Incidence and location of positive surgical margin among open, laparoscopic and robot-assisted radical prostatectomy in prostate cancer patients: a single institutional analysis
Atsushi KoizumiShintaro NaritaTaketoshi NaraK. TakayamaSohei KandaKazuyuki NumakuraHiroshi TsurutaAtsushi MaenoMingguo HuangMitsuru SaitoTakamitsu InoueNorihiko TsuchiyaShigeru SatohHiroshi NanjoTomonori Habuchi
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To evaluate the positive surgical margin rates and locations in radical prostatectomy among three surgical approaches, including open radical prostatectomy, laparoscopic radical prostatectomy and robot-assisted radical prostatectomy. We retrospectively reviewed clinical outcomes at our institution of 450 patients who received radical prostatectomy. Multiple surgeons were involved in the three approaches, and a single pathologist conducted the histopathological diagnoses. Positive surgical margin rates and locations among the three approaches were statistically assessed, and the risk factors of positive surgical margin were analyzed. This study included 127, 136 and 187 patients in the open radical prostatectomy, laparoscopic radical prostatectomy and robot-assisted radical prostatectomy groups, respectively. The positive surgical margin rates were 27.6% (open radical prostatectomy), 18.4% (laparoscopic radical prostatectomy) and 13.4% (robot-assisted radical prostatectomy). In propensity score-matched analyses, the positive surgical margin rate in the robot-assisted radical prostatectomy was significantly lower than that in the open radical prostatectomy, whereas there was no significant difference in the positive surgical margin rates between robot-assisted radical prostatectomy and laparoscopic radical prostatectomy. In the multivariable analysis, PSA level at diagnosis and surgical approach (open radical prostatectomy vs robot-assisted radical prostatectomy) were independent risk factors for positive surgical margin. The apex was the most common location of positive surgical margin in the open radical prostatectomy and laparoscopic radical prostatectomy groups, whereas the bladder neck was the most common location in the robot-assisted radical prostatectomy group. The significant difference of positive surgical margin locations continued after the propensity score adjustment. Robot-assisted radical prostatectomy may potentially achieve the lowest positive surgical margin rate among three surgical approaches. The bladder neck was the most common location of positive surgical margin in robot-assisted radical prostatectomy and apex in open radical prostatectomy and laparoscopic radical prostatectomy. Although robot-assisted radical prostatectomy may contribute to the reduction of positive surgical margin, dissection of the bladder neck requires careful attention to avoid positive surgical margins.Keywords:
Surgical margin
Laparoscopic radical prostatectomy
Margin (machine learning)
Objectives To compare the surgical outcomes of laparoscopic radical prostatectomy and robot‐assisted radical prostatectomy, including the frequency and location of positive surgical margins. Methods The study cohort comprised 708 consecutive male patients with clinically localized prostate cancer who underwent laparoscopic radical prostatectomy ( n = 551) or robot‐assisted radical prostatectomy ( n = 157) between J anuary 1999 and S eptember 2012. Operative time, estimated blood loss, complications, and positive surgical margins frequency were compared between laparoscopic radical prostatectomy and robot‐assisted radical prostatectomy. Results There were no significant differences in age or body mass index between the laparoscopic radical prostatectomy and robot‐assisted radical prostatectomy patients. Prostate‐specific antigen levels, G leason sum and clinical stage of the robot‐assisted radical prostatectomy patients were significantly higher than those of the laparoscopic radical prostatectomy patients. Robot‐assisted radical prostatectomy patients suffered significantly less bleeding ( P < 0.05). The overall frequency of positive surgical margins was 30.6% ( n = 167; 225 sites) in the laparoscopic radical prostatectomy group and 27.5% ( n = 42; 58 sites) in the robot‐assisted radical prostatectomy group. In the laparoscopic radical prostatectomy group, positive surgical margins were detected in the apex (52.0%), anterior (5.3%), posterior (5.3%) and lateral regions (22.7%) of the prostate, as well as in the bladder neck (14.7%). In the robot‐assisted radical prostatectomy patients, they were observed in the apex, anterior, posterior, and lateral regions of the prostate in 43.0%, 6.9%, 25.9% and 15.5% of patients, respectively, as well as in the bladder neck in 8.6% of patients. Conclusions Positive surgical margin distributions after robot‐assisted radical prostatectomy and laparoscopic radical prostatectomy are significantly different. The only disadvantage of robot‐assisted radical prostatectomy is the lack of tactile feedback. Thus, the robotic surgeon needs to take this into account to minimize the risk of positive surgical margins.
