Positive Surgical Margin Status Research Articles

Association between maximal urethral length preservation and postoperative continence after robot-assisted radical prostatectomy: a meta-analysis and systematic review.

Urinary incontinence is a common complication following robot-assisted radical prostatectomy (RARP). Urethral length has been identified as a factor affecting postoperative continence recovery. In this meta-analysis, we examined the association between use of the maximal urethral length preservation (MULP) technique and postoperative urinary continence in patients undergoing RARP. We conducted a comprehensive search of PubMed, Web of Science, Embase, and the Cochrane Library up to December 31, 2023. The quality of the literature was assessed using the Newcastle-Ottawa Scale. A random-effects meta-analysis was performed to synthesize data and calculate the odds ratio (OR) from eligible studies on continence and MULP. Six studies involving 1869 patients met the eligibility criteria. MULP was positively associated with both early continence (1 month after RARP; Z = 3.62, P = 0.003, OR = 3.10, 95% confidence interval [CI]: 1.68-5.73) and late continence (12 months after RARP; Z = 2.34, P = 0.019, OR = 2.10, 95% CI: 1.13-3.90). Oncological outcomes indicated that MULP did not increase the overall positive surgical margin rate or the positive surgical margin status at the prostate apex (both P > 0.05). In conclusion, the use of the MULP technique in RARP significantly improved both early and late postoperative continence outcomes without compromising oncological outcomes.

Risk classification system using the detailed positive surgical margin status for predicting biochemical recurrence after robot-assisted radical prostatectomy.

This study aimed to evaluate the risk classification system using the detailed positive surgical margin (PSM) status to predict biochemical recurrence (BCR) after robot-assisted radical prostatectomy (RARP). We retrospectively analyzed 427 patients who underwent RARP between January 2016 and March 2020. We investigated risk factors for BCR using univariate and multivariate Cox proportional hazard regression models. The biochemical recurrence-free survival (BRFS) rate was assessed using the Kaplan-Meier method. The median follow-up period was 43.4 months and 99 patients developed BCR. In the multivariate analysis, maximum PSM length>5.0mm and the International Society of Urological Pathology grade group (ISUP GG) at the PSM ≥3 were predictive factors for BCR in patients with a PSM. In the multivariate analysis, these factors were also independent predictive factors in the overall study population, including patients without a PSM. We classified the patients into four groups using these factors and found that the 1-year BRFS rates in the negative surgical margin (NSM) group, low-risk group (PSM and neither factor), intermediate-risk group (either factor), and high-risk group (both factors) were 94.9%, 94.5%, 83.1%, and 52.9%, respectively. The low-risk group showed similar BRFS to the NSM group (p=0.985), while the high-risk group had significantly worse BRFS than the other groups (p<0.001). Maximum PSM length>5.0mm and ISUP GG at the PSM ≥3 were independent predictive factors for BCR after RARP. Risk classification for BCR using these factors is considered to be useful and might help urologists decide on additional treatment after RARP.

Evaluatoion of intraoperative histology during nerve-sparing radical prostatectomy

Background. Currently, for patients with localized PC, intact erectile function, and low risk of extracapsular extension radical prostatectomy (RP) with nerve-sparing (NS) technique is indicated. The proven method of intraoperative control for the presence of positive surgical margin is the study of fresh frozen sections.Aim. To evaluate the method of intraoperative histological examination (cito-histology) in NS RP.Materials and methods. A prospective clinical study was conducted to examine fresh frozen sections in laparoscopic NS RP. Between February of 2021 and May of 2022, 90 patients diagnosed with prostate cancer underwent laparoscopic NS RP performed by the same surgeon. The patients were divided into 2 groups: group A (n = 40) included patients who underwent laparoscopic NS RP and intraoperative histology; group B (control group) (n = 50) included patients who underwent standard laparoscopic NS RP. Rapid histological and final histological examinations of all removed samples were carried out at the City Clinical Hospital No. 1 named after N.I. Pirogov by one pathologist. The presence of tumor tissue in a stained resection margin was considered positive surgical margin.Results. Oncological processes in macrosamples obtained by intraoperative histology were observed in 32 (80 %) patients, of which primary positive surgical margin was found in 9 (22.5 %) patients. Conversion of (cito) positive surgical margin status into final negative surgical margin was observed in 4 (10 %) patients. Conversion of the surgical margin status of (cito) negative to positive was observed in 1 (2.5 %) patient due to the targeted examination of the area of interest, and not the entire surface of the prostate. Overall 2-year survival in groups A and B was 100 % and 96 %, respectively; cancer-specific 2-year survival was 100 % and 100 %, respectively. Depending on the pathological group, recurrence-free 2-year survival was: group A (pT2) – 90 %; group B (pT2) – 92 %, group A (pT3) – 91.3 %; group B (pT3) – 77.3 %.Conclusion. The proposed method of intraoperative histological examination allows to determine the presence and location of positive surgical margin, which indicates to the surgeon the necessity of additional tissue removal in the neurovascular bundle area, reduces the technical and economic burden on pathology department compared to other methods of rapid histological examination, and reduces contraindications to performing the NS technique in RP especially in the intermediate-risk group.

