Apical Positive Surgical Margins Research Articles

The Impact of Retro-apical Urethral Dissection Approach Technique on Positive Surgical Margins in Robotic-assisted Laparoscopic Radical Prostatectomy: A Study in Thailand

Objective: Among the various postoperative outcomes following robotic-assisted laparoscopic radical prostatectomy (RARP), positive surgical margins (PSMs) are a significant prognostic factor associated with biochemical recurrence (BCR). Many surgical techniques are available for RARP; however, the technique proposed in this study may improve surgical outcomes. This study aims to evaluate the incidence of post-operative PSMs in patients diagnosed with clinically localized prostate cancer at Siriraj Hospital using the retro-apical urethral dissection approach with a 30-degree-lens flip-up technique. Materials and Methods: A retrospective review of 2,114 consecutive patients who underwent RARP with the conventional technique was conducted using Siriraj Hospital’s database, from January 2007 to June 2022. Propensity score matching was employed to select a group of 284 men from the total cohort of 2,114 patients who underwent conventional radical prostatectomy (Group 1) for comparison against another group of 284 patients who underwent the retro-apical dissection technique (Group 2). The incidence of PSMs was then evaluated in each group. Results: Of the 568 patients, PSMs were observed in 219 patients. The overall incidence of PSMs decreased from 128 cases (45.1%) in Group 1 to 91 cases (32.0%) in Group 2 (p-value <0.01). Similar results were seen in the subgroup of patients with pT2 staging who had PSMs (52 cases vs 24 cases, p-value <0.01). PSMs occurred mostly at the apex with a total of 112 cases (52.1%). Conclusion: The retro-apical urethral dissection approach with a 30-degree-lens flip-up technique is associated with a lower risk of overall PSMs and the trend of apical PSMs, indicating its clinical significance.

Value of three-dimensional visualization of preoperative prostatic magnetic resonance imaging based on measurements of anatomical structures in predicting positive surgical margin after radical prostatectomy.

Positive surgical margin (PSM) or apical positive surgical margin (APSM) is an established predictive factor of biochemical recurrence or disease progression in prostate cancer (PCa) patients after radical prostatectomy. Since there are limited usable magnetic resonance imaging (MRI)-based models, we sought to explore the role of three-dimensional (3D) visualization for preoperative MRI in the prediction of PSM or APSM. From December 2016 to April 2022, 149 consecutive PCa patients who underwent radical prostatectomy were retrospectively selected from the Second Affiliated Hospital of Dalian Medical University. According to the presence of PSM or APSM, patients were divided into a PSM group (n=41) and a without PSM group (n=108) and into an APSM group (n=33) and a without APSM group (n=116). Twenty-one parameters, including prostate apical shape, PCa distance to the membranous urethra, and pubic angle, were measured on 3D visualization of MRI. The development of the nomogram models was built by the findings of multivariate logistic regression analysis for significant factors. To predict the probability of PSM, a longer PCa distance to the membranous urethra (OR=0.136, p=0.019) and the distance from the anterior peritoneum to the anterior border of the coccyx (work space AP, OR=0.240, p=0.030) were independent protective factors, while a type 3 prostate apical shape (OR=8.262, p=0.025) and larger pubic angle 2 (OR=5.303, p=0.029) were identified as independent risk factors. The nomogram model presented an area under the curve (AUC) of the receiver operating characteristic curve (ROC) of PSM of 0.777. In evaluating the incidence of APSM, we found that the distance to the membranous urethra (OR=0.135, p=0.014) was associated with a low risk of APSM, while larger pubic angle 1 (OR=4.666, p=0.043) was connected to a higher risk of APSM. The nomogram model showed that the AUC of APSM was 0.755. As 3D visualization for preoperative MRI showed good performance in predicting PSM or APSM, the tool might be potentially valuable, which also needs to be validated by multicenter, large-scale, prospective studies.

Impact of positive surgical margins (PSMs) after robotic prostatectomy on biochemical recurrence (BCR): Multicenter analysis.

To study and analyze any correlations between positive surgical margins after RARP and biochemical recurrence. We enrolled 105 patients who underwent robot-assisted radical prostatectomy (RARP) from 2016-2020 with PSMs on final pathology, all performed or supervised by a senior surgeon in two tertiary referral center. Pathology has been described indicating also the area (apical, base, mediolateral, anterior, or multiple) and the extent of PSMs: focal (≤3 mm) or extensive (>3 mm). Cox univariable and multi-variable regression models were used to find the correlation between clinico-pathologic factors: age, local staging, PSA, grading, area, and size of PSMs). We found a good correlation between PSA and grading and between PSA and local staging (T) (p < 0.001). There was no clear correlation between the PSM area with grading nor with T staging. There is a statistically significant correlation between extensive PSM and the worsening of grading and local staging (p < 0.001). BCR rate also has a strong correlation with the worsening of grading and local staging (T) (p < 0.001). A relevant fact is the difference between the BCR rate in the apical and base PSM (34.88%vs 62.5%; p < 0.001) which are the most frequent locations of PSMs. PSMs remain a predictor of BCR but which may have controversial significance. The likelihood of BCR increases as grading or local staging gets worse. However, apical PSM is a relatively less powerful predictor of postoperative BCR. This can help to better select patients for subsequent RT, which still causes important side effects.

