Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
J Endourol. 2012 Apr;26(4):361-5. doi: 10.1089/end.2011.0336. Epub 2012 Jan 10.
Positive surgical margins (PSM) during robot-assisted laparoscopic radical prostatectomy (RALP) are generally considered an adverse event. We attempted to identify the factors associated with PSM and their location.
Records of patients undergoing RALP between 2003 and 2009 were retrospectively reviewed. We collected demographic (age, race, body mass index [BMI]), cumulative surgical experience (years from RALP introduction at our center), clinical (prostate-specific antigen [PSA] levels, and biopsy Gleason sums), nerve-sparing technique (yes/no), and pathological variables, including stage (organ-confined vs. non), Gleason sums, prostate weight, status, and location of the surgical margins. Multivariate regression models were constructed to identify the factors associated with PSM at prostate apex, periphery, proximal, and all locations.
A total of 560 patients were analyzed. Median age was 60.1 (interquartile range [IQR] 55.1-64.7), 19% were African-Americans, median BMI was 28.1 (25.8-30.8 kg/m(2)), PSA levels were 5.3 (3.9-7.1 ng/mL), and prostate weight was 45.2 (36.8-57.0 g). Gleason sums were as follows: ≤6 in 42.5%, 7 in 53.4%, and >7 in 3.1%. Overall, PSM were reported in 130 (23.2%), including 58 (44.6%) apical, 81 (62.3%) peripheral, and 20 (15.4%) proximal. The overall rate of PSM was associated with surgical experience, PSA, prostate weight, and Gleason sums. Apical PSM were independently associated only with surgical experience. Peripheral PSM were associated with PSA, stage, Gleason sums, and prostate weight. Finally, proximal margin status showed an association with PSA levels only.
While peripheral, proximal, and overall PSM are largely associated with inherent disease biology (grade, PSA levels, etc.), apical margin status is independently associated only with cumulative surgical experience. These results suggest that a lower rates of positive apical margins may be obtained as the cumulative center experience grows, suggesting a potential role of a "teaching learning curve," independently from disease characteristics.
在机器人辅助腹腔镜前列腺根治性切除术（RALP）中，阳性切缘（PSM）通常被认为是一种不良事件。我们试图确定与 PSM 相关的因素及其位置。
回顾性分析 2003 年至 2009 年接受 RALP 治疗的患者的病历。我们收集了人口统计学（年龄、种族、体重指数[BMI]）、累积手术经验（RALP 在我们中心开展的年限）、临床（前列腺特异性抗原[PSA]水平和活检 Gleason 总和）、神经保留技术（是否）和病理变量，包括分期（器官局限 vs. 非局限）、Gleason 总和、前列腺重量、状态和手术切缘位置。构建多变量回归模型以确定与前列腺尖部、外周、近端和所有部位 PSM 相关的因素。
共分析了 560 例患者。中位年龄为 60.1（四分位间距[IQR]55.1-64.7），19%为非裔美国人，中位 BMI 为 28.1（25.8-30.8kg/m2），PSA 水平为 5.3（3.9-7.1ng/mL），前列腺重量为 45.2（36.8-57.0g）。Gleason 总和如下：≤6 占 42.5%，7 占 53.4%，>7 占 3.1%。总体而言，130 例（23.2%）报告有 PSM，其中 58 例（44.6%）为尖部，81 例（62.3%）为外周，20 例（15.4%）为近端。总体 PSM 发生率与手术经验、PSA、前列腺重量和 Gleason 总和有关。仅手术经验与尖部 PSM 独立相关。外周 PSM 与 PSA、分期、Gleason 总和和前列腺重量有关。最后，近端切缘状态仅与 PSA 水平有关。
虽然外周、近端和整体 PSM 主要与固有疾病生物学（分级、PSA 水平等）有关，但尖部切缘状态仅与累积手术经验独立相关。这些结果表明，随着中心累积经验的增加，获得更高的阳性尖部切缘率可能更低，提示存在“教学学习曲线”的潜在作用，这与疾病特征无关。
