Margins In Radical Prostatectomy Specimens Research Articles

Frozen section evaluation of margins in radical prostatectomy specimens: a contemporary study and literature review.

The utility of routine frozen section (FS) analysis for margin evaluation during radical prostatectomy (RP) remains controversial. A retrospective search was conducted to identify RPs evaluated by FS over a 5-year period. The potential of FS to discriminate between benign and malignant tissue and to predict final margins was evaluated. During the study period, 71 (12.3%) of 575 cases underwent FS evaluation of margins, generating 192 individual FSs. There were 8 FSs diagnosed as atypical/indeterminate because of significant freezing, crushing, and/or thermal artifacts; 11 as positive for carcinoma; and 173 as benign. Two FSs classified as benign were diagnosed as positive for carcinoma on subsequent permanent section. Frozen sections' sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for diagnosis of prostatic adenocarcinoma were 85%, 100%, 100%, 99%, and 99%, respectively. Overall RP final margin predictive accuracy was 81%. Positive FS was significantly associated with perineural invasion on biopsy and extraprostatic extension and higher stage disease on RP, but not with the overall final margin status. The high FS accuracy supports its use to guide the extent of surgery. However, FS cannot be used to predict the overall final margin status. Recognition of the histological artifacts inherent to the FS procedure is important to ensure appropriate utilization.

Biochemical recurrence rates are similar for pT2-positive surgical margins and pT3a.

Histological details of positive surgical margins in radical prostatectomy specimens have been related to outcome after surgery in rare studies recently published. Our objective is to assess whether the status of surgical margins, the extent and the Gleason score of positive margins, and the extent of the extraprostatic extension are predictive of biochemical recurrence post-radical prostatectomy. Three hundred sixty-five radical prostatectomy specimens were analyzed. The length of the positive surgical margin and extraprostatic extension and the Gleason score of the margin were recorded. Statistical analyses examined the predictive value of these variables for biochemical recurrence. 236 patients were stage pT2R0, 58 pT2R1, 25 pT3R0 and 46 pT3R1. Biochemical recurrence occurred in 11%, 31%, 20% and 45.7% of pT2R0, pT2R1, pT3R0 and pT3R1, respectively. The extent of the positive surgical margins and the Gleason score of the positive surgical margins were not associated with biochemical recurrence in univariate analysis in a mean follow up period of 35.9 months. In multivariate analyses, only the status of the surgical margins and the global Gleason score were associated with biochemical recurrence, with a risk of recurrence of 3.1 for positive surgical margins and of 3.8 for a Gleason score > 7. Positive surgical margin and the global Gleason score are significant risk factors for biochemical recurrence post-radical prostatectomy, regardless of the extent of the surgical margin, the extent of the extraprostatic extension, or the local Gleason score of the positive surgical margin or extraprostatic tissue. pT2R1 disease behaves as pT3R0 and should be treated similarly.

Prognostic Impact of Subclassification of Radical Prostatectomy Positive Margins by Linear Extent and Gleason Grade

We evaluated the relationship of progression to positive surgical margin linear length and Gleason grade at a positive surgical margin. We studied 2,150 prostatectomies done for pT2 or pT3a disease to determine grade, stage and surgical margin status. In patients with positive surgical margins we recorded the location, number, positive margin linear length and highest Gleason grade at a positive margin. The Kaplan-Meier method and log rank test were used to determine differences in progression-free probability among positive margin features. The concordance index was used to discriminate the accuracy of grouping surgical margin status as negative/positive vs positive margin linear length/highest Gleason grade. A total of 207 cases (10%) showed positive surgical margins, including 93 (45%) that were pT2+ and 114 (55%) that were pT3a. Patients with pT3a and positive margins had greater prostate specific antigen and tumor volume, and Gleason score 7 or greater than those with pT2+. A total of 45 patients with positive margins progressed. We then subcategorized positive margins. Of the patients 164 (79%) had 1 positive margin. Positive margin linear length was 1 mm or less, 1.1 to 3 and greater than 3 in 104 (50%), 55 (27%) and 48 cases (23%), respectively. Two-year progression-free probability was 95%, 91%, 83% and 47% in patients with negative margins and the 3 positive margin linear length groups, respectively (p <0.001). Gleason grade at a positive margin was 3 and 4/5 in 154 (74%) and 53 patients (26%), respectively. The latter group was significantly more likely to progress (p <0.001). The overall margin status concordance index was 0.636. It was not considerably enhanced by categorizing by positive surgical margin linear length/highest Gleason grade at positive margins. The linear extent of and highest Gleason grade at a positive surgical margin are associated with progression. However, subcategorization does not importantly add to predictive models using margin status only. More robust markers are needed in patients with positive surgical margins to warrant routine reporting and identify those at risk for biochemical recurrence.

