Location of extraprostatic extension and positive surgical margin in radical prostatectomy specimens

BACKGROUND: Extraprostatic extension and positive surgical margin increase a risk of treatment failure after radical prostatectomy in patients with localized prostate cancer. We analyzed the location of extraprostatic extension and positive surgical margin in radical prostatectomy specimens. MATERIALS AND METHODS: In 104 radical prostatectomy cases the location of the extraprostatic extension (EPE) and/or positive surgical margin (PSM) were studied using step-sectioned specimens. RESULTS: In 54 cases EPE and/or PSM were recognized. In 34 of 38 cases (89.5%) with EPE, the EPE was identified at lateral, posterolateral and/or posterior portions in base and/or middle of the prostate. Particularly, in 31 cases (81.6%) the EPE was found posterolaterally. Only in 5 of these 34 cases (14.7%) PSM resulted from the EPE. When 35 cases with PSM were evaluated, the PSM occurred apically in 22 (62.9%) and anteriorly in 11 (31.4%). Only in 4 cases (14.3%) PSM was caused by EPE of apical and/or anterior portions. CONCLUSIONS: The majority of EPE were observed at the posterolateral portion of the prostatic base and/or middle. However, PSM were frequently identified apically and/or anteriorly. These findings suggest that modifications of surgical technique of apical dissection might reduce the frequency of PSM.     

Surgical margin status of open versus laparoscopic radical prostatectomy specimens

Objectives:   To compare the surgical margin (SM) status between open and laparoscopic radical prostatectomy (RRP and LRP, respectively) specimens.
Methods:   Surgical specimens from 137 patients undergoing LRP and 220 patients undergoing RRP for clinically localized prostate cancer were included in the analysis. SM status in each resected specimen, including the number of positive SM as well as their location, was examined.
Results:   The incidence of positive SM in the LRP group was significantly greater than that in the RRP group. Despite the lack of significant difference in the proportion of solitary positive SM between these two groups, the proportion of multiple positive SM in the LRP group was significantly greater than that in the RRP group. There was no significant difference in the incidence of anterior positive SM between the two groups, while the incidences of positive SM at the apex, posterior site and bladder neck in the LRP group were significantly greater than those in the RRP group. Furthermore, there were no significant preoperative parameters predicting positive SM in the LRP group. On the other hand, the biopsy Gleason score and clinical T stage were identified as significant predictors of positive SM in the RRP group, of which the biopsy Gleason score was independently related to the presence of positive SM.
Conclusions:   Clinical T stage and Gleason score could be useful predictors of SM status following RRP, while positive SM in LRP specimens were detected irrespective of preoperative parameters, suggesting the need for an effort for further refining the LRP procedure.     

Interobserver variability between expert urologic pathologists for extraprostatic extension and surgical margin status in radical prostatectomy specimens

Accurate Gleason score, pathologic stage, and surgical margin (SM) information is critical for the planning of post-radical prostatectomy management in patients with prostate cancer. Although interobserver variability for Gleason score among urologic pathologists has been well documented, such data for pathologic stage and SM assessment are limited. We report the first study to address interobserver variability in a group of expert pathologists concerning extraprostatic soft tissue (EPE) and SM interpretation for radical prostatectomy specimens. A panel of 3 urologic pathologists selected 6 groups of 10 slides designated as being positive, negative, or equivocal for either EPE or SM based on unanimous agreement. Twelve expert urologic pathologists, who were blinded to the panel diagnoses, reviewed 40x whole-slide scans and provided diagnoses for EPE and SM on each slide. On the basis of panel diagnoses, as the gold standard, specificity, sensitivity, and accuracy values were high for both EPE (87.5%, 95.0%, and 91.2%) and SM (97.5%, 83.3%, and 90.4%). Overall kappa values for all 60 slides were 0.74 for SM and 0.63 for EPE. The kappa values were higher for slides with definitive gold standard EPE (kappa=0.81) and SM (kappa=0.73) diagnoses when compared with the EPE (kappa=0.29) and SM (kappa=0.62) equivocal slides. This difference was markedly pronounced for EPE. Urologic pathologists show good to excellent agreement when evaluating EPE and SM. Interobserver variability for EPE and SM interpretation was principally related to the lack of a clearly definable prostatic capsule and crush/thermal artifact along the edge of the gland, respectively.     

