Positive Surgical Margins After Radical Prostatectomy: A Systematic Review and Contemporary Update

Yossepowitch, Ofer; Briganti, Alberto; Eastham, James A.; Epstein, Jonathan I.; Graefen, Markus; Montironi, Rodolfo; Touijer, Karim

doi:10.1016/j.eururo.2013.07.039

Cited by 357 publications

(314 citation statements)

References 74 publications

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“…However, in 6.5 -32% of radical prostatectomy surgeries a positive surgical margin is found. 3 This has been consistent across the surgical approaches for radical prostatectomy (open vs. laparoscopic vs. robotic assisted laparoscopic). 3,9 Some risks that can increase the likelihood of a positive surgical margin include pathologic stage (pT2 and higher), preoperative PSA level, tumor volume, increased BMI, and surgeon experience.…”

Section: Discussionsupporting

confidence: 54%

“…3 This has been consistent across the surgical approaches for radical prostatectomy (open vs. laparoscopic vs. robotic assisted laparoscopic). 3,9 Some risks that can increase the likelihood of a positive surgical margin include pathologic stage (pT2 and higher), preoperative PSA level, tumor volume, increased BMI, and surgeon experience. 3,9,10 Positive surgical margins following radical prostatectomy are known to be an unfavorable prognostic factor in prostate cancer.…”

Section: Discussionsupporting

confidence: 54%

“…3,9 Some risks that can increase the likelihood of a positive surgical margin include pathologic stage (pT2 and higher), preoperative PSA level, tumor volume, increased BMI, and surgeon experience. 3,9,10 Positive surgical margins following radical prostatectomy are known to be an unfavorable prognostic factor in prostate cancer. PSMs are associated with an increase in biochemical recurrence and local disease recurrence.…”

Section: Discussionmentioning

confidence: 99%

“…8 However, 6.5 -32% of radical prostatectomy surgeries have a positive surgical margin (PSM). 3 PSM's are associated with an increased risk for biochemical recurrence (BCR) which is indicated by a PSA level greater than 0.2 ng/mL. However, the percentage of men that will actually have a BCR who had positive surgical margins post operatively is relatively low, ranging from 16.6-40%.…”

Section: Introductionmentioning

confidence: 99%

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Positive Surgical Margin after Radical Prostatectomy: Effect on Oncologic Outcomes

Choi¹,

Hill²,

Deem³

2016

WVMJ

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Objective: A treatment dilemma exists when finding positive surgical margins after radical prostatectomy. Our aim is to better understand the effect of positive surgical margins (PSM) on biochemical recurrence and differences between delayed vs immediate treatment after radical prostatectomy.Materials and Methods: Records for patients who underwent radical prostatectomy for prostate cancer from 2000-2010 were identified and analyzed in our local registry.Results: 468 patients underwent radical prostatectomy. 56 subjects were found to have a PSM (12%). 51 patients chose surveillance. With a mean follow-up of 61 months, 38 patients (75%) remained cancer free. Overall, 13 patients developed biochemical recurrence (PSA > 0.2). 6 patients underwent salvage external beam radiation (XRT) and continue to do well. Conclusion:Despite positive surgical margins, 75% of men remained cancer free at 5 years with no adjuvant radiation. Undergoing salvage XRT when biochemical recurrence occurs offers patients an opportunity to avoid radiation and have acceptable outcomes.3

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Section: Discussionsupporting

confidence: 54%

Section: Discussionsupporting

confidence: 54%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Positive Surgical Margin after Radical Prostatectomy: Effect on Oncologic Outcomes

Choi¹,

Hill²,

Deem³

2016

WVMJ

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“…18,37,42,43,49 The outcome of positive surgical margin status is a complex one, with its clinical impact increasingly scrutinized. 50 A recent randomized controlled trial did not show a beneficial effect of MRI+DWI 33 on surgical margins. There were a number of potential limitations to the trial that diluted the ability to detect a difference in surgical margin status between groups, including: limited power; specified criteria for deciding how to modify the surgical plan based on imaging (including a wider excision at sites of tumour) was not part of the study design; limitations of the surgical technique associated with robotic surgery, including the lack of a specified surgical protocol for various types of imaging findings; and the protocol detailing communication between the radiologist and the urologist could be improved.…”

Section: Discussionmentioning

confidence: 96%

Multiparametric magnetic resonance imaging for pre-treatment local staging of prostate cancer: A Cancer Care Ontario clinical practice guideline

