Risk Of Positive Surgical Margins Research Articles

Borderline resectable pancreatic cancer: More than an anatomical concept

Borderline resectable pancreatic cancer (BRPC) accounts for about 10–15% of newly diagnosed pancreatic cancer, and its management requires a skilled multidisciplinary team. The main definition of BRPC refers to resectability, but also a high risk of positive surgical margins and recurrence. This raises questions about the value of surgery and suggests an opportunity to utilize preoperative treatment in this subset of patients.Besides technical borderline resectable disease which is defined on anatomical and radiological criteria, there is also a biological borderline resectable disease which is defined on clinical and biological prognostic factors. Technical borderline resectable disease requires tumor shrinkage with aggressive therapy including modern drug combinations +/− radiotherapy to achieve radical surgery. Biological BRPC needs always an early systemic treatment in order to select the best candidates for subsequent radical surgery. It is important to distinguish between these different clinical scenarios, both in clinical practice and for clinical trials design.

Predicting the risk of positive surgical margins following robotic-assisted radical prostatectomy.

The number of men receiving radical prostatectomy (RP) in Victoria, Australia, increased seven-fold in the period 1993-2010, and increasingly robotic-assisted radical prostatectomy (RARP) is being utilized over the open and laparoscopic approaches. The longer-term oncological outcomes of RARP are beginning to be reported in the literature. The objective of this review was to determine whether any preoperative variables may be associated with the occurrence of positive surgical margins (PSMs) following RARP and how these may translate into subsequent risk of biochemical recurrence (BCR). A systematic review of English articles from 2005 to present was performed through a MEDLINE search. Search terms included "positive surgical margins", "biochemical recurrence", "radical prostatectomy" and "prostate cancer". All studies included for review were retrospective analyses of series that reported on rates of PSM and BCR achieved with RARP, and considered potential factors that may influence the rates observed. RARP appears to confer lower rates of PSM when compared to the established approaches. Recent reports included in this review indicate that RARP should be able to provide excellent oncological outcomes as a result.

Intraoperative Frozen Section of the Prostate Reduces the Risk of Positive Margin Whilst Ensuring Nerve Sparing in Patients with Intermediate and High-Risk Prostate Cancer Undergoing Robotic Radical Prostatectomy: First Reported UK Series

Introduction: Nerve sparing during robotic radical prostatectomy (RRP) considerably improves post-operative potency and urinary continence as long as it does not compromise oncological outcome. Excision of the neurovascular bundle (NVB) is often performed in patients with intermediate and high risk prostate cancer to reduce the risk of positive surgical margin raising the risk of urinary incontinence and impotence. We present the first UK series outcomes of such patients who underwent an intra-operative frozen section (IOFS) analysis of the prostate during RRP allowing nerve sparing. Patients and Methods: We prospectively analysed the data of 40 patients who underwent an IOFS during RRP at our centre from November 2012 until November 2014. Our IOFS technique involved whole lateral circumferential analysis of the prostate during RRP with the corresponding neurovascular tissue. An intrafascial nerve spare was performed and the specimen was removed intra-operatively via an extension of the 12 mm Autosuture™ camera port without undocking robotic arms. It was then painted by the surgeon and sprayed with “Ink Aid” prior to frozen section analysis. The corresponding NVB was excised if the histopathologist found a positive surgical margin on frozen section. Results: Median time to extract the specimen, wound closure and re-establishment of pneumoperitoneum increased the operative time by 8 min. Median blood loss for IOFS was 130 ± 97 ml vs. 90 ± 72 ml (p = NS). IOFS was not associated with major complications or with blood transfusion. PSM decreased significantly from non-IOFS RRP series of 28.7 to 7.8% (p < 0.05). Intra-operative PSM on the prostate specimen was seen in 8/40 margin analysis (20%) leading to an excision of the contra-lateral nerve bundle. On analysis of the nerve bundle on a paraffin embedded block, 6 nerve bundle matched tumor on the specimen whereas 2 NVB were retrospectively removed unnecessarily in our series. All 40 patients have undetectable PSA at a mean follow up of 21.2 months (SD 7.79). Functional data at 18 months confirms a reduction in the urinary incontinence from 37% in the IOFS group vs 57% in the non-IOFS group (p = NS). IOFS technique has resulted in a significant increase in intravesical nerve sparing in both T2/T3 patients with intermediate and high risk prostate cancer when appropriately counselled and selected (T2 from 100% in the IOFS group versus 67% and T3 from 100% in the IOFS group to 42%) (p < 0.05). Conclusion: Introduction of the IOFS analysis during intrafascial nerve spare RRP has reduced PSM and the rate of urinary incontinence.