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Surgical excision of the whole prostate through a radical prostatectomy procedure is part of the standard of care for prostate cancer. Positive surgical margins (cancer cells having spread into surrounding nonresected tissue) occur in as many as 1 in 5 cases and strongly correlate with disease recurrence and the requirement of adjuvant treatment. Margin assessment is currently only performed by pathologists hours to days following surgery and the integration of a real-time surgical readout would benefit current prostatectomy procedures. Raman spectroscopy is a promising technology to assess surgical margins: its in vivo use during radical prostatectomy could help insure the extent of resected prostate and cancerous tissue is maximized. We thus present the design and development of a dual excitation Raman spectroscopy system (680- and 785-nm excitations) integrated to the robotic da Vinci surgical platform for in vivo use. Following validation in phantoms, spectroscopic data from 20 whole human prostates immediately following radical prostatectomy are obtained using the system. With this dataset, we are able to distinguish prostate from extra prostatic tissue with an accuracy, sensitivity, and specificity of 91%, 90.5%, and 96%, respectively. Finally, the integrated Raman spectroscopy system is used to collect preliminary spectroscopic data at the surgical margin in vivo in four patients.
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Salvage radical prostatectomy (SRP) has been one of the common procedures for the patients with a failure after primary treatment. We present a case of SRP with rare surgical history. To our knowledge, this is the first report of salvage surgery for residual prostate gland including prostate cancer after unsuccessful radical prostatectomy. We indicated new possibility for salvage radical prostatectomy.
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You have accessJournal of UrologyProstate Cancer: Localized IV1 Apr 2014MP46-04 GLEASON SCORE AT THE SURGICAL MARGIN AND THE RISK OF BIOCHEMICAL RECURRENCE AFTER RADICAL PROSTATECTOMY Viacheslav Iremashvili, Lizet Pelaez, Merce Jorda, Ramgopal Satyanarayana, and Mark Soloway Viacheslav IremashviliViacheslav Iremashvili More articles by this author , Lizet PelaezLizet Pelaez More articles by this author , Merce JordaMerce Jorda More articles by this author , Ramgopal SatyanarayanaRamgopal Satyanarayana More articles by this author , and Mark SolowayMark Soloway More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1437AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives Several pathological parameters are well-known to be associated with the risk of prostate cancer progression after radical prostatectomy. These include Gleason score (GS), which reflects the biological aggressiveness of the cancer, and the presence of tumor at surgical margin, which is associated with the completeness of cancer excision. Gleason score at the surgical margin (GSM) theoretically can represent the aggressiveness of the cancer tissue that was left behind and therefore be associated with the risk of recurrence. However, little is known about this association. The aim of our analysis is to establish if GSM improves our ability to predict biochemical recurrence after radical prostatectomy. Methods In our radical prostatectomy database we indentified 892 men who had both low and high grade cancer (pathological GS 3 + 4/5 or 4/5 + 3). These patients were selected because in them there might be additional information provided by the GSM compared to the final GS of the prostate. The prostate was step-sectioned at 3 to 5-mm intervals in transverse planes into separate blocks that were embedded for analysis. All slides with a positive margin were reviewed and the GSM was recorded for each case. To determine if the GSM has independent predictive value with regards to the biochemical outcome we compared the predictive performance of four multivariate Cox regression models, one composed of traditional pathological and clinical variables (model 1) and others additionally including GSM recorded as Gleason sum (model 2), predominantly high- vs. low-grade cancer (model 3) and GSM being higher or lower compared to the overall GS (model 4). The predictive performance of these models was quantified using the Harrell’s c-index. Results Out of 152 prostatectomy specimens with GS 3+4/5 and positive margin, 25 (16%) had GSM ≥ 4+3, while out of 74 specimens with GS 4/5+3, 38 (51%) had a GSM≤3 + 4. Over a mean follow-up of 3.1 years, 173 (21%) of patients had biochemical recurrence (BCR). The GSM recorded in different ways was significantly associated with the risk of BCR in all multivariate models. The c-index for models 1 through 4 was 0.738, 0.750, 0.748 and 0.746 respectively. Conclusions Our findings suggest that GSM may be an independent predictor of BCR after radical prostatectomy in patients with mixed cancer. Addition of GSM to established factors resulted in a modest improvement in predictive value of the model. Taken together these findings support the idea that information about GSM may improve the accuracy of predictions of the risk of BCR after radical prostatectomy. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e511 Advertisement Copyright & Permissions© 2014Metrics Author Information Viacheslav Iremashvili More articles by this author Lizet Pelaez More articles by this author Merce Jorda More articles by this author Ramgopal Satyanarayana More articles by this author Mark Soloway More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...
