Skip to main content
SpringerLink
Log in

Management of Positive Surgical Margins Following Radical Prostatectomy

  • Chapter
  • First Online:
Robotic Urologic Surgery

  • 904 Accesses

Abstract

The widespread use of prostate specific antigen (PSA) for prostate cancer screening has significantly increased the number of patients diagnosed with the disease. Currently, approximately 90% of patients over 50 years of age with prostate cancer have clinically localized disease.1 Although several treatment options (i.e., external radiotherapy, brachytherapy, or cryotherapy) are available for these patients, radical prostatectomy (RP) is still the gold standard treatment, providing an excellent oncological outcome with a significant survival benefit compared to conservative management options.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 99.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 129.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Jemal A, Siegel R, Ward E, Hao Y, Xu J, Thum MJ. Cancer statistics, 2009. CA Cancer J Clin. 2009;59:225-249.

    Article  PubMed  Google Scholar 

  2. Swindle P, Eastham JA, Ohori M, et al. Do margins matter? The prognostic significance of positive surgical margins in radical prostatectomy specimens. J Urol. 2005;174:903-907.

    Article  PubMed  Google Scholar 

  3. Wieder JA, Soloway MS. Incidence, etiology, location, prevention and treatment of positive surgical margins after radical prostatectomy for prostate cancer. J Urol. 1998;160:299-315.

    Article  PubMed  CAS  Google Scholar 

  4. Godoy G, Tareen BU, Lepor H. Site of positive surgical margins influences biochemical recurrence after radical prostatectomy. BJU Int. 2009;104:1610-1614.

    Article  PubMed  Google Scholar 

  5. Eastham JA, Kuriowa K, Ohori M, et al. Prognostic significance of location of positive margins in radical prostatectomy specimens. Urology. 2007;70:965-969.

    Article  PubMed  Google Scholar 

  6. Han M, Partin AW, Chan DY, Walsh PC. An evaluation of decreasing incidence of positive surgical margins in a large retropubic prostatectomy series. J Urol. 2004;171:23-26.

    Article  PubMed  Google Scholar 

  7. Eastham JA, Kattan MW, Riedel E, et al. Variations among individual surgeons in the rate of positive surgical margins in radical prostatectomy specimens. J Urol. 2003;170:2292-2295.

    Article  PubMed  Google Scholar 

  8. Nielsen ME. How bad are positive margins after radical prostatectomy and how are they best managed? J Urol. 2009;182:1257-1258.

    Article  PubMed  Google Scholar 

  9. Stephenson AJ, Wood DP, Kattan MW, et al. Location, extent and number of positive surgical margins do not improve accuracy of predicting prostate cancer recurrence after radical prostatectomy. J Urol. 2009;182:1357-1363.

    Article  PubMed  Google Scholar 

  10. Badani KK, Kaul S, Menon M. Evolution of robotic radical prostatectomy: assessment after 2766 procedures. Cancer. 2007;110:1951-1958.

    Article  PubMed  Google Scholar 

  11. Epstein JI, Sauvageot J. Does close but negative margins in radical prostatectomy specimens increase the risk of postoperative progression. J Urol. 1997;157:241-243.

    Article  PubMed  CAS  Google Scholar 

  12. Bolla M, Collette L, Blank L, et al. Long-term results with immediate androgen suppression and external irradiation in patients with locally advanced prostate cancer (an EORTC study): a phase III randomized trial. Lancet. 2002;360:103-106.

    Article  PubMed  CAS  Google Scholar 

  13. Yossepowitch O, Bjartell A, Eastham JA, et al. Positive surgical margins in radical prostatectomy: outlining the problem and its long-term consequences. Eur Urol. 2009;55:87-99.

    Article  PubMed  Google Scholar 

  14. Thurairaja R, Osborn J, Mc Farlane J, Bahl A, Persad R. Radical prostatectomy with positive margins: how are patients managed. BJU Int. 2006;97:445-450.

    Article  PubMed  Google Scholar 

  15. Zietman AL, Coen JJ, Shipley WU, Althausen AF. Adjuvant irradiation after radical prostatectomy for adenocarcinoma of prostate: analysis of freedom from PSA failure. Urology. 1993;42:292-298.

    Article  PubMed  CAS  Google Scholar 

  16. Shikanov S, Song J, Royce C, et al. Length of positive surgical margin after radical prostatectomy as a predictor of biochemical recurrence. J Urol. 2009;182:139-144.

    Article  PubMed  Google Scholar 

  17. Kwak KW, Lee HM, Choi HY. Impact of capsular incision on biochemical recurrence after radical perineal prostatectomy. Prostate Cancer Prostatic Dis. 2009;12:1-9.

