UROLOGICAL SURVEY
Endourology & laparoscopy
Preoperative and Intraoperative Risk Factors for Side-Specific Positive Surgical Margins in Laparoscopic Radical Prostatectomy for Prostate Cancer
Secin FP, Serio A, Bianco FJ Jr, Karanikolas NT, Kuroiwa K, Vickers A, Touijer K, Guillonneau B
Department of Urology, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
Eur Urol. 2007; 51: 764-71
OBJECTIVES: Identification of variables predicting positive surgical margins (PSMs) in patients undergoing laparoscopic radical prostatectomy (LRP) for clinically localized prostate cancer is lacking. Our objective was to determine preoperative risk factors and the association of ipsilateral degree of neurovascular bundle dissection (intraoperative factor) with side-specific PSMs in these patients.
MATERIAL AND METHODS: Between October 2002 and April 2005, one surgeon performed LRP on 407 previously untreated patients. Of 814 evaluable prostate sides, 728 harboured prostate cancer in the specimen and composed the study population. For each prostate side, we obtained clinical stage, biopsy Gleason, maximum percentage of tumour in the biopsy, suspected extracapsular extension (ECE) on endorectal coil magnetic resonance imaging (MRI), degree of neurovascular bundle (NVB) dissection, and PSMs. PSM was defined as cancer cells at the inked margins. Logistic regression analyses with random effects were generated.
RESULTS: Of the 728 prostate sides with cancer, 51 (7%) had at least one PSM. In multivariable analysis, higher PSA (p=0.01), Gleason score of 7 compared with </=6 in the biopsy (p=0.04), lower prostate volume on MRI (p=0.01), and interfascial NVB dissection compared with intrafascial dissection (p=0.01) were associated with an increased risk of side-specific PSMs. Suspected ECE on MRI (p=0.9) and clinical stage (p=0.3) were not significantly associated with side-specific PSMs. A subset analysis of 321 patients with bilateral tumours did not show statistically significant differences in PSMs according to tumour side (p=0.3).
CONCLUSIONS: High serum prostate-specific antigen, biopsy Gleason score of 7, low prostate volume, and interfascial NVB dissection were independently associated with side-specific PSMs after LRP, and should be considered during planning of the LRP surgical strategy.
Editorial Comment
Preoperative PSA, clinical stage, and biopsy Gleason score can predict positive surgical margins preoperatively. Furthermore, a positive surgical margin has been shown to be associated with biochemical recurrence rates up to 50% at 10 years after radical prostatectomy. The authors present their experience in improving the surgical technique to optimize clinical outcome and survival. Their conclusion states that neurovascular bundle preservation is not a risk factor for increase rates of positive margins when the technique is applied adequately in selected patients. Other factors such as elevated serum PSA (> 10 ng/mL), small glands (< 30 g), biopsy Gleason scores of 7, degree of neurovascular bundle dissection, and presence of bulky disease should be considered by laparoscopic surgeons when planning the operation to decrease the incidence of positive surgical margins.
Dr. Fernando J. Kim
Chief of Urology, Denver Health Med Ctr
Assistant Professor, Univ Colorado Health Sci Ctr
Denver, Colorado, USA
Limitations of Laparoscopy for Bilateral Nephrectomy for Autosomal Dominant Polycystic Kidney Disease
Lipke MC, Bargman V, Milgrom M, Sundaram CP
Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana 46202-5289, USA
J Urol. 2007; 177: 627-31
PURPOSE: We retrospectively studied outcomes following bilateral hand assisted laparoscopic nephrectomy.
MATERIALS AND METHODS: We retrospectively reviewed the charts of 18 patients with symptomatic autosomal dominant polycystic kidney disease who underwent bilateral hand assisted laparoscopic nephrectomy. Preoperative radiographic imaging was reviewed retrospectively to determine kidney size based on an ellipsoid shape. A visual analog pain scale with scores of 0 to 10 to assess pain related to autosomal dominant polycystic kidney disease was measured preoperatively and postoperatively.
RESULTS: Average patient age was 48.2 years (range 30 to 64). Of the patients 14 successfully underwent bilateral hand assisted laparoscopic nephrectomy, while 4 required open conversion. A total of 16 patients underwent nephrectomy for pain and 2 underwent surgery for frequent recurrent symptomatic urinary tract infections. All patients except 1 underwent renal transplantation before bilateral nephrectomy. There was a significant difference in the volume of the right and left kidneys between the hand assisted laparoscopic and open groups (mean +/- SD 1,043 +/- 672 and 1,058 +/- 603.8 vs 4,052 +/- 548 and 3,592 +/- 1,752 cm (3), p < 0.001 and 0.06 respectively). There were 5 complications, including wound infection and protracted ileus in 2 patients each, and incisional hernia in 1. In addition, the difference in mean preoperative and postoperative visual analog pain scores was statistically significant (6.9, range 3 to 10 and 0.5, range 0 to 2, p < 0.05).
CONCLUSIONS: Bilateral laparoscopic hand assisted nephrectomy is a safe and reliable option in patients requiring removal of the 2 kidneys in a single setting. Rather than performing staged nephrectomies, hand assisted laparoscopic nephrectomy allows the single administration of general anesthesia and provides effective relief of bothersome symptoms in patients with symptomatic autosomal dominant polycystic kidney disease. This procedure is safe in patients with renal transplants. Patients with massive polycystic kidneys with a kidney volume of greater than 3,500 cc are at increased risk for open conversion and they may have improved outcomes if open nephrectomy is attempted from the outset.
Editorial Comment
The new era of minimally invasive surgery demonstrates the feasibility of bilateral nephrectomies performed laparoscopically. There are no more questions that patients recover faster with better outcomes than the open counterpart is. Moreover, this less invasive approach allows patients to undergo 2 procedures in one setting providing innumerous benefits to patients that in the past had to experience staged operations. The authors demonstrated limitations to the technique when the polycystic kidneys are massively large decreasing the working space.
Dr. Fernando J. Kim
Chief of Urology, Denver Health Med Ctr
Assistant Professor, Univ Colorado Health Sci Ctr
Denver, Colorado, USA
Publication Dates
-
Publication in this collection
04 Apr 2007 -
Date of issue
Feb 2007
