Positive Margin Rate Research Articles

Efficacy of Degarelix in the Neoadjuvant Setting in Managing Locally Advanced Prostate Cancer.

Background Prostate cancer holds a substantial presence in the global cancer landscape, and a considerable proportion of diagnoses occur at late stages, particularly in India. Management of locally advanced prostate cancer necessitates a multimodal treatment strategy. A critical part of this strategy is neoadjuvant androgen deprivation therapy, typically administered via luteinizing hormone-releasing hormone (LHRH) analogs. This study explores the potential of an alternative approach: neoadjuvant therapy with degarelix, an LHRH antagonist, and its impact on perioperative and postoperative outcomes in patients undergoing radical prostatectomy for locally advanced or high-risk prostate cancer. Methodology We conducted a retrospective, non-randomized clinical study at Apollo Hospitals in Chennai, India. Patients diagnosed with locally advanced or high-risk prostate cancer who underwent radical prostatectomy were included. Participants were patients treated with neoadjuvant degarelix and subsequent radical prostatectomy between March 2020 and June 2022. We excluded patients receiving radical radiotherapy, those switching from LHRH agonists to antagonists, and those contraindicated for androgen deprivation therapy due to existing comorbidities. For comparison, we selected a group from the institutional database who received conventional treatment (i.e., without neoadjuvant therapy). Results The study compared two groups, each with 32 patients. The groups had no significant difference in total operative duration and console times. The postoperative pathological assessment showed significantly lower margin positivity rates and notable pathological downstaging in the group receiving neoadjuvant degarelix compared to the control group. The incidence of node positivity, prostate-specific antigen levels at three months postoperative, and number of pads used per day at one month did not differ significantly between the two groups. Conclusions Our study suggests that neoadjuvant degarelix could notably enhance patient outcomes in locally advanced prostate cancer management. The benefits include improved symptom control, significant reductions in margin positivity rates, and facilitated surgical procedures. Neoadjuvant degarelix therapy could potentially enhance the feasibility of the surgical intervention in locally advanced prostate cancer management, thus suggesting a promising pathway for improved patient care.

Hypertension Linked to Worse Upper Tract Urothelial Cancer Outcomes

Hypertension Linked to Worse Upper Tract Urothelial Cancer Outcomes

Transperitoneal Versus Retroperitoneal Robotic-Assisted Partial Nephrectomy in Patients with Obesity.

Introduction: We aim to compare transperitoneal (TP) and retroperitoneal (RP) robotic partial nephrectomy (RPN) in obese patients. Obesity and RP fat can complicate RPN, especially in the RP approach where working space is limited. Materials and Methods: Using a multi-institutional database, we analyzed 468 obese patients undergoing RPN for a renal mass (86 [18.38%] RP, 382 [81.62%] TP). Obesity was defined as body mass index ≥30 kg/m2*. A 1:1 propensity score matching was performed adjusting for age, previous abdominal surgery, tumor size, R.E.N.A.L nephrometry score, tumor location, surgical date, and participating centers. Baseline characteristics and perioperative and postoperative data were compared. Results: In the propensity score-matched cohort, 79 (50%) TP patients were matched with 79 (50%) RP patients. The RP group had more posterior tumors (67 [84.81%], RP versus 23 [29.11%], TP; P < .001), while the other baseline characteristics were comparable. Warm ischemia time (interquartile range; 15 [10, 12], RP versus 14 [10, 17] minutes, TP; P = .216), operative time (129 [116, 165], RP versus 130 [95, 180] minutes, TP; P = .687), estimated blood loss (50 [50, 100], RP versus 75 [50, 150] mL, TP; P = .129), length of stay (1 [1, 1], RP versus 1 [1, 2] day, TP; P = .319), and major complication rate (1 [1.27%], RP versus 3 [3.80%], TP; P = .620) were similar. No significant difference was observed in positive surgical margin rate and delta estimated glomerular filtration at follow-up. Conclusion: TP and RP RPN yielded similar perioperative and postoperative outcomes in obese patients. Obesity should not be a factor in determining optimal approach for RPN.

