radical prostatectomy and open retropubic radical prostatectomy]. Nihon Hinyokika Gakkai Zasshi 2013; 104:635-43. [PMID: 24187850 DOI: 10.5980/jpnjurol.104.635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To investigate the superiority in 2 radical prostatectomies, we compared the initial results of robotic-assisted radical prostatectomy (RARP) to those of retropubic radical prostatectomy (RRP) performed during the same period at Nagakubo hospital. PATIENTS AND METHODS The study was conducted on a total of 160 patients having undergone radical prostatectomy from April 2009 to March 2012 (92 patients with RARP and 68 with RRP). We investigated surgical stress, cancer control, functional outcomes and complications in both groups. RESULTS Surgical stress; operation time was significantly shorter with RRP; however, blood loss and serum total protein loss were significantly less with RARP. White blood cell count at 2 days after surgery was significantly less with RARP. The rates of analgesic use and SIRS were similar. Although the date on which taking solid meals resumed did not differ, the duration of indwelling urethral catheter and admission period were significantly shorter with RARP. Cancer control; the rates of positive surgical margin were 27.2% and 19.1% with RARP and RRP, respectively (p = 0.24), and biochemical recurrence was seen in 12.0% and 19.1% with RARP and RRP, respectively (p = 0.73), which were not significantly different. Continence; urinary continence outcomes with RARP and RRP were 17% and 4% for urinary continence at discharge (p = 0.01), 1.8 and 3.3 months for no more than one pad per day (p < 0.01), and 4.3 and 6.2 months for pad free (p = 0.03), respectively. Sexual function; erection recovery within 6 mo was only observed with RARP; however, overall recovery rate of erection was 65% and 75% with RARP and RRP, respectively (p = 0.69). COMPLICATIONS 1 case with a rectal injury was seen in both groups, but complication rates were 8.7% and 16.2% with RARP and RRP, respectively (p = 0.22). CONCLUSION In spite of our initial experience of RARP, surgical stress and complications with RARP were considered to be superior to that with RRP. Cancer control and sexual function showed no significant difference between RARP and RRP, however, urinary continence outcome is significantly superior with RARP. Our data suggest that treatment outcome after initial experience with RARP is not inferior to that with RRP, and better results are expected by improving surgical techniques.
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Presence of positive surgical margin in patients with organ-confined prostate cancer equals to extracapsular extension negative surgical margin. A plea for TNM staging system reclassification. Urol Oncol 2013; 31:1497-503. [DOI: 10.1016/j.urolonc.2012.04.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Revised: 04/14/2012] [Accepted: 04/16/2012] [Indexed: 11/21/2022]
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Røder MA, Thomsen FB, Berg KD, Christensen IBJ, Brasso K, Vainer B, Iversen P. Risk of biochemical recurrence and positive surgical margins in patients with pT2 prostate cancer undergoing radical prostatectomy. J Surg Oncol 2013; 109:132-8. [PMID: 24155174 DOI: 10.1002/jso.23469] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 09/27/2013] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVE To investigate risk factors associated with positive surgical margins (PSM) and biochemical recurrence (BR) in organ confined tumors (pT2) after radical prostatectomy (RP) for localized prostate cancer (PCa). METHODS Between 1995 and 2011, 1,649 patients underwent RP at our institution. The study includes the 1,133 consecutive patients with pT2 tumors at final histopathology. Logistic regression analysis was used for risk of PSM. Risk of BR, defined as the first PSA ≥ 0.2 ng/ml, was analyzed with Kaplan-Meier and Cox regression analysis. RESULTS Median follow-up was 3.6 years (range: 0.5-15.5 years). In logistic regression, NS surgery was independently associated with an increased risk of pT2 PSM (OR = 1.68, 95% CI: 1.3-2.0, P = 0.01) relative to non-NS surgery. NS surgery was not independently associated with BR but the interaction of PSM and NS surgery trended (P = 0.08) to increase the risk of BR compared to PSM and non-NS surgery. CONCLUSION Several factors influence the risk of pT2 PSMs in radical prostatectomy. In our cohort pT2 PSM is associated with NS surgery and trend to increase risk of BR compared to non-NS surgery. The optimal selection of candidates for NS surgery is still not clear.