    Article  Google Scholar 

  18. Yee DS, Narula N, Amin MB, Skarecky DW, Ahlering TE. Robot-assisted radical prostatectomy: current evaluation of surgical margins in clinically low-, intermediate-, and high-risk prostate cancer. J Endourol. 2009;23:1461-1465.

    Article  PubMed  Google Scholar 

  19. Salomon L, Anastasiadis AG, Levrel O, et al. Location of positive margins after retropubic, perineal and laparoscopic radical prostatectomy for organ-confined prostate cancer. Urology. 2003;61:386-390.

    Article  PubMed  Google Scholar 

  20. Palisaar RJ, Nadus J, Graefen M, Erbersdobler A, Haese H, Huland H. Influence of nerve-sparing (NS) procedure during radical prostatectomy (RP) on margin status and biochemical failure. Eur Urol. 2005;47:176-184.

    Article  PubMed  Google Scholar 

  21. Ward JF, Zincke H, Bergstralh EJ, Slezak JM, Myers RP, Blute ML. The impact of surgical approach (nerve bundle preservation versus wide local excision) on surgical margins and biochemical recurrence following radical prostatectomy. J Urol. 2004;172:1328-1332.

    Article  PubMed  Google Scholar 

  22. Ohori M, Wheeler TM, Kattan MW, Goto Y, Scardino PT. Prognostic significance of positive surgical margins in radical prostatectomy specimens. J Urol. 1995;154:1818-1824.

    Article  PubMed  CAS  Google Scholar 

  23. Barrocas DA, Han M, Epstein JI, et al. Does capsular incision at retropubic radical prostatectomy affect disease-free survival in otherwise organ-confined prostate cancer? Urology. 2001;58:746-751.

    Article  Google Scholar 

  24. Myers RP, Goellner JR, Cahill DR. Prostate shape, external striated urethral sphincter and radical prostatectomy: the apical dissection. J Urol. 1987;138:543-550.

    PubMed  CAS  Google Scholar 

  25. Srougi M, Nesrallah LJ, Kauffmann JR, Nesrallah A, Leite KRM. Urinary continence and pathological outcome after bladder neck preservation during radical retropubic prostatectomy: a randomized prospective trial. J Urol. 2001;165:815-818.

    Article  PubMed  CAS  Google Scholar 

  26. Hall GS, Kramer CE, Epstein JI. Evaluation of radical prostatectomy specimens. A comparative analysis of sampling methods. Am J Surg Pathol. 1992;16:315-324.

    Article  PubMed  CAS  Google Scholar 

  27. Tsuboi T, Ohori M, Kuroiwa K, et al. Is intraoperative frozen section analysis an efficient way to reduce positive surgical margins? Urology. 2005;66:1287.

    Article  PubMed  Google Scholar 

  28. Eggener SE, Roehl KA, Smith ND, Antenor JA, Han M, Catalona WJ. Contemporary survival results and the role of radiation therapy in patients with negative seminal vesicle invasion following radical prostatectomy. J Urol. 2005;173:1150-1155.

    Article  PubMed  Google Scholar 

  29. Watson RB, Civantos F, Soloway MS. Positive surgical margins with radical prostatectomy: detailed pathological analysis and prognosis. Urology. 1996;40:80-90.

    Article  Google Scholar 

  30. Hernandez DJ, Epstein JI, Trock BJ, Tsuzuki T, Carter HB, Walsh PC. Radical retropubic prostatectomy. How often do experienced surgeons have positive margins when there is extraprostatic extension in the region of the neurovascular bundle? J Urol. 2005;173:446-449.

    Article  PubMed  Google Scholar 

  31. Vis AN, Schroeder FH, Van der Kwast TH. The actual value of the surgical margins status as a predictor of disease progression in men with early prostate cancer. Eur Urol. 2006;50:258-265.

    Article  PubMed  Google Scholar 

  32. Touijer K, Kuroiwa K, Eastham JA, et al. Risk-adjusted analysis of positive surgical margins following laparoscopic and retropubic radical prostatectomy. Eur Urol. 2007;52:1090-1096.

    Article  PubMed  Google Scholar 

  33. Boccon-Gibod L, Rovery V, Vordos D, Toublanc M, Delmas V, Boccon-Gibod L. Radical prostatectomy for prostate cancer: the perineal approach increases the risk of surgically induced positive margins and capsular incisions. J Urol. 1998;160:1383-1385.

    Article  PubMed  CAS  Google Scholar 

  34. Brown JA, Garlitz C, Gomella LG, et al. Pathologic comparison of laparoscopic versus open radical retropubic prostatectomy specimens. Urology. 2003;62:482-486.