The Impact of Prostate Volume in Open Radical Prostatectomy: A Single Centre Experience

BackgroundEven the most experienced surgeons experience technical difficulties and challenges when operating on very large prostates, regardless of surgical technique. Our goal was to determine whether preoperative prostate volume has an impact on functional and oncological outcomes after open radical prostatectomy. Materials and MethodsWe reviewed the records of 909 patients who underwent open radical prostatectomy by a single surgeon at our institution. Variables were compared across quartile distributions of prostate volume as defined by preoperative transrectal ultrasound examination, including group A with prostate volume < 30ccm 3, group B with prostate volume ≥ 30ccm 3 and < 50ccm 3, group C with prostate volume ≥ 50ccm 3 and < 70ccm 3 and group D with prostate volume ≥ 70ccm3. Factors assessed in this analysis were patient age, preoperative prostate specific antigen (p-PSA), Gleason score, pathological stage, margin status, operative time, cystography leakage, early continence, biochemical recurrence (BCR)-free, and overall-survival (OS). The complication rates were classified using Clavien Dindo classification. ResultsThere were no statistically relevant differences between the groups considering preoperative factors such as age, p-PSA, Gleason score, and tumor stadium. Patients with a very large prostate had slightly higher percentage of anastomosis leakage, severe Clavien Dindo complication rates (≥ 3), longer operation time and severe early incontinence (IV°) rates, simultaneously having lower positive margin rates. Nevertheless, the early continence rates, BCR-free and OS were similar regardless of the prostate size. Conclusionsopen radical prostatectomy for patients with very large prostate is a viable therapy option with slightly higher urinary leakage-, early incontinence- and complication-rates that takes slightly more operation time. However, the functional and oncological outcomes are similar when compared to smaller prostates.

Robotic-assisted tumor enucleation versus robotic-assisted partial nephrectomy for intermediate and high complexity renal cell carcinoma: a single-institution experience

ObjectivesTo compare the perioperative and oncological outcomes of robotic-assisted tumor enucleation (RATE) and robotic-assisted partial nephrectomy (RAPN) in the treatment of intermediate and high complexity renal cell carcinoma (RCC).MethodsWe retrospectively collected the data of 359 patients with intermediate and high complexity RCC who underwent RATE and RAPN. The perioperative, oncological, and pathological outcomes of the two groups were compared, and univariate and multivariate analyses were used to evaluate the risk factors for warm ischemia time (WIT) > 25 min.ResultsCompared with RAPN group, patients in RATE group had shorter operative time (P < 0.001), shorter WIT (P < 0.001), and less estimated blood loss (EBL) (P < 0.001). The decrease rate of estimated glomerular filtration rate (eGFR) in RATE group was better than that in RAPN group (P < 0.001). Multivariable analysis showed that RAPN and higher PADUA score were independent risk factors for WIT > 25 min (both P < 0.001). The rate of positive surgical margin was similar between the two groups, but the local recurrence rate of the RATE group was higher than that of the RAPN group (P = 0.027).ConclusionsRATE and RAPN have similar oncological outcomes for the treatment of intermediate and high complexity RCC. In addition, RATE was superior to RAPN in perioperative outcomes.

Surgeon Quality and Patient Survival After Resection for Non-Small-Cell Lung Cancer.

The quality and outcomes of curative-intent lung cancer surgery vary in populations. Surgeons are key drivers of surgical quality. We examined the association between surgeon-level intermediate outcomes differences, patient survival differences, and potential mitigation by processes of care. Using a baseline population-based surgical resection cohort, we derived surgeon-level cut points for rates of positive margins, nonexamination of lymph nodes, nonexamination of mediastinal lymph nodes, and wedge resections. Applying the baseline cut points to a subsequent cohort from the same population-based data set, we assign surgeons into three performance categories in reference to each metric: 1 (<25th percentile), 2 (25th-75th percentile), and 3 (>75th percentile). The sum of performance scores created three surgeon quality tiers: 1 (4-6, low), 2 (7-9, intermediate), and 3 (10-12, high). We used chi-squared, Wilcoxon-Mann-Whitney, and Kruskal-Wallis tests to compare patient characteristics between the baseline and subsequent cohorts and across surgeon tiers. We applied Cox proportional hazards models to examine the association between patient survival and surgeon performance tier, sequentially adjusting for clinical stage, patient characteristics, and four specific processes. From 2009 to 2021, 39 surgeons performed 4,082 resections across the baseline and subsequent cohorts. Among 31 subsequent cohort surgeons, five were tier 1, five were tier 2, and 21 were tier 3. Tier 1 and 2 surgeons had significantly worse outcomes than tier 3 surgeons (hazard ratio [HR], 1.37; 95% CI, 1.10 to 1.72 and 1.19; 95% CI, 1.00 to 1.43, respectively). Adjustment for specific processes mitigated the surgeon-tiered survival differences, with adjusted HRs of 1.02 (95% CI, 0.8 to 1.3) and 0.93 (95% CI, 0.7 to 1.25), respectively. Readily accessible intermediate outcomes metrics can be used to stratify surgeon performance for targeted process improvement, potentially reducing patient survival disparities.

