Positive surgical margins and robot-assisted laparoscopic prostatectomy

There has long been discussion over whether a lack of tactile sensation affects the likelihood of positive surgical margins (PSMs) in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). A new single-institution cohort offers data on PSM rates in that institution’s most current 500 cases — with a specific emphasis on patients with clinically high-risk disease.

Yee et al., from the University of California, Irvine Medicine Center, have reported PSM rates categorized by pathologic stage and D’Amico risk stratification, starting with their 251st patient, who was the first patient to be treated using their current RALP technique. Their database includes 500 consecutive patients since 2005.

Patients with clinical stage T2b/T3 disease or a Gleason score of 8 to 10 and multiple cores with >30% involvement underwent wide excision of the neurovascular bundle. PSM was defined as ink on tumor.

The results of the retrospective analysis of their database show the following:

  • The overall PSM rate was 7.4 percent.
  • When broken down by pathologic stage, the PSM rates were 3.1 percent in pT2 patients, 15.9 percent in pT3 patients, and 55.6 percent in pT4 patients.
  • PSMs occurred in 13 low-risk patients (4.9 percent), 10 intermediate-risk (5.8 percent) patients, and 14 high-risk patients (22.6 percent).
  • For the 62 high-risk patients treated in this database, the median pretreatment PSA was 6.9 (range 2.2-97.9); the biopsy Gleason score was 6 to 7 in 26 percent of the patients and 8 to 10 in the other 74 percent.
  • For patients with preoperatively palpable disease (i.e., a positive digital rectal examination), the PSM rate was 9.9 percent overall, broken down by clinical stage as follows:  cT1 = 6.0 percent, cT2 = 7.7 percent, and cT3 = 26.3 percent.
  • No PSMs occurred along the neurovascular bundle.

The authors conclude that, since 2005, they have used their current RALP technique to treat 500 men with clinically low-, intermediate-, and high-risk prostate cancer “with acceptable surgical margin rates.” They also state that, in their opinion, rates for PSMs were acceptable even in patients with high-risk and usually palpable disease, despite the lack of tactile sensation with the robot.

4 Responses

  1. What about the $64k question? How do these results compare with those for open surgery and laparoscopic no-robot surgery (say by using results from the same institution)?

    More important to me, what’s your takeaway on all this, Mike? The infolink seems to be going out of its way not to have an opinion on this.

  2. Leah:

    1. I don’t know if the same type of data are available from the same surgeon (Aherling) using open surgery.

    2. It takes time to learn to carry out a new surgical procedure well. These data appear to be comparable to those from other series carried out by respected surgeons using open and non-robotic laparoscopic techniques.

    3. The “New” Prostate Cancer InfoLink has always believed that an appropriately skilled and experienced surgeon can get high quality outcomes regardless of the equipment that they use (assuming that they are using good equipment and aren’t being forced to try to operate with a knife and fork).

    4. We really don’t have “a take away” beyond the usual one that surgical outcomes are more about the skill and experience of the surgeon than they are about the “gizmos” that they chose to use.

  3. Leah,

    The results are roughly comparable to those from a whole, broad range of publications related to open and laparoscopic prostatectomy There is no news here. This paper would seem more a partial validation that these surgeons are in keeping with the herd. This would seem useful if you wanted to be their patient. So this might be the “take away.”

    To know if there are real differences in PSM across techniques, one would have to conduct a prospective trial that relied upon equally experienced surgeons. This would not seem on the horizon. If it was done, I doubt it would show a difference, in that as with so many things, PSM is about tumor characteristics, as measured by stage, and surgeon experience.


  4. As to “tactile feel:” A physician here in Wichita I consider as experienced an expert in open RP surgery as anyone in the country, with well over 2,000 such surgeries, and who has moved to RALP as preference, when asked about the loss of “tactile feel,” remarked that the visual with RALP more than compensates for the supposed loss many appear concerned about.

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