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.

ABSTRACT

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.