    Article  Google Scholar 

  35. Salomon L, Anastasiadis AG, Levrel O, et al. Outcome and complications of radical prostatectomy in patients with PSA  <  10 ng/ml: comparison between the retropubic, perineal and laparoscopic approach. Prostate Cancer Prostatic Dis. 2002;5:285-290.

    Article  PubMed  CAS  Google Scholar 

  36. Sofer M, Hamilton-Nelson KL, Schlesselman J, Soloway MS. Risk of positive margins and biochemical recurrence in relation to nerve-sparing radical prostatectomy. J Clin Oncol. 2002;20:1853-1858.

    Article  PubMed  Google Scholar 

  37. Rees MA, Resnick MI, Oesterling JE. Use of prostate-specific antigen, Gleason score, and digital rectal examination in staging patients with newly diagnosed prostate cancer. Urol Clin North Am. 1997;24:379-386.

    Article  PubMed  CAS  Google Scholar 

  38. Rifkin MD, Zerhouni EA, Gatsonis CA, et al. Comparison of magnetic resonance imaging and ultrasonography in staging early prostate cancer. Results of a multi-institucional cooperative trial. N Engl J Med. 1990;323:621-626.

    Article  PubMed  CAS  Google Scholar 

  39. Augustin H, Fritz GA, Fhammer T, Auprich M, Pummer K. Accuracy of 3-Tesla magnetic resonance imaging for staging of prostate cancer in comparison to the Partin tables. Acta Radiol. 2009;50:562-569.

    Article  PubMed  CAS  Google Scholar 

  40. Brown JA, Rodin DM, Harisinghani M, Dahl DM. Impact of preoperative endorectal MRI stage classification on neurovascular bundle sparing aggressiveness and the radical prostatectomy positive margin rate. Urol Oncol. 2009;27:174-179.

    Article  PubMed  Google Scholar 

  41. Zhang J, Hricak H, Shukla Dave A, Ishill NM, Reuter VE, Eastham JA. Clinical stage T1a prostate cancer: evaluation with endorectal MR imaging and MR spectroscopic imaging. Radiology. 2009;253:425-434.

    Article  PubMed  Google Scholar 

  42. Makarov DV, Trock BJ, Humphreys EB, et al. Updated nomogram to predict pathologic stage of prostate cancer given prostate-specific antigen level, clinical stage, and biopsy Gleason score (Partin tables) based on cases 2000 to 2005. Urology. 2007;69:1095-1101.

    Article  PubMed  Google Scholar 

  43. Bhojani N, Salomon L, Capitanco U, et al. External validation of the updated Partin tables in a cohort of French and Italian men. Int J Radiat Oncol Biol Phys. 2009;73:347-352.

    Article  PubMed  Google Scholar 

  44. Alkhateeb S, Alibhai S, Fleshner N, et al. Impact of positive surgical margins after radical prostatectomy differs by disease risk group. J Urol. 2010;183:145-150.

    Article  PubMed  Google Scholar 

  45. Obek C, Sadek S, Lai S, Civantos F, Rubinowics D, Soloway M. Positive surgical margins with radical retropubic prostatectomy: anatomic site-specific pathologic analysis and impact on prognosis. Urology. 1999;54:682-688.

    Article  PubMed  CAS  Google Scholar 

  46. Blute ML, Bostwick DG, Bergstralh EJ, et al. Anatomic site-specific positive margins in organ-confined prostate cancer and its impact on outcome after radical prostatectomy. Urology. 1997;50:733-739.

    Article  PubMed  CAS  Google Scholar 

  47. Grossfeld GD, Chang JJ, Broering JM, et al. Impact of positive margins of prostate cancer recurrence and use of secondary cancer treatment: data from CAPSURE database. J Urol. 2000;163:1171-1177.

    Article  PubMed  CAS  Google Scholar 

  48. D’Amico AV, Whittingt on R, Malkowicz SB, et al. A multivariate analysis of clinical and pathological factors that predict for prostate specific antigen ­failure after radical prostatectomy for prostate ­cancer. J Urol. 1995;154:131-138.

    Article  PubMed  Google Scholar 

  49. Pfitzenmaier J, Pahernick S, Tremmel T, Haferkamp A, Buse S, Hohenfellnwer M. Positive surgical margins after radical prostatectomy: do they have an impact on biochemical or clinical progression? BJU Int. 2008;102:1413-1418.

    Article  PubMed  Google Scholar 

  50. Hricak H, Wang L, Wei DC, et al. The role of preoperative endorected magnetic resonance imaging in the decision regarding whether to preserve or resect neurovascular bundles during radical retropubic prostatectomy. Cancer. 2004;100:2655-2663.