The role of image-guided volume-adapted high-dose-rate endorectal brachytherapy boost in total neoadjuvant treatment of distal locally advanced rectal cancer.

3611 Background: Endorectal brachytherapy has been used as palliative or preoperative treatment for advanced or locally advanced rectal cancer, with moderate radiation induced toxicity. This study aimed to explore the efficacy of high-dose-rate 192Ir brachytherapy combined with external beam radiotherapy (EBRT) in total neoajuvant treatment (TNT) of distal rectal cancer. Methods: From January 2017 to December 2022, eligible rectal adenocarcinoma patients were assessed as clinical stage II -III, with primary tumor located in distal rectum (≤5 cm from anal verge). The local staging was determined using endorectal ultrasound and magnetic resonance imaging (MRI). In addition, cases included in this study underwent preoperative semiweekly endorectal brachytherapy of 8-12Gy/2-3F/1-1.5w, followed by EBRT of 45-50.4Gy/25-28F, fluorouracil-based concurrent and consolidation chemotherapy. The brachytherapy was image-guided volume-adapted, and delivered by multi-channel 192Ir source applicators with different diameters. Radiation proctitis was graded from 0 to 4 using Radiation Therapy Oncology Group (RTOG) criteria. Results: A total of 40 cases were enrolled in this retrospective study, biopsy-proven and diagnosed as clinical stage II (n = 8), stage III (n = 32). The rates of T4 and positive circumferential resection margin (CRM) were 35% and 87.5% respectively. The median value of the interval from completion of radiotherapy to operation was 86 days (interquartile range: 75-98 days). After neoadjuvant treatment, 2 cases were undergoing the watch-and-wait strategy with sustained clinical complete response (cCR), 38 patients received operation and R0 resection rate was 97.4%. The pathological complete response (pCR) rate was 28.9%, and major pathological regression rate was 67.5%. The theoretical rate of anus preservation was 62.5%, including 6 of 21 cases underwent abdominoperineal resection but achieved pCR, 17 cases underwent low anterior resection or intersphincteric resection, and 2 cases with sustained cCR. After a median follow-up of 37 months (range 12-68 months), the 3-year disease-free survival, local-regional reccurence-free survival and overall survival was 81.1% (95%CI: 64.3%-91.2%), 94.9% (95%CI: 80.6%-98.5%) and 96.9% (95%CI: 82.1%-99.4%), respectively. No patients experienced Grade ≥3 radiation proctitis. The median Wexner fecal incontinence score of anus-preserving cases was 1 (range 0-8). Subgroup analysis showed that the complete response rate (pCR or sustained cCR) was lower in cases received 2 fractions brachytherapy than those received 3 fractions (27.8% vs 36.4%). Conclusions: The addition of image-guided volume-adapted high-dose-rate 192Ir endorectal brachytherapy boost to TNT could improve the pathological tumor response and anus preservation rate in distal locally advanced rectal cancer.

Zonal origin of prostate cancer: comparison of long-term outcomes after radical prostatectomy

PurposeTo assess the impact of zonal origin on positive bladder neck (BN) margins and prostate-specific antigen (PSA) failure or early adjuvant therapy in the patients with complete long-term follow-up after radical prostatectomy (RP).MethodsA set of 4512 men were identified who underwent RP in Western Australia (WA) from March 2000 to December 2016 and had complete long-term follow-up. The t-test, Pearson chi-square test and Kaplan–Meier method with the log-rank test were used to evaluate differences between the transition zone (TZ) and peripheral/central zone (PZ/CZ) cancer. Univariate and multivariable Cox proportional hazard regression models were applied to assess parameters on PSA failure and early treatment.ResultsThe positive BN margin rate for TZ cancer fell significantly over the study period. However, BN margin rates increased for PZ/CZ cancer over the time. Data of 4512 patients with median follow-up of 9.1 years confirmed that the high-risk TZ tumours with negative margins had a significant lower rate of PSA failure or early treatment compared to those high-risk PZ/CZ tumours with negative margins.ConclusionProstate cancer zonal origin significantly impacts long-term biochemical outcomes in high-risk and margin-negative patients. BN invasion with margin involvement is more frequent in the TZ cancer and can be reduced by pre-operative identification of cancer zonal origin and adjustment of surgical procedures.