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Affiliation(s)
- Martin Andreas Røder
- Copenhagen Prostate Cancer Center, University of Copenhagen, Copenhagen, Denmark; Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Stember DS, Nelson CJ, Mulhall JP. Preoperative Erectile Function Is an Independent Predictor for Decision to Spare Cavernous Nerves During Radical Prostatectomy. J Sex Med 2013; 10:2101-7. [DOI: 10.1111/jsm.12195] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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21
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Gacci M, Simonato A, Lanciotti M, Ennas M, Varca V, Maffezzini M, Imbimbo C, Gontero P, Schiavina R, Carini M, Martorana G, Nicita G, Mirone V, Carmignani G. The impact of prior TURP on radical prostatectomy surgical margins: a multicenter analysis. Urol Int 2013; 91:62-8. [PMID: 23735440 DOI: 10.1159/000346748] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 12/20/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To analyze positive surgical margins (PSM) after radical prostatectomy (RP) in the overall population and in patients previously treated with transurethral resection of the prostate (TURP). MATERIALS AND METHODS 2,408 patients treated with RP for clinically localized prostate cancer (PCa) were consecutively enrolled in 135 departments. We correlated PSM rates and all preoperative, surgical and pathological features. We stratified the site of PSM as unique or multifocal. Moreover, we analyzed differences between 75 patients who had undergone previous TURP and the remaining 2,333 patients. RESULTS In the entire study population, we identified 702 patients with PSM (29%). Using univariate analysis, we reported a significant correlation between overall PSM and prostate-specific antigen (PSA), stage cT, biopsy Gleason score, number of biopsy cores, number of positive cores, percentage of positive cores and nerve-sparing approach. PSM proved to be strongly dependent on pT in particular in patients with pT2 PCa. When we compared the data from 75 patients previously treated with TURP and those from 2,333 without previous prostatic surgery, a statistically significant difference in margin localization was found. Moreover, we analyzed the 75 patients mentioned above, stratified in incidental PCa diagnosed at TURP or PCa detected with prostate biopsy for PSA rising during the post-TURP follow-up: no statistical differences were found between the 2 groups regarding margin status, even if PSM were more frequent in incidental PCa with no significance deriving from the stratification for PSM location at the apex or base. CONCLUSION Men treated with TURP before RP presented an overall incidence of PSM similar to those without previous TURP, but with a higher risk of PSM at the bladder neck and a lower risk of PSM at the prostatic apex.
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Affiliation(s)
- Mauro Gacci
- Department of Urology, University of Florence, Italy.
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Thiel DD, Hutchinson R, Diehl N, Tavlarides A, Williams A, Parker AS. Impact of fellowship training on one-year outcomes of robotic-assisted prostatectomy. JSLS 2013; 16:195-201. [PMID: 23477165 PMCID: PMC3481249 DOI: 10.4293/108680812x13291597717220] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES We examined 1-year functional and oncologic outcomes for robotic-assisted laparoscopic prostatectomy (RALP) from a single surgeon entering practice directly from fellowship training. METHODS We prospectively analyzed the first 100 RALPs performed by one fellowship-trained robotic surgeon. Data included resident involvement during the procedure, perioperative data, and surgical complications (scored using the Clavien grading system). Health-related quality of life (HRQOL) data were captured using the EPIC questionnaire at baseline (prior to surgery) and at 1-year follow-up. RESULTS Eighty-two patients (82%) had hospital stays of 2 days or less without any postoperative complications, urethral catheter removal was within 14 days of surgery, and none required readmission to the hospital. The overall positive margin rate was 21% (19% for patients with T2 disease). Clavien grades 1 through 4 complication rates, respectively, were 4%, 10%, 1%, and 1%. There were no deaths, reoperations, or bladder neck contractures. One patient (1%) required a blood transfusion within the 90-day perioperative period. At 1-year follow-up, 78% of patients reported wearing no pads; 41.3% of patients with baseline and 1-year follow-up data reported having intercourse. CONCLUSIONS We provide baseline data pertaining to the morbidity, oncologic efficacy, continence results, and potency outcomes of new surgeons performing RALP.