Impact of multiparametric magnetic resonance imaging targeted biopsy on functional outcomes in patients following robot-assisted laparoscopic radical prostatectomy.

Multiparametric magnetic resonance imaging guided prostate biopsy (mpMRI PBx) leads to a higher rate of successful nerve-sparing in robot-assisted laparoscopic prostatectomy (ns-RALP) for prostate cancer (PCa). This study aimed to evaluate the impact of mpMRI PBx compared to standard ultrasound-guided PBx on functional outcomes focusing on erectile function in patients following ns-RALP. All RALPs performed between 01/2016 and 06/2021 were retrospectively stratified according to (attempted) ns vs. non ns RALPs and were then categorized based on the PBx technique (mpMRI PBx vs. standard PBx). We compared RALP outcomes such as pathological tumor stage, rates of secondary nerve resection (SNR) and positive surgical margin status (PSM). Furthermore, we explored the association between PBx-technique and patient-reported outcomes assessed 12 months after RALP using the prospectively collected 26-item Expanded Prostate Cancer Index Composite (EPIC-26) questionnaire. Chi-square tests and logistic regression analysis were conducted. A total of 849 RALPs included 517 (61%) procedures with (attempted) ns. Among these, 37.5% were diagnosed via preoperative mpMRI PBx. Patients with a preoperative standard PBx had a 57% higher association of PSM (p = 0.030) compared to patients with mpMRI PBx and a 24% higher risk of erectile dysfunction (ED) 12 months post RALP (p = 0.025). When ns was attempted, we observed a significantly higher rate of SNR in patients who underwent a standard PBx compared to those who received a mpMRI PBx (50.8% vs. 26.7%, p < 0.001) prior RALP. In comparison, upgrading occurred more often in the standard PBx group (50% vs. 40% mpMRI PBx, p = 0.008). The combination of mpMRI PBx for PCa diagnosis followed by ns-RALP resulted in significantly fewer cases of SNR, better oncological outcomes and reduced incidence of ED 1 year after surgery. This included fewer PSM and a lower rate of postoperative tumor upgrading.

Lifestyle and Clinical Factors in a Nationwide Stage III and IV Renal Cell Carcinoma Study.

The aim was to investigate whether patient-related or clinical risk factors present at the diagnosis of advanced stage renal cell carcinoma (RCC) had an impact on the overall mortality, cancer-specific mortality, and recurrence risk in a national cohort. Patients registered with stage III and IV RCC in the Danish Renal Cancer Database (DaRenCa) in 2014-2016 were included in the study and followed up until recurrence or death. We conducted a Cox Proportional Hazard Model to examine the association between several variables and the development of RCC. These variables included BMI, hypertension, smoking status, symptoms at diagnosis, performance status, multidisciplinary team (MDT) discussion, surgical margin, and primary metastasis. Separate analyses were performed for cc-RCC and non-ccRCC patients. In our cohort of 929 patients, 424 individuals died from RCC during the follow-up period, with a median follow-up time of 4.1 (95% CI: 0.8-5.0) years for ccRCC and 2.0 (95% CI: 0.1-5.0) years for non-ccRCC. A multivariate analysis demonstrated that a positive surgical margin (HR 1.53 and 1.43), synchronous metastasis (HR 2.06 and 3.23), and poor performance status (HR 4.73 and 5.27) were significantly associated with a decreased 5-year overall and cancer-specific survival, respectively. Furthermore, a positive surgical margin was associated with a higher risk of recurrence in ccRCC. MDT discussion was found to reduce mortality risk in non-ccRCC. Clinical- and disease-related variables have a greater impact on RCC mortality and recurrence than the selected lifestyle-related factors. The inclusion of MDT discussion in the diagnosis and management of advanced RCC should be further evaluated for its potential to improve patient outcomes.

Comprehensive analysis of predictive factors for upstaging in intraprostatic cancer after radical prostatectomy: Different patterns of spread exist in lesions at different locations.