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Objectives To compare the oncological outcomes of robot‐assisted laparoscopic radical prostatectomy with those of open radical prostatectomy in contemporary K orean prostate cancer patients. Methods From a group of 1172 patients consisting of 592 (50.5%) robot‐assisted laparoscopic radical prostatectomy and 580 (49.5%) open radical prostatectomy cases carried out between 1992 and 2008, 175 robot‐assisted laparoscopic radical prostatectomy cases were matched with an equal number of open radical prostatectomy cases by propensity scoring based on patient age, preoperative prostate‐specific antigen, biopsy G leason score and clinical tumor stage. Competing‐risks survival analyses were used to evaluate oncological outcomes, including rates of positive surgical margin, biochemical‐recurrence, adjuvant therapy, cancer‐specific survival, overall survival and metastasis‐free survival during the mean follow up of 58.4 months. Results Positive surgical margin rates were comparable between robot‐assisted laparoscopic radical prostatectomy and open radical prostatectomy cohorts (19.4% vs 21.8%), with comparable rates for all pathological stages and risk subgroups. Positive surgical margin rates according to location were comparable, with the apical margin being the most common location. Robot‐assisted laparoscopic radical prostatectomy recovered higher lymph node yields compared with open radical prostatectomy (12.5 vs 3.8; P < 0.001). The robot‐assisted laparoscopic radical prostatectomy and the open radical prostatectomy groups showed equal oncological outcomes regarding 5‐year biochemical recurrence‐free survival (log‐rank P = 0.651), metastasis‐free survival (log‐rank P = 0.876), cancer‐specific survival (log‐rank P = 0.076) and overall survival (log‐rank P = 0.648), respectively. Between groups, there was no difference in the rate of adjuvant therapy, time to first adjuvant therapy failure or in the rate of subsequent secondary treatment. Conclusions Robot‐assisted laparoscopic radical prostatectomy represents an effective surgical approach for the treatment of prostate cancer in the K orean population, as it provides equivalent oncological outcomes to open radical prostatectomy.
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To evaluate the positive surgical margin rates and locations in radical prostatectomy among three surgical approaches, including open radical prostatectomy, laparoscopic radical prostatectomy and robot-assisted radical prostatectomy. We retrospectively reviewed clinical outcomes at our institution of 450 patients who received radical prostatectomy. Multiple surgeons were involved in the three approaches, and a single pathologist conducted the histopathological diagnoses. Positive surgical margin rates and locations among the three approaches were statistically assessed, and the risk factors of positive surgical margin were analyzed. This study included 127, 136 and 187 patients in the open radical prostatectomy, laparoscopic radical prostatectomy and robot-assisted radical prostatectomy groups, respectively. The positive surgical margin rates were 27.6% (open radical prostatectomy), 18.4% (laparoscopic radical prostatectomy) and 13.4% (robot-assisted radical prostatectomy). In propensity score-matched analyses, the positive surgical margin rate in the robot-assisted radical prostatectomy was significantly lower than that in the open radical prostatectomy, whereas there was no significant difference in the positive surgical margin rates between robot-assisted radical prostatectomy and laparoscopic radical prostatectomy. In the multivariable analysis, PSA level at diagnosis and surgical approach (open radical prostatectomy vs robot-assisted radical prostatectomy) were independent risk factors for positive surgical margin. The apex was the most common location of positive surgical margin in the open radical prostatectomy and laparoscopic radical prostatectomy groups, whereas the bladder neck was the most common location in the robot-assisted radical prostatectomy group. The significant difference of positive surgical margin locations continued after the propensity score adjustment. Robot-assisted radical prostatectomy may potentially achieve the lowest positive surgical margin rate among three surgical approaches. The bladder neck was the most common location of positive surgical margin in robot-assisted radical prostatectomy and apex in open radical prostatectomy and laparoscopic radical prostatectomy. Although robot-assisted radical prostatectomy may contribute to the reduction of positive surgical margin, dissection of the bladder neck requires careful attention to avoid positive surgical margins.
