Intraoperative technologies to assess margin status during radical prostatectomy - a narrative review

Area of Science:

• Urology
• Surgical Oncology
• Medical Imaging

Background:

• Positive surgical margin (PSM) is a significant concern in radical prostatectomy for prostate cancer (PCa), linked to higher recurrence rates and need for further treatments.
• Current strategies like multiparametric MRI (mpMRI) and fusion biopsy help, but cannot always prevent PSM due to limitations in imaging and surgical dissection.

Purpose of the Study:

• To review established and emerging intraoperative techniques for assessing positive surgical margins (PSM) during radical prostatectomy.
• To highlight advancements aimed at reducing PSM rates and improving nerve-sparing surgical outcomes.

Main Methods:

• Review of established intraoperative frozen section techniques, specifically neurovascular structure-adjacent frozen section examination (NeuroSAFE).
• Exploration of novel ex vivo (fluorescent confocal microscopy, intraoperative PET-CT) and in vivo (augmented reality, PSMA-fluorescent guided surgery) technologies for PSM assessment.
• Discussion of the advantages and limitations of each technique.

Main Results:

• NeuroSAFE technique effectively reduces PSM rates and supports nerve-sparing surgery but faces barriers in accessibility, cost, and time.
• Emerging ex vivo and in vivo technologies offer potential solutions for real-time, intraoperative PSM assessment with varying logistical demands.
• In vivo technologies provide intracorporeal analysis, enhancing surgical precision.

Conclusions:

• Continuous innovation in intraoperative assessment techniques is crucial for minimizing PSM in prostate cancer surgery.
• New technologies promise to overcome limitations of current methods, potentially making PSM assessment more accessible and efficient.
• Further development and validation of these advanced techniques are essential for widespread clinical adoption and improved patient outcomes.