Purpose: Positive surgical margins (PSM) during robot-assisted radical prostatectomy (RARP) negatively influence patients' prognosis. The aim of our study was to identify risk factors for PSM in patients with organ-confined prostate cancer (PCa). Methods: A clinical database of all patients that underwent a RARP at our institution was used. Uni- and multivariable logistic regression analyses were conducted on the PSM rates for all patients with organ-confined PCa. Results: Altogether, 1,600 patients were identified, including 1,085 organ-confined PCa with a PSM rate of 7.8%. On multivariable analysis, bilateral nerve-sparing (OR 3.025, 95% CI 1.587-5.765), surgeon volume <200 cases (OR 1.881, 95% CI 1.120-3.159) and a preoperative PSA >10 ng/ml (OR 3.674, 95% CI 1.379-9.796) remained independent prognostic factors. In a subgroup of patients undergoing a nerve-sparing RARP, the quality of the prostate biopsy (OR 2.398, 95% CI 1.325-4.341) was the sole independent risk factor for a PSM. Conclusion: An elevated preoperative PSA, surgical experience and a nerve-sparing procedure are all significantly associated with a higher risk for a PSM after RARP. For those undergoing a nerve sparing RARP, an accurate preoperative biopsy with detailed information on the location of positive cores is essential to prevent PSMs.

Keywords:
Prostate cancer, Positive surgical margins, Robot-assisted radical prostatectomy, Nerve-sparing, Organ-confined disease
1.
Swindle P, Eastham JA, Ohori M, Kattan MW, Wheeler T, Maru N, Slawin K, Scardino PT: Do margins matter? The prognostic significance of positive surgical margins in radical prostatectomy specimens. J Urol 2005;174:903-907.
2.
Shikanov S, Song J, Royce C, Al-Ahmadie H, Zorn K, Steinberg G, Zagaja G, Shalhav A, Eggener S: Length of positive surgical margin after radical prostatectomy as a predictor of biochemical recurrence. J Urol 2009;182:139-144.
3.
Lake AM, He C, Wood DP Jr: Focal positive surgical margins decrease disease-free survival after radical prostatectomy even in organ-confined disease. Urology 2010;76:1212-1216.
4.
Grossfeld GD, Chang JJ, Broering JM, Miller DP, Yu J, Flanders SC, Henning JM, Stier DM, Carroll PR: Impact of positive surgical margins on prostate cancer recurrence and the use of secondary cancer treatment: data from the capsure database. J Urol 2000;163:1171-1177; quiz 1295.
5.
Heidenreich A, Bellmunt J, Bolla M, Joniau S, Mason M, Matveev V, Mottet N, Schmid HP, van der Kwast T, Wiegel T, Zattoni F; European Association of Urology: EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and treatment of clinically localised disease. Eur Urol 2011;59:61-71.
6.
Yossepowitch O, Bjartell A, Eastham JA, Graefen M, Guillonneau BD, Karakiewicz PI, Montironi R, Montorsi F: Positive surgical margins in radical prostatectomy: outlining the problem and its long-term consequences. Eur Urol 2009;55:87-99.
7.
Budäus L, Isbarn H, Eichelberg C, Lughezzani G, Sun M, Perrotte P, Chun FK, Salomon G, Steuber T, Köllermann J, Sauter G, Ahyai SA, Zacharias M, Fisch M, Schlomm T, Haese A, Heinzer H, Huland H, Montorsi F, Graefen M, Karakiewicz PI: Biochemical recurrence after radical prostatectomy: multiplicative interaction between surgical margin status and pathological stage. J Urol 2010;184:1341-1346.
8.
Sooriakumaran P, Haendler L, Nyberg T, Gronberg H, Nilsson A, Carlsson S, Hosseini A, Adding C, Jonsson M, Ploumidis A, Egevad L, Steineck G, Wiklund P: Biochemical recurrence after robot-assisted radical prostatectomy in a European single-centre cohort with a minimum follow-up time of 5 years. Eur Urol 2012;62:768-774.
9.
Patel VR, Coelho RF, Rocco B, Orvieto M, Sivaraman A, Palmer KJ, Kameh D, Santoro L, Coughlin GD, Liss M, Jeong W, Malcolm J, Stern JM, Sharma S, Zorn KC, Shikanov S, Shalhav AL, Zagaja GP, Ahlering TE, Rha KH, Albala DM, Fabrizio MD, Lee DI, Chauhan S: Positive surgical margins after robotic assisted radical prostatectomy: a multi-institutional study. J Urol 2011;186:511-516.
10.
Novara G, Ficarra V, Mocellin S, Ahlering TE, Carroll PR, Graefen M, Guazzoni G, Menon M, Patel VR, Shariat SF, Tewari AK, Van Poppel H, Zattoni F, Montorsi F, Mottrie A, Rosen RC, Wilson TG: Systematic review and meta-analysis of studies reporting oncologic outcome after robot-assisted radical prostatectomy. Eur Urol 2012;62:382-404.
11.
