Laparoscopic radical prostatectomy: impact of modified apical and posterolateral dissection in reduction of positive surgical margins in patients with clinical stage T2 prostate cancer and high risk of extracapsular extension.

PURPOSE: To determine whether modifications of extraperitoneal endoscopic radical prostatectomy (EERP) reduce the rate of a positive surgical margin (PSM) in men with clinical stage T(2) prostate cancer and a high risk of extracapsular extension. PATIENTS AND METHODS: A consecutive series of 182 men with stage cT(2) tumors and a high risk of extracapsular extension underwent EERP by a single surgeon (VP). The patients were divided into two groups: 71 patients who underwent a standard EERP (group 1) and 111 patients who underwent EERP with the modified technique (group 2). The basic principles of the modified technique are more thorough and wider resection of the posterolateral prostatic pedicles and extensive excision of periprostatic soft tissue at the apex, which results in better mobilization and exposure of the apex before the urethral transection. Differences in PSM rates were analyzed statistically. RESULTS: No significant differences were found between the two groups regarding the clinical and pathologic findings (P > 0.05). The rate of PSM was 28% in group 1 and 10% in group 2 (P < 0.001). Group 2 was less than one third as likely to have PSM as group 2 (odds ratio 2.9; 95% confidence interval 1.6, 3.9). The strongest (P < 0.0001) independent predictors of PSM were the surgical technique, the presence of extracapsular disease, and the volume of the cancer. Preservation of the neurovascular bundles had no impact on margin status (P = 0.93). Functional outcomes and complication rates were not adversely affected by these modifications. CONCLUSION: The modified dissection in EERP significantly reduces the rate of PSM in patients with stage cT(2) prostate cancer and a high risk of extracapsular extension.

Laparoscopic radical prostatectomy: the value of intraoperative frozen sections.

OBJECTIVE: To examine the clinical and pathological value of intraoperative frozen section (IFS) in patients undergoing laparoscopic radical prostatectomy (L-RPE) for clinically localized prostate cancer. METHODS: The study includes 198 consecutive cases of L-RPE. After removal of the prostate, a 2-3mm circumferential specimen was obtained from the apical and bladder neck soft-tissue margin and submitted for IFS examination. In cases suspicious for capsular incision (n=57), IFS were taken from the neurovascular bundle/lateral pedicle. RESULTS: The IFS diagnosis from the apical, bladder neck, and neurovascular bundle/lateral pedicle soft-tissue margins was adenocarcinoma in 12 (6%), 1 (0.5%), and 2 (1%) cases, respectively. Patient age, clinical stage, and mean specimen weight were not associated with cancer at the apical IFS. The accuracy, sensitivity, specificity, positive and negative predictive value of the apical IFS to predict cancer in the permanent section of the apical soft-tissue margin was 96%, 70%, 97%, 58%, and 98%, respectively. All the patients (n=15) with cancer at IFS had wide resections of additional tissue in the area of positive soft-tissue margin and all had no cancer in the additional resected tissue. Especially at the apex, IFS decreases the overall PSM status on surgical specimen by 5.1% (apical PSM from 8.6% to 3.5%). CONCLUSION: Because of the low predictive value of IFS of bladder neck and neurovascular bundle/lateral pedicle their use is not recommended. IFS of the apex should be performed to reduce the PSM rate.