Impact of surgical margin status on long-term cancer control after radical prostatectomy

To determine whether previously described technical modifications that significantly decreased the positive surgical margin (PSM) rate have translated into improved long-term cancer control, as SM status is generally recognized as an independent risk factor for biochemical recurrence (BR) after radical retropubic prostatectomy (RRP), and is the only factor that can be modified by surgical technique.

Between March 1994 and December 2004, 996 consecutive patients had RRP as the sole treatment for clinically localized prostate cancer. The surgery was done by one surgeon (C.B.B.) and the data were prospectively reviewed.

The overall PSM rate was 8.8%; the PSM rate by pathological stage was 1.7%, 24.2% and 27.1% for men with pT2, pT3a and pT3b disease, respectively (P < 0.001). In all, 968 of 996 (97.2%) patients were available for the follow-up (mean 6.4 years); 69 of 883 (7.8%) with negative SMs (NSMs) developed BR, vs 29 of 85 (34%) with PSMs (P < 0.001). The actuarial 5- and 10-year biochemical disease-free survival was 92.1% and 89.6%, and 70.6% and 59.9%, for patients with NSM and PSM, respectively (P < 0.001). On multivariate analysis, PSM, pathological stage and Gleason grade were the strongest predictors of BR (P < 0.001). The preoperative prostate-specific antigen level, and clinical stage T1c and T2a disease were not associated with recurrence. The hazard ratio (95% confidence interval) for BR in patients with PSMs was 3.27 (2.1-5.1).

RRP including the previously described surgical modifications not only decreased the PSM rate but also resulted in excellent long-term cancer control. The importance of meticulous surgical technique in RRP cannot be overemphasised.