Modified Extrafascial Radical Retropubic Prostatectomy Technique Decreases Frequency of Positive Surgical Margins in T2 Cancers 3
Stanford University, Palo Alto, California, United States European Urology
(Impact Factor: 13.94).
07/2000; 38(1):64-73. DOI: 10.1159/000020254
In an effort to decrease the frequency of postoperative positive surgical margins (+SM), a modified extrafascial radical prostatectomy technique was developed and evaluated.
402 consecutive radical prostatectomy specimens removed for clinical stage T2 cancers from 1987 to 1994 were histologically examined prospectively for tumor volume, extraprostatic extension and +SM. Surgical technique modification was introduced in 1990. We compared the histologic status and biological outcome of the prostatectomy cases in 1987-1989 (n = 166) to those treated from 1990 to 1994 (n = 236).
The two series were comparable in (1) clinical stage and preoperative (PSA, (2) tumor volume, grade and location, and (3) capsular penetration, seminal vesicle and lymph node status. +SM fell from 32 to 25% overall, but for 146 (36%) prostates with a tumor volume <2 cm(3), +SM fell from 21 to 6% which was statistically significant. Outcome measured by biological progression showed a decrease from 33% for +SM to 13% for -SM for cases with a tumor volume <2 cm(3). For cancer volumes >2 cm(3), the incidence of +SM did not vary significantly. We describe the anatomic details necessary for exposure of periprostatic fascias and extrafascial dissection at (1) the prostatourethral junction which ensures wide excision of the anterior and apical aspect of the prostate, (2) the posterior and apical area (development of the prerectal space), lateral and posterior areas at the base of the prostate which ensures wide excision of the rectoprostatic fascia (Denonvilliers's fascia) and lateral prostatic fascia.
Differences in surgical technique probably accounted for the significant decrease in +SM for those T2 cancers with volumes < or =2 cm(3) which represents 36% of the T2 cancers in our series. Recent screening with PSA (T1c cancers) increases the incidence of these cancers < or =2cm(3). This modified uni- or bilateral anatomic extrafascial prostatectomy with improved +SM and biological progression rates for T2 cases should be evaluated for T1c cases.
Available from: Ganesh V Raj
- "The type of NVB dissection (intrafascial, interfascial , or extrafascial)  "
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ABSTRACT: Objective: Describe the rationale for and surgical modifications to the original Montsouris technique for laparoscopic radical prostatectomy (LRP). Methods: This is a retrospective review of laparoscopic prostatectomy and experience involving 1071 cases performed between January 1998 and March 2006 at two centres: the Departments of Urology of the Institut Mutualiste Montsouris, Paris, France (first 502 cases) and Memorial Sloan-Kettering Cancer Center, New York, NY (next 569 cases). Results: Since the first systematic description of the LRP technique, several modifications have been implemented. Most of the modifications have not yet been subjected to rigorous prospective evaluation, but, in our experience, they reduce complications or shorten operative time, and presumably lead to better oncologic results with improved preservation of quality of life. We describe those modifications to the LRP technique 8 yr after the program started, including urachal-sparing transperitoneal approach, extended lymph node dissection, systematic identification of the posterior longitudinal fascia of the detrusor muscle during dissection of the posterior bladder neck, intra/inter/extrafascial dissection of the neurovascular bundles, anatomic dissection of the apex with ligature of the dorsal vascular complex after its sectioning, anchoring of the anterior urethrovesical anastomotic stitches to the endopelvic fascia and pubovesical ligaments, extraction and evaluation of the specimen before completing the anastomosis, and use of postoperative care pathways. Conclusions: LRP technique has been refined, which allowed us to decrease the positive surgical margins rate and improve functional outcomes. It is hoped younger laparoscopic surgeons can take advantage of our experience to build on their expertise.
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ABSTRACT: The objective of this work was to compare the amount of residual periprostatic tissue for radical prostatectomy performed by the partial NS (PNS) technique with that performed by the nerve-sparing (NS) or wide-resection (WR) techniques. Retrospective histomorphologic evaluation of radical prostatectomy specimens (RPSs) from patients undergoing laparoscopic radical prostatectomy (LRP) or robot-assisted radical prostatectomy (RARP) was performed. The posterolateral regions corresponding to the neurovascular bundle in RPSs from 48 patients who had undergone NS, PNS, or WR during LRP (n = 30) or RARP (n = 18) were examined by two pathologists unaware of the technique used. The RPSs were evaluated at the base, mid-gland, and apex. The amount of periprostatic tissue at each site was recorded. Measurements were analyzed by use of a linear mixed model. For both LRP and RARP, each gradation of nerve-preservation was associated with periprostatic tissue, except PNS and WR did not differ for LRP at the apex and base or for RARP at the apex, mid-gland, and base. For LRP, a greater amount of tissue was on the left side of the prostate than on the right at the mid-gland level (P = 0.004) whereas for RARP the opposite was found (P = 0.024). Of 18 separate analyses, 13 were significantly associated. The study is limited by its retrospective design. The amount of periprostatic tissue in the neurovascular bundle area correlates well with the nerve-preservation approach used during LRP and RARP, providing anatomic evidence supporting the PNS approach. We also describe a novel finding of laterality bias at the mid-gland level in LRP and RARP specimens.
Available from: David Ian Quinn
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ABSTRACT: Although predicting outcome for men with clinically localized prostate cancer (PC) has improved, the staging system and nomograms used to do this are based on results from the North American health system. To be internationally applicable, these models require testing in cohorts from a variety of different health systems based on the predominant PC case identification methods used.
We studied 732 men with localized PC treated with radical prostatectomy and no preoperative therapy between 1986 and 1999 at one Australian institution to determine the effect of clinicopathologic features on disease-free survival.
Preoperative serum prostate-specific antigen (PSA) concentration, Gleason score, pathologic stage, and year of surgery were independent predictors of outcome. Although margin status demonstrated only a trend toward significance in multivariate modeling overall, it proved to be independent in subgroups based on later year of surgery (1986 to 1994 v 1995 to 1998), preoperative PSA of less than 10 ng/mL, and Gleason score > or = 7. Adjuvant radiation therapy improved disease-free survival rates in patients with multiple surgical margin involvement.
This work confirms the prognostic significance of pathologic stage, Gleason score, and preoperative serum PSA. In the context of a contemporaneous screening effect in Australia, these findings may have implications for methods that predict outcome following surgery as screening becomes more prevalent in a population. The independent prognostic effect of margin status may alter with an increase in the proportion of screening-identified PCs. Staging systems and nomograms that predict outcome following surgery require validation in cohorts with different health practices before being universally applied.
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