    Article  PubMed  Google Scholar 

  51. Ohori M, Abbas F, Wheeler TM, Kattan MW, Scardino PT, Lerner SP. Pathological features and prognostic significance of prostate cancer in the apical section determined by whole mount histology. J Urol. 1999;162:1391-1392.

    Google Scholar 

  52. Connolly SS, O’Toole GC, O’Malley KJ, et al. Positive apical margins after radical retropubic prostatectomy, truth or artifacts. Scand J Urol Nephrol. 2004;38:26-31.

    Article  PubMed  Google Scholar 

  53. Epstein JI, Pizov G, Walsh PC. Correlation of pathologic findings with progression after radical retropubic prostatectomy. Cancer. 1993;71:3582-3593.

    Article  PubMed  CAS  Google Scholar 

  54. Sofer M, Hamilton-Nelson KL, Civantos F, Soloway MS. Positive surgical margins after radical retropubic prostatectomy: the influence of site and number on progression. J Urol. 2002;167:2453-2456.

    Article  PubMed  Google Scholar 

  55. Rabbani F, Vora KC, Yunis LH, et al. Biochemical recurrence rates in patients with positive surgical margin at radical prostatectomy with further negative resected tissue. BJU Int. 2009;104:605-610.

    Article  PubMed  Google Scholar 

  56. Graefen M, Noldus J, Pichlmeier U, et al. Early prostate specific antigen relapse after radical prostatectomy: prediction on the basis of preoperative and postoperative tumor characterístics. Eur Urol. 1999;36:21-30.

    Article  PubMed  CAS  Google Scholar 

  57. Karakiewicz PI, Eastham JA, Graefen M, et al. Prognostic impact of positive surgical margins in surgically treated prostate cancer: multi-institutional assessment of 5831 patients. Urology. 2005;66:1245-1250.

    Article  PubMed  Google Scholar 

  58. Simon MA, Kim S, Soloway M. Prostate specific antigen recurrence rates are low after radical retropubic prostatectomy and positive margins. J Urol. 2006;175:140-144.

    Article  PubMed  Google Scholar 

  59. Kausik SJ, Blute ML, Sebo TJ, et al. Prognostic significance of positive surgical margins in patients with extraprostatic carcinoma after radical prostatectomy. Cancer. 2002;95:1215-1219.

    Article  PubMed  Google Scholar 

  60. Mac Donald OK, Schild SE, Vora SA, et al. Radiotherapy for men with isolated increase in serum prostate specific antigen after radical prostatecomy. J Urol. 2003;170:1833-1837.

    Article  Google Scholar 

  61. Freedland S, Humphreys EB, Mangold LA, et al. Risk of prostate cancer-specific mortality following biochemical recurrence after radical prostatectomy. JAMA. 2005;294:433-439.

    Article  PubMed  CAS  Google Scholar 

  62. Stephenson AJ, Scardino PT, Kattan MW, et al. Predicting the outcome of salvage radiation therapy for recurrent prostate cancer after radical prostatectomy. J Clin Oncol. 2007;25:2035-2041.

    Article  PubMed  Google Scholar 

  63. Stephenson AJ, Shariat SF, Zelefsky MJ, et al. Salvage radiotherapy for recurrent prostate cancer after radical prostatectomy. JAMA. 2004;291:1325-1332.

    Article  PubMed  CAS  Google Scholar 

  64. Loeb S, Roehl KA, Viprakasit DP, Catalona WJ. Long-term rates of undetectable PSA with initial observation and delayed salvage radiotherapy after radical prostatectomy. Eur Urol. 2008;54:88-96.

    Article  PubMed  Google Scholar 

  65. Swanson GP, Hussey MA, Tangen CM, et al. Predominant treatment failure in postprostatectomy patients is local: analysis of patterns of treatment failure in SWOG 8794. J Clin Oncol. 2007;25:2225-2229.

    Article  PubMed  Google Scholar 

  66. Leventis AK, Shahrokh FS, Kattan MW, Butler EB, Wheeler TM, Slawin KM. Prediction of response to salvage radiation therapy in patients with prostate cancer recurrence after radical prostatectomy. J Clin Oncol. 2001;19:1030-1039.

    PubMed  CAS  Google Scholar 

  67. Pasquier D, Ballerean C. Adjuvant and salvage radiotherapy after radical prostatectomy for prostate cancer: a literature review. Int J Radiat Oncol Biol Phys. 2008;72:972-979.