Preoperative Multiparametric Prostate Magnetic Resonance Imaging Structured Report Informs Risk for Positive Apical Surgical Margins During Radical Prostatectomy.

The prostatic apex is the most frequent location of positive surgical margin (PSM) after surgery. Data regarding the ability of multiparametric magnetic resonance imaging (mpMRI) to prospectively identify men at risk for apical PSMs (aPSMs) using a structured report are lacking. The aims of the study are to determine and to compare the rate of aPSM in men with versus without prospectively flagged at-risk prostate lesions during clinical mpMRI interpretation using whole-mount histopathology as the reference standard. This single-center, retrospective study of prospectively collected data included treatment-naive men with abnormal 3T mpMRI (PI-RADS v2 score ≥3) between January 2016 and December 2018 followed by surgery. During routine clinical interpretation, radiologists flagged prostate lesions abutting the apical most gland and/or encircling the distal most prostatic urethra using standardized language available as a "pick list" option in the structured report. Logistic regression was used to compare the rate of PSM in 2 groups (flagged vs nonflagged men). Propensity score covariate adjustment corrected for potential selection bias according to age, prostate-specific antigen (PSA), PSA density, grade group, and pT stage. The estimate was further adjusted by including surgeon as a covariate. A total of 428 men were included. A statistically significant higher proportion of aPSMs was noted in flagged (56% [51/91]) compared with nonflagged apical lesions (31% [105/337]; adjusted odds ratio, 2.5; 95% confidence interval, 1.6-4.1; P < 0.01). The difference in aPSM between both groups also varied according to the surgeon performing the RP. Prostate-specific antigen, PSA density, lesion size, apical location, Prostate Imaging Reporting & Data System score, grade group, pT stage, and surgeon's experience were associated with higher PSM rate. Biochemical recurrence, defined as PSA greater than 0.2 ng/mL on 2 measurements after RP, was significantly associated with PSM status (propensity score adjusted odds ratio, 3.1; 95% confidence interval, 1.8-5.3; P < 0.0001); however, patients flagged by radiologists did not have a significant difference in biochemical recurrence rates as compared with nonflagged patients ( P = 0.11). Standard language built into structured reports for mpMRI of the prostate helps identify preoperatively patients at risk for aPSM. Multiparametric MRI is able to identify patients at increased risk for aPSM, and this information can be conveyed in a structured report to urologists, facilitating patient counseling and treatment decisions.

MP57-17 THE COLLAR TECHNIQUE FOR APICAL DISSECTION DURING ROBOT-ASSISTED RADICAL PROSTATECTOMY: UPDATED SERIES AFTER FIVE YEARS FROM ITS INTRODUCTION