Accurate assessment of the clinical staging is crucial for determining the need for radical prostatectomy (RP) in prostate cancer (PCa). However, the current methods for PCa staging may yield incorrect results. This study aimed to comprehensively analyze independent predictors of postoperative upstaging of intraprostatic cancer. We conducted a retrospective analysis of data from intraprostatic cancer patients who underwent radical surgery between March 2019 and December 2022. Intraprostatic cancer was defined as a lesion confined to the prostate, excluding cases where multiparameter magnetic resonance imaging (mpMRI) showed the lesion in contact with the prostatic capsule. We assessed independent predictors of extraprostatic extension (EPE) and analyzed their association with positive surgical margin (PSM) status. In addition, based on the distance of the lesion from the capsule on mpMRI, we divided the patients into non-transition zone and transition zone groups for further analysis. A total of 500 patients were included in our study. Logistic regression analysis revealed that biopsy Gleason grade group (GG) (odds ratio, OR: 1.370, 95% confidence interval, CI: 1.093-1.718) and perineural invasion (PNI) (OR: 2.746, 95% CI: 1.420-5.309) were predictive factors for postoperative EPE. Both biopsy GG and PNI were associated with lateral (GG: OR: 1.270, 95% CI: 1.074-1.501; PNI: OR: 2.733, 95% CI: 1.521-4.911) and basal (GG: OR: 1.491, 95% CI: 1.194-1.862; PNI: OR: 3.730, 95% CI: 1.929-7.214) PSM but not with apex PSM (GG: OR: 1.176, 95% CI: 0.989-1.399; PNI: OR: 1.204, 95% CI: 0.609-2.381) after RP. Finally, PNI was an independent predictor of EPE in the transition zone (OR: 11.235, 95% CI: 2.779-45.428) but not in the non-transition zone (OR: 1.942, 95% CI: 0.920-4.098). PNI and higher GG may indicate upstaging of tumors in patients with intraprostatic carcinoma. These two factors are associated with PSM in locations other than the apex of the prostate. Importantly, cancer in the transition zone of the prostate is more likely to spread externally through nerve invasion than cancer in the non-transition zone.

CCT6A dysregulation in surgical prostate cancer patients: association with disease features, treatment information, and prognosis.

Chaperonin-containing tailless complex polypeptide 1 subunit 6A (CCT6A) involves several solid cancers' development and progression, while its clinical utility in prostate cancer management is rarely revealed. Consequently, the present study intended to investigate the linkage of CCT6A with disease features, treatment information, and prognosis of surgical prostate cancer patients. CCT6A in 220 surgical prostate cancer patients was determined via immunohistochemistry. Additionally, survival analyses on data from the public databases were performed to validate the prognostic value of CCT6A further. CCT6A expression was upregulated in tumor tissue than in adjacent tissue (P < 0.001). Increased CCT6A was related to elevated Gleason score (P < 0.001) and pathological T stage (P = 0.029). CCT6A was increased in patients with positive surgical margin status (vs. negative) (P = 0.029) and patients with adjuvant external-beam radiation therapy (vs. no) (P = 0.001). Concerning the prognostic value, high tumor CCT6A was linked with shortened disease-free survival (DFS) (P = 0.009), which was also validated through further Cox's proportional hazard regression model analyses (hazard ratio: 2.695, 95% CI: 1.086-6.683, P = 0.032), whereas CCT6A was not correlated with overall survival (OS) (P > 0.050). Additionally, the Gene Expression Profiling Interactive Analysis database indicated that high tumor CCT6A was related to shortened DFS (P = 0.036), but it was not associated with OS (P > 0.050); meanwhile, the Human Protein Atlas database suggested that high tumor CCT6A was linked with reduced OS (P = 0.048). Tumor CCT6A high expression correlates with the elevated Gleason score, pathological T stage, and shortened DFS in surgical prostate cancer patients.

Risks and benefits of partial nephrectomy performed with limited or with zero ischaemia time.

To test the hypothesis that longer warm ischaemia time (WIT) might have a marginal impact on renal functional outcomes and might, in fact, reduce haemorrhagic risk intra-operatively. Data from 1140 patients treated with elective partial nephrectomy (PN) for a cT1-2 cN0 cM0 renal mass were prospectively collected. WIT was defined as the duration of clamping of the main renal artery with no refrigeration and was tested as a continuous variable. The primary outcome of the study was evaluation of the effect of WIT on renal function (estimated glomerular filtration rate [eGFR]) postoperatively, at 6 months and in the long term (measured between 1 and 5 years after surgery). The secondary outcome of the study was haemorrhagic risk, defined as estimated blood loss (EBL) or peri-operative transfusions. Multivariable linear, logistic and Cox regression analyses, accounting for age, Charlson comorbidity index, clinical size, preoperative eGFR and year of surgery, were used and the potential nonlinear relationship between WIT and the study outcomes was modelled using restricted cubic splines. A total of 863 patients (76%) underwent PN with WIT and 277 (24%) without. The baseline median eGFR was 87.3 (68.8-99.2) mL/min/1.73m2 for the on-clamp population and 80.6 (63.2-95.2) mL/min/1.73m2 for the off-clamp population. The median duration of WIT was 17 (13-21) min. At multivariable analyses predicting renal function, longer WIT was associated with decreased postoperative eGFR (estimate: -0.21, 95% confidence interval [CI] -0.31; -0.11 [P < 0.001]). Conversely, no association between WIT and eGFR was recorded at 6-month or long-term follow-up (all P > 0.8). At multivariable analyses predicting haemorrhagic risk, clampless resection with no ischaemia time and PN with short WIT was associated with an increased EBL (estimate: -21.56, 95% CI -28.33; -14.79 [P < 0.001]) and peri-operative transfusion rate (estimate: -0.009, 95% CI -0.01; -0.003 [P = 0.002]). No association between WIT and positive surgical margin status was recorded (all P = 0.1). Patients and clinicians should be aware that performing PN with very limited or even with zero WIT might increase bleeding and the need for peri-operative transfusion while not improving long-term renal function outcomes.