Biochemical failure in men following radical retropubic prostatectomy: impact of surgical margin status and location

PURPOSE: The significance of isolated positive apical surgical margins in radical retropubic prostatectomy (RRP) specimens remains controversial. We examine the effects of margin status and location on biochemical recurrence rates in patients undergoing RRP. MATERIALS AND METHODS: Of 800 patients with RRP we identified 498 without pathological evidence of lymph node, seminal vesicle or adjacent organ involvement and with at least 6 months of followup. Patients were subdivided into apex only positive (AM+), nonapical isolated positive (OM+), multiple positive (MM+) and negative (SM-) surgical margins. The rate and interval to biochemical disease recurrence were determined in each group. Univariate and multivariate analysis as well as Kaplan-Meier curves were used to test differences among these groups. RESULTS: Of the 498 men who met our inclusion criteria 400 were SM-, 28 were AM+, 57 were OM+ and 13 were MM+ at a median followup of 49, 59, 64 and 83 months, respectively. Biochemical recurrence rates for SM-, AM+, OM+ and MM+ were 9.3%, 21.4%, 26.3% and 30.8%, respectively. Median time to biochemical failure in the SM-, AM+, OM+ and MM+ groups was 34, 19.5, 46.0 and 6.8 months, respectively. Biochemical recurrence was not statistically different among the AM+, OM+ and MM+ groups. On univariate analysis AM+, OM+ and MM+ were significant predictors of recurrence (p < 0.05, < 0.005, and <0.05, respectively). On multivariate models only pretreatment prostate specific antigen and OM+ were independent predictors of biochemical recurrence. CONCLUSIONS: A positive surgical margin conveys increased risk for biochemical recurrence. Patients with AM+ experienced biochemical recurrence more frequently and rapidly than those with SM-. AM+ conveys a similar risk of recurrence compared with OM+ and MM+. Apical margin status did not independently predict biochemical recurrence.     

Closest distance between tumor and resection margin in radical prostatectomy specimens: lack of prognostic significance

Complete removal of the tumor by surgery offers the best chance for cancer cure; however, many prostate cancer patients who have negative surgical margins at radical prostatectomy will still experience local and distant tumor recurrence. In other organs, the closest distance between tumor and resection margin has prognostic significance. This has not been adequately studied in prostatectomy specimens. We undertook a prospective study of 278 consecutive margin-negative whole-mount prostatectomy cases. The anatomic location and closest distance between tumor and resection margin, measured with an ocular micrometer, were analyzed. All the slides were reviewed by a single pathologist, and data were collected prospectively. The closest distance between tumor and resection margin ranged from 0.02 to 5.0 mm (mean, 0.7 mm; median, 0.5 mm) and correlated with patient age (P = 0.03), prostate weight (P = 0.002), Gleason score (P = 0.001), pathologic stage (P = 0.01), tumor volume (P < 0.001), and perineural invasion (P < 0.001). The closest distance between tumor and resection margin was not a significant predictor of PSA recurrence in univariate or multivariate logistic regression; and we do not, therefore, advocate reporting the closest distance between tumor and resection margin as a standard part of the surgical pathology report on prostatectomy specimens.     

Computerized tomography and transrectal ultrasound in the assessment of local extension of prostatic cancer before radical retropubic prostatectomy

The value of computerized tomography and transrectal ultrasound in the demonstration of local extension of prostatic cancer was evaluated in 38 patients undergoing radical retropubic prostatectomy. Transrectal ultrasound proved to be reliable for the demonstration of local extension of cancer beyond the prostatic capsule (sensitivity 86 per cent, specificity 94 per cent and accuracy 90 per cent). Invasion of the seminal vesicles was demonstrated by ultrasound, with a sensitivity of 29 per cent, specificity 100 per cent and accuracy 77 per cent. The addition of transrectal ultrasound scanning to clinical evaluation increased sensitivity in relation to detection of extraprostatic involvement from 15 to 92 per cent. When computerized tomography scanning was added to clinical examination, the sensitivity increased from 15 to only 46 per cent. Transrectal ultrasound is valuable for the preoperative evaluation of patients in whom radical prostatectomy is being considered as treatment for clinically localized prostatic cancer.     

