Surgical margins after radical prostatectomy: Technique does matter

Several studies have shown that a positive surgical margin is an independent predictor of biochemical recurrence after radical prostatectomy, said James A. Eastham, MD, associate professor of urology, Memorial Sloan-Kettering Cancer Center, New York.

"The unanswered question is, 'Are positive margins an inherent result of tumor biology or can incidence be reduced by surgical technique?'," Dr. Eastham said.

Even in patients with extracapsular extension-those considered at high risk for recurrence-there was a substantially different outcome when margins were negative. In men with pathologic T3 disease who had a negative margin, approximately 67% were free of biochemical recurrence compared with approximately 30% of those with a positive margin. (Also see, "Surgeon experience, technique influence RP outcomes," page 15.)

Technique matters

Research suggests that surgical margins reflect more than just the biology of the cancer. Dr. Eastham reviewed a database that included both academic and private practice urologists at two large urban centers (J Urol 2003; 170:2292-5). Forty-four surgeons performed 4,629 radical prostatectomies for clinical stage T1-T3NxM0 prostate cancer from 1983 to 2002. A variety of factors were examined, including surgical volume and the individual surgeon as potential risks for having positive margins. The researchers found that surgeon volume was predictive of the likelihood of having a positive margin.

"Depending on the surgeon who did the operation, a patient was either more or less likely to have a positive surgical margin, again suggesting that surgical technique matters," Dr. Eastham said. "It's not just the volume that's important. It is more what you did at the time of surgery that matters."

For urologists performing prostatectomy, the challenge comes in avoiding positive surgical margins while maintaining continence and potency.

"These goals often oppose each other," Dr. Eastham said. "Improvement in one area is likely to result in deficiencies in other areas. So it's not just having the lowest margin rate possible; it's also being able to preserve continence and potency the best way possible."

"A positive surgical margin influences the patient's follow-up treatment, which is another reason to examine your own surgical outcomes," said E. David Crawford, MD, professor of urology/radiation oncology at University of Colorado Health Sciences Center, Denver. "Since the techniques for performing radical prostatectomies have changed over the years, some surgeons may benefit from learning new techniques that have been shown to be successful in reducing positive surgical margins."

Dr. Crawford suggests enrolling in courses, reviewing surgical videos, or observing procedures at different institutions.

"The bottom line is to evaluate your results," Dr. Eastham said. "If you're doing well, keep doing it. If you're not doing so well, try and figure out what you can do differently to improve outcomes. Studies show that technique matters and that we can all strive to do better."