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Intraoperative margin assessment using fluorescence confocal microscopy during robot-assisted radical prostatectomy:

Mario de Angelis1,2,3, Edoardo Beatrici4,2,3, Natali Rodriguez Penaranda5,2,3

  • 1Department of Urology, European Institute of Oncology (IEO), IRCCS, Milan, Italy.

BJU International
|March 25, 2026
PubMed
Summary

Fluorescence confocal microscopy (FCM) is feasible for intraoperative assessment of positive surgical margins (PSMs) during robot-assisted radical prostatectomy (RARP), showing good accuracy and rapid results. Applying length thresholds improves diagnostic performance for clinically significant PSMs.

Keywords:
Histologfluorescence confocal microscopynerve‐sparing surgerypositive surgical marginsrobot‐assisted radical prostatectomysurgical margin assessment

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Area of Science:

  • Urology
  • Surgical Oncology
  • Medical Imaging

Background:

  • Accurate intraoperative assessment of positive surgical margins (PSMs) is crucial during robot-assisted radical prostatectomy (RARP) to optimize oncological outcomes.
  • Current methods for margin assessment can be time-consuming, potentially delaying surgical decisions.
  • Fluorescence confocal microscopy (FCM) offers a potential solution for rapid, real-time margin evaluation.

Purpose of the Study:

  • To evaluate the feasibility of adopting fluorescence confocal microscopy (FCM) for intraoperative assessment of PSMs in a real-world RARP setting.
  • To determine the diagnostic performance of FCM compared to final histopathology for identifying PSMs.

Main Methods:

  • A prospective observational study included 101 patients undergoing RARP with intraoperative ex vivo FCM scanning of prostate specimens.
  • Digital FCM images were reviewed in real-time by a pathologist blinded to final pathology results.
  • Diagnostic metrics (sensitivity, specificity, PPV, NPV, accuracy) were calculated for any PSM and clinically significant PSMs (≥3 mm).

Main Results:

  • FCM demonstrated high diagnostic accuracy for any PSM (91.1%) and clinically significant PSMs (92.1%).
  • Sensitivity and specificity were robust for both any PSM (88.2% and 91.7%) and significant PSMs (93.8% and 91.8%).
  • The median time from prostate extraction to intraoperative report was 13 minutes, compatible with surgical workflows.

Conclusions:

  • Intraoperative margin assessment using FCM is feasible in RARP, offering good diagnostic accuracy and rapid turnaround times.
  • Diagnostic performance is enhanced when focusing on clinically significant PSMs (≥3 mm).
  • Further multicenter and randomized trials are needed to confirm the impact of FCM on oncological and functional outcomes.