Assessing the Trade-off Between the Safety and Effectiveness of Off-clamp Robotic Partial Nephrectomy for Renal Masses with a High RENAL Score: A Propensity Score–matched Comparison of Perioperative and Functional Outcomes in a Multicenter Analysis

BackgroundTumors with a high nephrometry score represent a challenging surgical scenario for which robotic partial nephrectomy (RPN) is a primary option in expert hands. ObjectiveTo compare perioperative and functional outcomes of off-clamp and on-clamp RPN in patients with renal masses with a high RENAL score (≥9). Design, setting, and participantsFor this retrospective analysis, an RPN data set including 1604 patients treated at three institutions between 2003 and 2021 was queried for cases with a RENAL score ≥9. Outcome measurements and statistical analysisWe used 1:1 propensity score matching (PSM) to select a cohort in which imbalances between the off-clamp and on-clamp groups were minimized. We used χ2 and Student t tests to compare categorical and continuous variables, respectively. The Kaplan-Meier method was used to compare the probability of having an estimated glomerular filtration rate (eGFR) ≥45 ml/min during follow-up. Univariable and multivariable analyses were performed to identify predictors of a trifecta outcome (negative surgical margin status, no Clavien-Dindo grade ≥3 complications, eGFR decline ≤30%) and of retaining eGFR ≥45 ml/min over time. Results and limitationsFrom an overall cohort of 354 patients (142 on-clamp, 212 off-clamp), a homogeneous PSM cohort of 78 patients in each group was selected (p ≥ 0.17). In the PSM cohort, operative time was significantly shorter in the off-clamp group (p < 0.001). There were no differences between the groups in the rates of severe complications (p = 0.32) and positive surgical margins (p = 0.24). The rate of trifecta achievement was significantly higher in the off-clamp group (83.3% vs 67.9%; p = 0.03). Warm ischemia time >20 min was independently negatively associated with trifecta achievement (odds ratio 0.32, 95% confidence interval 0.14–0.74). Moreover, the off-clamp group had a significantly higher probability of retaining eGFR ≥45 ml/min over time (3 yr: 95.9% vs 81.6%; p = 0.03); every 1-min increase in warm ischemia time reduced this probability by 1.3%. ConclusionsWe found a favorable trade-off between the benefits and risks of off-clamp RPN, with similar perioperative outcomes and a net benefit in terms of trifecta achievement and long-term renal function outcomes in comparison to on-clamp RPN. Patient summaryThe complexity of surgery for kidney tumors can be assessed using the RENAL score, which is a measure of the location and size of a kidney tumor. In a multicenter series of patients with tumors with a high RENAL score, we compared outcomes between strategies with (on-clamp) and without (off-clamp) clamping of kidney blood vessels during robot-assisted removal of part of the affected kidney. We found that off-clamp surgery results in better postoperative kidney function.

Trends in Positive Surgical Margins in cT3-T4 Oral Cavity Squamous Cell Carcinoma.

Positive surgical margins in oral cavity squamous cell carcinoma are associated with cost escalation, treatment intensification, and greater risk of recurrence and mortality. The positive margin rate has been decreasing for cT1-T2 oral cavity cancer over the past 2 decades. We aim to evaluate positive margin rates in cT3-T4 oral cavity cancer over time, and determine factors associated with positive margins. Retrospective analysis of a national database. National Cancer Database 2004 to 2018. All adult patients diagnosed between 2004 and 2018 who underwent primary curative intent surgery for previously untreated cT3-T4 oral cavity cancer with known margin status were included. Logistic univariable and multivariable regression analyses were performed to identify factors associated with positive margins. Among 16,326 patients with cT3 or cT4 oral cavity cancer, positive margins were documented in 2932 patients (18.1%). Later year of treatment was not significantly associated with positive margins (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.96-1.00). The proportion of patients treated at academic centers increased over time (OR 1.02, 95% CI 1.01-1.03). On multivariable analysis, positive margins were significantly associated with hard palate primary, cT4 tumors, advancing N stage, lymphovascular invasion, poorly differentiated histology, and treatment at nonacademic or low-volume centers. Despite increased treatment at academic centers for locally advanced oral cavity cancer, there has been no significant decrease in positive margin rates which remains high at 18.1%. Novel techniques for margin planning and assessment may be required to decrease positive margin rates in locally advanced oral cavity cancer.