The value of triple antibody (34βE12 + p63 + AMACR) cocktail stain in radical prostatectomy specimens with crushed surgical margins

BackgroundTriple antibody cocktail immunohistochemical staining is routinely used as an ancillary method to establish a diagnosis of prostate cancer in biopsies with small foci of atypical glands. Crush artefact can...

An Exploratory Study of Endorectal Magnetic Resonance Imaging and Spectroscopy of the Prostate as Preoperative Predictive Biomarkers of Biochemical Relapse After Radical Prostatectomy

Radical prostatectomy has significant side effects. Preoperative information predicting its long-term outcome would be valuable to patients and physicians. We determined whether pretreatment endorectal magnetic resonance imaging/magnetic resonance spectroscopic imaging predicts biochemical recurrence after radical prostatectomy. Of 202 patients who underwent endorectal magnetic resonance imaging/magnetic resonance spectroscopic imaging from January 2000 to December 2002 before radical prostatectomy 130 satisfied study inclusion criteria and were included in analysis. We compared imaging factors with potential predictive capability to biochemical recurrence data, including magnetic resonance imaging risk score based on local disease extent and magnetic resonance spectroscopic imaging index lesion characteristics, such as the number of voxels and degree of metabolic abnormality (magnetic resonance spectroscopic imaging grade). We evaluated associations of these imaging variables with time to biochemical recurrence by Cox proportional hazards regression adjusted for known predictors of biochemical recurrence, such as stage, grade and prostate specific antigen. At a median 68-month followup there were 26 biochemical failures. Risk score, lesion volume and high grade voxels each correlated with time to biochemical recurrence. In a model combining clinical parameters risk score, lesion volume and at least 1 high grade voxel the magnetic resonance spectroscopic imaging variables remained significant but the magnetic resonance imaging score dropped out. Index lesion volume on magnetic resonance spectroscopic imaging and high grade magnetic resonance spectroscopic imaging voxels correlate with time to biochemical recurrence after radical prostatectomy even when adjusted for clinical data. Results suggest the preoperative predictive usefulness of endorectal magnetic resonance imaging/magnetic resonance spectroscopic imaging in patients considering radical prostatectomy.

Biochemical Recurrence After Radical Prostatectomy: Multiplicative Interaction Between Surgical Margin Status and Pathological Stage

A positive surgical margin after radical prostatectomy is considered an adverse prognostic feature. However, few groups have explored the potential interaction between surgical margin status and other cancer characteristics, specifically pathological stage. We addressed the first degree of interaction between positive surgical margins and other established adverse predictors of biochemical recurrence after radical prostatectomy. We used univariate and multivariate analysis to test the effect of surgical margin status on biochemical recurrence in 4,490 patients treated at a single institution between 1992 and 2008. We systematically tested all first-degree interactions between surgical margin status, and pretreatment prostate specific antigen, pT and pN stage, and radical prostatectomy Gleason sum. If interactions were significant, we quantified the effect on the biochemical recurrence rate. Overall 850 patients (18.9%) had positive surgical margins. In those with negative vs positive surgical margins the 5-year biochemical recurrence-free survival rate was 95% vs 83%, 74% vs 62% and 47% vs 29% for pT2, pT3a and pT3b disease, respectively. In multivariate models only the pT stage-surgical margin status interaction achieved independent predictor status (p = 0.003). Negative vs positive surgical margin multivariate HRs were 1 vs 2.9, 2.3 vs 4.3 and 4.1 vs 5.6 in pT2, pT3a and pT3b cases, respectively. Compared to negative surgical margins, positive surgical margins increase the absolute biochemical recurrence 5-year rate by 12% to 18%. More importantly, positive surgical margins may substantially worsen the prognosis beyond that of the original pathological disease stage.

