Of RALP and positive surgical margins post-surgery

The apex of the prostate (the tip end of organ, farthest from the bladder) is the most common site in which positive surgical margins seem to be found after robot-assisted laparoscopic prostatectomy (RALP).

Guru et al. have published a retrospective analysis of data on the impact of two differing surgical techniques for dorsal vein control on surgical margins rates.

Between August 2005 and January 2008, 480 patients received RALPs at the Roswell Park Cancer Institute in Buffalo, NY. The authors reviewed the Institute’s robotic prostatectomy quality assurance database to identify all patients shown to have prostate cancer at the apex on final pathologic evaluation. The rate of positive apical margins was then compared between two surgical techniques used at the Institute during this timeframe: Group 1 consisted of 145 patients who underwent apical dissection after cold incision of the dorsal venous complex (DVC), without previous suture ligation; Group 2 consisted of 158 patients who underwent suture ligation of the DVC before apical dissection.

The results reported by the authors are as follows:

  • Of 480 patients, 303 patients (63 percent) had prostate cancer in the apex.
  • Age, body mass index, prostate-specific antigen level, and clinical stage were similar in both groups of patients.
  • The overall apical positive margin rate was 5 percent.
  • Group 1 patients had an apical positive margin rate of 2 percent, while Group 2 patients had a positive margin rate of 8 percent (P = 0.02).
  • Mean operative blood loss estimated by the attending anesthesiologist was 331 ml in Group 1 and 268 mL in Group 2 (P = 0.044).
  • One patient in group 1 needed blood transfusion.

The authors conclude that the cold incision of the DVC before suture ligation reduces the rate of apical margin involvement during RALP.

The “New” Prostate Cancer InfoLink  would raise just one question about this report. Were all patients in Group 1 treated by one specific surgeon and all patients inGroup 2 treated by another, different surgeon? If this is the case, then the  nature of the apical dissection may not be the only factor involved, although it does seem likely that the cold dissection technique is a better method of minimizing risk for positive surgical margins at the apex of the prostate.

3 Responses

  1. Can you clarify the location of the apex. The article says the apex is the top of the prostate. To me, that would indicate the area next to the bladder, which is the base. Can you clarify this for me.


    Sorry Les … poor choice of terminology. I have modified the language in the article! Mike

  2. So, to sum up, a difference in surgical procedure correlates with a fourfold increase in risk for a positive margin (2% vs. 8%). The trade-off is a risk of increased blood loss during surgery.

  3. Yes … In this study, as carried out by the surgeons at Roswell Park, during the timeframe specified. To know whether this result applied more generally, one would need to review comparable data from other institutions to see whether comparable results could be found elsewhere. We cannot simply assume that these data apply to every other group of surgeons.

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