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Affiliation(s)
- David D Thiel
- Department of Urology, Mayo Clinic, Jacksonville, Florida 32224, USA
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Røder MA, Thomsen FB, Christensen IJ, Toft BG, Brasso K, Vainer B, Iversen P. Risk factors associated with positive surgical margins following radical prostatectomy for clinically localized prostate cancer: Can nerve-sparing surgery increase the risk? Scand J Urol 2012. [DOI: 10.3109/00365599.2012.749425] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Sooriakumaran P, Wiklund P. Reply from Authors re: Anders Bjartell “A Robot Saved My Life”: Is It a Myth? Eur Urol 2012;62:775–6. Eur Urol 2012. [DOI: 10.1016/j.eururo.2012.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Alkhateeb SS, Alibhai SM, Finelli A, Fleshner NE, Jewett MA, Zlotta AR, Trachtenberg J. Does nerve-sparing radical prostatectomy increase the risk of positive surgical margins and biochemical progression? Urol Ann 2011; 2:58-62. [PMID: 20882155 PMCID: PMC2943681 DOI: 10.4103/0974-7796.65107] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2010] [Accepted: 05/31/2010] [Indexed: 11/05/2022] Open
Abstract
Background: Since the introduction of nerve-sparing radical prostatectomy (NSRP), there have been concerns about the increased risks of positive surgical margins (PSM) and biochemical progression (BP). We examined the relationship of NSRP with PSM and BP using a large, mature dataset. Materials and Methods: Patients who underwent RP for clinically localized prostate cancer at our center between 1997 and 2008 were identified. Patients who received neoadjuvant therapy were excluded. We examined the relation of NSRP to the rate of PSM and BP in univariate and multivariate analyses adjusting for clinical and pathological variables including age, pretreatment prostate-specific antigen (PSA) levels and doubling time, and pathological stage and grade. Results: In total, 856 patients were included, 70.9% underwent NSRP and 29.1% had non-NSRP. PSM rates were 13.5% in the NSRP group compared to 17.7% in non-NSRP (P=0.11). In a multivariate analysis, non-NSRP was preformed in patients with a higher pathological stage (HR 1.95, 95% CI 1.25–3.04, P=0.003) and a higher baseline PSA level (HR 1.04, 95% CI 1.01–1.08, P=0.005). With a median follow-up of 41 months, BP-free survival was 88% for non-NSRP compared to 92% for the NSRP group (log rank P=0.018); this difference was not significant in a multivariate Cox regression analysis (HR 0.54, 95% CI 0.28–1.06, P=0.09). Conclusion: When used in properly selected patients, NSRP does not seem to increase the risk of PSM and disease progression. The most effective way of resolving this issue is through a randomized clinical trial; however, such a trial is not feasible.
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Affiliation(s)
- Sultan Saud Alkhateeb
- Division of Urology, Department of Surgical Oncology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, Canada
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Chin JL, Srigley J, Mayhew LA, Rumble RB, Crossley C, Hunter A, Fleshner N, Bora B, McLeod R, McNair S, Langer B, Evans A. Guideline for optimization of surgical and pathological quality performance for radical prostatectomy in prostate cancer management: evidentiary base. Can Urol Assoc J 2011; 4:13-25. [PMID: 20165572 DOI: 10.5489/cuaj.08105] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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."
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Affiliation(s)
- Joseph L Chin
- Regional Head of Surgical Oncology, London Health Sciences Centre, London, ON
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Moore BM, Savdie R, PeBenito RA, Haynes AM, Matthews J, Delprado W, Rasiah KK, Stricker PD. The impact of nerve sparing on incidence and location of positive surgical margins in radical prostatectomy. BJU Int 2011; 109:533-8. [DOI: 10.1111/j.1464-410x.2011.10361.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Patel VR, Coelho RF, Rocco B, Orvieto M, Sivaraman A, Palmer KJ, Kameh D, Santoro L, Coughlin GD, Liss M, Jeong W, Malcolm J, Stern JM, Sharma S, Zorn KC, Shikanov S, Shalhav AL, Zagaja GP, Ahlering TE, Rha KH, Albala DM, Fabrizio MD, Lee DI, Chauhan S. Positive surgical margins after robotic assisted radical prostatectomy: a multi-institutional study. J Urol 2011; 186:511-6. [PMID: 21680001 DOI: 10.1016/j.juro.2011.03.112] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Indexed: 11/26/2022]
Abstract
PURPOSE Positive surgical margins are an independent predictive factor for biochemical recurrence after radical prostatectomy. We analyzed the incidence of and associative factors for positive surgical margins in a multi-institutional series of 8,418 robotic assisted radical prostatectomies. MATERIALS AND METHODS We analyzed the records of 8,418 patients who underwent robotic assisted radical prostatectomy at 7 institutions. Of the patients 323 had missing data on margin status. Positive surgical margins were categorized into 4 groups, including apex, bladder neck, posterolateral and multifocal. The records of 6,169 patients were available for multivariate analysis. The variables entered into the logistic regression models were age, body mass index, preoperative prostate specific antigen, biopsy Gleason score, prostate weight and pathological stage. A second model was built to identify predictive factors for positive surgical margins in the subset of patients with organ confined disease (pT2). RESULTS The overall positive surgical margin rate was 15.7% (1,272 of 8,095 patients). The positive surgical margin rate for pT2 and pT3 disease was 9.45% and 37.2%, respectively. On multivariate analysis pathological stage (pT2 vs pT3 OR 4.588, p<0.001) and preoperative prostate specific antigen (4 or less vs greater than 10 ng/ml OR 2.918, p<0.001) were the most important independent predictive factors for positive surgical margins after robotic assisted radical prostatectomy. Increasing prostate weight was associated with a lower risk of positive surgical margins after robotic assisted radical prostatectomy (OR 0.984, p<0.001) and a higher body mass index was associated with a higher risk of positive surgical margins (OR 1.032, p<0.001). For organ confined disease preoperative prostate specific antigen was the most important factor that independently correlated with positive surgical margins (4 or less vs greater than 10 ng/ml OR 3.8, p<0.001). CONCLUSIONS The prostatic apex followed by a posterolateral site was the most common location of positive surgical margins after robotic assisted radical prostatectomy. Factors that correlated with cancer aggressiveness, such as pathological stage and preoperative prostate specific antigen, were the most important factors independently associated with an increased risk of positive surgical margins after robotic assisted radical prostatectomy.