Comparison of Perioperative, Functional, and Oncological Outcomes of Transperitoneal and Extraperitoneal Laparoscopic Radical Prostatectomy.

This study aimed to compare the oncological, functional, and perioperative outcomes of localized and locally advanced prostate cancer treated with intraperitoneal or extraperitoneal laparoscopic radical prostatectomy (LRP). From April, 2008, through December, 2020, 266 patients underwent laparoscopic radical prostatectomy, 168 cases with an extraperitoneal approach (E-LRP) and 98 cases using a transperitoneal approach (T-LRP). The clinical, perioperative, functional, and oncological outcomes were collected and compared between these groups. At the 3-, 12- and 24-monthfollow-ups, the functional outcomes tested were urinary function (urinary domain of EPIC) and sexual function (sexual domain of EPIC). The oncological outcomes of biochemical recurrence, biochemical recurrence-free survival, and positive surgical margin status were evaluated. Univariable and multivariable Cox regression analyses were used to identify factors predictive for biochemical recurrence. All statistical analyses used the R program. The patient characteristics were similar between the E-LRP and T-LRP groups except for higher prostatic-specific antigen (PSA) in the T-LRP group. The T-LRP had lower overall operative time (222.5 min vs. 290 min, p 0.001), decreased blood loss (400 ml vs. 800 ml, p < 0.001), and shorter hospital stays (4 days vs. 7 days, p < 0.001) compared to the E-LRP. Early sexual intercourse with penetration at 3 months was higher in the T-LRP group (36.7% vs. 15.5%, p 0.001). Urinary continence (no pads) was not different between the T-LRP and E-LRP groups at 3 and 24 months after surgery but higher in the E-LRP group at 12 months (1% vs. 3%; p=0.419, 85.1 vs. 83.7%; p=0.889, 47.4% vs. 34.6%; p=0.028, respectively). The EPIC questionnaire was used to assess functional outcomes at 3, 12, and 24 months after surgery and found that urinary function was significantly higher in the T-LRP group at 3 and 12 months (p < 0.001) but did not show a difference at 24 months (p=0.734), and sexual function scores were higher in the T-LRP group at 12 and 24 months (p=0.001). The positive surgical margin rate was higher in the E-LRP (38.7% vs. 21.4%; p=0.006). The BCR rate was not different between the groups (36.3% in the E-LRP group and 27.6% in the E-LRP group; p=0.184). Transperitoneal laparoscopic radical prostatectomy (T-LRP) was found to be superior to extraperitoneal radical prostatectomy (E-LRP) in perioperative outcomes such as decreased operative time, decreased blood loss, shorter hospital stay, lower positive surgical margin, and improved early sexual intercourse and sexual function. The urinary functional outcome was better in the T-LRP group at 3 and 12 months. These findings support the use of transperitoneal laparoscopic radical prostatectomy, as our study patients exhibited significant benefits from this procedure.

Retzius-sparing robot-assisted radical prostatectomy in a medium size oncological center holds adequate oncological and functional outcomes

Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) has emerged as a surgical option for patients with prostatic cancer in high-volume centers. The objective is to assess oncological and functional outcomes when implementing RS-RARP in a medium-volume center without previous experience of robotic surgery. This is a prospective observational single-center study. Patients operated between July 2017 and April 2020 were divided into two consecutive groups, A and B, each with 104 patients. The surgeons had prior experience in laparoscopic surgery and underwent robotic training. Positive surgical margin (PSM) status, urinary continence, and erectile function projected by Kaplan–Meier curves, together with patient reported quality of life outcomes at 12 months post-surgery were documented. Median patient age was 63 years (IQR = 59–67), overall PSM rate were 33%, 28% for pT2 disease. Pre-operative values showed no significant difference between both groups. The rate of urinary continence dropped from 81 to 78% (SE = 5.7) (Group A) and from 90 to 72% (SE = 6.3) (Group B) using the International Consultation on Incontinence Questionnaire-Short Form. Baseline sexual function was regained in 41% (Group A) and 47% (Group B) of patients. The median Expanded Prostate Index Composite-26 total score decreased from 86 to 82. These outcomes relate favorably to prior reports. There was a clinically significant decrease in median operative time in the successive groups with post-operative complications occurring in less than 2% of surgical procedures overall. A 12-month follow-up suggests that RS-RARP may be safely introduced in a medium-volume center without previous experience of robotic surgery.