Network meta-analysis comparing the clinical outcomes and safety of robotic, laparoscopic, and transanal total rectal mesenteric resection for rectal cancer

Objective: To methodically assess the clinical effectiveness and safety of robot-assisted total rectal mesenteric resection (RTME), laparoscopic-assisted total rectal mesenteric resection (laTME), and transanal total rectal mesenteric resection (taTME). Methods: A computer search was conducted on PubMed, Embase, Cochrane Library, and Ovid databases to identify English-language reports published between January 2017 and January 2022 that compared the clinical efficacy of the three surgical procedures of RTME, laTME, and taTME. The quality of the studies was evaluated using the NOS and JADAD scales for retrospective cohort studies and randomized controlled trials, respectively. Direct meta-analysis and reticulated meta-analysis were performed using Review Manager software and R software, respectively. Results: Twenty-nine publications comprising 8,339 patients with rectal cancer were ultimately included. The direct meta-analysis indicated that the length of hospital stay was longer after RTME than after taTME, whereas according to the reticulated meta-analysis the length of hospital stay was shorter after taTME than after laTME (MD=-0.86, 95%CI: -1.70 to -0.096, P=0.036). Moreover, the incidence of anastomotic leak was lower after taTME than after RTME (OR=0.60, 95%CI: 0.39 to 0.91, P=0.018). The incidence of intestinal obstruction was also lower after taTME than after RTME (OR=0.55, 95%CI: 0.31 to 0.94, P=0.037). All of these differences were statistically significant (all P<0.05). There were no statistically significant differences between the three surgical procedures regarding the number of lymph nodes cleared, length of the inferior rectal margin, or rate of positive circumferential margins (all P>0.05). An inconsistency test using nodal analysis revealed no statistically significant differences between the results of direct and indirect comparisons of the six outcome indicators (all P>0.05). Furthermore, we detected no significant overall inconsistency between direct and indirect evidence. Conclusion: taTME has advantages over RTME and laTME, in terms of radical and surgical short-term outcomes in patients with rectal cancer.

Oncologic safety of breast conservation following NACT in women with locally advanced breast cancer.

Breast conservation surgery (BCS) is the accepted standard of treatment for early breast cancer, with evidence from randomized controlled and population-based studies. The oncological outcome of BCS in locally advanced breast cancer (LABC) is mainly available from retrospective series with a small sample size and a shorter follow-up duration. A retrospective observational study of 411 non-metastatic LABC patients who received neoadjuvant chemotherapy (NACT) followed by surgery from 2011 to 2016. We retrieved the data from a prospectively maintained database and electronic medical records. Survival data were analyzed by Kaplan-Meier curves and Cox regression using Statistical Package for the Social Sciences 25 and STATA 14. 146/411 (35.5%) women had BCS with a margin positivity rate of 3.42%. With a median follow-up of 64 months (IQR 61, 66), the local relapse rate was 8.9% in BCS and 8.3% after mastectomy. The estimated 5-year locoregional recurrence-free survival (LRFS), recurrence-free survival (RFS), distant disease-free survival (DDFS) and overall survival (OS) rates of BCS were 86.9%, 63.9%, 71% and 79.3%, and 90.1%, 57.9%, 58.3% and 71.5% in the mastectomy group. On univariate analysis, BCS showed superior survival outcomes compared to mastectomy (unadjusted HR (95% CI) for RFS: 0.70 (0.50-1), DDFS: 0.57 (0.39-0.84), OS: 0.58 (0.36-0.93)). After adjusting for age, cT stage, cN stage, poorer chemotherapy response (ypT0/is, N0) and radiotherapy, BCS and mastectomy groups were found comparable in terms of LRFS (HR: 1.1, 0.53-2.3), DDFS (HR: 0.67, 0.45-1.01), RFS (HR: 0.80, 0.55-1.17) and OS (HR: 0.69, 0.41-1.14). BCS is technically feasible in LABC patients. LABC patients who respond well to NACT can be offered BCS without compromising survival outcomes.