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Affiliation(s)
- Vipul R Patel
- Global Robotics Institute, Florida Hospital-Celebration Health, University of Central Florida College of Medicine, Orlando, Florida, USA.
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Oh JJ, Hong SK, Byun SS, Choe G, Lee SE. Prognostic significance of positive surgical margins after radical prostatectomy among pT2 and pT3a prostate cancer. Urol Oncol 2011; 31:595-600. [PMID: 21658977 DOI: 10.1016/j.urolonc.2011.05.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2011] [Revised: 04/27/2011] [Accepted: 05/01/2011] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the prognostic significance of positive surgical margins (PSM)s among patients who underwent radical prostatectomy (RP) for pT2 and pT3a prostate cancer. PATIENTS AND METHODS We reviewed the records of 658 patients who were revealed to have pT2 and pT3a prostate cancer after undergoing RP without neoadjuvant or adjuvant treatment. For our analysis, patients were subgrouped as the following: group 1: 406 (61.7%) with negative surgical margins (NSM)s and no extracapsular extension of tumor (ECE); group 2: 99 (15.0%) with PSMs and no ECE; group 3: 63 (9.6%) with NSMs and ECE; and group 4: 90 (13.7%) with PSMs and ECE. The effects of various variables on biochemical recurrence (BCR)-free survival were assessed via uni- and multivariate analyses. RESULTS During median follow-up of 36 months, group 1 had significantly higher BCR-free survival compared with the other 3 groups (P < 0.001). However, no significant differences in BCR-free survivals were observed among the group 2, 3, and 4 (all P > 0.05). In multivariate analysis, PSM (P = 0.009) was observed to be significantly associated with BCR-free survival among groups 1 and 2 combined. Among groups 3 and 4, pathologic Gleason score (P = 0.002), but not PSM (P = 0.668), was the only significant predictor for BCR-free survival in multivariate analysis. CONCLUSIONS According to our results, PSM is significantly associated with biochemical outcome after RP in pT2 prostate cancer. Meanwhile, patients with pT2 tumor and PSM appear to have comparable biochemical outcome compared with those with stage pT3a tumor independent of their marginal status.
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Affiliation(s)
- Jong Jin Oh
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
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Fu Q, Moul JW, Sun L. Contemporary radical prostatectomy. Prostate Cancer 2011; 2011:645030. [PMID: 22110994 PMCID: PMC3200259 DOI: 10.1155/2011/645030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Accepted: 02/17/2011] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Qiang Fu
- Division of Urology, Department of Surgery, Duke Prostate Center, Duke University Medical Center, P.O. Box 3707, Durham, NC 27710, USA
| | - Judd W. Moul
- Division of Urology, Department of Surgery, Duke Prostate Center, Duke University Medical Center, P.O. Box 3707, Durham, NC 27710, USA
| | - Leon Sun
- Division of Urology, Department of Surgery, Duke Prostate Center, Duke University Medical Center, P.O. Box 3707, Durham, NC 27710, USA
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Tewari AK, Shevchuk MM, Sterling J, Grover S, Herman M, Yadav R, Mudalair K, Srivastava A, Rubin MA, Zipfel WR, Maxfield FR, Xu C, Webb WW, Mukherjee S. Multiphoton microscopy for structure identification in human prostate and periprostatic tissue: implications in prostate cancer surgery. BJU Int 2011; 108:1421-9. [PMID: 21443651 DOI: 10.1111/j.1464-410x.2011.10169.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE • To test whether multiphoton microscopy (MPM) might allow identification of prostatic and periprostatic structures with magnification and resolution similar to gold standard histopathology. MATERIAL AND METHODS • The present study included 95 robotic radical prostatectomy patients who consented to participate in an Institutional Review Board-approved study starting in 2007. • The types of specimens used for imaging were excised surgical margins and biopsies, and sections obtained from the excised prostate. • The specimens were imaged with a custom-built MPM system. • All images were compared with haematoxylin/eosin histopathology of the same specimen. RESULTS • MPM of freshly excised, unprocessed and unstained tissue can identify all relevant prostatic and periprostatic structures, such as nerves, blood vessels, capsule, underlying acini and also pathological changes, including prostate cancer. • Histological confirmation and correlation of these structures and pathologies have validated the findings of MPM. CONCLUSIONS • MPM shows great promise as a tool for real-time intra-surgical histopathology without needing excision or administration of contrast agents. • The results will, however, need to be confirmed in true surgical settings using a miniaturized MPM microendoscope.
