Patterns of positive specimen margins and detectable prostate specific antigen after radical perineal prostatectomy

Positive specimen margins and detectable postoperative prostate specific antigen (PSA) levels were analyzed after 200 consecutive radical perineal prostatectomies for clinical stages T1 and T2 adenocarcinoma of the prostate. Clinical parameters that correlated with lymph node metastases in concomitant pelvic lymphadenectomies were also noted. At a mean followup of 35 months 79% of the patients had undetectable PSA levels. Step-section pathological analysis of specimens obtained by either nerve sparing or extended radical modifications revealed that 41% of the tumors were organ confined and 56% had negative margins. Selective sacrifice of the posterolateral periprostatic fascia and the enclosed neurovascular bundle achieved negative margins and undetectable PSA levels despite capsular penetration in 15% of all patients. Of all positive margins with the perineal approach, solitary positive apical and posterolateral margins were infrequent (7% and 16%, respectively) but solitary positive anterior margins were more so (25%). Of those positive anterior margins 41% appeared to be artifactual and 45% might have been eliminated by avoiding avulsion of the puboprostatic ligaments. Pelvic lymphadenectomy could have been eliminated in 58% of the patients (clinical stage T2b or less, biopsy Gleason score 6 or less and PSA level 11 or less, for a node negative predictive value of 99%).