Robot-assisted nipple-sparing mastectomy and immediate breast reconstruction with gel implant and latissimus dorsi muscle flap: Our initial experience.

This study reports the preliminary results of da Vinci robot XI robot-assisted nipple-sparing mastectomy immediate breast reconstruction (R-NSMIBR) with gel implant and latissimus dorsi muscle flap. A total of 15 patients who underwent R-NSMIBR with gel implant and latissimus dorsi muscle flap surgery for breast cancer between September 2022 and November 2022 were evaluated. Mean total operative time for R-NSMIBR was 361.9±77.0min. As the learning curve increased, the robot arm docking time decreased rapidly from the initial 25-10min. Average total blood loss was 27.8±10.7mL and posterior surgical margin positivity rate was 0%. Perioperative complications and local recurrences or deaths were not observed at a mean follow-up of 3±1month 15 patients were satisfied with postoperative aesthetic results. R-NSMIBR with a gel implant and latissimus dorsi muscle flap could be a new therapeutic option for breast reconstruction.

O074 Localisation using multiple magnetic seeds in unilateral breast surgery: a report of clinical and radiological outcomes in a tertiary breast cancer centre

Abstract Introduction Magnetic seeds (Magseeds) are becoming increasingly used as a method of localising non-palpable breast lesions. The cost effectiveness and reduced scheduling conflicts in comparison with wire localization has led to increased popularity in recent years. There's a paucity of data on outcomes when using multiple magseeds in one breast. In this study, we assess the radiological, operative and pathological outcomes of inserting multiple magseeds in the same breast. Methods A retrospective analysis of all magseed guided excisions preformed at the MMUH breast surgery department between January 2020 and December 2022. 40 patients with more than one magseed inserted unilaterally were included. Primary outcome measures were successful excision of lesion(s) and magseed retrieval. Secondary outcomes included re-excision rate and perioperative complications. Results The mean distance between magseeds was 48.3 and 42.5 mm on ML and CC views respectively. 9/40 used magseeds for bracketing while the rest used for excision of discrete lesions. Mean operative time was 56.65 minutes and 55% of the procedures were wide local excisions. There was no reported difficulties identifying magseeds intra-operatively or in the specimen mammogram. The mean specimen size is 33.42 mm while the mean size of the final lesion is 15.49 mm. Invasive ductal carcinoma was the commonest pathological outcome. The rate of positive margins was 20% and re-excision was 15%. One patient proceeded to completion mastectomy. Conclusion Multiple magseed localisation is a feasible, safe and effective method when utilized in bracketing a unifocal lesion or separate lesion excisions in unilateral breast surgery.

O046 Reduction of surgical complications via 3D printed/virtual models available during (robotic-assisted) radical prostatectomy

Abstract Introduction Prostate cancer is the leading cancer in males in the UK and mostly treated via robotic-assisted radical prostatectomy (RARP). The prognosis of prostate cancer is promising especially if detected early. Studies have shown that the use of 3D patient-specific models has positive effects on surgical outcomes in other fields. This systematic review aims to assess whether 3D printed and virtual models reduce surgical complications for patients undergoing RARP. Methods This study was a systematic review conducted using PRISMA guidelines from comprehensive databases - PubMed and Medline. These were then screened using an inclusion and exclusion criteria, to remove papers that were not relevant to the research question. Last, each abstract was screened for relevancy and duplicates were removed. Results A total of 201 patients had the use of 3D patient-specific modelling of the prostate to aid in surgery. Across all studies, a decrease in positive surgical margin rates was reported, indicating better outcomes for patients. However, no statistically significant difference was found between intervention and control groups, in nerve sparing, bladder neck sparing and postoperative SHIM score. A decrease in detectable PSA was found in intervention groups. Furthermore, the use of 3D models did lead to more surgeons changing the pre-operative plan, suggesting that 3D modelling enhances surgical planning – leading to potentially improved outcomes. Conclusion The use of 3D modelling has positive outcomes for patients undergoing RARP, however, the extent is still unclear as research in this area remains limited.