The Impact of Positive Surgical Margins on Mortality Following Radical Prostatectomy During the Prostate Specific Antigen Era

The presence of a positive surgical margin at radical prostatectomy has been linked to an increased risk of postoperative biochemical recurrence. We evaluated the impact of margin status on subsequent clinical progression and mortality. We reviewed the records of 11,729 patients who underwent prostatectomy between 1990 and 2006. Survival was estimated for patients with vs without a positive margin and compared using the log rank test. Cox proportional hazards regression models were used to analyze the impact of margin status on survival. Overall 3,651 (31.1%) men were identified with a positive margin. Median postoperative followup was 8.2 years (IQR 4.4, 12.1). The 10-year biochemical recurrence-free rate for patients with and without a positive margin was 56% and 77%, respectively (p <0.001), while 10-year local recurrence-free survival was 89% vs 95% (p <0.001). Margin status also stratified systemic progression-free survival (93% vs 97%, p <0.001), cancer specific survival (96% vs 99%, p <0.001) and overall survival (83% vs 88%, p <0.001). On multivariate analysis the presence of a positive margin was associated with increased risk of biochemical recurrence (HR 1.63, 95% CI 1.47-1.80, p <0.0001), local recurrence (HR 1.78, 95% CI 1.45-2.19, p <0.0001) and receipt of salvage therapy (HR 1.79, 95% CI 1.58-2.02, p <0.0001) but was not a significant predictor of systemic progression (p = 0.95), cancer specific death (p = 0.15) or overall mortality (p = 0.16). The presence of a positive margin increased the risk of biochemical recurrence, local recurrence and the need for salvage treatment but was not independently associated with systemic progression, cancer specific death or overall mortality. These results should be considered when evaluating patients for adjuvant therapy.

Variations Among Experienced Surgeons in Cancer Control After Open Radical Prostatectomy

Complications and functional outcomes after prostate surgery vary among surgeons to a greater extent than may be accounted for by chance. This excessive variation is known as heterogeneity. We explored whether there is also heterogeneity among high volume surgeons with respect to cancer control after surgery. The study cohort consisted of 7,725 patients with clinically localized prostate cancer treated with open radical prostatectomy at 4 major American academic medical centers from 1987 to 2003 by 1 of 54 surgeons. We defined biochemical recurrence as serum prostate specific antigen 0.4 ng/ml or greater followed by a higher level. Multivariate random effects models were used to evaluate prostate cancer recurrence heterogeneity among surgeons after adjusting for case mix (prostate specific antigen, pathological stage and grade), surgery year and surgeon experience. We found statistically significant heterogeneity in the prostate cancer recurrence rate independent of surgeon experience (p = 0.002). Seven experienced surgeons had an adjusted 5-year prostate cancer recurrence rate of less than 10% while another 5 had a rate that exceeded 25%. Significant heterogeneity remained on sensitivity analysis adjusting for possible differences in followup, patient selection and stage migration. Patient risk of recurrence may differ depending on which of 2 surgeons is seen even if the surgeons have similar experience levels. Surgical randomized trials are imperative to determine and characterize the roots of these variations.

Predictors of Positive Surgical Margins After Laparoscopic Robot Assisted Radical Prostatectomy

We identified the predictors of positive surgical margins in a series of patients undergoing robot assisted laparoscopic radical prostatectomy. We prospectively collected data from 322 patients who underwent robot assisted laparoscopic radical prostatectomy for clinically localized prostate cancer between April 2005 and October 2008, and who had not received any prior hormonal therapy. Positive surgical margins were observed in 95 cases (29.5%). Specifically positive surgical margins were at the apex in 22 cases (6.8%), anterior in 5 (1.6%) and posterolateral in 68 (21%). Among the preoperative variables prostate volume on transrectal ultrasound (HR 0.420, p = 0.002) and cT stage (HR 2.217, p = 0.008) were independent predictors of the presence of any positive surgical margin in the cohort while cT stage (HR 2.070, p = 0.025) and biopsy Gleason score (p = 0.019) were predictors of posterolateral positive surgical margins. Considering pathological variables only extraprostatic extension of the primary tumor was an independent predictor of any positive surgical margin (HR 11.852, p <0.001) and posterolateral positive surgical margins (HR 7.484, p <0.001) in the series. Of those patients with organ confined disease positive surgical margins were present in 21 (10.6%). Only perineural invasion was an independent predictor of any positive surgical margin (HR 4.096, p = 0.028) while a not statistically significant trend was identified with regard to posterolateral positive surgical margins (HR 6.938, p = 0.067). Pathological extension of the primary tumor was the most relevant predictor of positive surgical margins. In patients with organ confined disease the presence of perineural invasion was significantly associated with positive surgical margins.

Operator is an Independent Predictor of Detecting Prostate Cancer at Transrectal Ultrasound Guided Prostate Biopsy

We investigated whether interoperator differences exist in the setting of prostate cancer detection by transrectal ultrasound guided prostate biopsy. Our secondary aim was to investigate whether a learning curve exists for prostate cancer detection. A prospective database from 2000 to 2008 including 9,072 transrectal ultrasound guided prostate biopsies at our institution was limited to 4,724 done at initial presentation. Biopsies were performed by 4 uroradiologists. The OR for detecting cancer on transrectal ultrasound guided prostate biopsy was calculated for likely independent prognostic variables, including operator. We also examined the rate of biopsy positivity in increments, comparing the first and last cohorts. The senior radiologist (AT) with the most biopsies (75%) was considered the referent for prostate cancer detection. Univariate and multivariate logistic regression modeling was used to determine significant covariates with p <0.05 deemed relevant. Prostate cancer was detected in 2,331 men (49.3%). Operators performed a median of 514 transrectal ultrasound guided prostate biopsies (range 187 to 3,509) with a prostate cancer detection rate of 43.8% to 52.4% (p = 0.001). Other significant covariates were prostate specific antigen, suspicious lesions on ultrasound, nodule on digital rectal examination, smaller prostate volume and increasing patient age. Operator was a significant multivariate predictor of cancer detection (OR 0.67 to 0.89, p = 0.003). No learning curve was detected and biopsy rates were consistent throughout the series. Significant differences in prostate cancer detection exist among operators who perform transrectal ultrasound guided prostate biopsy even in the same setting. The volume of previously performed transrectal ultrasound guided prostate biopsies does not appear to influence the positive prostate cancer detection rate, nor could a learning curve be identified. Differences in prostate cancer detection among operators are likely related to unknown differences in expertise or technique. Further research is needed.

Evaluation of modern pathological criteria for positive margins in radical prostatectomy specimens and their use for predicting biochemical recurrence

To assess the interpretation of modern criteria for evaluating surgical margins (SMs), by examining the incidence of positive SMs (PSMs) and subsequent biochemical recurrence in a single-surgeon series of radical prostatectomy (RP) at two institutions, as the criteria for determining PSMs after RP are subject to individual interpretation, and this might explain some of the variability in biochemical recurrence rates with different rates of PSMs. We reviewed 301 consecutive perineal RPs by one surgeon (T.K.) at Emory University Hospital (EUH) and the Medical University of South Carolina (MUSC), with each pathology department using modern criteria to evaluate the SMs. The SM status and biochemical recurrence (BCR) were analysed, the latter defined as a prostate-specific antigen level of > or =0.2 ng/mL. There were 158 perineal RPs at EUH followed by 143 at MUSC. PSMs were reported in 39 patients (24.7%) at EUH, whereas six (4.2%) were positive at MUSC. The overall BCR rates were similar between the groups, but BCR within margin-positive cases was 100% at MUSC vs 25.6% at EUH (P < 0.01). The presence of tumour at <1 mm from the margin did not increase the rate of BCR compared to those with obvious negative SMs (P = 0.731). In this single-surgeon series, using the same criteria to evaluate the SMs resulted in significantly different PSM rates and margin-positive BCR rates between the institutions. Although the reason for these differences is difficult to determine, the study shows clearly that tumour within 1 mm of the margin should not be classified as margin-positive.

Association Between Hospital and Surgeon Radical Prostatectomy Volume and Patient Outcomes: A Systematic Review

We examined the association between hospital and surgeon volume, and patient outcomes after radical prostatectomy. Databases were searched from 1980 to November 2007 to identify controlled studies published in English. Information on study design, hospital and surgeon annual radical prostatectomy volume, hospital status and patient outcome rates were abstracted using a standardized protocol. Data were pooled with random effects models. A total of 17 original investigations reported patient outcomes in categories of hospital and/or surgeon annual number of radical prostatectomies, and met inclusion criteria. Hospitals with volumes above the mean (43 radical prostatectomies per year) had lower surgery related mortality (rate of difference 0.62, 95% CI 0.47-0.81) and morbidity (rate difference -9.7%, 95% CI -15.8, -3.6). Teaching hospitals had an 18% (95% CI -26, -9) lower rate of surgery related complications. Surgeon volume was not significantly associated with surgery related mortality or positive surgical margins. However, the rate of late urinary complications was 2.4% lower (95% CI -5, -0.1) and the rate of long-term incontinence was 1.2% lower (95% CI -2.5, -0.1) for each 10 additional radical prostatectomies performed by the surgeon annually. Length of stay was lower, corresponding to surgeon volume. Higher provider volumes are associated with better outcomes after radical prostatectomy. Greater understanding of factors leading to this volume-outcome relationship, and the potential benefits and harms of increased regionalization is needed.

Predicting an Optimal Outcome After Radical Prostatectomy: The Trifecta Nomogram

The optimal outcome after radical prostatectomy for clinically localized prostate cancer is freedom from biochemical recurrence along with the recovery of continence and erectile function, a so-called trifecta. We evaluated our series of open radical prostatectomy cases to determine the likelihood of this outcome and develop a nomogram predicting the trifecta. We reviewed the records of patients undergoing open radical prostatectomy for clinical stage T1c-T3a prostate cancer at our center during 2000 to 2006. Men were excluded if they received preoperative hormonal therapy, chemotherapy or radiation therapy, if pretreatment prostate specific antigen was more than 50 ng/ml, or if they were impotent or incontinent before radical prostatectomy. A total of 1,577 men were included in the study. Freedom from biochemical recurrence was defined as post-radical prostatectomy prostate specific antigen less than 0.2 ng/ml. Continence was defined as not having to wear any protective pads. Potency was defined as erection adequate for intercourse upon most attempts with or without phosphodiesterase-5 inhibitor. Mean patient age was 58 years and mean pretreatment prostate specific antigen was 6.4 ng/ml. A trifecta outcome (cancer-free status with recovery of continence and potency) was achieved in 62% of patients. In a nomogram developed to predict the likelihood of the trifecta baseline prostate specific antigen was the major predictive factor. Area under the ROC curve for the nomogram was 0.773 and calibration appeared excellent. A trifecta (optimal) outcome can be achieved in most men undergoing radical prostatectomy. The nomogram permits patients to estimate preoperatively their likelihood of an optimal outcome after radical prostatectomy.

Do Margins Matter? The Prognostic Significance of Positive Surgical Margins in Radical Prostatectomy Specimens

Purpose The prognostic significance of positive surgical margins (PSM) in radical prostatectomy (RP) specimens remains unclear. While most studies have concluded that a PSM is an independent adverse prognostic factor, others report that surgical margin status has no effect on prognosis. One reason for these discordant conclusions is the variable number of patients with a PSM who receive adjuvant therapy and the differing statistical methods used to account for the effects of the time course of adjuvant treatment on recurrence. We evaluated the prognostic significance of PSMs using multiple methods of analysis accounting for patients who received adjuvant therapy. Materials and Methods We analyzed 1,389 consecutive patients with clinical stage T1–3 prostate cancer treated with RP by 2 surgeons from 1983 to 2000. Of 179 patients with a PSM, 37 received adjuvant therapy (AT), 29 radiation therapy and 8 received hormonal therapy. Because the method used to account for men receiving AT can affect the outcome of the analysis, data were analyzed by the Cox proportional hazards technique accounting for patients receiving AT using 5 methods: 1) exclusion, 2) inclusion (AT ignored), 3) censoring at time of AT, 4) failing at time of AT and 5) considering AT as a time dependent covariate. Results Overall 179 patients (12.9%) had a PSM, including 6.8% of 847 patients with pT2 and 23% of 522 patients with pT3 disease. A PSM was a significant predictor of cancer recurrence when analyzed using methods 1, 3, 4 and 5 (p=0.005, p=0.014, p=0.0005, p=0.002, respectively). However, it was not a predictor of recurrence using method 2 in which AT was ignored (p=0.283). Using method 5 multivariate analysis demonstrated that a PSM (p=0.002) was an independent predictor of 10-year progression-free probability (PFP) along with Gleason score (p=0.0005), extracapsular extension (p=0.0005), seminal vesicle invasion (p <0.0005), positive lymph nodes (p <0.0005) and preoperative serum prostate specific antigen (p <0.0001). Using method 5 the 10-year PFP was 58% ± 12% and 81% ± 3% for patients with and without a PSM, respectively (p <0.00005). The relative risk of recurrence in men with a PSM using method 5 was 1.52 (95% confidence interval 1.06–2.16). Conclusions We confirm that a PSM has a significant adverse impact on PFP after RP in multivariate analysis using multiple statistical methods to account for patients who received AT. While prostate cancer screening strategies have resulted in a majority of men having organ confined disease at RP, surgeons should continue to strive to reduce the rate of positive surgical margins to improve cancer control outcomes.

Do Margins Matter? The Prognostic Significance of Positive Surgical Margins in Radical Prostatectomy Specimens

Do Margins Matter? The Prognostic Significance of Positive Surgical Margins in Radical Prostatectomy Specimens

Are positive surgical margins in radical prostatectomy specimens an independent prognostic marker?

A positive surgical margin (PSM) is considered an adverse prognostic indicator in patients undergoing radical prostatectomy (RP). However, there are discrepancies among studies concerning the effect of PSM on prognosis. In addition, the significance of PSM location and extent is uncertain. The aim of this study was to examine the impact of surgical margin status on serum prostate-specific antigen (sPSA) relapse in men consecutively receiving RP in a non-screened population. In total, 219 prostatectomy specimens were examined microscopically. The mean follow-up time was 62 months (range 6-121 months). Tumour grade (Gleason score), pathological tumour stage and tumour involvement of the surgical margins were recorded. The 71 specimens with one or more PSM were re-examined with regard to location, number of locations and total linear extent of PSM. Kaplan-Meier plots and Cox proportional hazards regression were used in the univariate analyses. Multivariate analyses controlling for the known preoperative sPSA, pathological stage and Gleason score were also performed, using Cox proportional hazards regression. In the univariate analyses, PSM without regard to location, PSM at the anterior prostate or at the apex, PSM at three or more locations and linear extent of PSM > or =6mm were associated with a statistically significant higher hazard ratio of PSA relapse. However, none of these variables remained statistically significant when controlling for the known risk factors. In this non-screened prostate cancer population PSM status (linear extent, location and number of locations) had an impact on postoperative sPSA recurrence. In multivariate analyses PSM showed a strong trend (p approximately 0.06) towards having an independent statistically significant negative influence on the risk of PSA relapse following RP.

Prognostic Significance of Location of Positive Margins in Radical Prostatectomy Specimens

Cancer at the resection margin is associated with an increased risk of biochemical recurrence after radical prostatectomy (RP) even after adjusting for other known clinical and pathologic risk factors. In this study, we assessed the prognostic significance of sites of positive surgical margins (+SMs) in RP specimens. We reviewed the data from 2442 patients with clinical Stage T1-T3 prostate cancer treated with RP from 1983 to 2004 who had had tumor maps generated from whole mount sections. The site of +SMs was assigned to six different areas (apex, bladder neck, seminal vesicle, anterior, posterolateral, and posterior). Of the 2442 patients, 201 (8.2%) had a +SM at a single site and 74 (3.0%) had a +SM at multiple sites in the RP specimen. The posterolateral and apex sections were the most commonly involved sites for a +SM. Those with a +SM had a greater risk of biochemical recurrence than those with negative surgical margins (hazard ratio 1.39, 95% confidence interval 1.004 to 1.92; P = 0.047). We found that a +SM at the posterolateral site was significantly associated with an increased risk of biochemical recurrence (hazard ratio 2.80 for +SMs versus negative SMs at the posterolateral region; 95% confidence interval 1.76 to 4.44). The effect on biochemical recurrence was influenced by the site of the +SM, with a posterolateral location having the most significant effect on prognosis. This heterogeneity of margin status has implications for predictive modeling, as well as the recommendation for adjuvant radiotherapy.

Positive Surgical Margins in Soft Tissue Following Radical Cystectomy for Bladder Cancer and Cancer Specific Survival

We evaluated risk factors for positive soft tissue surgical margins and the impact of soft tissue surgical margins on metastatic progression and disease specific survival in patients treated with radical cystectomy for bladder cancer. A total of 1,589 patients who underwent radical cystectomy for primary urothelial cancer at our institution were included in the study. Several variables were analyzed including gender, age, use of perioperative chemotherapy, tumor stage, tumor grade, presence of carcinoma in situ, pathological vascular invasion, bladder pathology, status of soft tissue surgical margins, lymph node status, number of lymph nodes removed and number of positive lymph nodes. End points were freedom from progression to metastases and disease specific survival. Positive soft tissue surgical margins were detected in 67 patients (4.2%). Risk factors for positive soft tissue surgical margins were female gender (p = 0.04), pathological stage, vascular invasion in the radical cystectomy specimen, lymph node metastases (all p < or = 0.001) and median number of positive lymph nodes (p = 0.002). In addition, nonpure transitional cell carcinoma histology (p = 0.001) was associated with positive soft tissue surgical margins. In the 5 years after cystectomy, rates of disease specific survival for the negative and positive soft tissue surgical margin groups were 72% (95% CI 69-75) and 32% (95% CI 19-54), respectively. On multivariate analysis disease specific death was associated with tumor stage, positive soft tissue surgical margins, vascular invasion, presence of positive lymph nodes, number of nodes removed and number of positive nodes. Risk factors for positive soft tissue surgical margins are female gender, locally advanced cancer, presence of vascular invasion and mixed histology. Patients with positive soft tissue surgical margins have poor prognosis, and positive soft tissue surgical margins were found to be independently associated with disease specific death.

Clinical Significance of Benign Glands at Surgical Margins in Robotic Radical Prostatectomy Specimens

Completion of robotic radical prostatectomy compared with conventional open retropubic radical prostatectomy can result in different alterations in the prostatectomy specimens. One difference appears to be an increased incidence of benign glands at the margins, which has been associated with an increase in postoperative prostatic-specific antigen (PSA) levels. We compared the frequency and clinical significance of benign prostate glands at the surgical margins in radical prostatectomy specimens obtained by robotic versus open retropubic prostatectomy. We reviewed 38 consecutive prostatectomy specimens from patients with biopsy-proven prostate cancer. Of these 38 specimens, 25 (65%) were obtained by robotic resection and 13 (35%) by open retropubic prostatectomy. Each case was analyzed for Gleason score, pathologic stage, including margin status, and the presence or absence of benign glands at the surgical margin. The study endpoint was the postoperative serum PSA level. A significantly greater incidence (P = 0.035) of benign glands at the surgical margins was found within the robotic group compared with the open retropubic prostatectomy group (54% versus 15%). With a median follow-up of 12.5 months for the robotic group and 24.5 months for the robotic prostatectomy group, only 2 patients, who also had had positive surgical margins, had a continued and persistent increase in the postoperative PSA level after an initial nadir. The early clinical follow-up data of our study have suggested that patients undergoing robotic radical prostatectomy with negative surgical margins achieve a PSA nadir of less than 0.1 ng/mL, irrespective of the presence or absence of benign prostatic tissue at the surgical margins.

Do Tumor Volume, Tumor Volume Ratio, Type of Nerve Sparing and Surgical Experience Affect Prostate Specific Antigen Recurrence After Laparoscopic Radical Prostatectomy? A Matched Pair Analysis

We assessed the impact of tumor volume, tumor volume ratio (tumor volume-to-prostate volume), surgical experience and type of nerve sparing procedure on biochemical recurrence after laparoscopic radical prostatectomy. Of 1,600 laparoscopic radical prostatectomies performed between March 1999 and May 2006 we evaluated 555 patients who had at least 24 months of followup and received neither neoadjuvant nor adjuvant therapy. Of 555 patients 81 had biochemical recurrence and were match paired in 3 groups with those without recurrence. Matching decisions were based on factors such as age, preoperative prostate specific antigen, pathological stage, Gleason score, surgical margin status with localization, tumor volume, type of nerve sparing procedure, surgeon and date of operation that are related to surgical experience. We evaluated the impact of tumor volume and tumor volume ratio, type of nerve sparing procedure and surgeon on biochemical recurrence, and excluded the factor being investigated in each matched pair. Tumor volumes were 3.58 vs 3.3 cc and tumor volume ratios were 0.081 vs 0.071 in the biochemical recurrence and no biochemical recurrence groups, respectively (p=0.026 and p=0.040). At the second match pair the numbers of nonnerve sparing, unilateral and bilateral nerve sparing procedures were 65, 12 and 4 vs 62, 13 and 6, respectively, without statistical significance. At the last match pair the volume of cases for the first generation and the other generations were 56 and 25 vs 59 and 22, respectively, also without statistical significance. Although surgical experience based on an adequate training program and type of nerve sparing procedure do not have a significant impact on biochemical recurrence, tumor volume and tumor volume ratio do.