Predictors of trainees' proficiency during the learning curve of robot-assisted radical prostatectomy at high- -volume institutions: results from a multicentric series.

The aim of this series was to evaluate predictors of Proficiency score (PS) achievement on a multicentric series of robot-assisted radical prostatectomies (RARP) performed by trainee surgeons with two different surgical techniques at four tertiary-care centers. Four institutional datasets were merged and queried for RARPs performed by surgeons during their learning curve (LC) between 2010 and 2020 using two different approaches (Group A, Retzius-sparing RARP, n = 164; Group B, standard anterograde RARP, n = 79). Logistic regression analysis was performed to identify predictors of PS achievement for the overall trainee cohort. For all analyses, a two-sided p <0.05 was considered significant. Group B showed significantly increased median operative time, positive surgical margins (PSM) status, increased number of nerve-sparing procedures, shorter LC time (each p <0.04). PS, continence status, potency, biochemical recurrence and 1-year trifecta rates were comparable between groups (each p >0.3). On multivariable analysis, time from LC starting ≥12 months (OR = 2.79; 95%IC [1.15-6.76]; p = 0.02) and a nerve-sparing intent (OR = 3.18; 95%IC [1.15-8.77]; p = 0.02) were independent predictors of PS score achievement (Table 3). Higher PS rates for RARP trainees may be expected after 12 months from LC beginning. Short-term training courses are unlikely to confer proper surgical training, while long-term structured training programs seem to be beneficial on perioperative outcomes.

MRI versus non-MRI diagnostic pathways before radical prostatectomy: Impact on nerve-sparing, positive surgical margins, and biochemical recurrence

PurposeMagnetic resonance imaging (MRI) prior to biopsy has improved detection of clinically significant prostate cancer (CaP), but its impact on surgical outcomes is less well established. We compared MRI vs. non-MRI diagnostic pathways among patients receiving radical prostatectomy (RP) for impact on surgical outcomes. Materials and methodsMen diagnosed with CaP and receiving RP at Loyola University Medical Center (2014–2021) were categorized into MRI or non-MRI diagnostic pathways based on receipt of MRI before prostate biopsy. Primary outcomes of interest included positive surgical margin (PSM) rates, the performance of bilateral nerve-sparing, and biochemical recurrence (BCR). Multivariable logistic regression models, Kaplan-Meier curves, and Cox proportional hazards regression were employed. ResultsOf 609 patients, 281 (46.1%) were in the MRI and 328 (53.9%) in the non-MRI groups. MRI patients had similar PSA, biopsy grade group (GG) distribution, RP GG, pT stage, and RP CaP volume compared to non-MRI patients. PSM rates were not statistically different for the MRI vs. non-MRI groups (22.8% vs. 26.8%, P = 0.25). Bilateral nerve-sparing rates were higher for the MRI vs. non-MRI groups (OR 1.95 (95%CI 1.32–2.88), P = 0.001). The MRI group demonstrated improved BCR (HR 0.64 (95%CI 0.41–0.99), P = 0.04) after adjustment for age, PSA, RP GG, pT, pN, and PSM status. On meta-analysis, a 5.2% PSM reduction was observed but high heterogeneity for use of nerve-sparing. ConclusionsAn MRI-based diagnostic approach selected patients for RP with a small reduction in PSM rates, greater utilization of bilateral nerve-sparing, and improved cancer control by BCR compared to a non-MRI approach even after adjustment for known prognostic factors.

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.

The status of surgical margins in relation to the type of surgical approach in the management of early-stage cervical cancer: Canadian Cervical Cancer Collaborative (4C) study (533)

