Prasanna Sooriakumaran1, Abhishek Srivastava2, Shahrokh F Shariat3, Phillip D Stricker4, Thomas Ahlering5, Christopher G Eden6, Peter N Wiklund7, Rafael Sanchez-Salas8, Alexandre Mottrie9, David Lee10, David E Neal11, Reza Ghavamian2, Peter Nyirady12, Andreas Nilsson7, Stefan Carlsson7, Evanguelos Xylinas13, Wolfgang Loidl14, Christian Seitz15, Paul Schramek16, Claus Roehrborn17, Xavier Cathelineau8, Douglas Skarecky5, Greg Shaw18, Anne Warren19, Warick J Delprado4, Anne-Marie Haynes4, Ewout Steyerberg20, Monique J Roobol20, Ashutosh K Tewari13. 1. Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden. Electronic address: sooriakumaran@gmail.com. 2. Department of Urology, Montefiore Medical Center, New York, NY, USA. 3. Department of Urology, Weill Cornell Medical College-New York Presbyterian Hospital, New York, NY, USA; Department of Urology, Medical University of Vienna, Vienna, Austria. 4. Prostate Cancer Centre, St. Vincent's Clinic, Sydney, Australia. 5. Department of Urology, University of California-Irvine School of Medicine, Irvine, CA, USA. 6. Department of Urology, Royal Surrey County Hospital, Guildford, UK. 7. Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden. 8. Department of Urology, L'Institut Mutualiste Montsouris, Paris, France. 9. Department of Urology, Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium. 10. Department of Urology, University of Pennsylvania, Philadelphia, PA, USA. 11. Department of Uro-oncology, University of Cambridge, Cambridge, UK; Uro-oncology Research Group, Cancer Research UK, Cambridge Research Institute, Cambridge, UK. 12. Department of Urology, Semmelweis University, Budapest, Hungary. 13. Department of Urology, Weill Cornell Medical College-New York Presbyterian Hospital, New York, NY, USA. 14. Department of Urology, St. Vincent's Hospital, Linz, Austria. 15. Department of Urology, Medical University of Vienna, Vienna, Austria. 16. Department of Urology, Saint John of God Hospital, Vienna, Austria. 17. Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA. 18. Uro-oncology Research Group, Cancer Research UK, Cambridge Research Institute, Cambridge, UK. 19. Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK. 20. Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands.
Abstract
BACKGROUND: Positive surgical margins (PSMs) are a known risk factor for biochemical recurrence in patients with prostate cancer (PCa) and are potentially affected by surgical technique and volume. OBJECTIVE: To investigate whether radical prostatectomy (RP) modality and volume affect PSM rates. DESIGN, SETTING, AND PARTICIPANTS: Fourteen institutions in Europe, the United States, and Australia were invited to participate in this study, all of which retrospectively provided margins data on 9778 open RP, 4918 laparoscopic RP, and 7697 robotic RP patients operated on between January 2000 and October 2011. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES: The outcome measure was PSM rate. Multivariable logistic regression analyses and propensity score methods identified odds ratios for risk of a PSM for one modality compared with another, after adjustment for age, preoperative prostate-specific antigen, postoperative Gleason score, pathologic stage, and year of surgery. Classic adjustment using standard covariates was also implemented to compare PSM rates based on center volume for each minimally invasive surgical cohort. RESULTS AND LIMITATIONS: Open RP patients had higher-risk PCa at time of surgery on average and were operated on earlier in the study time period on average, compared with minimally invasive cohorts. Crude margin rates were lowest for robotic RP (13.8%), intermediate for laparoscopic RP (16.3%), and highest for open RP (22.8%); significant differences persisted, although were ameliorated, after statistical adjustments. Lower-volume centers had increased risks of PSM compared with the highest-volume center for both laparoscopic RP and robotic RP. The study is limited by its nonrandomized nature; missing data across covariates, especially year of surgery in many of the open cohort cases; lack of standardized histologic processing and central pathology review; and lack of information regarding potential confounders such as patient comorbidity, nerve-sparing status, lymph node status, tumor volume, and individual surgeon caseload. CONCLUSIONS: This multinational, multi-institutional study of 22 393 patients after RP suggests that PSM rates might be lower after minimally invasive techniques than after open RP and that PSM rates are affected by center volume in laparoscopic and robotic cases. PATIENT SUMMARY: In this study, we compared the effectiveness of different types of surgery for prostate cancer by looking at the rates of cancer cells left at the margins of what was removed in the operations. We compared open, keyhole, and robotic surgery from many centers across the globe and found that robotic and keyhole operations appeared to have lower margin rates than open surgeries. How many cases a center and surgeon do seems to affect this rate for both robotic and keyhole procedures.
BACKGROUND: Positive surgical margins (PSMs) are a known risk factor for biochemical recurrence in patients with prostate cancer (PCa) and are potentially affected by surgical technique and volume. OBJECTIVE: To investigate whether radical prostatectomy (RP) modality and volume affect PSM rates. DESIGN, SETTING, AND PARTICIPANTS: Fourteen institutions in Europe, the United States, and Australia were invited to participate in this study, all of which retrospectively provided margins data on 9778 open RP, 4918 laparoscopic RP, and 7697 robotic RP patients operated on between January 2000 and October 2011. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES: The outcome measure was PSM rate. Multivariable logistic regression analyses and propensity score methods identified odds ratios for risk of a PSM for one modality compared with another, after adjustment for age, preoperative prostate-specific antigen, postoperative Gleason score, pathologic stage, and year of surgery. Classic adjustment using standard covariates was also implemented to compare PSM rates based on center volume for each minimally invasive surgical cohort. RESULTS AND LIMITATIONS: Open RP patients had higher-risk PCa at time of surgery on average and were operated on earlier in the study time period on average, compared with minimally invasive cohorts. Crude margin rates were lowest for robotic RP (13.8%), intermediate for laparoscopic RP (16.3%), and highest for open RP (22.8%); significant differences persisted, although were ameliorated, after statistical adjustments. Lower-volume centers had increased risks of PSM compared with the highest-volume center for both laparoscopic RP and robotic RP. The study is limited by its nonrandomized nature; missing data across covariates, especially year of surgery in many of the open cohort cases; lack of standardized histologic processing and central pathology review; and lack of information regarding potential confounders such as patient comorbidity, nerve-sparing status, lymph node status, tumor volume, and individual surgeon caseload. CONCLUSIONS: This multinational, multi-institutional study of 22 393 patients after RP suggests that PSM rates might be lower after minimally invasive techniques than after open RP and that PSM rates are affected by center volume in laparoscopic and robotic cases. PATIENT SUMMARY: In this study, we compared the effectiveness of different types of surgery for prostate cancer by looking at the rates of cancer cells left at the margins of what was removed in the operations. We compared open, keyhole, and robotic surgery from many centers across the globe and found that robotic and keyhole operations appeared to have lower margin rates than open surgeries. How many cases a center and surgeon do seems to affect this rate for both robotic and keyhole procedures.
Authors: Shane M Pearce; Joseph J Pariser; Sanjay G Patel; Blake B Anderson; Scott E Eggener; Gregory P Zagaja Journal: World J Urol Date: 2015-06-05 Impact factor: 4.226
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