MP75-04 OFF-CLAMP TECHNIQUE OFFERS IMPROVED RENAL FUNCTION OUTCOMES AFTER ROBOTIC PARTIAL NEPHRECTOMY IN LOW AND INTERMEDIATE COMPLEXITY TUMORS

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy V1 Apr 2016MP75-04 OFF-CLAMP TECHNIQUE OFFERS IMPROVED RENAL FUNCTION OUTCOMES AFTER ROBOTIC PARTIAL NEPHRECTOMY IN LOW AND INTERMEDIATE COMPLEXITY TUMORS Daniel C. Rosen, David J. Paulucci, Ronney Abaza, Daniel D. Eun, Ashok K. Hemal, Louis S. Krane, and Ketan K. Badani Daniel C. RosenDaniel C. Rosen More articles by this author , David J. PaulucciDavid J. Paulucci More articles by this author , Ronney AbazaRonney Abaza More articles by this author , Daniel D. EunDaniel D. Eun More articles by this author , Ashok K. HemalAshok K. Hemal More articles by this author , Louis S. KraneLouis S. Krane More articles by this author , and Ketan K. BadaniKetan K. Badani More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1722AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Several arterial clamping techniques have been reported to reduce the deleterious effects of warm ischemia time (WIT) on renal function following partial nephrectomy (PN). Since there is a paucity of comparative data on each technique, the present study compared renal function and surgical outcomes between selective arterial (SAC), main artery (MAC), and off-clamp (OC) techniques in patients undergoing robotic PN (RPN) with low and intermediate complexity tumors. METHODS The present study identified 1,145 patients from 4 medical institutions who underwent RPN from January 2008 to June 2015. Patients with two kidneys, a RENAL score < 10, follow up > 3 months, and a tumor not abutting the main renal artery or vein were included for analysis providing 346 (78.3%) MAC, 37 (8.4%) SAC and 59 (13.3%) OC patients. The percentage change in eGFR was compared between groups using an analysis of covariance. Positive surgical margins (PSM), estimated blood loss (EBL), length of stay (LOS), complications and non-neoplastic parenchymal volume (NNPV) removed were also compared. RESULTS R.E.N.A.L. score (5.8 vs. 6.9 vs. 6.5, p=.001), tumor size (2.2 cm vs. 2.9 vs. 3.1, p<.001) and median follow-up (15.9 months vs. 6 vs. 14.6, p=.002) differed between OC vs. SAC vs. MAC RPN patients respectively. The percentage reduction in eGFR at 13.9 months was significantly lower in OC vs. SAC or MAC RPN (2.5% vs. -7.0 % vs. -9.9%, p=.001) adjusting for R.E.N.A.L. score, American Society of Anesthesiologists score (ASA), body mass index (BMI) and baseline eGFR (Figure 1). In a multivariable cox proportional hazards model, the risk of CKD upstaging was not different in patients undergoing OC vs SAC or MAC (HR= 0.51, p=.260). A trend towards greater EBL (178.0 cc vs. 130.3 vs. 117.1, p=.051) was seen in OC vs. SAC RPN. There were no differences in NNPV removed (p=.586), PSM (p=.849) or complications (p=.693). CONCLUSIONS This study suggests that there may be a renal function advantage to OC RPN. No difference in NNPV removed between groups suggests that the lack of ischemic damage underlies the renal function benefit of OC RPN. Improved renal function without increased risk of PSM or complications suggests that when technically feasible, OC RPN is a consideration in patients with low and intermediate complexity tumors. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e979-e980 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Daniel C. Rosen More articles by this author David J. Paulucci More articles by this author Ronney Abaza More articles by this author Daniel D. Eun More articles by this author Ashok K. Hemal More articles by this author Louis S. Krane More articles by this author Ketan K. Badani More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Perineural invasion status, Gleason score and number of positive cores in biopsy pathology are predictors of positive surgical margin following laparoscopic radical prostatectomy.

This study was designed to define possible preoperative predictors of positive surgical margin after laparoscopic radical prostatectomy. We retrospectively analyzed the records of 296 patients with prostate cancer diagnosed by prostate biopsy, and eventually treated with laparoscopic radical prostatectomy. The prognostic impact of age, prostate volume, preoperative prostate-specific antigen, biopsy Gleason score, maximum percentage tumor per core, number of positive cores, biopsy perineural invasion, capsule invasion on imaging, and tumor laterality on surgical margin was assessed. The overall positive surgical margin rate was 29.1%. Gleason score, number of positive cores, perineural invasion, tumor laterality in the biopsy specimen, and prostate volume significantly correlated with risk of positive surgical margin by univariate analysis (P < 0.05). Gleason score (odds ratio [OR] = 2.286, 95% confidence interval [95% CI] = 1.431–3.653, P = 0.001), perineural invasion (OR = 4.961, 95% CI = 2.656–9.270, P < 0.001), and number of positive cores (OR = 4.403, 95% CI = 1.878–10.325, P = 0.001) were independent predictors of positive surgical margin at the multivariable logistic regression analysis. Patients with perineural invasion, higher biopsy Gleason scores and/or a large number of positive cores in biopsy pathology had more possibility of capsule invasion. The positive surgical margin rate in patients with capsule invasion (49.5%) was much higher than that with localized disease (17.8%). In contrast, prostate volume showed a protective effect against positive surgical margin (OR = 0.572, 95% CI = 0.346–0.945, P = 0.029). Gleason score, perineural invasion, and number of positive cores in the biopsy specimen were preoperative independent predictors of positive surgical margin after laparoscopic radical prostatectomy while prostate volume was a protective factor against positive surgical margin.

