Pathologic analysis of capsular and incisional denudation and positive margin status in the development of a robot-assisted laparoscopic prostatectomy program

The aim of this study is to explore the use of pathologically confirmed capsular incision and denudation as a measure of adequacy of extirpation following robot-assisted laparoscopic prostatectomy (RALP). All patients who underwent RALP at the George Washington University Medical Center during the first 2 years of inception of the robotic prostatectomy program were included. All pathologic specimens were reviewed by a single pathologist. One hundred twenty-eight men who underwent RALP during the first 2 years were identified. Sixty-four patients underwent RALP during the first year (group 1) and all pathologic specimens were reviewed retrospectively. Sixty-four patients underwent RALP during the second year (group 2) after revision of our operative technique and all pathologic specimens were reviewed prospectively. Of patients in group 1, 18 (28%) had a positive surgical margin (PSM), and 18 (28%) with negative surgical margins were found to have capsular incision or denudation. In group 1, 32 (50%) patients had evidence of iatrogenic capsular violation. Group 2 consisted of 13 (20%) patients with a PSM and 9 (14%) margin-negative patients with capsular incision or denudation. Group 2 had a total of 22 (34%) patients with evidence of iatrogenic capsular violation. Overall reduction in positive margins was not statistically significant between the groups. Improvement in capsular incision/denudation rate and overall capsular violation between the two groups was statistically significant (P < 0.03 and <0.0055). Surgical margin status alone underestimates the overall quality of surgical resection after RALP because not all capsular violations result in a PSM. Surgeon-guided pathologic review in addition to intraoperative experience may improve oncologic success during the RALP learning curve.