You have accessJournal of UrologyCME1 May 2022MP57-17 THE COLLAR TECHNIQUE FOR APICAL DISSECTION DURING ROBOT-ASSISTED RADICAL PROSTATECTOMY: UPDATED SERIES AFTER FIVE YEARS FROM ITS INTRODUCTION Angelo Mottaran, Carlo Andrea Bravi, Luca Sarchi, Pietro Piazza, Fernando Gonzalez Meza, Marco Corsetti, Sophie Knipper, Marco Paciotti, Marco Amato, Rui Farinha, Stefano Puliatti, Simone Scarcella, Celine Sinatti, Geert De Naeyer, Ruben De Groote, and Alexandre Mottrie Angelo MottaranAngelo Mottaran More articles by this author , Carlo Andrea BraviCarlo Andrea Bravi More articles by this author , Luca SarchiLuca Sarchi More articles by this author , Pietro PiazzaPietro Piazza More articles by this author , Fernando Gonzalez MezaFernando Gonzalez Meza More articles by this author , Marco CorsettiMarco Corsetti More articles by this author , Sophie KnipperSophie Knipper More articles by this author , Marco PaciottiMarco Paciotti More articles by this author , Marco AmatoMarco Amato More articles by this author , Rui FarinhaRui Farinha More articles by this author , Stefano PuliattiStefano Puliatti More articles by this author , Simone ScarcellaSimone Scarcella More articles by this author , Celine SinattiCeline Sinatti More articles by this author , Geert De NaeyerGeert De Naeyer More articles by this author , Ruben De GrooteRuben De Groote More articles by this author , and Alexandre MottrieAlexandre Mottrie More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002640.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Apical dissection is a challenging step during robot-assisted radical prostatectomy (RARP), and may affect the risk of positive surgical margins (PSM). For this delicate surgical step, we previously described the “Collar” technique that allowed us to lower the rate of PSM. After five years from its introduction, we want to update our series on this novel surgical technique. METHODS: A total of 1716 consecutive patients underwent RARP at OLV hospital (Aalst, Belgium) between 2010 and 2020. As of June 2015, the “Collar” technique was utilized during apical dissection, which included the incision of the urethral sphincter complex (USC) 2–3 mm distally to the apex; the underlying smooth muscle was exposed and incised closer to the apex to preserve the maximal length of the lissosphincter. Standard technique consisted in sharp and direct division of membranous urethra at the level of the urethra-prostatic junction without dissection of single components of the USC. Multivariable logistic regression tested the association between technique employed (standard vs. Collar technique) and risk of PSM and, in separate analysis, apical PSM, after adjusting for preoperative PSA level, pathologic grade, stage, and nodal status. RESULTS: A total of 1034 (60%) and 682 (40%) men received collar and standard technique, respectively. Despite higher rate of International Society of Urologic Pathology group was ≥3 at final pathology in the collar vs. standard technique group (39% vs. 32%; p=0.002), preoperative PSA, stage, and nodal status did not differ between the groups (all p ≥0.075). Overall, 269 (16%) patients had PSM, and 134/269 (50%) were apical PSM. There were no differences between the groups with respect to both PSM (17% vs. 15% in standard vs. collar technique group) and apical PSM (8% vs. 7% in standard vs. collar technique group; both p ≥0.3). After adjusting for confounders, patients receiving the collar technique had lower odds of overall PSM (odds ratio [OR]: 0.78; 95% confidence interval [CI]: 0.75, 0.82; p <0.0001). Similar results were found when apical PSM was the outcome of interest, with lower probability of apical PSM for men in the collar vs. standard technique group (OR: 0.82; 95%CI: 0.81, 0.82; p <0.0001). CONCLUSIONS: The collar technique during apical dissection reduces the rates of both overall and apical positive surgical margins as compared to traditional surgical technique. Future investigations are warranted to confirm also functional results. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e988 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Angelo Mottaran More articles by this author Carlo Andrea Bravi More articles by this author Luca Sarchi More articles by this author Pietro Piazza More articles by this author Fernando Gonzalez Meza More articles by this author Marco Corsetti More articles by this author Sophie Knipper More articles by this author Marco Paciotti More articles by this author Marco Amato More articles by this author Rui Farinha More articles by this author Stefano Puliatti More articles by this author Simone Scarcella More articles by this author Celine Sinatti More articles by this author Geert De Naeyer More articles by this author Ruben De Groote More articles by this author Alexandre Mottrie More articles by this author Expand All Advertisement PDF DownloadLoading ...

The detection rate of apical tumour involvement on preoperative MRI and its impact on clinical outcomes in patients with localized prostate cancer.

To determine the diagnostic performance of radiological apical tumour involvement (radATI) in preoperative prostate MRI, referenced to pathological ATI (pathATI) at radical prostatectomy specimens. To investigate risk factors for apical positive surgical margins (APSM). A retrospective cohort of consecutive patients with biopsy-proven PCa who underwent MRI and robot-assisted radical prostatectomy between July 2015 and March 2020 was studied (n = 177). Clinical, imaging, pathology, oncology and functional data were retrieved. The diagnostic accuracy of MRI to detect pathATI was analysed. Multivariate logistic regression was used to find independent predictors for APSM. radATI and pathATI was found in 121 (68%) and 161 (91%) patients, respectively. The diagnostic metrics of sensitivity, specificity, PPV, and NPV were 69, 38, 92, and 11%, respectively. APSM were present in 43 (24%) patients. Patients with radATI were more likely to have APSM (37/121 (31%)) than thosewithout radATI (6/56 (11%)) (OR 3.67 [95% CI 1.45-9.31], p = 0.004). This was confirmed in multivariate analysis. Only 2/56 (4%) patients without radATI developed a biochemical recurrence compared to 25/120 (21%) patients with radATI (hazard ratio 6.68 [95% CI 3.03-14.8], p = 0.003). Prostate cancer extends into the apex in the majority of cases. Clinicians are advised to report on the presence or absence of radiological apical tumour involvement as it is anindependent risk factor for apical positive surgical margins and is even associated with biochemical recurrence.

Prediction of a positive surgical margin and biochemical recurrence after robot-assisted radical prostatectomy

The positive surgical margin (PSM) and biochemical recurrence (BCR) are two main factors associated with poor oncotherapeutic outcomes after prostatectomy. This is an Asian population study based on a single-surgeon experience to deeply investigate the predictors for PSM and BCR. We retrospectively included 419 robot-assisted radical prostatectomy cases. The number of PSM cases was 126 (30.1%), stratified as 22 (12.2%) in stage T2 and 103 (43.6%) in stage T3. Preoperative prostate-specific antigen (PSA) > 10 ng/mL (p = 0.047; odds ratio [OR] 1.712), intraoperative blood loss > 200 mL (p = 0.006; OR 4.01), and postoperative pT3 stage (p < 0.001; OR 6.901) were three independent predictors for PSM while PSA > 10 ng/mL (p < 0.015; hazard ratio [HR] 1.8), pT3 stage (p = 0.012; HR 2.264), International Society of Urological Pathology (ISUP) grade > 3 (p = 0.02; HR 1.964), and PSM (p = 0.027; HR 1.725) were four significant predictors for BCR in multivariable analysis. PSMs occurred mostly in the posterolateral regions (73.8%) which were associated with nerve-sparing procedures (p = 0.012) while apical PSMs were correlated intraoperative bleeding (p < 0.001). A high ratio of pT3 stage after RARP in our Asian population-based might surpass the influence of PSM on BCR. PSM was less significant than PSA and ISUP grade for predicting PSA recurrence in pT3 disease. Among PSM cases, unifocal and multifocal positive margins had a similar ratio of the BCR rate (p = 0.172) but ISUP grade > 3 (p = 0.002; HR 2.689) was a significant BCR predictor. These results indicate that PSA and pathological status are key factors influencing PSM and BCR.