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Affiliation(s)
- Ashutosh K Tewari
- Lefrak Center of Robotic Surgery and Prostate Cancer Institute, James Buchanan Brady Foundation, Weill Cornell Medical College, New York, USA.
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Soloway MS. Re: Williams et al.: Radical retropubic prostatectomy and robotic-assisted laparoscopic prostatectomy: likelihood of positive surgical margin(s) (Urology 2010;76:1097-1101). Urology 2011; 77:263-4. [PMID: 21195861 DOI: 10.1016/j.urology.2010.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2009] [Revised: 12/31/2009] [Accepted: 01/05/2010] [Indexed: 11/18/2022]
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Brimo F, Partin AW, Epstein JI. Tumor Grade at Margins of Resection in Radical Prostatectomy Specimens Is an Independent Predictor of Prognosis. Urology 2010; 76:1206-9. [DOI: 10.1016/j.urology.2010.03.090] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 02/25/2010] [Accepted: 03/04/2010] [Indexed: 11/29/2022]
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Reply. Urology 2010. [DOI: 10.1016/j.urology.2010.04.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Leroy TJ, Thiel DD, Duchene DA, Parker AS, Igel TC, Wehle MJ, Goetzl M, Thrasher JB. Safety and Peri-Operative Outcomes During Learning Curve of Robot-Assisted Laparoscopic Prostatectomy: A Multi-Institutional Study of Fellowship-Trained Robotic Surgeons Versus Experienced Open Radical Prostatectomy Surgeons Incorporating Robot-Assisted Laparoscopic Prostatectomy. J Endourol 2010; 24:1665-9. [PMID: 20849279 DOI: 10.1089/end.2009.0657] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Timothy J. Leroy
- Department of Urology, Mayo Clinic Florida, Jacksonville, Florida
| | - David D. Thiel
- Department of Urology, Mayo Clinic Florida, Jacksonville, Florida
| | - David A. Duchene
- Department of Urology, University of Kansas Medical Center, Kansas City, Kansas
| | - Alex S. Parker
- Department of Urology, Mayo Clinic Florida, Jacksonville, Florida
| | - Todd C. Igel
- Department of Urology, Mayo Clinic Florida, Jacksonville, Florida
| | - Michael J. Wehle
- Department of Urology, Mayo Clinic Florida, Jacksonville, Florida
| | - Manilo Goetzl
- Department of Urology, University of Kansas Medical Center, Kansas City, Kansas
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Gettman MT, Blute ML. Radical prostatectomy: does surgical technique influence margin control? Urol Oncol 2010; 28:219-25. [PMID: 20219563 DOI: 10.1016/j.urolonc.2009.07.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Fleshner NE, Evans A, Chadwick K, Lawrentschuk N, Zlotta A. Clinical significance of the positive surgical margin based upon location, grade, and stage. Urol Oncol 2010; 28:197-204. [DOI: 10.1016/j.urolonc.2009.08.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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39
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Tewari AK, Patel ND, Leung RA, Yadav R, Vaughan ED, El-Douaihy Y, Tu JJ, Amin MB, Akhtar M, Burns M, Kreaden U, Rubin MA, Takenaka A, Shevchuk MM. Visual cues as a surrogate for tactile feedback during robotic-assisted laparoscopic prostatectomy: posterolateral margin rates in 1340 consecutive patients. BJU Int 2010; 106:528-36. [PMID: 20192955 DOI: 10.1111/j.1464-410x.2009.09176.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To analyse consecutive cases of robotic-assisted laparoscopic prostatectomy (RALP), present the incidence of nerve-sparing-related positive surgical margins (SM+), include visual cues that might assist in smoothly changing to the robotic platform, and discuss the scientific rationale for 'intersensory integration' which might explain the 'reverse Braille' phenomenon, i.e. the ability to feel when vision is greatly enhanced, as the lack of tactile feedback during RALP is often cited as a disadvantage of robotic surgery, interfering with a surgeon's ability to make intraoperative oncological decisions. PATIENTS AND METHODS Data from 1340 consecutive patients undergoing RALP from one institution were analysed and trends for positive posterolateral SM+ (PLSM+) were correlated with oncological variables before and after RALP. A sample of patient slides were reviewed by a extramural pathologist. Multivariate regression modelling was used to compare the projected rates of PLSM+ vs the actual rate, given the effect of a conscious effort to use visual cues. Finally, video recordings of the procedure were systematically reviewed and correlated with anatomical and histopathological images in an integrated session involving the surgeon and