Precision prostatectomy: Analysis of surgical pathology findings of a promising and novel surgical approach for patients with low to intermediate-risk prostate cancer
Alhamar M, Gupta N, Oyedeji O, Hogan K, Sood A, Arora S, Schultz D, Jeong W, Williamson S, Menon M, and Hassan O. Precision prostatectomy: Analysis of surgical pathology findings of a promising and novel surgical approach for patients with low to intermediate-risk prostate cancer. Modern Pathology 2020; 33(3):850-852.
Background: Precision Prostatectomy (PP) is a novel surgical approach introduced at our institution to treat low to intermediate-risk prostate cancer. It includes radical resection of the dominant nodule (DN) side, with preservation of neurovascular bundle, capsule, & 5-10 mm of prostatic tissue on the contralateral side. Here we report on the surgical pathology findings and outcome data on PP. Design: Detailed pathological findings were studied from PP patients. Post-operative erectile function & biochemical recurrence (BCR) were studied. Clinical selection criteria for PP included: (1) PSA ≤15 ng/mL (2) clinical stage ≤cT2 (3) a dominant unilateral lesion with grade group (GG) ≤3 (4) no primary Gleason score ≥4 contralaterally. Results: A total of 77 patients were studied, with median age 59 (range 47-75). Median pre-operative PSA was 5.5 (1.4 -23) and median number of positive biopsies was 3 (1-9). A second mapping biopsy was performed in 35/77 (45%). Most (64/77, 83%) had frozen section evaluation of the precision side. Of the PP specimens, median GG was 2 (1-5), median tumor percentage was 6% (1-32%). Almost all (75/77, 97%) had a DN, whereas 2/77 (3%) showed scattered microscopic tumor foci. Median DN size was 20 mm (4-35) & most (60/77, 78%) had secondary nodule(s) (SN). Median number of SN was 2 (1-6) & median size was 8 mm (1-30). Positive resection margin was present in 33/77 (43%) with a median linear extent of 3 mm (0.5 - 48). This was at the DN in 16/33 (49%), SN in 10/33 (30%), & both in 7/33 (21%). The DN was incompletely excised in the PP side in 4 cases (3 of these were midline, whereas the diagnostic biopsy missed the DN in the 4th). For the remainder, positive margin was present on the radical side, which would render the same results as a radical prostatectomy (RP) approach. Overall 20/77 had positive margin at the PP side (See Table 1). Only one patient (1%) had a positive lymph node. Median follow up was 8 months (1-24). All patients had excellent results with post-op erectile function & 3 had BCR. BCR was not significantly correlated with the status of DN excision (p= 0.8) (Table & Figure1). (Table presented) Conclusions: PP promises excellent post-op erectile function compared to RP. Pre-op saturation biopsy to map the tumor may aid in optimizing cancer control in these patients. Although initial results are promising, longer follow up is needed to assess long-term outcomes.