Novel anatomical apical dissection utilizing puboprostatic "open-collar" technique: Impact on apical surgical margin and early continence recovery.

PurposeTo evaluate the impact of modifications to anatomical apical dissection including a puboprostatic open-collar technique, which visualizes the lateral aspect of the apex and dorsal vein complex (DVC) covering the rhabdosphincter while preserving the puboprostatic collar, on positive surgical margin (PSM) and continence recovery.MethodsOne-hundred-and-sixty-seven patients underwent gasless single-port retroperitoneoscopic radical prostatectomy using a three-dimensional head-mounted display system. Sequentially modified surgical techniques comprised puboprostatic open-collar technique, sutureless transection of the DVC, retrograde urethral dissection, and anterior reconstruction. The associations of these modifications with PSM and continence recovery were assessed.ResultsThe puboprostatic open-collar technique, sutureless DVC transection, and retrograde urethral dissection were significantly associated with lower apical PSM (P = 0.003, 0.003, and 0.010, respectively). The former two also showed similar associations in 84 patients with anterior apical tumor (P = 0.021 and 0.030, respectively). Among 92 patients undergoing all of these three procedures, overall and apical PSM rates were 13.0% and 3.3%, respectively. Retrograde urethral dissection (odds ratio [OR] 2.73, P = 0.004) together with nerve sparing (OR 2.77, P = 0.003) and anterior apical tumor (OR 0.45, P = 0.017) were independently associated with immediate continence recovery. A multivariable model for 3-month continence recovery included anterior apical tumor (OR 0.28, P = 0.003) and puboprostatic open-collar technique (OR 3.42, P = 0.062). Immediate and 3-month continence recovery rates were 56.3% and 85.4%, respectively, in 103 patients undergoing both the puboprostatic open-collar technique and retrograde urethral dissection.ConclusionNovel anatomical apical dissection utilizing a puboprostatic open-collar technique may favorably impact on both apical surgical margin and continence recovery.

Positive association between preoperative lymphocyte-to-monocyte ratio and risk of the status of positive surgical margins by prostate cancer: results in 497 consecutive patients treated only by radical prostatectomy.

BackgroundPositive surgical margins (PSM) is one of the most important factors affecting the prognosis of prostate cancer (PCa) patients after radical prostatectomy (RP). Although some studies have found the preoperative systematic inflammation-based scores the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR) can predict the incidence and prognosis of PCa, few studies have explored the predictive value of preoperative systematic inflammation-based scores on the PSMs for PCa patients after RP.MethodsFrom June 2014 to September 2020 a total of 497 patients underwent RP at our institution. Blood samples from all patients were collected within one week before surgery. Preoperative clinical characteristics including age, body mass index (BMI), prostate-specific antigen (PSA), and biopsy Gleason sum (BGS) were assessed. Postoperatively pathological specimens were assessed for pathological Gleason sum (PGS), pathological stage, and margin status.ResultsIn the multivariable analysis including preoperative variables, PSA and LMR were the independent predictive factors for PSM (OR: 2.817; 95% CI, 1.836–4.320, P<0.001; OR: 1.124; 95% CI, 1.018–1.240, P=0.021. Considering pre-, intra-, and postoperative variables, BGS, perineural invasion, seminal vesicle invasion (SVI), pathologic Gleason sum (PGS) combined, were associated with increased risk of PSM in the univariable analysis (P<0.001 for all variables). However, in the multivariable analysis, perineural invasion (OR: 2.672; 95% CI, 1.649–4.330; P<0.001), PGS (OR: 2.52; 95% CI, 1.556–4.082; P<0.001) were independent predictive factors for the incidence of PSM. Finally, LMR was shown to be an independent predictive factor (OR: 0.881; 95% CI, 0.779–0.996; P=0.043) for apical PSMs, with increasing LMR predicting the lower incidence of apex location. And we also found that LMR was an independent factor that predicts multifocal positive margins (OR: 1.179; 95% CI, 1.023–1.358; P=0.023).ConclusionsPreoperative LMR could be used as an independent predictor to predict the incidence of PSMs after RP. And Considering pre-, intra-, and postoperative variables, we also found that preoperative LMR could predict the occurrence of apical and multifocal PSMs.

