Elsevier

European Urology

Volume 59, Issue 4, April 2011, Pages 613-618
European Urology

Prostate Cancer
The Prognostic Significance of Capsular Incision Into Tumor During Radical Prostatectomy

https://doi.org/10.1016/j.eururo.2010.12.005Get rights and content

Abstract

Background

The prognostic significance of capsular incision (CapI) into tumor during radical prostatectomy (RP) with otherwise organ-confined disease remains uncertain.

Objective

To evaluate the impact of CapI into tumor on oncologic outcome.

Design, setting, and participants

A retrospective review of 8110 consecutive patients with prostate cancer treated at Ottawa Hospital and at Memorial Sloan–Kettering Cancer Center, both tertiary academic centers, between 1985 and 2008.

Intervention

All patients underwent an open, laparoscopic or robotic RP.

Measurements

Patients were divided into four pathologic categories: group 1 (CapI group), positive surgical margins (PSMs) without extraprostatic extension (EPE); group 2, negative surgical margins (NSMs) without EPE; group 3, NSM with EPE; group 4, PSMs with EPE. Estimates of recurrence-free survival were generated with the Kaplan-Meier method. Recurrence was defined as a prostate-specific antigen (PSA) >0.2 ng/ml and rising. Cox proportional hazards regression was used to estimate the hazard ratio (HR) for recurrence controlling for pretreatment PSA, RP date, RP Gleason sum, seminal vesicle invasion, and lymph node involvement. Pathologic categories were defined in the model by including the variables EPE and surgical margins (SMs) as well as their interaction.

Results and limitations

Median follow-up was 37.3 mo. The 5-yr recurrence-free probability after RP for the CapI group was 77% (95% confidence interval [CI], 72–83). This was not only inferior to patients with NSMs and no EPE (log rank p < 0.0001) but also to those with NSMs and EPE (log rank p = 0.0002). In multivariate analysis the interaction between EPE and SM was not significant (p = 0.26). In the adjusted model excluding the interaction term, patients with EPE had an increased risk for recurrence (HR: 1.80; 95% CI, 1.49–2.17; p < 0.0001) as did those with positive margins (HR: 1.81; 95% CI, 1.51–2.15; p < 0.0001). This was a retrospective study.

Conclusions

CapI into tumor has a significant impact on patient outcome following RP. Patients, who otherwise would have organ-confined disease, will now have a higher probability of recurrence than those with completely resected extraprostatic disease.

Introduction

Despite a better understanding of prostatic anatomy, advances in surgical technique and technology, and the downward stage migration since the introduction of prostate-specific antigen (PSA) testing, positive surgical margins (PSMs) following radical prostatectomy (RP) still occur in approximately 11% to 38% of patients [1]. Furthermore, the increased utilization of nerve sparing during RP and the impact of various techniques available (interfascial vs intrafascial) is also unclear. Numerous studies have documented PSMs to be an important predictor of biochemical, local, and potentially systemic progression [1], [2], [3], [4], [5], [6]. The impact of capsular incision (CapI) into tumor during a radical retropubic prostatectomy (RRP) on patient outcome, however, is less clear. CapI is commonly described as positive margins without extraprostatic extension (EPE) of tumor. Earlier studies found that CapI appeared to have a negligible influence on cancer recurrence, but more contemporary series have shown this not to be the case [7], [8]. In this study we evaluate the impact of CapI into tumor on patient outcome.

Section snippets

Patient selection

A retrospective review was conducted of our prostate cancer database after receiving institutional review board approval. Between 1985 and 2008, 8110 consecutive patients were treated with an RP at Ottawa Hospital and at Memorial Sloan-Kettering Cancer Center (MSKCC) for clinically localized prostate adenocarcinoma. Patients having received neoadjuvant therapy (n = 968), adjuvant radiotherapy (n = 67), or having incomplete data sets (n = 220) were excluded, leaving 6855 patients included in the

Results

A total of 6855 patients were included in this retrospective study with a median follow-up time of 37.3 mo (interquartile range: 14.9–71.6 mo). Procedures were performed via open (5340 of 6855, 77.9%), laparoscopic (1275 of 6855, 18.6%), or robotic (240 of 6855, 3.5%) technique. Of 5530 patients with data regarding nerve sparing, 4102 (74.1%) underwent bilateral nerve sparing, 880 (15.9%) underwent unilateral nerve sparing, and 548 (9.9%) had a bilateral nerve resection. In the entire cohort,

Discussion

The majority of contemporary studies have found CapI to have a detrimental impact on recurrence-free survival [3], [4], [5], [6], [7], [8] (Table 3). Our study clearly supports this finding as patients with a CapI into tumor not only had higher rates of recurrence than patients with organ-confined disease and NSMs, but also higher than patients with extracapsular disease that was fully resected. Modifying the TNM staging to include PSMs as pT3 has been suggested in a prior study by Freedland et

Conclusions

CapI into tumor, while uncommon, appears to have a significant impact on patient outcome following RRP. Patients, who otherwise would have organ-confined disease, will be made to have a higher probability of recurrence than those with completely resected extraprostatic disease. Limiting CapI is therefore of utmost importance and is an important quality indicator of RP. This study suggests that patients with CapI into tumor may benefit from adjuvant radiotherapy, as would patients with

Cited by (0)

View full text