Original contributionRole of frozen section analysis of surgical margins during robot-assisted laparoscopic radical prostatectomy: a 2608-case experience
Introduction
In spite of the considerable progress of surgical technique, positive surgical margins (+SMs) are not uncommonly seen in radical prostatectomy (RP) specimens (eg, 11%-38% [1]), presumably due to such causes as extraprostatic extension of the tumor. Nevertheless, there are no reliable tools, other than meticulous assessment of prostate biopsy in rare cases, to preoperatively determine the presence of extraprostatic extension. Indeed, +SM is considered to be a poor prognostic indicator, which correlates with a high risk of biochemical recurrence (eg, up to 50% at 5 years after RP [2], [3]). Thus, the importance of achieving negative surgical margins (−SMs) to reduce the risk of recurrence has been well recognized.
Intraoperative frozen section analysis (FSA) of surgical margins (SMs) during RP has been used to prevent incomplete tumor resection. When the margin is positive for carcinoma on FSA, additional tissue is often excised until a negative FSA at the site is obtained. However, it remains controversial whether intraoperative FSA really contributes to reducing the rates of +SM on the final resection specimen. Uncertainty also remains regarding the appropriate site/number of specimens to send for FSA and the selection of patients on whom to perform FSA. In this study, we retrospectively reviewed our experience of 2608 RP cases with or without intraoperative FSA in a single institution to assess its role in the final status of SMs.
Section snippets
Patient population
We studied consecutive patients with prostatic adenocarcinoma who had undergone robot-assisted laparoscopic RP at our institution between June 2004 and September 2011. From our institutional review board–approved surgical pathology electronic database, we identified 2608 cases coded as RP specimens, including 1128 (43.3%) in which intraoperative FSA was done to assess the areas suspected of having +SMs. Additional patients (n = 23) who had received therapy with hormonal reagents or radiation
Results
Table 1 summarizes the clinicopathologic features of the patients with (1128 cases; 43.3%) and without (1480 cases; 56.7%) intraoperative FSA of the prostate. Between these 2 cohorts, there were statistically significant differences in age of the patients, GS on biopsy, and pT stage on RP. No significant differences were found in preoperative PSA, GS on RP, pN stage, and estimated cancer volume. Patients undergoing FSA were younger than those not undergoing FSA (P < .001). Similarly, patients
Discussion
Intraoperative FSA of SMs is a frequent part of the standard procedure in most radical surgeries for solid tumors. In RPs, +SM is considered to be a poor prognostic indicator, which correlates with a high risk of biochemical recurrence [2], [3]. However, FSA has yet to prove a significant benefit to RP patients in terms of the risk of incomplete resection and subsequent biochemical recurrence [3]. Some of these studies lacked the control cohort of no FSA and/or involved relatively small numbers
References (15)
- et al.
Positive surgical margins in radical prostatectomy: outlining the problem and its long-term consequences
Eur Urol
(2009) - et al.
Intraoperative frozen section analysis of urethral margin biopsies during radical prostatectomy
Urology
(2011) - et al.
Residual benign prostatic glands at the urethrovesical anastomosis after radical retropubic prostatectomy: prediction and impact on disease outcome
Eur Urol
(2004) - et al.
Intraoperative frozen section analysis during nerve sparing laparoscopic radical prostatectomy: feasibility study
J Urol
(2003) - et al.
Neurovascular structure-adjacent frozen-section examination (NeuroSAFE) increases nerve-sparing frequency and reduces positive surgical margins in open and robot-assisted laparoscopic radical prostatectomy: experience after 11 069 consecutive patients
Eur Urol
(2012) - et al.
Analysis of apical soft tissue margins during radical retropubic prostatectomy
J Urol
(2001) - et al.
Role of intraoperative biopsies during radical retropubic prostatectomy
Urology
(2004)
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The impact of routine frozen section analysis during nephroureterectomy or segmental ureterectomy for urothelial carcinoma on final surgical margin status and long-term oncologic outcome
2023, Urologic Oncology: Seminars and Original InvestigationsThe Use of Augmented Reality to Guide the Intraoperative Frozen Section During Robot-assisted Radical Prostatectomy
2021, European UrologyCitation Excerpt :A systematic IFS analysis of the posterolateral prostatic surface (NeuroSAFE) showed a significantly higher rate of NS approach and lower rates of PSMs with conversion to a definitive negative surgical margin in 86% of cases, suggesting that the benefit of increased NS was not achieved at the expense of higher rates of PSMs with both the open [11] and the robotic approach [13]. Recently, the diffusion of imaging-guided surgery has led to a more selective approach for IFS, despite there being no consensus regarding the appropriate sites, methods, or clinical indications for an IFS analysis [27]. Indeed, the accuracy of mpMRI to identify the dominant index PCa has been proposed as a promising tool for mpMRI guided IFS.
The impact of routine frozen section analysis during partial cystectomy for bladder cancer on surgical margin status and long-term oncologic outcome
2020, Urologic Oncology: Seminars and Original InvestigationsCitation Excerpt :Intraoperative consultation on SMs has also been widely used to determine whether the resection margin is free of tumor. We have indeed demonstrated our findings indicating that routine FSA of the SMs during urological surgeries, including partial nephrectomy, radical prostatectomy, and partial or total penectomy, is useful in at least select patients [8–11]. Several other studies have also suggested that FSA of the ureteral margins during radical cystectomy/cystoprostatectomy contributes to reducing the rate of final positive SMs [10,12–16].
Intraoperative Frozen Section for Margin Evaluation During Radical Prostatectomy: A Systematic Review
2020, European Urology FocusCitation Excerpt :Baseline characteristics of included patients are summarised in Table 1 (more details according to RP with IFS or without IFS are provided in Supplementary Table 1). The average age was similar across all studies, though two studies found that patients in whom IFS was performed were statistically significantly younger than those in whom IFS was not performed (Kakiuchi et al [24] study: 59.5 vs 61.1 yr old, and Mirmilstein et al [27] study: 58 vs 62 yr old). Pathological stage did not vary significantly between studies (see Table 2).
“Real-time” Assessment of Surgical Margins During Radical Prostatectomy: State-of-the-Art
2020, Clinical Genitourinary Cancer
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Y. K. and B. C. contributed equally.