Abstract P4-02-01: Only in lobular breast cancer MRI use is associated with a lower risk of positive surgical margins and a reduced number of mastectomies. A real-world analysis in The Netherlands

Abstract Background The value of magnetic resonance imaging (MRI) for patients with breast cancer remains under debate. Breast MRI may contribute to the planning of local therapy, but also bears the risk of overtreatment. We analyzed the use of MRI and its impact on surgical treatment and risk of detecting contralateral breast cancer in the Netherlands. Patients and methods All patients who underwent primary surgery for stage I-III invasive breast cancer in the years 2011-2013 were identified through the Netherlands Cancer Registry. The following data were documented: year of diagnosis, hospital type and volume, age at diagnosis, clinical T and N stage, histological type and grade, presence of multifocality in resection specimen, hormone receptor status, HER2 status and use of MRI. We analyzed whether MRI use was related to type of surgery (primary or secondary mastectomy or breast conserving surgery), surgical margin involvement, and diagnosis of synchronous contralateral breast cancer. Results MRI was performed in 10,819 (29,8%) out of 36,333 patients newly diagnosed with invasive breast cancer and treated with primary surgery in the years 2011-2013 in the Netherlands. Use of MRI did not clearly increase in this period. In the multivariate analysis, patients younger than 50 years of age compared to patients aged 70 years or older (OR 6.34, 95% CI 5.86-6.87), patients with lobular breast cancer compared to those with ductal carcinoma (OR 3.46; 95% CI 3.23-3.70) and patients with multifocal tumors compared to those without multifocality (OR 2.30, 95% CI 2.15-2.45) were more likely to undergo MRI. Hospital volume (&amp;lt;150 versus &amp;gt;150) was only marginally related to MRI use (OR 0.93; 95% CI 0.87-0.99). Patients with invasive breast cancer undergoing MRI were more likely to undergo primary mastectomy than those without MRI (OR 1.21; 95% CI 1.15-1.28), but the subgroup with invasive lobular cancer undergoing MRI were less likely to undergo primary mastectomy (OR 0.85; 95% CI 0.75-0.98). A significantly lower risk of positive surgical margins was seen in patients with lobular breast cancer and breast conserving surgery who had undergone MRI as compared to those without MRI (OR 0.58, 95% CI 0.44-0.78) and, consequently, also a lower risk of secondary mastectomy (OR 0.60, 95% CI 0.41-0.87). Risk of positive surgical margins was not reduced by MRI use in patients with invasive ductal carcinoma (OR 0.91; 95% CI 0.77-1.07). Patients who underwent MRI were almost four times more frequently diagnosed with contralateral breast cancer, compared to those in whom MRI was not performed (OR 3.60, 95% CI 3.06-4.24). Conclusion Breast MRI was significantly more often used in younger patients, patients with lobular and/or multifocal breast cancer. Interestingly, MRI use was associated with less primary and secundary mastectomies in lobular invasive breast cancer, in contrast to an increased number of primary mastectomies in patients with invasive ductal cancer. MRI was further associated with an almost fourfold higher incidence of contralateral breast cancer. Citation Format: Tjan-Heijnen VC, Lobbes MB, Vriens IJ, van Bommel AC, Nieuwenhuijzen GA, Smidt ML, Boersma LJ, van Dalen T, Smorenburg CH, Siesling S, Voogd AC. Only in lobular breast cancer MRI use is associated with a lower risk of positive surgical margins and a reduced number of mastectomies. A real-world analysis in The Netherlands. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-02-01.

Comparison of Perioperative and Early Oncologic Outcomes between Open and Robotic Assisted Laparoscopic Prostatectomy in a Contemporary Population Based Cohort

We compared rates of positive surgical margins, use of postoperative radiation therapy, and perioperative outcomes between robotic assisted laparoscopic and open radical prostatectomy in a contemporary population based cohort. In the National Cancer Data Base from 2010 through 2011 patients who underwent robotic assisted laparoscopic prostatectomy (73,131) and open radical prostatectomy (23,804) for nonmetastatic prostate adenocarcinoma were identified. Covariates included age, race, Charlson comorbidity index, prostate specific antigen, biopsy Gleason score, clinical stage, final Gleason score, pathological T stage, lymph node dissection, nodal status, facility type, hospital volume and year of surgery. Multivariable logistic regression was used to identify factors associated with positive surgical margins, use of adjuvant/salvage radiation therapy, prolonged length of stay, readmission and 30-day mortality. Outcomes were also compared in 1:1 propensity matched cohorts. Analysis of propensity matched cohorts showed robotic assisted laparoscopic prostatectomy reduced the risk of positive surgical margins (OR 0.88, 95% CI 0.83-0.93, p <0.01), the use of radiation therapy (OR 0.71, 95% CI0.63-0.80, p <0.01) and 30-day mortality (OR 0.28, 95% CI 0.13-0.60, p<0.01). The protective effect of robotic assisted laparoscopic prostatectomy for positive surgical margins was found in patients with pT2 disease only (pT2-OR 0.85, 95% CI 0.79-0.91, p <0.01; pT3-OR 0.94, 95% CI 0.86-1.04, p=0.2). Similar results were obtained using multivariable regression. In a contemporary large national cohort, robotic assisted laparoscopic prostatectomy was independently associated with clinically meaningful reductions in positive surgical margins, postoperative radiation therapy and 30-day mortality compared to open radical prostatectomy. The oncologic benefit was primarily in patients with organ confined disease. Limitations were those associated with any observational study, namely the potential for bias due to unmeasured confounders.