the pathology team. RESULTS The incidence of PLSM+ was 2.1%, which gradually declined to 1.0% in the last 100 patients. The reduction in PLSM+ occurred despite an increased rate of high-risk tumours operated on during this period. Forecasting analysis showed that the actual PLSM+ rate declined by half in the most recent 1000 patients, due to an integrated effort involving the use of visual cues during surgery. The following visual cues were considered important; appreciation of periprostatic (lateral prostatic) fascial compartments; colour and texture of the tissue; periprostatic veins as a landmark for athermal dissection; signs of inflammation; and a freely separating bloodless plane showing loose shiny areolar tissue. CONCLUSION Adapting to the robotic platform is easy and there is no compromise of the oncological safety of this procedure. Experienced surgeons can use visual cues to assist during nerve-sparing RALP and achieve low PLSM+ rates.
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Affiliation(s)
- Ashutosh K Tewari
- Lefrak Center of Robotic Surgery and Institute of Prostate Cancer, James Buchanan Brady Foundation Department of Urology,Weill Medical Collage, Cornell University, 525 East 68th Street, Starr 900, New York, NY 10065, USA.
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Coelho RF, Chauhan S, Orvieto MA, Palmer KJ, Rocco B, Patel VR. Predictive factors for positive surgical margins and their locations after robot-assisted laparoscopic radical prostatectomy. Eur Urol 2010; 57:1022-9. [PMID: 20163911 DOI: 10.1016/j.eururo.2010.01.040] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Accepted: 01/26/2010] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Rafael F Coelho
- Global Robotics Institute, Florida Hospital Celebration Health, Celebration, FL, USA
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Is the transition from open to robotic prostatectomy fair to your patients? A single-surgeon comparison with 2-year follow-up. J Robot Surg 2009; 3:201-7. [DOI: 10.1007/s11701-009-0162-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Accepted: 10/18/2009] [Indexed: 11/26/2022]
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Labanaris AP, Zugor V, Takriti S, Smiszek R, Engelhard K, Nützel R, Kühn R. The role of conventional and functional endorectal magnetic resonance imaging in the decision of whether to preserve or resect the neurovascular bundles during radical retropubic prostatectomy. ACTA ACUST UNITED AC 2009; 43:25-31. [DOI: 10.1080/00365590802326610] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
| | - Vahudin Zugor
- Department of Urology, Salzgitter Medical Center, Salzgitter, Germany
| | | | | | - Karl Engelhard
- Radiology, Martha Maria Medical Center, Nürnberg, Germany
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Impact of capsular incision on biochemical recurrence after radical perineal prostatectomy. Prostate Cancer Prostatic Dis 2009; 13:28-33. [PMID: 19488066 PMCID: PMC2834323 DOI: 10.1038/pcan.2009.19] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The prognostic implications of capsular incision (CI) remain to be defined. We evaluated the impact of CI on biochemical recurrence (BCR) and the potential risk factors of CI. Between June 1995 and July 2007, 266 patients with follow-up for at least 6 months, who had neither the seminal vesicle nor lymph node involvement on prostatectomy specimen, were included. Patients with insufficient biopsy data and those with neoadjuvant and/or adjuvant therapy were excluded. CI was defined as tumor extending into the inked margins, at sites except the apex of the prostate, without documented extraprostatic extension (EPE). There were 186 with organ-confined disease and negative surgical margins (pT2/SM–), 12 with organ-confined disease and an apex-only positive margin (pT2/AM+), 35 with CI, 19 with EPE and negative surgical margins (pT3a/SM–) and 13 with EPE and positive surgical margins (pT3a/SM+). We compared BCR-free probability among these five groups and the risk factors for CI were assessed. The 3-year BCR-free probability for each group was 92.7% for pT2/SM–, 75.8% for pT2/AM+, 70.7% with CI, 84% with pT3/SM– and 51% in pT3/SM+. That for CI was worse than pT2/SM– (P=0.007), not significantly different from pT2/AM+ and pT3/SM– (P=0.614, P=0.318, respectively), but better than pT3/SM+ (P=0.044), adjusting for the pre-operative prostate-specific antigen and pathological Gleason score. The risk for CI was significantly associated with more than 25% positive biopsy cores. CI seems to affect BCR and is more likely to occur in proportion to positive biopsy cores.
