Apr 14, 2016 - Key Words: Radical Prostatectomy, Prostate Size, Surgical Margin. Received: ..... A large prostate at radical retropubic prostatectomy does not ...
Original Article
Acta Medica Anatolia
doi: 10.5505/actamedica.2016.30502
Volume 4 Issue 3 2016
Relationship between Prostate Size and Positive Surgical Margin in the Open Radical Prostatectomy Surgery Mehmet Emin Özyalvaçlı1, Ramazan Kocaaslan2, Uğur Yücetaş3, Erkan Erkan3, Ali Feyzullah Şahin4, Mustafa Kadıhasanoğlu3, Yusuf Şahin3, Erdinç Ünlüer2 Department of Urology, Abant Izzet Baysal University, Bolu, Turkey Department of Urology, Kafkas University, Kars, Turkey 3 Department of Urology, Ministry of Health Istanbul Education and Research Hospital, Istanbul, Turkey 4 Department of Urology, Sifa University, İzmir, Turkey 1 2
Abstract Introduction: Our study aims to reveal the correlation between positive surgical margins and prostate volume, thus determining a cutoff value for the prostate volume to predict PCM in patients with open radical prostatectomy. Methodology: In our study, a number of 450 patients who had undergone radical prostatectomy surgery at 2 centers within the last 5 years was evaluated. Age, total PSA, number of positive cores for prostate cancer, Gleason score, transfusion amount and prostate volume were all evaluated in the study. Evaluated all these parameters, 170 consecutive patients of whom data were available were included in the study Results: Stage T3 and PSA>10 ng/dL were statistically significant for positive surgical margins (p=0,002 and p 10 ng / dL when compared to those with ≤10 ng / dl (95% CI: 1.18 to 6.04; p = 0.018). We also found that stage T3 increased the risk for PCM by 8.51 times than the stage T2 (95% CI: 3.54 to 20.51, p = 10
>10
≤34,5 >34,5 T2 T3
Acta Med Anatol 2016;4(3):107-111
Positive surgical margins after radical prostatectomy have been reported as 11% to 46% in several studies (14-16). Our study suggested this rate as 36.5%. One of the most important factors in the development of local recurrence after RP is the positivity of surgical margins (17, 18).In a study, the recurrence rate was found 19% in patients with positive surgical margin, whereas it was 7% in those with negative (19). The nonrecurring rate over 5 years in patients with positive surgical margin was 64%, whereas it was found 83% in those with negative surgical margin. As a consequence, positive surgical margin has shown to be an independent risk factor of PSA recurrence, with an emphasis on the importance of its prevalence and number (20). One study showed a 10-year-survival rate of 88% in recurrent patients, while it was found 93% in those without recurrence, emphasizing that recurrence could be a sign for additional treatment (21). However, publications pointing out the effect of PCM on metastatic progression and cancer-specific mortality are fairly not very consistent. Wright et al. reported in a study that the mortality risk due to prostate cancer was 1.7 times higher in patients with PCM than those without it (22). Chalfie et al. suggested the adverse effect of PCM on survival in their study (23), but they also noted that this effect was relatively low when compared to Gleason score and pathological stage. In current studies, the relationship between prostate volume and PCM was evaluated for all surgical treatment methods of prostate cancer (2, 13, 24, 25). In a study of Freedland et al., a number of 1602 patients who received open RP surgery were evaluated. In this study, the rate of high-grade disease was found to be significantly higher in those with lower prostate weight (with the risk being elevated by 7.61 times in patients with PV of 20 g compared to those with ≥100 g). Again, in this study, PCM was significantly higher in patients with lower PV (with the risk being elevated by 3.09 times in patients with PV of 20 g compared to those with ≥100 g). Furthermore, in this study, biochemical progression was found higher in patients with lower PV (with the 109
Original Article risk being elevated by 3.94 times in patients with PV of 20 g compared to those with ≥100 g). When the study was evaluated; high-grade cancer, advanced disease and biochemical progression were all found significantly higher after RP in patients with lower PV, suggesting a possibly prognostic importance of PV on prostate cancer (2). Unlike our study, this study did not indicate a cut-off value for PV; various prostate volumes were rather compared. In a multicenter study of Patel VR et al., 6169 robotic RP patients due to prostate cancer were included in the study. This study investigated any relevant factors associated with PCM as well as its incidence in robotic RP. The rates for PCM in patients with T2 and T3 were found to be 9.5% and 37.2%, respectively. In multivariate analysis, pathological stage (4.588 times higher in patients with T3 than those of T2) and preoperative PSA (2.918 times higher in patients with PSA >10 ng/dl than those with ≤4) were found to be independent predictive factors for PCM in robotic RP. Again, this study demonstrated a correlation of increased PV with decreased PCM (24). Similarly, elevated PSA levels and stage were found to be an independent predictive factor for PCM in our study. We also found that any value of PV under 34.5 cc was an independent predictive factor for PCM. In their study, Link BA et al. investigated whether the prostate weight had any effect on pathological and operative outcomes in 1847 patients who underwent robotic RP by 4 distinct surgeons. Prostate weights were classified as 75 g. The grade, tumor size and stage were found to be significantly lower in patients with > 75 g. Likewise; biochemical non-recurrence was significantly higher in patients with larger prostates (3). The presence of PCM does not only affect patients based on their oncologic outcomes, but also raises generalized anxiety and often increases the need for additional treatment (26). Therefore, surgeons should make more of an effort to decrease the rates of positive surgical margins, while trying to maintain the quality of life of patients in terms of postoperative urinary and erectile function. In general; the grade of disease, stage, biochemical progression and positivity for surgical margin tend to increase in patients with lower prostate volume. This is related to a deteriorated course of illness. The reason for increased positivity of surgical margin in those with lower prostate volume may be the challenge of distinguishing between prostatovesical and prostatourethral junctions. In conclusion, we found that the prostate volume had an important role in positivity of surgical margins. It is likely that addition of prostate volume as well to nomograms used before surgery may be useful in improving of risk assessment in prostate cancer. Furthermore, evaluation of the prostate volume can be used as a prognostic factor for prostate cancer. Our study is a breakthrough in that it provides with a cutoff value in determining the positivity of surgical margins. Yet, further studies are needed with greater numbers of patients.
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