Comparison of oncological and health‐related quality of life outcomes between open and robot‐assisted radical prostatectomy for localised prostate cancer – findings from the population‐based Victorian Prostate Cancer Registry

To compare the short-term oncological and health-related quality of life (HRQOL) outcomes between open (ORP) and robot-assisted (RARP) radical prostatectomy in the population-based Victorian Prostate Cancer Registry. This is a prospective cohort of patients with prostate cancer who had RP (1117 ORP and 885 RARP) between January 2009 and June 2012. The oncological outcomes of interest were: positive surgical margin (PSM) and biochemical recurrence (BCR), defined as postoperative PSA level of >0.2ng/mL. The HRQOL outcomes were: sexual and urinary bother, assessed using the Expanded Prostate Cancer Index Composite at 1- and 2-years after diagnosis. For univariate comparison of continuous variables the Student's t-test or Mann-Whitney U-test were used, and the Pearson's chi-squared test was used for categorical variables. Bonferroni correction was applied to account for multiple testing, with a threshold for significance of P < 0.003 for univariate analyses. The inverse-probability-treatment-weighting (IPTW) approach was used to adjust for differences in baseline characteristics between ORP and RARP patients [including age, National Comprehensive Cancer Network (NCCN) risk categories, hospitals, and year of RP] in all multivariate analyses. Logistic regressions were used to analyse for PSM, Cox regressions for BCR, and ordinal logistic regressions for HRQOL outcomes. All multivariate analyses also adjusted for surgeons' average annual caseload, and employed the robust standard errors for clustering by surgeon. ORP and RARP patients were followed for a median of 19and 17months, respectively. The proportion of patientswith NCCN low-risk prostate cancer was significantly higher among RARP patients (21% vs 26%; P= 0.002). Most RPs was done in private hospitals (77% ORP, and 85% RARP, P < 0.001). A higher proportion of RARP patients were operated by surgeons with higher annual caseloads (65% RARP and 53% ORP operated by surgeons with >20case/year; P < 0.001). In the IPTW-adjusted multivariate analyses, RARP patients had a lower risk of PSM (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.38-0.81), and BCR (hazard ratio [HR] 0.73, 95% CI 0.55-0.99). In the sensitivity analyses (excluding public hospital patients), the lower PSM risk with RARP remained (OR 0.63, 95% CI 0.38-0.81), but the lower BCR risk with RARP was no longer statistically significant (HR 0.79, 95% CI 0.57-1.12). At 1-year follow-up, 61% of ORP and 59% of RARP patients reported 'moderate-big' sexual bother (P = 0.2), while 14% of ORP and 11% of RARP patients reported 'moderate-big' urinary bother (P = 0.08). The sexual and urinary bothers at 2years were similar between ORP and RARP. In multivariate analyses, there were no statistically significant differences in the HRQOL outcomes between ORP and RARP. We report on a large population-based comparative study of ORP and RARP with better short-term oncological outcomes favouring RARP, but no significant differences in HRQOL outcomes. The results have to be interpreted taking into account significant surgeon heterogeneity in a population-based study.

81P Clinicopathologic factors related to margin involvement, reoperation, and residual breast cancer in primary operable breast cancer

Aim/Background: Positive or involved margins result in higher rates of local recurrence in breast cancer patients and often need further operations. Identification of patients at increased risk for positive surgical margins may enhance clinical pre-operative decision-making.Methods: A retrospective study of 1468 primary operable breast patients were enrolled in our current margin analysis study, and factors associated with positive surgical margin, re-excision, and residual cancer detection in the re-excision specimen were analyzed.Results: Among them, 103 (7%) patients were found to have positive surgical margin involvement. The positive surgical margin involved rate was 10.7% (78/730) in breast-conserving surgery patients, and 3.4% (25/743) in total mastectomy group (P < 0.0001). In multivariate analysis, the positive surgical margin involvement was associated with lower body surface area (BSA), larger tumor size (HR = 1.458, CI = 1.162-1.831), pathologic multifocal (HR = 2.801, CI: 1.160-6.762), and without MRI use (HR = 2.381, CI = 1.318-4.301).No further re-excision was performed in the 25 margin-positive total mastectomy patients. Among the 78 breast-conserving surgery patients with positive surgical margin, 55(70.5%) received further re-excision. Patients without MRI pre-operative evaluation, or DCIS were factors related to re-operation.Among the 55 patients with positive surgical margin and who had undergone further surgical excision, 31 (56.4%) were found to have residual tumor in the re-excision specimen. Compared with the no residual tumor in the second operation group, no difference in tumor size, lymph node status, Ki-67, pathologic multifocal, or MRI use was found. The only difference was that DCIS histologic subtype was associated with higher residual tumor than other types of breast cancer.Conclusions: Lower BSA, larger tumor size, pathologic multifocal, and without MRI use were associated with increased risk for positive surgical margin involvement. Patients with DCIS who had positive surgical margin involvement were associated with increased risk for re-operation and residual cancer found at second operation.Disclosure: All authors have declared no conflicts of interest. Aim/Background: Positive or involved margins result in higher rates of local recurrence in breast cancer patients and often need further operations. Identification of patients at increased risk for positive surgical margins may enhance clinical pre-operative decision-making. Methods: A retrospective study of 1468 primary operable breast patients were enrolled in our current margin analysis study, and factors associated with positive surgical margin, re-excision, and residual cancer detection in the re-excision specimen were analyzed. Results: Among them, 103 (7%) patients were found to have positive surgical margin involvement. The positive surgical margin involved rate was 10.7% (78/730) in breast-conserving surgery patients, and 3.4% (25/743) in total mastectomy group (P < 0.0001). In multivariate analysis, the positive surgical margin involvement was associated with lower body surface area (BSA), larger tumor size (HR = 1.458, CI = 1.162-1.831), pathologic multifocal (HR = 2.801, CI: 1.160-6.762), and without MRI use (HR = 2.381, CI = 1.318-4.301). No further re-excision was performed in the 25 margin-positive total mastectomy patients. Among the 78 breast-conserving surgery patients with positive surgical margin, 55(70.5%) received further re-excision. Patients without MRI pre-operative evaluation, or DCIS were factors related to re-operation. Among the 55 patients with positive surgical margin and who had undergone further surgical excision, 31 (56.4%) were found to have residual tumor in the re-excision specimen. Compared with the no residual tumor in the second operation group, no difference in tumor size, lymph node status, Ki-67, pathologic multifocal, or MRI use was found. The only difference was that DCIS histologic subtype was associated with higher residual tumor than other types of breast cancer. Conclusions: Lower BSA, larger tumor size, pathologic multifocal, and without MRI use were associated with increased risk for positive surgical margin involvement. Patients with DCIS who had positive surgical margin involvement were associated with increased risk for re-operation and residual cancer found at second operation. Disclosure: All authors have declared no conflicts of interest.