    Article  PubMed  Google Scholar 

  68. Trock BJ, Han M, Freedland SJ, et al. Prostate cancer specific survival following salvage radiotherapy vs. observation in men with biochemical recurrence after radical prostatectomy. JAMA. 2008;299:2760-2769.

    Article  PubMed  CAS  Google Scholar 

  69. Takayma TK, Lange PH. Radiotherapy for local recurrence of prostate cancer after radical prostatectomy. Urol Clin North Am. 1994;21:687-700.

    Google Scholar 

  70. Coetzee LJ, Hars V, Paulson DF. Postoperative prostate-specific androgen as a prognostic indicator in patients with margin-positive prostate cancer undergoing adjuvant radiotherapy after radical prostatectomy. Urology. 1996;47:232-235.

    Article  PubMed  CAS  Google Scholar 

  71. Wilt TJ, Mac Donald R, Rutks I, Shamilyan TA, Taylor BC, Kane RL. Systematic review: comparative effectiveness and harms of treatment for clinically localized prostate cancer. Ann Intern Med. 2008;148:435-448.

    PubMed  Google Scholar 

  72. Graham SM, Holzbeierlein JM. Adjuvant radiation therapy after radical prostatectomy: when is it indicated? Curr Urol Rep. 2009;10:194-198.

    Article  PubMed  Google Scholar 

  73. Bolla M, Von Poppel H, Collete L, et al. Postoperative radiotherapy after radical prostatectomy: a randomized controlled trial (EORTC trial 22911). Lancet. 2005;366:572-578.

    Article  PubMed  Google Scholar 

  74. Thompson IM Jr., Tangen CM, Paradelo J, et al. Adjuvent radiotherapy for pathologically advanced prostate cancer: A randomized clinical trial, Jama 2006 Nov 15;296(19):2329-2335.

    Google Scholar 

  75. Wiegel T, Battker D, Steiner U, et al. Phase III ­postoperative adjuvant radiotherapy after radical prostatectomy compared with radical prostatectomy alone in pT3 prostate cancer with ­postoperative undetectable prostate-specific antigen: ARO 96-02/AUO AP 09/95. J Clin Oncol. 2009;27:2928-2930.

    Article  Google Scholar 

  76. Morgan SC, Waldron TS, Eapen L, Mayhew EW, Lukka U. Adjuvant radiotherapy following radical prostatectomy for pathological T3 or margin-positive prostate cancer: a systematic review and meta-analysis. Radiother Oncol. 2008;88:1-9.

    Article  PubMed  Google Scholar 

  77. Zincke H, Utz DC, Taylor WF. Bilateral pelvic lymphadenectomy and radical prostatectomy for clinical stage C prostatic cancer: role of adjuvant treatment for residual cancer and in disease progression. J Urol. 1986;135:1199-1205.

    PubMed  CAS  Google Scholar 

  78. Messing EM, Manola J, Yao J, et al. Immediate versus deferred androgen deprivation treatment in patients with node-positive cancer after radical prostatectomy and pelvic lymphadenectomy. Lancet Oncol. 2006;7:472-479.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Urology, Department of Surgery, University of São Paulo Medical School, São Paulo, Brazil

    Miguel Srougi M.D.

  2. Global Robotics Institute – Urology, Florida Hospital Celebration Health, Celebration, FL, USA

    Rafael Ferreira Coelho M.D.

  3. Florida Hospital Celebration Health, Celebration, FL, USA

    Vipul R. Patel M.D.

  4. College of Medicine, Florida Hospital Celebration Health, University of Central Florida, Celebration, FL, USA

    Vipul R. Patel M.D.

  5. Florida Hospital Celebration Health Global Robotics Institute, Celebration, FL, USA

    Vipul R. Patel M.D.

Authors
  1. Miguel Srougi M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rafael Ferreira Coelho M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Vipul R. Patel M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

Editor information

Editors and Affiliations

  1. Florida Hospital Celebration Health, Global Robotics Institute, Celebration Place 410, Celebration, 34747, Florida, USA

    Vipul R. Patel

Rights and permissions

Reprints and permissions

Copyright information

© 2011 Springer-Verlag London Limited

About this chapter

Cite this chapter

Srougi, M., Coelho, R.F., Patel, V.R. (2011). Management of Positive Surgical Margins Following Radical Prostatectomy. In: Patel, V. (eds) Robotic Urologic Surgery. Springer, London. https://doi.org/10.1007/978-1-84882-800-1_20

Download citation

  • DOI: https://doi.org/10.1007/978-1-84882-800-1_20

  • Published:

  • Publisher Name: Springer, London

  • Print ISBN: 978-1-84882-799-8

  • Online ISBN: 978-1-84882-800-1

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation