Positive Surgical Margins in Radical Prostatectomy: Outlining the Problem and Its Long-Term Consequences

Yossepowitch, Ofer; Bjartell, Anders; Eastham, James A.; Graefen, Markus; Guillonneau, Bertrand; Karakiewicz, Pierre I.; Montironi, Rodolfo; Montorsi, F.

doi:10.1016/j.eururo.2008.09.051

Cited by 219 publications

(157 citation statements)

References 72 publications

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“…As with previous reviews the only cancer outcome with sufficient data for meta-analysis was positive margin rate [5] which is an established indicator of surgical quality and is considered by some to be a proxy measure of longer term cancer outcomes such as biochemical recurrence [17]. The difficulty in meta-analysing data from nonrandomised studies is illustrated by alternative estimates of positive margin rates for robotic and laparoscopic prostatectomy given by four further meta-analyses contemporary to our own which used either random effects models including only direct comparisons [18,19,20] or a propensity matching approach including both comparative studies and non-comparative cohorts [21].…”

Section: Discussionmentioning

confidence: 99%

“…Instead we used discrete event simulation to encompass interconnecting events such as cancer recurrence and urinary incontinence together with their subsequent successful or unsuccessful treatment, allowing men to reenter health states that they had previously occupied. This was important since the main difference in outcome was in positive margin status which influenced rates of later cancer recurrence [17].…”

Section: Discussionmentioning

confidence: 99%

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Comparative Cost-effectiveness of Robot-assisted and Standard Laparoscopic Prostatectomy as Alternatives to Open Radical Prostatectomy for Treatment of Men with Localised Prostate Cancer: A Health Technology Assessment from the Perspective of the UK National Health Service

et al. 2013

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Background: Robot-assisted laparoscopic prostatectomy is increasingly used compared to a standard laparoscopic technique but it remains uncertain whether potential benefits offset higher costs.Objective: To determine cost-effectiveness of robotic prostatectomy.Design, Setting, Participants: Care pathway description and model-based cost-utility analysis. We studied men with localised prostate cancer able to undergo either robotic or laparoscopic prostatectomy for cure. Data Sources:We used data from a meta-analysis, other published literature, and costs from United Kingdom (UK) National Health Service (NHS) and commercial sources.Outcome Measurements and Statistical Analysis: Care received by men for ten years following radical prostatectomy was modelled. Clinical events, their effect on quality of life, and associated costs were synthesised assuming 200 procedures were performed annually. Results and Limitations: Over ten years robotic prostatectomy was on average [95% confidence interval] £1412 (€1595) [£1304 (€1473) to £1516 (€1713)] more costly than laparoscopic prostatectomybut more effective with mean (95% confidence interval) gain in quality adjusted life years (QALY) of 0.08 (0.01 to 0.15). The incremental cost-effectiveness ratio (ICER) was £18,329 (€20,708) with an 80% probability that robotic prostatectomy was cost-effective at a threshold of £30,000 (€33,894)/QALY. The ICER was sensitive to the throughput of cases and the relative positive margin rate favouring robotic prostatectomy. Conclusions:Higher costs of robotic prostatectomy may be offset by modest health gain resulting from lower risk of early harms and positive margin provided more than 150 cases are performed each year.Considerable uncertainty persists in the absence of directly comparative randomised data.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Comparative Cost-effectiveness of Robot-assisted and Standard Laparoscopic Prostatectomy as Alternatives to Open Radical Prostatectomy for Treatment of Men with Localised Prostate Cancer: A Health Technology Assessment from the Perspective of the UK National Health Service

et al. 2013

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“…PSMs are associated with an increase in biochemical recurrence and local disease recurrence. 8,[11][12][13][14] Wiegel et al have shown that patients treated with adjuvant radiation therapy had a higher percentage of progression free survival versus those who had a wait and see treatment approach (56% vs. 35%). However, they also concluded that adjuvant radiation therapy does not improve metastasis free survival and overall survival.…”

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.…”

Section: Introductionmentioning

confidence: 99%

“…The authors concluded that a randomized trial in patients with positive surgical margin comparing immediate postoperative radiation therapy to salvage radiation therapy is critically needed before definitive recommendations can be made. 8 This study investigated oncologic outcomes after radical prostatectomy with a positive surgical margin of those who did not have immediate radiation. We investigated whether or not a positive surgical margin had an impact on biochemical recurrence and also the overall outcome after the radical prostatectomy.…”

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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Ultrasensitive prostate‐specific antigen level as a predictor of biochemical progression after robot‐assisted radical prostatectomy: Towards risk adapted follow‐up

Grivas

Bruin²,

Barwari

et al. 2018

Clinical Laboratory Analysis

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Background Ultrasensitive prostate‐specific antigen (USPSA) is useful for stratifying patients according to their USPSA‐based risk. Aim of our study was to determine the usefulness of USPSA as predictor of biochemical recurrence (BCR) after robot‐assisted radical prostatectomy (RARP). Methods This retrospective study included 213 prostate cancer patients who had a postoperative USPSA between 0.01 and 0.2 ng/mL and at least 2 years of follow‐up. We developed predictive models for BCR with PSA ≥0.2 and ≥0.5 ng/mL. Results A total of 103 patients (48.3%) had BCR at a median follow‐up of 13.3 months. Higher postoperative USPSA (odds ratio [OR] = 4.73, P < 0.01), bilateral positive surgical margin in both sides (OR = 1.32, P = 0.044), higher average PSA rise (OR = 1.67, P = 0.031), ISUP grade group ≥3 (OR = 1.48, P = 0.003), and shorter interval since RARP (OR = 0.58, P < 0.001) were independent predictors of BCR with PSA ≥0.2 ng/mL. Higher postoperative USPSA (OR = 3.85, P < 0.01), bilateral positive surgical margin (OR = 1.34, P = 0.011), ISUP grade group ≥3 (OR = 1.5, P = 0.002), and shorter interval since RARP (OR = 0.61, P = 0.001) were independent predictors of BCR with PSA ≥0.5 ng/mL. The areas under the curve for the first and second model were 0.865 and 0.834, respectively. Conclusion Ultrasensitive PSA after RARP is a useful prognostic indicator of BCR which could guide postoperative risk stratification and layout follow‐up scheduling.

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Positive Surgical Margins in Radical Prostatectomy: Outlining the Problem and Its Long-Term Consequences

Cited by 219 publications

References 72 publications

Comparative Cost-effectiveness of Robot-assisted and Standard Laparoscopic Prostatectomy as Alternatives to Open Radical Prostatectomy for Treatment of Men with Localised Prostate Cancer: A Health Technology Assessment from the Perspective of the UK National Health Service

Comparative Cost-effectiveness of Robot-assisted and Standard Laparoscopic Prostatectomy as Alternatives to Open Radical Prostatectomy for Treatment of Men with Localised Prostate Cancer: A Health Technology Assessment from the Perspective of the UK National Health Service

Positive Surgical Margin after Radical Prostatectomy: Effect on Oncologic Outcomes

Ultrasensitive prostate‐specific antigen level as a predictor of biochemical progression after robot‐assisted radical prostatectomy: Towards risk adapted follow‐up

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