Patient selection for laparoscopic excision of adrenal metastases: A multicenter cohort study

IntroductionThe use of laparoscopy for the excision of adrenal metastasis remains controversial. We aimed to report oncological and perioperative outcomes of laparoscopic excision of adrenal metastases and to seek for predictive factors of unfavorable oncological outcomes. MethodsA retrospective chart review was conducted and all consecutive patients who underwent laparoscopic adrenalectomy (LA) in the setting of metastatic cancer in two academic urology departments from November 2006 through January 2014 were included. Primary tumors were categorized as pulmonary, renal or “other primary” tumors to allow statistical comparison. Unfavorable surgical outcomes were defined as the occurrence of either postoperative complications and/or positive surgical margins. ResultsForty-three patients who underwent a total of 45 LA were included for analysis. There were 8 complications (17.8%). Positive surgical margins were found in 12 specimens (26.7%). After a median follow-up of 37 months, estimated overall survival rates were 89.5% and 51.5% at 1 year and 5 years, respectively. In multivariable analysis the only predictor of unfavorable surgical outcomes was a tumor size >5 cm (OR = 20.5; p = 0.001). In multivariate analysis the pulmonary (OR = 0.3; p = 0.008) or “other” (OR = 0.1; p = 0.0006) origin of the primary tumor was the only prognostic factor of shorter cancer specific survival. ConclusionLaparoscopic resection of adrenal metastasis can be safely performed in most patients but is associated with an increased risk of positive surgical margins and postoperative complications in larger tumors (>5 cm). Adrenalectomy provides better oncological outcomes in metastases from renal cell carcinoma compared to other primary tumors.

Evaluation of positive surgical margins in patients undergoing robot-assisted and open radical prostatectomy according to preoperative risk groups

ObjectivesRecent studies showed that robot-assisted radical prostatectomy (RARP) represents an oncologically safe procedure in patients with prostate cancer (PCa), where the rate of positive surgical margins (PSMs) might be lower in patients treated with RARP as compared with that of those undergoing the open approach (open RP [ORP]). The aim of this study is to analyze the rate of PSMs according to preoperative risk groups in a large cohort of patients treated with RARP and ORP in a single institution with standardized surgical technique and pathological examination. Materials and methodsWe evaluated 6,194 consecutive patients with PCa undergoing either ORP (71.1%) or RARP (28.9%) between 1992 and 2014. Logistic regression analyses were used to test the association between type of surgery and PSMs in each preoperative risk group (low vs. intermediate vs. high) after adjusting for confounders. ResultsOverall, 21.6% patients had PSMs. RARP was associated with a lower rate of PSMs in low-risk (11.5 vs. 15.4%, P = 0.01), intermediate-risk (18.9 vs. 23.5%, P = 0.008), and high-risk patients (19.7 vs. 30.1%, P<0.001). In multivariable analyses, after stratification according to risk group categories, no difference in PSMs between RARP and ORP was observed for low-risk (odds ratio [OR] = 0.87, P = 0.46) and intermediate-risk patients (OR = 0.84, P = 0.19). Conversely, RARP was associated with lower odds of PSMs in high-risk patients (OR = 0.69, P = 0.04). Similar results were observed when our analyses were repeated after accounting for pathological characteristics, in patients treated between 2006 and 2014 and in a cohort of men treated by high-volume surgeons (all P≤ 0.03). ConclusionsThe introduction of RARP at our institution led to a significant reduction in the risk of PSMs in patients with PCa with high-risk disease.