Evaluating Incidence, Location, and Predictors of Positive Surgical Margin Among Chinese Men Undergoing Robot-Assisted Radical Prostatectomy.

PurposeTo evaluate the incidence and locations of positive surgical margin (PSM) among Chinese men undergoing RARP and identify the preoperative predictors for PSM.MethodsWe retrospectively identified 393 patients who underwent RARP according to inclusion criteria by single surgeon in our hospital. PSM was defined as the presence of cancer adjacent to inked surface of the specimen and categorized into four groups based on locations: apex, posterolateral, base, and multifocal. Logistic regression analysis was performed to identify the predictors of overall and location-specific PSM.ResultsThe overall PSM rate was 133/393 (34%). The PSM rates for pT2, pT3, and pT4 stage were 63/278 (23%), 50/89 (56%), and 20/26 (77%), respectively. The estimated rates for apical, posterolateral, basal, and multifocal PSM were 8%, 4%, 7%, and 14%, respectively. In univariate analysis, overall PSM related to tPSA, f/tPSA, percentage of positive needles, and Gleason score. Multifocal PSM correlated with smoking history, drinking history, tPSA, f/tPSA, percentage of positive needles, and Gleason score. In multivariate analysis, percentage of positive needles reminded the only independent predictor for overall (OR = 10.5, 95% CI: 2.58–44.4) and basal PSM (OR = 24.0, 95% CI: 3.22–179.4). The f/tPSA (OR = 2.59, 95% CI: 2.18–5.71) and percentage of positive needles (OR = 31.0, 95% CI: 3.17–303) were independent risk factors for multifocal PSM.ConclusionThe multifocal sites were the most common location of positive surgical margin, followed by apical and basal sites among Chinese patients undergoing RARP. The percentage of positive needles was an independent predictor for overall, basal, and multifocal PSM.

Obese men undergoing radical prostatectomy: Is robotic or retropubic better to limit positive surgical margins? Results from SEARCH.

To evaluate the association between obesity and positive surgical margins in patients undergoing retropubic radical prostatectomy versus robotic-assisted laparoscopic prostatectomy. We retrospectively reviewed the data of 3141 men undergoing retropubic radical prostatectomy and 1625 undergoing robotic-assisted laparoscopic prostatectomy between 1988 and 2017 at eight Veterans Health Administration hospitals. The positive surgical margin location (peripheral, apical, bladder neck, overall) was determined from pathology reports. We adjusted for age, race, prostate-specific antigen, surgery year, prostate weight, pathological grade group, extracapsular extension, seminal vesicle invasion, hospital surgical volume and surgical method (in analyses not stratified by surgical method). Interactions between body mass index and surgical approach were tested. Among all patients, higher body mass index was associated with increased odds of overall, peripheral and apical positive surgical margins (OR 1.02-1.03, P≤0.02). Although not statistically significant, there was a trend between higher body mass index and increased odds of bladder neck positive surgical margins (OR 1.03, P=0.09). Interactions between body mass index and surgical method were significant for peripheral positive surgical margins only (P=0.024). Specifically, there was an association between body mass index and peripheral positive surgical margins among men undergoing retropubic radical prostatectomy (OR 1.04, P<0.001), but not robotic-assisted laparoscopic prostatectomy (OR 1.00, P=0.98). Limitations include lacking individual surgeon data and lacking central pathology review. In this multicenter cohort, higher body mass index was associated with increased odds of positive surgical margins at all locations except the bladder neck. Furthermore, there was a significant association between obesity and peripheral positive surgical margins in men undergoing retropubic radical prostatectomy, but not robotic-assisted laparoscopic prostatectomy. Long-term clinical significance requires further study.

The value of transperineal apical prostate biopsy in predicting urethral/apical margin status after radical prostatectomy.

To investigate potential preoperative predictors of urethral or apical positive surgical margin (PSM) and the value of apical prostate biopsy in predicting urethral/apical margin status after radical prostatectomy (RP). A total of 531 patients who underwent RP during 2010 to 2017 at West China Hospital were enrolled in this retrospective study. Preoperative and postoperative factors including age, BMI, PSA, clinical T stage and biopsy Gleason score were analyzed. Univariate analysis and logistic regression were used to find out the potential predictive factors for PSM. Two logistic regression models were built to evaluate the role of apical prostate biopsy in predicting urethral/apical margin status. The overall PSM rate was about 30.1% (160/531) and 97 of them were reported urethral/apical PSM. The incidence of urethral or apical PSM in patients with positive cores in the apical prostate was higher than those without (23.0% vs 9.9%, P < .001). We further found that the multivariable model with positive apical prostate biopsy could significantly increase the predictive value of urethral or apical PSM status (AUC: 0.744 vs 0.783, P = .016). Our analysis also showed that neo-adjuvant hormone therapy was an independent protective factor for urethral or apical PSM in patients with positive apical prostate biopsy, but not all patients. This study revealed the necessity of apical prostate biopsy to predict the risk of apical or urethral PSM. In clinical practice, neo-adjuvant hormone therapy should be given when patients with positive apical prostate biopsy to reduce the presence of PSM, especially patients with high/very high risk prostate cancer.

