Positive surgical margins in radical prostatectomy: Outlining the problem and its long-term consequences Journal Article


Authors: Yossepowitch, O.; Bjartell, A.; Eastham, J. A.; Graefen, M.; Guillonneau, B. D.; Karakiewicz, P. I.; Montironi, R.; Montorsi, F.
Article Title: Positive surgical margins in radical prostatectomy: Outlining the problem and its long-term consequences
Abstract: Context: This review focuses on positive surgical margins (PSM) in radical prostatectomy (RP). Objective: To address the etiology, incidence, and oncologic impact of PSM and discuss technical points to help surgeons minimize their positive margin rate. An evidence-based approach to assist clinicians in counseling patients with a PSM is provided. Evidence acquisition: A literature search in English was performed using the National Library of Medicine database and the following key words: prostate cancer, surgical margins, and radical prostatectomy. Seven hundred sixty-eight references were scrutinized, and 73 were selected for rigorous review based on their pertinence, study size, and overall contribution to the field. Evidence synthesis: In contemporary series, PSM are reported in 11-38% of patients undergoing RP. Although variability exists in the pathologic interpretation of surgical margins, PSM are associated with an increased hazard of biochemical recurrence (BCR) and local disease recurrence as well as the need for secondary cancer treatment. A posterolateral PSM appears to confer the greatest risk of recurrence, whereas the prognostic significance of positive apical margins remains controversial. The role of preoperative imaging and intraoperative frozen section analysis are being investigated to reduce margin positivity rates. Level-1 evidence indicates that adjuvant radiotherapy (RT) in men with PSM reduces BCR rates and clinical progression and possibly improves overall survival (OS). Conclusions: PSM in RP specimens are uniformly considered an adverse outcome. Regardless of approach (open or laparoscopic), attention to surgical detail is essential to minimize rates. For patients with a PSM destined to experience a cancer recurrence, RT is the only established treatment with curative potential. A randomized trial in patients with PSM comparing immediate postoperative RT to salvage RT is critically needed before definitive recommendations can be made. © 2008 European Association of Urology.
Keywords: cancer survival; cancer surgery; surgical technique; review; cancer recurrence; postoperative period; treatment planning; cancer radiotherapy; nuclear magnetic resonance imaging; cancer diagnosis; laboratory diagnosis; laparoscopic surgery; preoperative evaluation; prostate specific antigen; evidence based practice; surgical approach; high risk patient; prostate cancer; gleason score; prostatectomy; psa; prostate biopsy; radical prostatectomy; cancer relapse; radiation therapy; frozen section; nerve sparing; transrectal ultrasonography; biochemical recurrence; pathologist; patient counseling; prostate surgery; endorectal mri; frozen section analysis; positive surgical margins; endorectal nuclear magnetic resonance imaging; nerve sparing radical prostatectomy; positive surgical margin
Journal Title: European Urology
Volume: 55
Issue: 1
ISSN: 0302-2838
Publisher: Elsevier Science, Inc.  
Date Published: 2009-01-01
Start Page: 87
End Page: 99
Language: English
DOI: 10.1016/j.eururo.2008.09.051
PROVIDER: scopus
PUBMED: 18838211
DOI/URL:
Notes: --- - "Cited By (since 1996): 24" - "Export Date: 30 November 2010" - "CODEN: EUURA" - "Source: Scopus"
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  1. James Eastham
    427 Eastham