MP62-08 SIGNIFICANT REDUCTION IN POSITIVE SURGICAL MARGINS AND BIOCHEMICAL RECURRENCE RISK AT 2 YEARS NOTED EARLIER FOR ROBOTIC PROSTATECTOMY: COMPREHENSIVE EVALUATION AND CUSUM ANALYSIS OF ONCOLOGICAL OUTCOMES

You have accessJournal of UrologyProstate Cancer: Localized V1 Apr 2015MP62-08 SIGNIFICANT REDUCTION IN POSITIVE SURGICAL MARGINS AND BIOCHEMICAL RECURRENCE RISK AT 2 YEARS NOTED EARLIER FOR ROBOTIC PROSTATECTOMY: COMPREHENSIVE EVALUATION AND CUSUM ANALYSIS OF ONCOLOGICAL OUTCOMES Arjun Sivaraman, Rafael Sanchez Salas, Dominique Prapotnich, Fabien Olivier, Kaixin Yu, Christian Doudeau, Stéphane David, Eric Barret, Fernando P. Secin, Alexandre Ingels, Francois Rozet, Marc Galiano, Annick Mombet, Nathalia Cathala, and Xavier Cathelineau Arjun SivaramanArjun Sivaraman More articles by this author , Rafael Sanchez SalasRafael Sanchez Salas More articles by this author , Dominique PrapotnichDominique Prapotnich More articles by this author , Fabien OlivierFabien Olivier More articles by this author , Kaixin YuKaixin Yu More articles by this author , Christian DoudeauChristian Doudeau More articles by this author , Stéphane DavidStéphane David More articles by this author , Eric BarretEric Barret More articles by this author , Fernando P. SecinFernando P. Secin More articles by this author , Alexandre IngelsAlexandre Ingels More articles by this author , Francois RozetFrancois Rozet More articles by this author , Marc GalianoMarc Galiano More articles by this author , Annick MombetAnnick Mombet More articles by this author , Nathalia CathalaNathalia Cathala More articles by this author , and Xavier CathelineauXavier Cathelineau More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2382AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The primary objective was to evaluate the learning curve of Minimally Invasive Radical Prostatectomy (MIRP) in our institution and apply the cumulative summation (CUSUM) analytical technique to identify salient learning curve transition points in terms of oncological outcomes. METHODS Clinical, pathologic, and oncological outcome data were collected from our prospectively collected MIRP database to estimate Positive Surgical margin (PSM) and Biochemical Recurrence (BCR) trends during a 15 year period from 1998 to 2013. All the RPs (laparoscopic (LRP) / Robotic Assisted [RARP]) were performed by 9 surgeons. PSM was defined as presence of cancer cells at inked margins. BCR was defined as serum Prostate Specific Antigen (PSA) >0.2 ng/ml and rising or start of secondary therapy. Surgical learning curve was assessed with the application of Kaplan-Meier curves, Cox regression model, CUSUM and logistic model in order to define the “transition point” of surgical improvement. RESULTS We identified 5547 patients with localized prostate cancer treated with MIRP (3846 - LRP and 1701 – RARP). Patient characteristics of LRP and RARP were similar. The overall risk of PSM in LRP was 25%, 20% and 17% for the first 50, 50 to 350 and >350 cases, respectively. For the same population, the 5-year BCR rate decreased from 21.5% to 16.7%. RARP started 3 years after the LRP program (after approximately 250 LRP). The PSM rate for RARP decreased from 21.8% to 20.4% and the corresponding 5-year BCR rate decreased from 17.6% to 7.9%. The CUSUM analysis showed significantly lower PSM and BCR at 2 years occurred at the transition point of 350 cases for LRP and 100 cases for RARP. (Figure 1) In multivariable analysis, predictors of BCR were PSA, Gleason score, extra prostatic disease, seminal vesicle invasion and number of operations (p < 0.05). Patients harboring PSM showed higher BCR risk (23% vs. 8%, p < 0.05) CONCLUSIONS Learning curve trends in our large, single center experience shows correlation between surgical experience and oncological outcomes in MIRP. Significant reduction in PSM and BCR risk at 2 years is noted after the initial 350 cases and 100 cases of LRP and RARP, respectively. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e783 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Arjun Sivaraman More articles by this author Rafael Sanchez Salas More articles by this author Dominique Prapotnich More articles by this author Fabien Olivier More articles by this author Kaixin Yu More articles by this author Christian Doudeau More articles by this author Stéphane David More articles by this author Eric Barret More articles by this author Fernando P. Secin More articles by this author Alexandre Ingels More articles by this author Francois Rozet More articles by this author Marc Galiano More articles by this author Annick Mombet More articles by this author Nathalia Cathala More articles by this author Xavier Cathelineau More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Does Preoperative Magnetic Resonance Imaging Reduce the Rate of Positive Surgical Margins at Radical Prostatectomy in a Randomised Clinical Trial?

BackgroundMagnetic resonance imaging (MRI) has the potential to help the surgeon tailor radical prostatectomy (RP) more accurately according to the location and extent of the tumour and thereby reduce the rate of positive surgical margins (PSMs). ObjectiveTo evaluate the benefit of performing MRI prior to RP. Design, setting, and participantsThis single-institution randomised trial included 438 patients between December 2009 and June 2012 who were scheduled for robot-assisted laparoscopic prostatectomy. The study was registered (ClinicalTrials.gov identifier NCT01347320). InterventionPatients were preoperatively randomly assigned to non-MRI or MRI groups. Outcome measurements and statistical analysisThe primary end point was the difference in the PSM rates between the two groups. Secondary end points were the rates of PSMs in clinical subgroups. Summary statistics were extracted from descriptive analyses, chi-square, or Fisher exact test, and logistic regression was used to analyse the data according to the intention-to-treat principle. Results and limitationsA total of 216 patients were randomised to non-MRI; 222 were randomised to MRI. There were 49 cases (23%) of PSMs in the non-MRI group and 43 cases (19%) in the MRI group (p=0.4). The relative and absolute risk reduction was 15% and 4%, respectively. Patients with cT1 constituted 55% of the cohort, in which the rate of PSMs was 27% in the non-MRI group and 16% in the MRI group (p=0.035). The relative and absolute risk reduction was 41% and 11%, respectively. A limitation was suboptimal communication between the radiologist and urologist. ConclusionsMRI prior to RP did not reduce the overall risk for PSMs in this patient cohort. However, at subgroup analysis we observed a possible benefit of MRI in patients with cT1. Patient summaryThis study could not demonstrate a definite benefit of performing magnetic resonance imaging before surgery for all patients. However, there was a possible improved result in patients in which physical examination could not detect the cancer.