The value of transperineal prostate apical zone biopsy in predicting urethral or apical margin status after radical prostatectomy in prostate cancer.

127 Background: To investigate potential preoperative predictors of positive surgical margin (PSM) after radical prostatectomy, and how to reduce the possibility of urethral or apical PSM with positive biopsy cores in the apical zone of prostate (AZP). Methods: 531 patients who had radical prostatectomy during 2010-2017 in West China hospital was enrolled. The logistic regression was used to assess the preoperative factors associated with PSM. 399 patients with high/very high risk prostate cancer were recognized by National comprehensive cancer Network guidelines and 339 patients were reported positive biopsy cores in the AZP. Results: The overall PSM rate of all patients was about 30.1% (160/531) and 117 of them were reported urethral or apical PSM. The occurrence rate of urethral or apical PSM in patients with positive cores in AZP was obviously higher than that in total group (p = 0.022). We further found that the addition of positive AZP to a standard multivariable model could significantly increase the predictive value of urethral or apical PSM (p = 0.016) in different groups. The analysis also showed that neo-adjuvant hormone therapy was an independent protective factor for urethral or apical PSM in positive AZP patients, but not all patients. Conclusions: This is the first study to investigate the necessity of getting cores in the apical zone by transperineal prostate biopsy to predict the possibility of apical or urethral PSM. In clinical practice, neo-adjuvant hormone therapy should be given when patients with AZP(+) to reduce the presence of PSM, especially patients with high/very high risk prostate cancer.

Risk of biochemical recurrence based on extent and location of positive surgical margins after robot-assisted laparoscopic radical prostatectomy

BackgroundThere are no published studies on the simultaneous effect of extent and location of positive surgical margins (PSMs) on biochemical recurrence (BCR) after robot-assisted laparoscopic prostatectomy (RALP). The aim was to report the incidence, extent, and location of PSMs over the inclusion period as well as the rates of BCR and cancer-related mortality, and determine if BCR is associated with PSM extent and/or location.MethodsRetrospective review of 530 consecutive patients who underwent RALP between 2003 and 2012. Kaplan-Meier (KM) survival analyses and Cox regressions were performed to determine variables associated with BCR.ResultsFor the 530 operated patients, evaluated at a median of 92 months (IQR, 87–99), PSMs were observed in 156 (29%), of which 24% were focal. Out of 172 PSMs, 126 (73%) were focal and 46 (27%) were extensive. The KM survival using BCR as endpoint was 0.81 (CI, 0.78–0.85) at 5 years and was 0.67 (CI, 0.61–0.72) at 10 years; and using cancer-related mortality as endpoint was 0.99 (CI, 0.99–1.00) at 5 years and 0.95 (CI, 0.92–0.98) at 10 years. Multi-variable analysis revealed the strongest predictors of BCR to be Gleason score ≥ 8 (HR = 7.97; CI, 4.38–14.51) and 4 + 3 (HR = 3.88; CI, 2.12–7.07), lymph nodes invasion (HR = 3.42; CI, 1.70–6.91), pT stage 3b or 4 (HR = 3.07; CI, 1.93–4.90), and extensive apical PSMs (HR = 2.62; CI, 1.40–4.90) but not focal apical PSMs (HR = 0.86; CI, 0.49–1.50; p = 0.586).ConclusionExtensive apical PSMs significantly increased the risk of BCR, independently from pT stage, Gleason score and lymph nodes invasion, while focal apical PSMs had no significant effect on BCR.

A Novel Approach for Apical Dissection During Robot-assisted Radical Prostatectomy: The “Collar” Technique

BackgroundApical dissection in robot-assisted radical prostatectomy (RARP) affects not only cancer control, but also continence recovery. ObjectiveTo describe a novel approach for apical dissection, the collar technique, to reduce apical positive surgical margins (PSMs). Design, setting, and participantsA total of 189 consecutive patients (81 in the control group, 108 in the collar technique group) underwent RARP at a single center. Primary outcome: rates of apical PSMs; secondary outcome: urinary continence. InterventionThe urethral sphincter complex is incised 2–3mm distally to the apex, to stay farther from it and reduce PSMs; the underlying smooth muscle is exposed and incised closer to the apex to preserve the maximal length of the lissosphincter. Outcome measurements and statistical analysisMann–Whitney U and chi-square tests compared median and proportions between the two groups, respectively. Univariate logistic regression tested the association between technique employed and risk of apical PSMs. Results and limitationsFourteen patients (7.4%) revealed apical PSMs (9.9% in the control group, 5.6% in the collar group; p=0.7). When the collar technique was used, significantly lower rates of apical PSMs occurred in pT2 disease (0% vs 7.1%; p=0.03). In case of apical tumor at preoperative magnetic resonance imaging (MRI; n=43), the collar technique determined significantly lower overall (9.7% vs 42%) and apical (3.2% vs 42%) PSMs (all p≤0.02). Continence recovery in the collar and control groups was similar. When preoperative MRI showed an apical tumor, the collar technique had a significantly lower risk of apical PSMs (odds ratio: 0.05, p=0.009). ConclusionsThe collar technique reduces the rates of apical PSMs in case of apical tumor, preserving the length of the lissosphincter. Patient summaryWe describe a novel approach for apical dissection during robot-assisted radical prostatectomy. Our technique reduces the rates of apical surgical margins in case of apical tumor at preoperative magnetic resonance imaging and leads to optimal continence recovery.