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Bong GW, Ritenour CW, Osunkoya AO, Smith MT, Keane TE. Evaluation of modern pathological criteria for positive margins in radical prostatectomy specimens and their use for predicting biochemical recurrence. BJU Int 2009; 103:327-31. [DOI: 10.1111/j.1464-410x.2008.08075.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Impact of nerve sparing on surgical margins and biochemical recurrence: results from the SEARCH database. Prostate Cancer Prostatic Dis 2008; 12:172-6. [PMID: 18626507 DOI: 10.1038/pcan.2008.40] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The effects of nerve sparing on the risk of positive surgical margins (PSMs) and biochemical recurrence after radical prostatectomy (RP) remain controversial. We examined data from 1018 men treated by RP between 1988 and 2006 at five centers in the Shared Equal Access Regional Cancer Hospital database. Neither bilateral nor unilateral nerve-sparing techniques were associated with a higher risk of PSM; on multivariate analysis of individual sides, the risk of PSM on either side was not increased by nerve sparing on either side. The risk for biochemical recurrence was not affected by bilateral or unilateral nerve sparing. When used on appropriately selected patients, nerve sparing does not increase the probability of PSM or biochemical recurrence after RP.
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Thiel DD, Francis P, Heckman MG, Winfield HN. Prospective Evaluation of Factors Affecting Operating Time in a Residency/Fellowship Training Program Incorporating Robot-Assisted Laparoscopic Prostatectomy. J Endourol 2008; 22:1331-8. [DOI: 10.1089/end.2008.0023] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- David D. Thiel
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Paula Francis
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Michael G. Heckman
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Howard N. Winfield
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Touijer K, Kuroiwa K, Eastham JA, Vickers A, Reuter VE, Scardino PT, Guillonneau B. Risk-Adjusted Analysis of Positive Surgical Margins Following Laparoscopic and Retropubic Radical Prostatectomy. Eur Urol 2007; 52:1090-6. [PMID: 17188801 DOI: 10.1016/j.eururo.2006.12.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2006] [Accepted: 12/06/2006] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To prospectively compare in a contemporary and contemporaneous series the positive surgical margin (PSM) rate between laparoscopic (LRP) and retropubic (RRP) radical prostatectomy at the same institution. METHODS Between 1 January 2003 and 30 June 2005, 1177 consecutive men with clinically localized adenocarcinoma of the prostate underwent radical prostatectomy at the same institution: 485 laparoscopically and 692 through a retropubic approach. Partin table probability of organ-confined (OC) disease was used as an index of disease aggressiveness: The PSM rate between the two approaches was compared, with adjustment for the OC probability. RESULTS Overall both surgical approaches had a comparable PSM rate of 11.3% after LRP and 11% after RRP. In a logistic regression analysis adjusting for OC probability, there was no statistically significant difference between LRP and RRP (odds ratio [OR]: 1.156; 95% confidence interval [%95 CI], 0.792, 1.686; p=0.5). There was a statistically significant decrease over time in the rate of PSM for LRP (OR: 0.71 per 100 patients treated; %95 CI, 0.57, 0.89; p=0.003), while that of RRP was unchanged (OR: 1.06 per 100 patients treated; %95 CI, 0.94, 1.21; p=0.3; p=0.002 for interaction between change over time and procedure). CONCLUSIONS In our institution, laparoscopic and retropubic radical prostatectomy provide comparable PSM rates for patients with clinically localized prostate cancer. The PSM rate over the study period remained unchanged in the RRP experience, indicating a mature and well-established operative technique, while that of LRP underwent a significant decrease, demonstrating that the procedure and therefore the results continued to evolve during the study.
