Positive surgical margins at radical prostatectomy: importance of intra-operative bladder neck frozen sections

Abstract

Objective: To determine if intraoperative frozen sections of the bladder neck during radical prostatectomy (RP) could decrease the incidence of final positive surgical margins at the bladder neck. Materials and Methods:This prospective cohort study included 51 consecutive men who underwent anatomic RP at University of Florida & Shands Jacksonville. All patients had intraoperative frozen section of bladder neck sent for analysis. Preoperative, operative, and postoperative data were collected and analyzed. Main Outcome Measures: Outcome measures were intraoperative bladder neck margin status, final pathologic bladder neck margin status, and postoperative urinary complications. Median follow-up for the 51 patients was 22 months. Results: The final positive surgical margin rate was 20% (10 patients). An additional three patients had positive surgical margins at the bladder neck intraoperatively. These patients then had a wider resection of the affected bladder neck until the frozen sections were negative for cancer or prostatic tissue. Final pathologic evaluation of bladder neck margin was negative for tumor or persistent prostatic tissue in all 51 men. Conclusion: With intra-operative frozen sections, we were able to obtain a negligible positive bladder neck margin rate. Surgeons who are still on the learning curve for RP should consider intra-operative frozen section of the bladder neck.

Biochemical recurrence rate in patients with positive surgical margins at radical prostatectomy with further negative resected tissue

“…The 98 patients having further tissue resected represent only 2.3% of the entire cohort treated during the period of the study; thus the 38 margins rendered negative represent 0.9% of the entire cohort, effectively reducing the PSM rate in the entire series from 13.9% to 13.0%. The studies reporting on the effect of resection of additional tissue on PSM are summarized in Table 3[11–14,18–25]. The rate of PSMs rendered negative in the reported studies range from 0.9% in the present series to 21%, with the relative reduction in PSM of 6.5–66.7%.…”

“…As such, in cases of capsular incision into the prostate that are recognized during RP, surgeons often resect additional tissue to achieve a NSM. While several investigators have reported on use of intraoperative FSA to render surgical margins negative [11–14,18–25], there is a paucity of data on the prognostic implications of this approach, with few studies evaluating BCR rates in those with PSMs that have been rendered negative [13,21].…”

Blunt apical dissection during anatomic radical retropubic prostatectomy

“…We do not believe our established technique is associated with increased morbidity, seeing that in our patients less than 65 years reported excellent urinary continence rates and favorable potency rates as assessed by their 12 month EPIC questionnaire. Previously we have reported on the outcomes of subjects treated utilizing this technique [11,12]. However, the outcomes from this reported technique should be corroborated by other surgeons.…”

Robotic-Assisted Laparoscopic Prostatectomy for High-Risk Prostate Cancer: Technical Considerations and Review of the Literature

“…Urologists should avoid the natural tendency to advance towards the prostate and use a perpendicular place of dissection between the bladder neck and prostate base to avoid a positive surgical margin. Frozen section analysis may be useful in selected cases [36, 37]. Visual clues to decrease the risk of posterior-lateral surgical margins include appreciation of periprostatic (lateral prostatic) fascial compartments; color and texture of the tissue; periprostatic veins as a landmark for athermal dissection; signs of inflammation; a freely separating bloodless plane showing loose shiny areolar tissue [38].…”