Delayed Esophagectomy is Associated With Inferior Survival: A National Cancer Database Study

Background: Locoregionally advanced esophageal cancer is typically treated with neoadjuvant chemoradiation followed by surgery 4 to 8 weeks later. Occasionally surgery is delayed &gt;12 weeks; outcomes of this approach are not well studied. We hypothesized that delayed esophagectomy after chemoradiation would have inferior long-term overall survival relative to planned trimodality esophagectomy. Methods: Adult patients with locally advanced esophageal cancer (T2−4aN0M0, T0−4aN+M0) who received multi-agent chemotherapy, radiation, and esophagectomy were identified in the 2018 National Cancer Database. Esophagectomy performed within 90 days from end of chemoradiation were categorized as “trimodality” and those ≥90 days were categorized as “delayed.” Primary outcome was overall survival measured using Kaplan-Meier estimates and Cox proportional hazard models. Secondary outcomes included surgical margin status, hospital length of stay, and readmission. Results: Included were 19 698 patients, 3905 (19.8%) “delayed.” Median time to surgery for trimodality patients was 51 days (IQR 41-63) versus 110 days (IQR 98-131) for delayed patients. Delayed patients tended to be older, non-white, have non-private insurance, and have more comorbidities. Overall survival was shorter for delayed patients (34.8 months) versus trimodality patients (43.1 months, P ≤ .001). In multivariable analysis, delay was associated with inferior overall survival (HR 1.15, 95% CI 1.08-1.23). Length of stay and readmission rate were similar between cohorts, but delay was associated with a higher rate of positive surgical margins (6.7% vs 4.6%, P ≤ .001). Conclusions: In the National Cancer Database, delayed esophagectomy is associated with inferior long-term survival. Nonetheless, delayed esophagectomy may be appropriate for select patients; further research is needed to identify the optimal approach.

Transition from standard robotic prostatectomy to Retzius-sparing prostatectomy: feasibility and early outcomes.

Retzius-sparing robotic-assisted radical prostatectomy (rsRARP) has gained popularity due to superior early continence outcomes compared to standard robotic prostatectomy (sRARP). We evaluate the results of a single surgeon who transitioned from sRARP to rsRARP and compare oncologic and functional outcomes. We retrospectively reviewed all prostatectomies performed by a single surgeon between June 2018 and October 2020. Perioperative, oncologic, and functional data were collected and analyzed. Patients who underwent sRARP were compared with those who underwent rsRARP. Both groups contained 37 consecutive patients each. Preoperative patient characteristics and biopsy results were similar between the two groups. Perioperative outcomes were significant for longer operative room time and higher proportion of T3 tumors in the rsRARP group. Thirty-day complication and readmission rates were similar between groups. There was no difference in early oncologic outcomes, including positive surgical margin rate, biochemical recurrence, and need for adjuvant or salvage treatments. The time to urinary continence and immediate continence rate was superior in the rsRARP group. The Retzius-sparing approach can be safely adopted by surgeons experienced in sRARP without compromising early oncologic outcomes and with the benefit of improved early continence recovery.

Risk Factors for Positive Margins in Breast-Conserving Surgery.

Introduction Breast-conserving surgery (BCS) followed by adjuvant radiotherapy has similar overall survival compared to mastectomybut is associated with higher rates of local recurrence. Positive surgical margins in BCS are the most important predictor of local recurrence. The aim of our study was to assess the risk factors associated with positive margins in women undergoing BCS for breast cancerin order to inform our clinical practice and minimize re-operation rates. Methods Patients with a diagnosis ofbreast cancer who underwent BCS from January 2013 to January 2021 were identified from our pathology database and included in the study. All patients underwent a lumpectomy with the removal of additional shaved cavity margins. Statistical analysis was used toassess the effect of patient clinical and pathological risk factors on the rate of positive margins. Results One hundred and twenty patients underwent BCS for breast cancer. Twenty-four percent of patients had positive margins. Of the 29 patients that underwent subsequent re-excisions, only 13 (45%) hadresidual disease in the re-excision specimen. In younger patients, tumors localized in lower quadrants and the presence of extensive intraductal component within invasive breast cancer increased the risk of positive margins. In addition, positive margins were encountered more significantly in patients with ductal carcinoma in situ (DCIS) compared to invasive tumors. Multivariate analysis showed that DCIS and young age were the only factors independently associated with positive margins. Conclusion DCIS and younger patients have a higher rate of positive margins during BCS than invasive breast cancer. For such patients at higher risk of positive margins, excision of cavity shave margins and intraoperative inking may be done to lower positive margin rates.Preoperative review of breast imaging, core biopsies, and counseling of patients about the likelihood of positive margins is important.

