Prostate CancerThe Prognostic Significance of Capsular Incision Into Tumor During Radical Prostatectomy
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
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