<b>Objectives:</b> Surgical margin status in women undergoing surgery for early-stage cervical cancer is considered an important prognostic factor. We sought to determine if positive or close surgical margin status (<3mm) is related to the type of surgical approach and associated with worse outcomes. <b>Methods:</b> A national retrospective cohort study of cervical cancer treated with a radical hysterectomy was conducted. Patients with stage IA1 (LVSI positive) to IIIC2 (FIGO 2018) with lesions up to 4cm at ten Canadian institutions from 2007-2019 were included. Surgical approaches for the radical hysterectomy included robotic/laparo- scopic (RLRH), abdominal (ARH), or laparoscopic-assisted vaginal/ vaginal hysterectomy (LVVRH). Recurrence-free survival (RFS) and overall survival (OS) were estimated using Kaplan-Meier analysis. Chi-square and log-rank tests were used to compare between cohorts. <b>Results:</b> A total of 960 patients met the inclusion criteria. The majority of patients had squamous histology (470, 49%), while 343 (35.7%) had adenocarcinomas and 113 (11.8%) had adenosquamous. Most were stage IB (681, 70.0%) and 183 (19%) were IA. Mode of surgery included: 495 (51.6%) RLRH, 88 (9.2%) LVVRH and 376 (39.2%) ARH. Surgical margins were negative in 819 (85.3%), positive in 15 (1.6%) or close in 103 (10.7%) patients. Factors predictive of close/positive margins included stage, tumor diameter, vaginal involvement, and parametrial extension; the surgical approach was not a predictor of margin status (p=0.38). Close/positive margins were associated with a higher risk of death on univariate analysis (HR: 2.53; 95% CI: 0.78-8.22) for positive margins and 1.83 (95% CI: 1.04-3.24) for close margins, p=0.05), but margin status was not significant for OS or PFS when adjusting for stage, histology, surgical approach, and adjuvant treatment. Overall, 71% of patients with positive margins and 60% of patients with close margins received adjuvant treatment. One patient (6.7%) with positive margins recurred distantly, despite having received adjuvant chemoradiation; 16 patients (15.3%) with close margins recurred (p=0.023), with 73% having received either adjuvant radiation or chemoradiation. The surgical approach was not statistically associated with either OS (p=0.067) or PFS (p=0.06). <b>Conclusions:</b> Positive or close surgical margins were not found to be associated with the use of the minimally invasive surgical (MIS) approach. MIS approach did not appear to negatively impact outcomes. Positive or close surgical margins were not associated with worse outcomes, possibly due to adjuvant treatment.

Scoring the Positive Margin Status in Partial Nephrectomy

Objective A clear resection margin is one of the trifecta outcomes in partial nephrectomy. We proposed a positive surgical margin scoring system and implemented it in our cases to assess its effect on the oncological outcomes.MethodsRetrospective review of prospectively collected multi-center data was performed for all the partial nephrectomy (PN) procedures performed between April 2009 and August 2019. Demographic data, RENAL nephrometry score, peri-operative data and margin status were collected. Positive surgical margin (PSM) cases were given a scoring system of I, II and III for PSM that are &lt;3mms, 3-5mms and &gt;5 mms, respectively. Postoperative, oncological results and adverse events were using Stats Direct. Data analysis was performed using t-test. Comparative data between the two groups was calculated using z-score calculator. p values of 0.05 or less were considered statistically significant.Results A total of 339 PN procedures were performed for histologically proven renal cancer. Forty four patients had PSM. There were 17, 16 and 11 patients with score I, II and III PSM, respectively. Those with a high RENAL nephrometry score had the highest rate of PSM (n=21) as opposed to the intermediate (n=13) and the low (n=10) score groups. After an average follow up of 38 months (10-132), a total of 21 recurrences were recorded; 14 had clear resection margins, 7 were PSM (PSM-I=1. PSM-II=2, PSM-III=4, respectively). ConclusionOverall patients with PSM status have a low chance of recurrent or metastatic disease although those with a wider PSM (III) have a higher chance of recurrent and/or metastatic disease. Tumour grade and pathological T-stage are independent factors for recurrence/metastasis. Larger cohort and longer follow up would be recommended.

On-clamp versus purely off-clamp robot-assisted partial nephrectomy in solitary kidneys: comparison of perioperative outcomes and chronic kidney disease progression at two high-volume centers.

Minimal literature describes the impact of hilar control on the progression to chronic kidney disease (pCKD) after robotic partial nephrectomy (RPN) in solitary kidneys (SK). The aim of this study was to compare purely off-clamp (ocRPN) vs. on-clamp robotic partial nephrectomy (onRPN) in SK and to identify predictors of pCKD at two high-volume centers. Between December 2013 and October 2019, 54 patients with SK underwent ocRPN and onRPN for renal tumors at two institutions. Baseline and perioperative data were analyzed. Newly onset of CKD stage 3b,4,5 (CKD3b,4,5) was assessed by Kaplan-Meier curves and compared for warm ischemia time (WIT) with the log-rank test. Cox regression analysis was used to identify predictors of pCKD. At a median follow-up of 13 months (IQR 6.3-34), newly onset of CKD3b and CKD 4.5 were observed in 11.1% and 7.4% of patients, respectively. onRPN was associated with a higher risk of progression to CKD 3b,4,5 stages (P=0.034) and higher rate of perioperative complications (P=0.03). On univariable analysis eGFR at discharge (eGFRd), positive surgical margins status (PSM) and WIT were predictors of newly onset of CKD3b,4,5 (each P<0.05). Multivariable analysis identified eGFRd (HR 0.88; CI 95% 0.81-0.96) and WIT (HR 1.09; CI 95% 1.02-1.16) as independent predictors of pCKD (each P<0.01). Main limitations include the retrospective nature of the study, the short-term follow-up and the lack of data adjustment for parenchymal volume loss. eGFRd and WIT during RPN are independent predictors of pCKD in SK. In this setting a critical reduction of WIT should be achieved according to the oncologic outcome. In patients with SK, WIT represents the only surgical modifiable factor of RPN for avoiding a quicker onset of pCKD.