Salerno

Finelli

Morash

et al. 2016

CUAJ

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Introduction: The utility of T2-weighted magnetic resonance imaging (MRI) in the local staging of prostate cancer is controversial. Due to the success of multiparametric MRI in cancer localization, there is renewed interested in MRI (± functional sequences) for local staging. Guidance on pre-treatment local staging of prostate cancer by MRI was developed using systematic review methodology and expert consultation. Methods: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and other databases were searched to identify studies comparing: (1) MRI staging vs. radical prostatectomy staging on diagnostic accuracy outcomes; and (2) MRI staging vs. routine clinical staging on clinical and patient outcomes. Studies meeting inclusion criteria were synthesized by outcome and sensitivity/ specificity analysis by tumour location was performed. Evidence quality of included studies was assessed and considered in recommendation formulation. Results: The literature search identified 2510 citations; 62 studies were included. Analysis of MRI ≥1.5 T plus endorectal coil (ER) (± functional sequences) in the detection of extraprostatic extension or seminal vesicle invasion showed modest sensitivities (≥50%) and excellent specificities (>85%) among patients scheduled for radical prostatectomy. MRI upstaging was shown in 20/21 studies, with large variation in correctness (11-85%). Scarcity of clinical and patient outcomes among studies limited synthesis and evaluation. Quality assessment found non-trivial biases. Conclusions: Modest imaging performance was shown for MRI (1.5 T + ER and 3 T ± ER) ± functional sequences in regards to sensitivity. Limitations in study design, reporting of clinical and patient outcomes, and the heterogeneous use of MRI tempered the strength of the recommendations.

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Trifecta Outcomes After Use of 3-Dimensional Digital Models for Planning of Robotic Prostatectomy

Shirk,

Reiter,

Wallen

et al. 2024

JAMA Netw Open

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ImportancePlanning complex operations such as robotic-assisted laparoscopic radical prostatectomy (RALP) requires surgeons to review 2-dimensional magnetic resonance imaging (MRI) scans to understand 3-dimensional (3D) patient anatomy. Three-dimensional digital models for planning RALP may allow better understanding of patient anatomy and may lead to better patient outcomes, although data are currently limited.ObjectiveTo determine surgical outcomes after RALP when surgeons reviewed 3D digital models during operative planning.Design, Setting, and ParticipantsThis study was a planned secondary analysis of a multicenter, single-blind, randomized clinical trial conducted at 6 large teaching hospitals in the US. The study was conducted between January 1, 2019, and December 31, 2022, and included patients undergoing RALP. Patients were assessed and recruited at the time of surgical consultation. Final data analysis was conducted between August and December 2023.InterventionPatients were randomized to either a control group undergoing usual preoperative planning with prostate biopsy results and multiparametric MRI only or to an intervention group in which imaging and biopsy results were supplemented with a 3D digital model. This model was viewed on the surgeon’s mobile phone in 3D format and picture-in-picture on the robotic console screen.Main Outcomes and MeasuresThe primary outcome measure for the overall study was oncologic outcomes after RALP, measured as prostate-specific antigen (PSA) detectability. Secondary outcomes were sexual function and urinary function, measured with Sexual Health Inventory for Men (SHIM) scores and rates of urinary incontinence, respectively, as well as use of salvage or adjuvant radiation therapy (RT) or androgen deprivation therapy (ADT). Trifecta outcomes were defined as undetectable PSA without RT or ADT, SHIM score categorically the same or greater than preoperatively, and complete continence. Univariate analysis was performed to compare outcomes between groups.ResultsThis trial included 92 patients undergoing RALP (51 in the control group and 41 in the intervention group). Their mean (SD) age was 62 (7.4) years; 10 patients (10.9%) were Black and 67 (72.8%) were White. At 18 months postsurgery, the intervention group had lower rates of biochemical recurrence (PSA level &gt;0.1 ng/mL, 0 vs 7 [17.9%]; absolute difference, 17.9% [95% CI, 1.8% to 31.8%]; P = .01) and were significantly less likely to undergo adjuvant or salvage RT (1 [3.1%] vs 12 [31.6%]; absolute difference, 28.5% [95% CI, 10.1% to 46.7%]; P = .002) compared with the control group. Sexual function at 18 months postsurgery was significantly better in the intervention group (mean [SD] SHIM score, 16.8 [8.7] vs 9.8 [7.7]; absolute difference, 7.0 [95% CI, 2.6 to 11.4]; P = .002) and urinary function was unchanged (total continence, 22 [78.6%] vs 29 [80.6%]; absolute difference, 2.0% [95% CI, −17.9% to 21.9%]; P = .84) compared with the control group. Trifecta outcomes were achieved for 12 (48.0%) patients in the intervention group and 3 patients (10.0%) in the control group (absolute difference, 38.0% [95% CI, 14.4% to 61.6%]; P = .002).Conclusions and RelevanceIn this secondary analysis of a randomized clinical trial, patients whose surgical planning of RALP involved 3D digital models had better oncologic and functional outcomes. Further work should assess the effect of 3D models in a broader set of patients, physicians, and hospital settings.Trial RegistrationClinicalTrials.gov Identifier: NCT03943368

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Positive Surgical Margins After Radical Prostatectomy: A Systematic Review and Contemporary Update

Cited by 357 publications

References 74 publications

Positive Surgical Margin after Radical Prostatectomy: Effect on Oncologic Outcomes

Positive Surgical Margin after Radical Prostatectomy: Effect on Oncologic Outcomes

Multiparametric magnetic resonance imaging for pre-treatment local staging of prostate cancer: A Cancer Care Ontario clinical practice guideline

Trifecta Outcomes After Use of 3-Dimensional Digital Models for Planning of Robotic Prostatectomy

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