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Affiliation(s)
- Karim Touijer
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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Bastide C, Soulié M, Davin JL, Rossi D. Marges après prostatectomie totale : aspects techniques et valeur pronostique. Prog Urol 2007; 17:182-8. [PMID: 17489315 DOI: 10.1016/s1166-7087(07)92260-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The status of surgical margins after radical prostatectomy is a major prognostic factor. The role of several technical aspects of radical prostatectomy, such have surgical access, bladder neck preservation or neurovascular bundle sparing, in generating supplementary positive margins has been controversial for many years. Positive margins along with other poor prognostic factors are important elements in the decision to perform adjuvant therapy after radical prostatectomy. This review of the literature, based on a Medline search, was designed to update these various issues encountered by urologists in their everyday practice.
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Secin FP, Serio A, Bianco FJ, Karanikolas NT, Kuroiwa K, Vickers A, Touijer K, Guillonneau B. Preoperative and Intraoperative Risk Factors for Side-Specific Positive Surgical Margins in Laparoscopic Radical Prostatectomy for Prostate Cancer. Eur Urol 2007; 51:764-71. [PMID: 17098356 DOI: 10.1016/j.eururo.2006.10.058] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2006] [Accepted: 10/23/2006] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Identification of variables predicting positive surgical margins (PSMs) in patients undergoing laparoscopic radical prostatectomy (LRP) for clinically localized prostate cancer is lacking. Our objective was to determine preoperative risk factors and the association of ipsilateral degree of neurovascular bundle dissection (intraoperative factor) with side-specific PSMs in these patients. MATERIAL AND METHODS Between October 2002 and April 2005, one surgeon performed LRP on 407 previously untreated patients. Of 814 evaluable prostate sides, 728 harboured prostate cancer in the specimen and composed the study population. For each prostate side, we obtained clinical stage, biopsy Gleason, maximum percentage of tumour in the biopsy, suspected extracapsular extension (ECE) on endorectal coil magnetic resonance imaging (MRI), degree of neurovascular bundle (NVB) dissection, and PSMs. PSM was defined as cancer cells at the inked margins. Logistic regression analyses with random effects were generated. RESULTS Of the 728 prostate sides with cancer, 51 (7%) had at least one PSM. In multivariable analysis, higher PSA (p=0.01), Gleason score of 7 compared with < or =6 in the biopsy (p=0.04), lower prostate volume on MRI (p=0.01), and interfascial NVB dissection compared with intrafascial dissection (p=0.01) were associated with an increased risk of side-specific PSMs. Suspected ECE on MRI (p=0.9) and clinical stage (p=0.3) were not significantly associated with side-specific PSMs. A subset analysis of 321 patients with bilateral tumours did not show statistically significant differences in PSMs according to tumour side (p=0.3). CONCLUSIONS High serum prostate-specific antigen, biopsy Gleason score of 7, low prostate volume, and interfascial NVB dissection were independently associated with side-specific PSMs after LRP, and should be considered during planning of the LRP surgical strategy.
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Affiliation(s)
- Fernando P Secin
- Department of Urology, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, United States
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Kaji Y, Kuroda K, Maeda T, Kitamura Y, Fujiwara T, Matsuoka Y, Tamura M, Takei N, Matsuda T, Sugimura K. Anatomical and metabolic assessment of prostate using a 3-Tesla MR scanner with a custom-made external transceive coil: Healthy volunteer study. J Magn Reson Imaging 2007; 25:517-26. [PMID: 17279524 DOI: 10.1002/jmri.20829] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
PURPOSE To examine the possibility of using a 3 Tesla (T) magnetic resonance (MR) scanner with a custom-made external coil to obtain ductal details of the prostate, high-quality spectra, and metabolite mapping corresponding to prostate zonal anatomy in healthy volunteers. MATERIALS AND METHODS MRI and two-dimensional (2D) chemical shift imaging (CSI) were performed in 16 healthy volunteers using a 3T scanner with a custom-made external transmit-receive (transceive) coil. Visualization of the prostatic duct-like structure was analyzed on T2-weighted (T2W) images. The resolution of the metabolite peaks and the distribution of metabolites in CSI were also assessed. RESULTS In the axial plane, 3-mm-thick images were better than 4-mm-thick images with the same voxel volume for assessing duct-like structures and prostatic urethra. Differentiation between inner and outer citrate (Cit) peaks was frequently observed (29 out of 30). The mean peak area ratio of choline (Cho) plus creatine (Cr) over Cit in the peripheral zone (PZ) was significantly lower than in the transition zone (TZ) (P = 0.014). CONCLUSION 3T MR examinations of the prostate using an external coil allow information to be collected about the details of duct-like structures, the high-quality spectra of Cit, and the zone-specific distribution of metabolites.
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Affiliation(s)
- Yasushi Kaji
- Department of Radiology, Kobe University, Graduate School of Medicine, Kobe, Japan.
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