Prostatic Ductal Adenocarcinoma Controlled for Tumor Grade, Stage, and Margin Status Does Not Independently Influence the Likelihood of Biochemical Recurrence in Localized Prostate Cancer After Radical Prostatectomy.

Prostatic ductal adenocarcinoma (PDA) has historically been considered to be an aggressive subtype of prostate cancer. To investigate if PDA is independently associated with worse biochemical recurrence (BCR)-free survival after radical prostatectomy. A review of 1584 radical prostatectomies was performed to grade, stage, and assess margin status in each tumor nodule. Radical prostatectomies with localized PDA (ie, those lacking metastasis) in the tumor nodule with the highest grade and stage and worst margin status were matched with prostatic acinar adenocarcinoma according to grade, stage, and margin status. The effect of PDA on BCR was assessed by multivariable Cox regression and Kaplan-Meier analyses. Prostatic ductal adenocarcinoma was present in 171 cases. We excluded 24 cases because of lymph node metastasis (n = 13), PDA not in the highest-grade tumor nodule (n = 9), and positive surgical margin in a lower-grade tumor nodule (n = 2). The remaining 147 cases included 26 Grade Group (GG) 2, 44 GG3, 6 GG4, and 71 GG5 cancers. Seventy-six cases had extraprostatic extension, 33 had seminal vesicle invasion, and 65 had positive margins. Follow-up was available for 113 PDA and 109 prostatic acinar adenocarcinoma cases. Prostate-specific antigen density (odds ratio, 3.7; P = .001), cancer grade (odds ratio, 3.3-4.3; P = .02), positive surgical margin (odds ratio, 1.7; P = .02), and tumor volume (odds ratio, 1.3; P = .02) were associated with BCR in multivariable analysis. Prostatic ductal adenocarcinoma, its percentage, intraductal carcinoma, and cribriform Gleason pattern 4 were not significant independent predictors of BCR. Advanced locoregional stage, higher tumor grade, and positive surgical margin status rather than the mere presence of PDA are more predictive of worse BCR-free survival outcomes following radical prostatectomy in men with a component of PDA.

The Analysis of Preoperative Wire Localization in Breast Conserving Surgery and Predictors of Surgical Margin Status

Background: At present, the breast conserving therapy (BCT) is considered a treatment of choice for early-stage breast cancer. BCT aims to achieve complete tumor resection with adequate margin and offers better cosmetic outcome. Objective: To describe the experience with preoperative wire localization technique for early breast cancer and analysis of factors affecting positive margin status. Materials and Methods: The authors retrospectively reviewed 190 patients with 206 malignant breast lesions treated by breast conserving surgery (BCS) after mammographic- or ultrasound- guided wire localization. Patient age, lesion type such as mass, mass with calcifications, calcifications alone, and architectural distortion, BI-RADS assessment categories, size, location, modalities of imaging guidance, number of wires used, radiological and surgical margin status, pathological diagnosis, and tumor focality were recorded. Results: A 14.56% of positive surgical margin rate was observed. Mixed-effects logistic regression analysis showed larger lesion size was a significant predictor for positive surgical margin status at larger than 1.5 cm versus 1.0 cm or smaller (p=0.033). Conclusion: The present study data suggested that larger tumor size is the only significant predictor for positive surgical margin status. To deal with non-palpable large tumor, surgeon and radiologist should pay particular attention to achieve adequate surgical margin. Keywords: Wire localization; Breast conserving surgery; Surgical margin status; Specimen radiography