Positive surgical margin in robot-assisted radical prostatectomy: correlation with pathology findings and risk of biochemical recurrence.

To analyze the correlation of surgical margin status with other findings on final pathology and risk of biochemical recurrence (BCR) in patients undergoing robot-assisted radical prostatectomy (RALP). Bundang Prostatectomy Database was reviewed to identify patients who underwent RARP from 2007 to 2011 and had a positive surgical margin (PSM) on final pathology. Pathology findings were reviewed. BCR-free survival was calculated using the Kaplan-Meier method. Cox univariable and multi-variable regression models were used to find the correlation between clinicopathologic factors and BCR. Eight hundred and fifteen patients were included in the analysis: 118 (14.48%) had apical positive margin, 152 (18.65%) had a positive margin in another site, and 545 (66.87%) had negative surgical margins. In patients with only apical PSM, stratified by clinical stage, Kaplan-Meier analysis demonstrated significant difference in BCR-free survival between the groups (log rank P<0.001). Multivariable Cox proportional hazards model showed maximal percentage of positive core is the strongest predictor of BCR (HR=3.131, P<0.001). Multivariable Cox proportional hazards model showed PSM is one of the powerful predictor of postoperative BCR (HR=3.123, P<0.001). PSM after RALP is one of the powerful predictor of BCR and apical PSM is relatively less powerful predictor of BCR. Maximal percentage of positive core is the most powerful preoperative predictors of BCR. Clinical stage and biopsy Gleason score are also associated with pathologic outcomes and BCR free survival rates in patients with positive apical margin only.

Long-term oncological outcomes of apical positive surgical margins at radical prostatectomy in the Shared Equal Access Regional Cancer Hospital cohort.

Approximately 29-38% of all positive surgical margins (PSMs) at radical prostatectomy (RP) involve the apex. The prognostic significance of apical PSM remains unclear. We therefore compared the long-term oncologic outcomes of men with apical PSMs to those with negative PSMs, apical and other PSMs, and other PSMs at RP. The SEARCH (Shared Equal Access Regional Cancer Hospital) database was used to identify 4031 men with prostate cancer (PCa) managed with RP with complete pathologic grade and stage data. Margin status was categorized as negative, apex only, or other positive. Multivariable Cox regression models adjusted for pathologic stage and grade were developed to test the relationship between margin status and biochemical recurrence (BCR), metastases and PCa death. In the final cohort, 34.3% had PSMs, whereas 65.7% had negative margins. Univariable analysis showed that compared with negative margins, apex-only PSM was associated with BCR (hazard ratio (HR): 1.4 [1.1-1.8]), but not metastases or PCa death, whereas apex and other PSMs were associated with BCR (HR: 3.3 [2.8-4]) and metastases (HR: 1.8 [1.02-3.1]) but not PCa death. Nonapical PSMs were associated with BCR (HR: 2.7 [2.4-3.1]), metastases (1.7 [1.2-2.5)] and PCa death (1.8 [1.05-3]). On multivariable analysis, apex-only, apex and other, and nonapical PSMs were associated with BCR but margin status was not associated with metastases or PCa death. In a large cohort of men undergoing RP, those with PSMs at the prostatic apex had lower BCR, metastases, or PCa death compared with those with PSMs at other locations. When adjusted for pathologic stage and grade, however, PSMs were associated with BCR but not long-term oncologic outcomes. These data confirm that men with apex-only PSMs may not be ideal candidates for adjuvant therapy after RP.

Marfan syndrome: A case report

Marfan syndrome (MS) is a disorder of the connective tissues characterized by various phenotypical and genetic manifestations. We present this case to show its rarity and to highlight the need of early diagnosis to avert the numerous complications that follow it. A 7-year-old male, who presented with an abnormal body physique that was noticed at age 2 months, poor vision that was noticed 5 years ago, recurrent chest pain that started 3 years ago, and recurrent easy tiredness that started 3 years ago. He developed poor vision 2 years later. Examination revealed an acutely ill-looking child with dyspnea, grade 4 apical positive surgical margins (PSM), grade 2 diastolic murmur (at the aortic area), multiple skeletal abnormalities with lens subluxation and iridodonesis. Diagnosis of MS was made and he was comanaged with ophthalmologists and orthopedic surgeons.

