ENDOUROLOGY & LAPAROSCOPY

Preoperative and Intraoperative Risk Factors for Side-Specific Positive Surgical Margins in Laparoscopic Radical Prostatectomy for Prostate Cancer
Secin FP, Serio A, Bianco FJ Jr, Karanikolas NT, Kuroiwa K, Vickers A, Touijer K, Guillonneau B
Department of Urology, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
Eur Urol. 2007; 51: 764-71

• Objectives: Identification of variables predicting positive surgical margins (PSMs) in patients undergoing laparoscopic radical prostatectomy (LRP) for clinically localized prostate cancer is lacking. Our objective was to determine preoperative risk factors and the association of ipsilateral degree of neurovascular bundle dissection (intraoperative factor) with side-specific PSMs in these patients.
• Material and Methods: Between October 2002 and April 2005, one surgeon performed LRP on 407 previously untreated patients. Of 814 evaluable prostate sides, 728 harboured prostate cancer in the specimen and composed the study population. For each prostate side, we obtained clinical stage, biopsy Gleason, maximum percentage of tumour in the biopsy, suspected extracapsular extension (ECE) on endorectal coil magnetic resonance imaging (MRI), degree of neurovascular bundle (NVB) dissection, and PSMs. PSM was defined as cancer cells at the inked margins. Logistic regression analyses with random effects were generated.
• Results: Of the 728 prostate sides with cancer, 51 (7%) had at least one PSM. In multivariable analysis, higher PSA (p=0.01), Gleason score of 7 compared with </=6 in the biopsy (p=0.04), lower prostate volume on MRI (p=0.01), and interfascial NVB dissection compared with intrafascial dissection (p=0.01) were associated with an increased risk of side-specific PSMs. Suspected ECE on MRI (p=0.9) and clinical stage (p=0.3) were not significantly associated with side-specific PSMs. A subset analysis of 321 patients with bilateral tumours did not show statistically significant differences in PSMs according to tumour side (p=0.3).
• Conclusions: High serum prostate-specific antigen, biopsy Gleason score of 7, low prostate volume, and interfascial NVB dissection were independently associated with side-specific PSMs after LRP, and should be considered during planning of the LRP surgical strategy.
  
  
• Editorial Comment
  Preoperative PSA, clinical stage, and biopsy Gleason score can predict positive surgical margins preoperatively. Furthermore, a positive surgical margin has been shown to be associated with biochemical recurrence rates up to 50% at 10 years after radical prostatectomy. The authors present their experience in improving the surgical technique to optimize clinical outcome and survival. Their conclusion states that neurovascular bundle preservation is not a risk factor for increase rates of positive margins when the technique is applied adequately in selected patients. Other factors such as elevated serum PSA (> 10 ng/mL), small glands (< 30 g), biopsy Gleason scores of 7, degree of neurovascular bundle dissection, and presence of bulky disease should be considered by laparoscopic surgeons when planning the operation to decrease the incidence of positive surgical margins.

Dr. Fernando J. Kim
Chief of Urology, Denver Health Med Ctr
Assistant Professor, Univ Colorado Health Sci Ctr
Denver, Colorado, USA