PD19-07 RISK FACTORS AND IMPACTS OF POSITIVE SURGICAL MARGIN IN AFRICAN AMERICAN UNDERGOING ROBOTIC-ASSISTED RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy II (PD19)1 Sep 2021PD19-07 RISK FACTORS AND IMPACTS OF POSITIVE SURGICAL MARGIN IN AFRICAN AMERICAN UNDERGOING ROBOTIC-ASSISTED RADICAL PROSTATECTOMY Shuo Liu, Bridget Krol, Justin Refugia, Adam Cohen, Ram Pathak, and Ashok Hemal Shuo LiuShuo Liu More articles by this author , Bridget KrolBridget Krol More articles by this author , Justin RefugiaJustin Refugia More articles by this author , Adam CohenAdam Cohen More articles by this author , Ram PathakRam Pathak More articles by this author , and Ashok HemalAshok Hemal More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002008.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prostate cancer disproportionately impacts African American (AA) males. Margin status remains an important measure of the quality of disease clearance by radical prostatectomy. Unfortunately, historical series have shown that AA men tend to fare worse in this metric comparing to other ethnicities. Furthermore, recent studies have reported positive surgical margin (PSM) rates of up to 34.7% in AA men undergoing robot-assisted radical prostatectomy (RARP). Our study aims to investigate the potential risk factors for PSM in this patient group and its impact on biochemical recurrence-free survival (BCRFS). METHODS: 246 AA men underwent RARP between 2009 and 2019 at our institution. Preoperative patient and disease characteristics, perioperative variables, postoperative and pathological outcomes were recorded and compared according to final margin status. Favorable PSM was defined as PSM noted on pathology with additional margins as negative or with a sub-millimeter unifocal margin. Unfavorable PSM was defined as any PSM not favorable. RESULTS: Adverse pathology (pathological stage >T3, pathological ISUP >3, or positive nodal disease) was seen in 45.1% (111). Favorable PSM status was observed in 52 (21.1%) and unfavorable PSM in 28 (11.4%). PSM was associated with reduction in BCRFS (log-rank p<0.001). Margin multifocality did not further increase disease recurrence. Patients with PSM had higher preoperative PSA (p<0.001), higher clinical risk category (p=0.007), higher pathological grade (p=0.002) and incidences of perineural invasion (PNI) (p<0.001), as well as higher percentages of clinical and pathological T3 disease. Furthermore, patients with PSM were more likely to clinically understaged on final pathological analysis (p<0.001). CONCLUSIONS: PSM rate in AA men remained high in the era of robot-assisted surgery and significantly affected BCRFS. These patients were also more likely to have other adverse pathological features. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e364-e364 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shuo Liu More articles by this author Bridget Krol More articles by this author Justin Refugia More articles by this author Adam Cohen More articles by this author Ram Pathak More articles by this author Ashok Hemal More articles by this author Expand All Advertisement Loading ...

PSMA-ligand uptake can serve as a novel biomarker in primary prostate cancer to predict outcome after radical prostatectomy

BackgroundThe prostate-specific membrane antigen (PSMA) is a relevant target in prostate cancer, and immunohistochemistry studies showed associations with outcome. PSMA-ligand positron emission tomography (PET) is increasingly used for primary prostate cancer staging, and the molecular imaging TNM classification (miTNM) standardizes its reporting. We aimed to investigate the potential of PET-imaging to serve as a noninvasive imaging biomarker to predict disease outcome in primary prostate cancer after radical prostatectomy (RP).MethodsIn this retrospective analysis, 186 primary prostate cancer patients treated with RP who had undergone a 68Ga-PSMA-11 PET up to three months prior to the surgery were included. Maximum standardized uptake value (SUVmax), SUVmean, tumor volume (TV) and total lesion (TL) were collected from PET-imaging. Moreover, clinicopathological information, including age, serum prostate-specific antigen (PSA) level, and pathological characteristics, was assessed for disease outcome prediction. A stage group system for PET-imaging findings based on the miTNM framework was developed.ResultsAt a median follow-up after RP of 38 months (interquartile range (IQR) 22–53), biochemical recurrence (BCR) was observed in 58 patients during the follow-up period. A significant association between a positive surgical margin and miN status (miN1 vs. miN0, odds ratio (OR): 5.428, p = 0.004) was detected. miT status (miT ≥ 3a vs. miT < 3, OR: 2.696, p = 0.003) was identified as an independent predictor for Gleason score (GS) ≥ 8. Multivariate Cox regression analysis indicated that PSA level (hazard ratio (HR): 1.024, p = 0.014), advanced GS (GS ≥ 8 vs. GS < 8, HR: 3.253, p < 0.001) and miT status (miT ≥ 3a vs. miT < 3, HR: 1.941, p = 0.035) were independent predictors for BCR. For stage I disease as determined by PET-imaging, a shorter BCR-free survival was observed in the patients with higher SUVmax (IA vs. IB stage, log-rank, p = 0.022).ConclusionPreoperative miTNM classification from 68Ga-PSMA-11 PET correlates with postoperative GS, surgical margin status and time to BCR. The association between miTNM staging and outcome proposes 68Ga-PSMA-11 PET as a novel non-invasive imaging biomarker and potentially serves for ancillary pre-treatment stratification.