Positive Surgical Margins in Radical Prostatectomy: Outlining the Problem and Its Long-Term Consequences

Ofer Yossepowitch, Anders Bjartell, James A. Eastham, Markus Graefen, Bertrand D. Guillonneau, Pierre I. Karakiewicz, Rodolfo Montironi, Franceso Montorsi

Research output: Contribution to journalArticle

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.

Original languageEnglish
Pages (from-to)87-99
Number of pages13
JournalEuropean Urology
Volume55
Issue number1
DOIs
Publication statusPublished - Jan 2009

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Keywords

  • Biochemical recurrence
  • Endorectal MRI
  • Frozen section analysis
  • Nerve sparing
  • Positive surgical margins
  • Prostate cancer
  • PSA
  • Radiation therapy
  • Radical prostatectomy

ASJC Scopus subject areas

  • Urology

Cite this

Yossepowitch, O., Bjartell, A., Eastham, J. A., Graefen, M., Guillonneau, B. D., Karakiewicz, P. I., Montironi, R., & Montorsi, F. (2009). Positive Surgical Margins in Radical Prostatectomy: Outlining the Problem and Its Long-Term Consequences. European Urology, 55(1), 87-99. https://doi.org/10.1016/j.eururo.2008.09.051