Fluorescence in prostate cancer surgery

Prostate cancer is different from many other solid tumours, mainly because of its multifocal growth pattern, which precludes a conservative approach during surgery. 1 Mottet N van den Bergh RCN Briers E et al. EAU-EANM-ESTROESUR-SIOG guidelines on prostate cancer—2020 update. Part 1: screening, diagnosis, and local treatment with curative intent. Eur Urol. 2021; 79: 243-262 Summary Full Text Full Text PDF PubMed Scopus (931) Google Scholar Moreover, even when spread to the locoregional lymph nodes, it cannot always be clearly identified during surgery. This has led to two different surgical management scenarios. For organ-confined disease, the inability to identify the boundaries of the tumour within the gland makes the radical excision of the gland necessary, which has a substantial effect on patients’ postoperative functional outcomes and leading to a not negligible rate of positive surgical margins. 2 Lane JA Donovan JL Davis M et al. Active monitoring, radical prostatectomy, or radiotherapy for localised prostate cancer: study design and diagnostic and baseline results of the ProtecT randomised phase 3 trial. Lancet Oncol. 2014; 15: 1109-1118 Summary Full Text Full Text PDF PubMed Scopus (179) Google Scholar For locally advanced disease involving locoregional lymph nodes, the inability to intraoperatively identify metastatic lymph nodes has limited the role of extended pelvic lymph node dissection to a staging procedure. 3 Lestingi JFP Guglielmetti GB Trinh QD et al. Extended versus limited pelvic lymph node dissection during radical prostatectomy for intermediate- and high-risk prostate cancer: early oncological outcomes from a randomized phase 3 trial. Eur Urol. 2021; 79: 595-604 Summary Full Text Full Text PDF PubMed Scopus (61) Google Scholar First-in-patient study of OTL78 for intraoperative fluorescence imaging of prostate-specific membrane antigen-positive prostate cancer: a single-arm, phase 2a, feasibility trialThis first-in-patient study showed that OTL78 was well tolerated and had the potential to improve prostate cancer detection. Optimal dosing was 0·03 mg/kg, 24 h preoperatively. PSMA-directed fluorescence imaging allowed real-time identification of visually occult prostate cancer and might help to achieve complete oncological resections. Full-Text PDF

Impact of renal sinus protrusions on achieving trifecta in robot-assisted partial nephrectomy.

The objective of this work is to assess the relationship between the morphological characteristics of a central tumour and the perioperative outcomes of robot-assisted partial nephrectomy (RAPN). We retrospectively analysed the data from 186 patients with central tumours involving the renal sinus, who underwent RAPN in a single-centre study between February 2015 and June 2022. All cases were assigned a RENAL nephrometry score based on preoperative images. The shape of the protruding portion of the tumour was classified into four types: 'flat', 'spherical', 'single-hump', and 'complex-hump', and was independently assessed by two readers. The trifecta is defined as the warm ischemia time within 25 min, negative surgical margins, and no major postoperative complications. Univariate and multivariate analyses were performed to identify the factors associated with the failing trifecta. Trifecta was achieved in 113 cases (60.8%), and the achievement rate in flat, spherical, single-hump, and complex-hump types was 83.3%, 74.5%, 64.3%, and 21.3%, respectively. Prolonged warm ischemia time was the primary cause of the failure to achieve the trifecta. The rate of positive surgical margins and upstage to pathological T3a was greater for complex humps while the rate of major complications and postoperative GFR preservation did not differ between shapes. On multivariate analysis for failing trifecta achievement, the complex-hump protrusion was found to be an independent positive predictor (odds ratio: 15.8; p< 0.001), whereas the height and width of protrusion were not significantly related. The degree of difficulty varied among central tumours, and it was not possible to precisely measure it with existing scoring systems. Complex-hump protrusions strongly correlate with failure to achieve the trifecta. Preoperative assessment of the morphology of protrusion is useful for predicting outcomes.