186 Does surgical approach impact on the risk of positive surgical margin at radical prostatectomy in patients with clinically localized prostate cancer? A single institution analysis

186 Does surgical approach impact on the risk of positive surgical margin at radical prostatectomy in patients with clinically localized prostate cancer? A single institution analysis

Surgical margins and biochemical recurrence risk at 2 years for robotic prostatectomy: Comprehensive evaluation and CUSUM analysis of oncological outcomes.

80 Background: To evaluate the learning curve of Minimally Invasive Radical Prostatectomy (MIRP) in our institution and apply the cumulative summation (CUSUM) analytical technique to identify salient learning curve transition points in terms of oncological outcomes. Methods: Clinical, pathologic, and oncological outcome data were collected from our prospectively collected MIRP database to estimate Positive Surgical margin (PSM) and Biochemical Recurrence (BCR) trends during a 15 year period from 1998 to 2013. All the RPs (laparoscopic (LRP) / Robotic Assisted [RARP]) were performed by 9 surgeons. PSM was defined as presence of cancer cells at inked margins. BCR was defined as serum Prostate Specific Antigen (PSA) &gt;0.2 ng/ml and rising or start of secondary therapy. Surgical learning curve was assessed with the application of Kaplan-Meier curves, Cox regression model, CUSUM and logistic model in order to define the “transition point” of surgical improvement. Results: We identified 5,547 patients with localized prostate cancer treated with MIRP (3,846 - LRP and 1,701 – RARP). Patient characteristics of LRP and RARP were similar. The overall risk of PSM in LRP was 25%, 20% and 17% for the first 50, 50 to 350 and &gt;350 cases, respectively. For the same population, the 5-year BCR rate decreased from 21.5% to 16.7%. RARP started 3 years after the LRP program (after approximately 250 LRP). The PSM rate for RARP decreased from 21.8% to 20.4% and the corresponding 5-year BCR rate decreased from 17.6% to 7.9%. The CUSUM analysis showed significantly lower PSM and BCR at 2 years occurred at the transition point of 350 cases for LRP and 100 cases for RARP. In multivariable analysis, predictors of BCR were PSA, Gleason score, extra prostatic disease, seminal vesicle invasion and number of operations (p &lt; 0.05). Patients harboring PSM showed higher BCR risk (23% vs. 8%, p &lt; 0.05). Conclusions: Learning curve trends of MIRP in our large, single center experience showed significant reduction in PSM and BCR risk at 2 years are noted after the initial 350 cases and 100 cases of LRP and RARP, respectively.

Management of bilateral Wilms tumor over three decades: The perspective of a single center

Outcomes of Wilms tumor improved in last 50 years and excellent survival rates can be achieved especially in case of non-metastatic disease and favorable histology. Nevertheless, bilateral cases still stand as a therapeutic challenge. Prognosis of bilateral Wilms tumor (BWT) is not as good as the unilateral tumors of similar stage and histology in terms of survival and renal function. Management of BWT is constantly evolving and still stands as a therapeutic challenge. This study is designed to review and share our experiences on this topic from a surgical standpoint. The records of patients treated in our clinic between 1980 and 2013 according to Turkish Pediatric Group of Oncology protocol were analyzed retrospectively and clinical data, surgical details, pathology results, long term outcomes were analyzed. Thirteen girls and 7 boys with a mean age of 2,5 years were treated. There were 2 patients with Wilms tumor-Aniridia-Growth Retardation complex and one with isolated hemihypertrophy. Metastasis were detected in lungs of 4 patients; liver of 2 and in the cranium of one. All patients except one with the presumptive diagnosis of unilateral Wilms tumor were given preoperative chemotherapy. To sum up; 19 nephroureterectomies, 8 partial nephrectomies and 13 enucleations were performed to 36 kidneys without any major early or late postoperative complications. Pathologic results revealed positive surgical margins in 2 lesions with enucleation and in 2 with partial nephrectomies and anaplasia in 4 patients. Two patients were not operated due to parental disapproval. Two patients had the need of dialysis; one was anephric and the others' renal functions recovered over a year. Seven patients received radiotherapy for pulmonary metastasis, positive surgical margins or local recurrences. Overall, 13 patients survived and 7 died due to metastasis, recurrences, and complication of dialysis and refusal of surgical treatment. Survival among all patients was 65% and 72.2% among operated ones. Of the 7 patients with the partial nephrectomy, 2 died and 5 survived. Among enucleation group, 8 out of 10 survived and 2 died. Survival was slightly higher among enucleation group (80% vs 71.4%). Median time of follow-up for survivors of disease is 5.8 years (min: 6 months and max: 14 years). Outcomes of BWT management have changed dramatically during the last few decades from only survival, to a long life expectancy without the need of renal replacement therapy owing to improvements in treatment options. We argue that positive surgical margins do not necessarily lead to local recurrence. For this reason it may be wiser to favor on more nephron sparing surgery than to achieve negative surgical margins. Adjuvant chemotherapy and radiotherapy may be adequate to prevent local recurrence. Also, survival did not differ significantly between different ways of nephron sparing surgeries, so it may be wiser to choose enucleation over partial nephrectomy which preserves more nephrons. Nephron-sparing surgery should have utmost importance despite the risk of positive margins. On the other hand, there is not enough data to interpret if positive surgical margins have role on distant metastases or not. Presence of metastasis and recurrence seems to be an important determinant of prognosis given the fact that none of the survivors had any metastasis or recurrence. Nephron preservation should be the aim while taking positive surgical margin risk on nephron sparing surgery side relying on postoperative chemotherapy and carefully planned radiotherapy to avoid recurrence. However, there is significant diversity on the management BWT in different centers and a certain validated guideline or protocol to provide the optimal treatment is still lacking.