Coelho RF, Chauhan S, Orvieto MA, Palmer KJ, Rocco B, Patel VR: Predictive factors for positive surgical margins and their locations after robot-assisted laparoscopic radical prostatectomy. Eur Urol 2010;57:1022-1029.
12.
Li K, Li H, Yang Y, Ian LH, Pun WH, Ho SF: Risk factors of positive surgical margin and biochemical recurrence of patients treated with radical prostatectomy: a single-center 10-year report. Chin Med J (Engl) 2011;124:1001-1005.
13.
Carvalhal GF, Daudi SN, Kan D, Mondo D, Roehl KA, Loeb S, Catalona WJ: Correlation between serum prostate-specific antigen and cancer volume in prostate glands of different sizes. Urology 2010;76:1072-1076.
14.
Zorn KC, Orvieto MA, Mikhail AA, Gofrit ON, Lin S, Schaeffer AJ, Shalhav AL, Zagaja GP: Effect of prostate weight on operative and postoperative outcomes of robotic-assisted laparoscopic prostatectomy. Urology 2007;69:300-305.
15.
Link BA, Nelson R, Josephson DY, Yoshida JS, Crocitto LE, Kawachi MH, Wilson TG: The impact of prostate gland weight in robot assisted laparoscopic radical prostatectomy. J Urol 2008;180:928-932.
16.
Msezane LP, Gofrit ON, Lin S, Shalhav AL, Zagaja GP, Zorn KC: Prostate weight: an independent predictor for positive surgical margins during robotic-assisted laparoscopic radical prostatectomy. Can J Urol 2007;14:3697-3701.
17.
Sooriakumaran P, John M, Wiklund P, Lee D, Nilsson A, Tewari AK: Learning curve for robotic assisted laparoscopic prostatectomy: a multi-institutional study of 3794 patients. Minerva Urol Nefrol 2011;63:191-198.
18.
White MA, De Haan AP, Stephens DD, Maatman TK, Maatman TJ: Comparative analysis of surgical margins between radical retropubic prostatectomy and RALP: are patients sacrificed during initiation of robotics program? Urology 2009;73:567-571.
19.
Rocco B, Matei DV, Melegari S, Ospina JC, Mazzoleni F, Errico G, Mastropasqua M, Santoro L, Detti S, de Cobelli O: Robotic vs open prostatectomy in a laparoscopically naive centre: a matched-pair analysis. BJU Int 2009;104:991-995.
20.
Atug F, Castle EP, Srivastav SK, Burgess SV, Thomas R, Davis R: Positive surgical margins in robotic-assisted radical prostatectomy: impact of learning curve on oncologic outcomes. Eur Urol 2006;49:866-871; discussion 871-872.
21.
Nelles JL, Freedland SJ, Presti JC Jr, Terris MK, Aronson WJ, Amling CL, Kane CJ: Impact of nerve sparing on surgical margins and biochemical recurrence: results from the search database. Prostate Cancer Prostatic Dis 2009;12:172-176.
22.
Ahyai SA, Zacharias M, Isbarn H, Steuber T, Eichelberg C, Köllermann J, Fisch M, Karakiewicz PI, Huland H, Graefen M, Chun FK: Prognostic significance of a positive surgical margin in pathologically organ-confined prostate cancer. BJU Int 2010;106:478-483.
23.
Liss M, Osann K, Ornstein D: Positive surgical margins during robotic radical prostatectomy: a contemporary analysis of risk factors. BJU Int 2008;102:603-608.
24.
Greco F, Hoda MR, Wagner S, Reichelt O, Inferrera A, Magno C, Fornara P: Bilateral vs unilateral laparoscopic intrafascial nerve-sparing radical prostatectomy: evaluation of surgical and functional outcomes in 457 patients. BJU Int 2011;108:583-587.
25.
Smith JA Jr, Scardino PT, Resnick MI, Hernandez AD, Rose SC, Egger MJ: Transrectal ultrasound versus digital rectal examination for the staging of carcinoma of the prostate: results of a prospective, multi-institutional trial. J Urol 1997;157:902-906.
26.
Shikanov S, Marchetti P, Desai V, Razmaria A, Antic T, Al-Ahmadie H, Zagaja G, Eggener S, Brendler C, Shalhav A: Short (≤1 mm) positive surgical margin and risk of biochemical recurrence after radical prostatectomy. BJU Int 2013;111:559-563.
27.
Kaufmann S, Kruck S, Kramer U, Gatidis S, Stenzl A, Roethke M, Scharpf M, Schilling D: Direct comparison of targeted MRI-guided biopsy with systematic transrectal ultrasound-guided biopsy in patients with previous negative prostate biopsies. Urol Int 2015;94:319-325.
28.
Yao A, Iwamoto H, Masago T, Morizane S, Honda M, Sejima T, Takenaka A: The role of staging MRI in predicting apical margin positivity for robot-assisted laparoscopic radical prostatectomy. Urol Int 2014;93:182-188.
© 2015 S. Karger AG, Basel
2015
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.