Outcomes assessment in men undergoing open retropubic radical prostatectomy, laparoscopic radical prostatectomy, and robotic-assisted radical prostatectomy

Objectives  

To review the various methods of outcomes assessment used for effectiveness studies comparing retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP), and robotic-assisted laparoscopic prostatectomy (RALP).     

Nerve-sparing radical prostatectomy: extraprostatic tumor extension and preservation of erectile function

A total of 52 patients underwent a nerve-sparing radical retropubic prostatectomy for clinical stage A or B prostatic cancer. The incidence of positive surgical margins (18 per cent of the patients with stages A and B1, and 57 per cent with stage B2 disease) was not significantly different (p less than 0.5) from that of 25 patients who underwent a standard radical retropubic prostatectomy by the same surgeon (18 per cent with stages A and B1, and 50 per cent with stage B2 cancer). Of 42 patients who were sexually potent preoperatively 41 (98 per cent) have had partial return of erectile function and 22 (52 per cent) have had return of erections sufficient for vaginal penetration. No correlation between clinical or pathological stage and postoperative potency was observed. Erections sufficient for penetration returned in 67 per cent of the patients less than 60 and 43 per cent of those more than 60 years old. The results suggest that with the nerve-sparing modification of radical retropubic prostatectomy sexual function can be preserved in the majority of patients with clinical stage A or B prostatic cancer without compromising the adequacy of tumor excision.     

Early catheter removal and postoperative status of bladder outflow after retropubic radical prostatectomy

Cystography was performed on 35 patients 6 to 7 days after retropubic radical prostatectomy (RRP), to determine the feasibility of early removal of the urinary catheter. The urethral catheter was removed the same day if no extravasation was evident on cystography. Uroflowmetry was also performed both immediately after early catheter removal and at follow-up 4 to 20 months later. The urethral catheter could be removed on postoperative day 6 or 7 from all but one patient. Three patients developed acute urinary retention after catheter removal, requiring reinsertion of a Foly catheter. During a mean follow-up of 8.3 months (range 4 to 20 months), 25 patients (71.4%) reported excellent continence (requiring no pad) and seven patients (20%) good continence (requiring a single pad). Immediately after early catheter removal, 12 patients (34%) showed obstruction on a maximum flow nomogram. The number of patients with obstruction decreased to eight during follow-up, three of whom suffered anastomotic stricture and one anterior urethral stricture, all of which required urethrotomy. Our results show that early catheter removal can be accomplished safely, although some patients may have difficulty with urination or develop acute urinary retention immediately after catheter removal, probably due to anastomotic edema. On the other hand, if the patients develop difficulty in urination some time after the operation, the possibility of anastomotic or urethral stricture should be considered. Therefore we recommend uroflowmetry within one year after RRP to identify anastomotic or urethral stricture.     

Head-to-head comparison of retropubic, perineal and laparoscopic radical prostatectomy