MP53-12 LONG TERM ONCOLOGICAL OUTCOMES OF APICAL POSITIVE SURGICAL MARGINS AT RADICAL PROSTATECTOMY IN THE SHARED EQUAL ACCESS REGIONAL CANCER HOSPITAL (SEARCH) COHORT

You have accessJournal of UrologyProstate Cancer: Staging I1 Apr 2015MP53-12 LONG TERM ONCOLOGICAL OUTCOMES OF APICAL POSITIVE SURGICAL MARGINS AT RADICAL PROSTATECTOMY IN THE SHARED EQUAL ACCESS REGIONAL CANCER HOSPITAL (SEARCH) COHORT Harpreet Wadhwa, Martha Terris, William Aronson, Christopher Kane, Christopher Amling, Matthew Cooperberg, Stephen Freedland, and Michael Abern Harpreet WadhwaHarpreet Wadhwa More articles by this author , Martha TerrisMartha Terris More articles by this author , William AronsonWilliam Aronson More articles by this author , Christopher KaneChristopher Kane More articles by this author , Christopher AmlingChristopher Amling More articles by this author , Matthew CooperbergMatthew Cooperberg More articles by this author , Stephen FreedlandStephen Freedland More articles by this author , and Michael AbernMichael Abern More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1706AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Approximately 29-38% of all positive surgical margins (PSM) at radical prostatectomy (RP) involve the apex. The prognostic significance of positive margins at the apex remains unclear. We therefore compared the long term the oncologic outcomes of men with only apical PSM to those with negative and non-apical PSM at RP. METHODS The SEARCH database was used to identify 2,625 men with prostate cancer (PCa) managed with RP and pelvic lymphadenectomy with complete pathologic grade and stage data. Men with positive lymph nodes were excluded. Margin status was categorized as negative, apex only, or other positive. Multivariable Cox regression models adjusted for pathologic stage and Gleason sum were developed to test the relationship between margin status and long-term oncologic outcomes (biochemical recurrence [BCR], metastases, PCa death). RESULTS In the final cohort 35.5% had PSM (6.0% apex only and 29.5% PSM at other locations) while 64.5% had negative surgical margins. At 78 months of median follow-up 891 men (33.9%) had BCR, 109 men (4.15%) developed metastases, and 64 men (2.44%) died of PCa. Univariable analysis showed that compared to negative margins, apex only PSM was associated with BCR (HR 1.52; 95% CI, 1.15-2.01), but not metastases or PCa death, while PSM at other locations were associated with increased likelihood for BCR (HR, 2.9; 95% CI, 2.53-3.32), metastases (HR 1.6; 95% CI, 1.11-2.43) and death (HR 1.9; 95% CI, 1.14-3.15). On multivariable analysis, apex only (HR 1.46; 95% CI, 1.11-1.93) and other positive margins (HR 2.1; 95% CI, 0.41-0.91) were associated with BCR but margin status was not associated with metastases or PCa death. CONCLUSIONS In multivariate analysis of large cohort of men undergoing RP, those with PSM at the prostatic apex were less likely to suffer BCR, metastases, or PCa death compared to those with PSM at other locations. When adjusted for pathologic stage and grade, however, PSM at any location were associated with BCR but not long term oncologic outcomes. These data suggest that men with apex only PSM may not be ideal candidates for adjuvant therapy after RP. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e640 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Harpreet Wadhwa More articles by this author Martha Terris More articles by this author William Aronson More articles by this author Christopher Kane More articles by this author Christopher Amling More articles by this author Matthew Cooperberg More articles by this author Stephen Freedland More articles by this author Michael Abern More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

A Critical Analysis of the Learning Curve and Postlearning Curve Outcomes of Two Experience- and Volume-Matched Surgeons for Laparoscopic and Robot-Assisted Radical Prostatectomy.

There remains equipoise with regard to whether laparoscopic radical prostatectomy (LRP) or robot-assisted radical prostatectomy (RARP) has any benefit over the other. Despite this, there is a trend for the increasing adoption of RARP at great cost to health services across the world. The aim was to critically analyze the learning curve and outcomes for LRP and RARP for two experience- and volume-matched surgeons who have completed the learning curve for LRP and RARP. Two experience- and volume-matched LRP and RARP surgeons who have completed the learning curve were compared with respect to their learning curve and outcomes for RARP and LRP. There were 531 RARP and 550 LRPs analyzed from April 2003 until January 2012 at two relatively high-volume United Kingdom centers. Outcome measures included operative time, blood loss, complication rate (Clavien-Dindo grade III), positive surgical margin (PSM) rate, and early continence rate. Learning curves for blood loss, operative times, and complication rate were similar between groups. The overall PSM rate and pT2 PSM rate learning curves were longer for RARP compared with LRP but shorter for early continence. Apical PSM showed no learning curve for RARP; however, a long learning curve for LRP and the rate was lower for RARP than for LRP (P=<0.001). This study of RARP and LRP identified that both modalities had long learning curves. Despite the long learning curve for RARP, significant benefits in lower PSM rates and better early continence in comparison with LRP exist. There are benefits to patients with RARP over LRP, especially those linked to better apical dissection (apical PSM and early continence).