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To investigate whether subgroups of prostate cancer patients, stratified by positive surgical margin locations, have different oncological outcomes following robot-assisted radical prostatectomy.A retrospective multicenter cohort study in prostate cancer patients undergoing robot-assisted radical prostatectomy was conducted at 10 institutions in Japan. Pre- and post-operative outcomes were collected from enrolled patients. Biochemical recurrence and clinical and pathological variables were evaluated among subgroups with different positive surgical margin locations.A total of 3195 patients enrolled in this study. Data from 2667 patients (70.1% [N = 1869] with negative surgical margins and 29.9% [N = 798] with positive surgical margins based on robot-assisted radical prostatectomy specimens) were analyzed. The median follow-up period was 25.0 months. The numbers of patients with apex-only, middle-only, bladder-neck-only, seminal-vesicle-only and multifocal positive surgical margins were 401, 175, 159, 31 and 32, respectively. In the multivariate analysis, PSA level at surgery, pathological Gleason score based on robot-assisted radical prostatectomy specimens, pathological T stage, pathological N stage and surgical margin status were independent risk factors significantly associated with biochemical recurrence-free survival. Patients undergoing robot-assisted radical prostatectomy with multifocal positive surgical margins and seminal-vesicle-only positive surgical margins were associated with worse biochemical recurrence-free survival than those with apex-only, middle-only and bladder-neck-only positive surgical margins. Patients undergoing robot-assisted radical prostatectomy with apex-only positive surgical margins, the most frequent positive surgical margin location, were associated with more favorable biochemical recurrence-free survival that those with middle-only and bladder-neck-only positive surgical margins. The study limitations included the lack of central pathological specimen evaluation.Although positive surgical margin at any locations is a biochemical recurrence risk factor after robot-assisted radical prostatectomy, positive surgical margin location status should be considered to accurately stratify the biochemical recurrence risk after robot-assisted radical prostatectomy.
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With increased incidence of prostate cancer and an increased number of patients undergoing radical prostatectomy in China, it will be necessary to elaborate the diagnosis, clinical significance and treatment of patients whose tumors have positive surgical margins following radical prostatectomy.Positive surgical margin, prostate cancer and radical prostatectomy were used as subject words and the medical literature in recent decades was searched using the PubMed database and the results are summarized.Using positive surgical margin, prostate cancer and radical prostatectomy as subject words the PubMed medical database produced 275 papers of pertinent literature. By further screening 28 papers were selected and they represent relatively large-scale clinical randomized and controlled clinical trials.A pertinent literature of 275 papers was identified and 28 papers on large clinical studies were obtained. Analysis of results indicated that the positive rate of surgical margin after radical prostatectomy is 20%-40%, and although most patients with positive surgical margins are stable for a considerable period, the data available now suggested that the presence of a positive surgical margin will have an impact on the patient's prognosis. The risk factors of positive surgical margin include preoperative prostate specific antigen level, Gleason's score and pelvic lymph node metastasis. The most common site with positive surgical margin is in apical areas of the prostate; therefore surgical technique is also a factor resulting in positive surgical margins. From data available now it appears that as long as the surgical technique is skilled, different surgical modes do not affect the rate of surgical margin. Adjuvant radiotherapy is mainly used to treat patients with positive surgical margin after radical prostatectomy, but combination with androgen deprivation therapy may increase the curative effect.The current data indicated that the presence of positive surgical margins can markedly affect the patient's prognosis. Therefore we should be aware how we reduce the positive surgical margin, how to diagnose positive surgical margin and how to treat when there are positive surgical margins.
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