OBJECTIVE: As more patients are diagnosed with prostate cancer at an early stage, it is becoming increasingly important to refine the technique of surgical excision. For this purpose we have generated objective data comparing three different surgical approaches used by three experienced surgeons. METHODS: We prospectively compared three contemporary personal series of 50 consecutive radical prostatectomy (RP) patients. The health-related quality of life was evaluated preoperatively and in months 1, 3, 6, 12 and 24. RESULTS: Considering in turn the patients undergoing retropubic, perineal and laparoscopic RP, the median procedure time was 2 h and 27 min, 1 h and 50 min and 4 h, with a transfusion rate of 2, 0 and 8%, respectively. In the perineal group there were more wound infections. Median catheter drainage was 7, 10 and 7 days and zero, 13 and one patients needed reinsertion of a catheter. Early continence varied considerably, with 57.4, 11.4 and 6.3% of patients pad-free after 1 month, but there were no differences in social continence (zero or one pad) with 97.8, 97.8 and 91.9% after 2 years. The Litwin score for incontinence (preoperative minus postoperative) was -24, -41 and -63% after 1 month and -13, +3 and -29% after 2 years. Twenty-nine, five and 15 patients had a preoperative five-item version of International Index of Erectile Function (IIEF-5) score of > or = 17 points and a nerve-sparing procedure. After 2 years, 48.1, 0 and 0% had an IIEF-5 score of > or = 17 points without the use of phosphodiesterase type 5 (PDE-5) inhibitors, but when including patients using inhibitors there were no significant differences. CONCLUSIONS: A comparison of morbidity, short-term convalescence and long-term side-effects of different surgical techniques is strongly biased by both the preoperative status of patients and the skill of the surgeons. Overall, we found some differences in the short-term results (e.g. early continence) and comparable long-term results.     

Robotic-assisted laparoscopic and radical retropubic prostatectomy generate similar positive margin rates in low and intermediate risk patients

ObjectiveRobotic-assisted laparoscopic prostatectomy (RALP) is being increasingly utilized. To assess the efficacy of the operation, we compared apical and overall margin status for RALP with radical retropubic prostatectomy (RRP) in a group of contemporary patients.Patients and methodsWe retrospectively reviewed 98 consecutive RRPs and then 94 RALPs from a single institution. Groups were analyzed and matched with regard to preoperative prostate-specific antigen (PSA), cancer grade, pathologic stage, and tumor volume. Surgical margins were quantitated.ResultsClinicopathologic parameters were compared and additional high risk patients were observed in the RRP vs. RALP group. To risk-adjust these patient groups, those meeting preoperative high risk criteria were excluded from further positive margin analysis. Postoperatively, the average tumor volume was 13% in both groups. Pathologic stage pT3 was similar between RRP (14%) and RALP (11%). A positive surgical margin (PSM) was found in 12 cases (14%) after RRP and 11 cases (13%) after RALP including apical margins. Positive margins at the apex, non-apex, and both were statistically similar between groups.ConclusionsIn this study, no differences were seen between robotic prostatectomy with regard to apical or overall margin status compared with open prostatectomy in lower risk patients. This suggests that despite improved visualization, RALP generates a similar margin status as RRP.     

Development and internal validation of a nomogram predicting extracapsular extension in radical prostatectomy specimens

Objectives: To present a nomogram predicting the side‐specific probability of extracapsular extension (ECE) in radical prostatectomy (RP) specimens. Methods: Three hundred and fifty‐four patients with T1c‐T3a prostate cancer undergoing RP were included in the analysis. A receiver operating characteristic (ROC) analysis was carried out to evaluate the predictive values of each clinical and pathological factor, separately and in combination. Based on logistic regression analysis, a nomogram predicting the side‐specific probability of ECE was developed. Results: Overall, 146 (40%) of 354 patients and 165 (23%) of 708 lobes had ECE pathologically. The areas under the ROC curve (AUC) of the standard features, such as serum PSA, clinical stage and biopsy Gleason sum on each side, in predicting side‐specific probability of ECE were 0.624, 0.627, and 0.747, respectively. When these three features were combined, AUC increased to 0.773 which was not significantly different from 0.791 of maximum percent of cancer alone (P = 0.613) and significantly enhanced by including maximum percent of cancer on each side, 0.799 (P = 0.022). The resulting nomogram was internally validated and had excellent calibration. Conclusions: The accuracy in predicting ECE is increased by combining standard clinical factors (clinical stage, serum PSA, highest Gleason score) and biopsy features, such as maximum percent of cancer in the cores. The developed nomogram is helpful when deciding whether or not neurovascular bundles can be preserved.