Nerve-sparing surgery and risk of positive surgical margins

A negative surgical margin in organ-confined prostate cancer is considered to be one criterion indicating a high-quality radical prostatectomy. Possible risk factors for positive surgical margins—including prostate volume, obesity or nerve-sparing surgery—have been investigated, but results are inconclusive. Cumulative evidence, however, indicates that surgical margin status is strongly influenced by surgical experience.

Distal ureterectomy techniques in laparoscopic and robot-assisted nephroureterectomy: Updated review.

Controversies exist about the best method for managing the distal ureter during the laparoscopic (LNU) and robot-assisted nephroureterectomy (RANU). Therefore, PubMed, Scopus and Web of Science databases were searched in order to identify articles describing the management of distal ureter during LNU or RANU in patients suffering from upper urinary tract urothelial cell carcinoma. Forty seven articles were selected for their relevance to the subject of this review. The approaches that are usually performed regarding the distal ureter management are open excision, transurethral resection of ureteral orifice (Pluck Technique), ureteric intussusception and pure LNU or pure RANU. Pure LNU and RANU with complete laparoscopic dissection and suture reconstruction of ureter and bladder cuff seems to be better tolerated than open nephroureterectomy providing equal efficacy, without deteriorating the oncological outcome, however evidence is poor. Transurethral resection of the ureteric orifice and the bladder cuff after occlusion of the ureter with a balloon catheter seems to be an attractive alternative option for low stage, low grade tumors of the renal pelvis and the proximal ureter, while stapling technique is correlated with the increased risk of positive surgical margins. The open resection of the distal ureter in continuity with the bladder cuff is considered the most reliable approach, preferred in our practice as well, however the existing data are based on retrospective and non-randomized studies.

C87: Bladder neck preservation and the risk of positive surgical margins after laparoscopic radical prostatectomy

C87: Bladder neck preservation and the risk of positive surgical margins after laparoscopic radical prostatectomy

Perioperative and renal functional outcomes of elective robot‐assisted partial nephrectomy (RAPN) for renal tumours with high surgical complexity

To evaluate the perioperative, postoperative and functional outcomes of robot-assisted partial nephrectomy (RAPN) for renal tumours with high surgical complexity at a large volume centre. Perioperative and functional outcomes of RAPNs for renal tumours with a Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score of ≥10 performed at our institution between September 2006 and December 2012 were collected in a prospectively maintained database and analysed. Surgical complications were graded according to the Clavien-Dindo classification. Serum creatinine and estimated glomerular filtration rate (eGFR) were assessed at the third postoperative day and 3-6 months after RAPN. In all, 44 RAPNs for renal tumours with PADUA scores of ≥10 were included in the analysis; 23 tumours (52.3%) were cT1b. The median (interquartile range; range) operative time, estimated blood loss and warm ischaemia time (WIT) were 120 (94, 132; 60-230) min, 150 (80, 200; 25-1200) mL and 16 (13.8, 18; 5-35) min, respectively. Two intraoperative complications occurred (4.5%): one inferior vena caval injury and one bleed from the renal bed, which were both managed robotically. There were postoperative complications in 10 patients (22.7%), of whom four (9.1%) were high Clavien grade, including two bleeds that required percutaneous embolisation, one urinoma that resolved with ureteric stenting and one bowel occlusion managed with laparoscopic adhesiolysis. Two patients (4.5%) had positive surgical margins (PSMs) and were followed expectantly with no radiological recurrence at a mean follow-up of 23 months. The mean serum creatinine levels were significantly increased after surgery (121.1 vs 89.3 μmol/L; P = 0.001), but decreased over time, with no significant differences from the preoperative values at the 6-month follow-up (96.4 vs 89.3 μmol/L; P = 0.09). The same trend was seen for eGFR. In experienced hands RAPN for renal tumours with a PADUA score of ≥10 is feasible with short WIT, acceptable major complication rate and good long-term renal functional outcomes. A slightly higher risk of PSMs can be expected due to the high surgical complexity of these lesions. The robotic technology allows a safe expansion of the indications of minimally invasive PN to anatomically very challenging renal lesions in referral centres.