Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
Department of Urology, Montefiore Medical Center, New York, NY, USA.
Eur Urol. 2014 Sep;66(3):450-6. doi: 10.1016/j.eururo.2013.11.018. Epub 2013 Nov 24.
Positive surgical margins (PSMs) are a known risk factor for biochemical recurrence in patients with prostate cancer (PCa) and are potentially affected by surgical technique and volume.
To investigate whether radical prostatectomy (RP) modality and volume affect PSM rates.
DESIGN, SETTING, AND PARTICIPANTS: Fourteen institutions in Europe, the United States, and Australia were invited to participate in this study, all of which retrospectively provided margins data on 9778 open RP, 4918 laparoscopic RP, and 7697 robotic RP patients operated on between January 2000 and October 2011.
The outcome measure was PSM rate. Multivariable logistic regression analyses and propensity score methods identified odds ratios for risk of a PSM for one modality compared with another, after adjustment for age, preoperative prostate-specific antigen, postoperative Gleason score, pathologic stage, and year of surgery. Classic adjustment using standard covariates was also implemented to compare PSM rates based on center volume for each minimally invasive surgical cohort.
Open RP patients had higher-risk PCa at time of surgery on average and were operated on earlier in the study time period on average, compared with minimally invasive cohorts. Crude margin rates were lowest for robotic RP (13.8%), intermediate for laparoscopic RP (16.3%), and highest for open RP (22.8%); significant differences persisted, although were ameliorated, after statistical adjustments. Lower-volume centers had increased risks of PSM compared with the highest-volume center for both laparoscopic RP and robotic RP. The study is limited by its nonrandomized nature; missing data across covariates, especially year of surgery in many of the open cohort cases; lack of standardized histologic processing and central pathology review; and lack of information regarding potential confounders such as patient comorbidity, nerve-sparing status, lymph node status, tumor volume, and individual surgeon caseload.
This multinational, multi-institutional study of 22 393 patients after RP suggests that PSM rates might be lower after minimally invasive techniques than after open RP and that PSM rates are affected by center volume in laparoscopic and robotic cases.
In this study, we compared the effectiveness of different types of surgery for prostate cancer by looking at the rates of cancer cells left at the margins of what was removed in the operations. We compared open, keyhole, and robotic surgery from many centers across the globe and found that robotic and keyhole operations appeared to have lower margin rates than open surgeries. How many cases a center and surgeon do seems to affect this rate for both robotic and keyhole procedures.
阳性切缘（PSM）是前列腺癌（PCa）患者生化复发的已知危险因素，并且可能受到手术技术和手术量的影响。
研究根治性前列腺切除术（RP）方式和手术量是否会影响 PSM 发生率。
设计、地点和参与者：邀请了欧洲、美国和澳大利亚的 14 个机构参与这项研究，所有机构均回顾性地提供了 9778 例开放式 RP、4918 例腹腔镜 RP 和 7697 例机器人 RP 患者的边缘数据，这些患者均于 2000 年 1 月至 2011 年 10 月间接受手术。
结局指标为 PSM 发生率。多变量逻辑回归分析和倾向评分方法确定了与另一种方式相比，一种方式发生 PSM 的风险比，调整因素包括年龄、术前前列腺特异性抗原、术后 Gleason 评分、病理分期和手术年份。还实施了经典的基于标准协变量的调整，以比较每个微创手术队列中基于中心手术量的 PSM 发生率。
与微创手术队列相比，开放式 RP 患者的平均手术时 PCa 风险更高，并且在研究时间范围内更早接受手术。机器人 RP 的原始切缘率最低（13.8%），腹腔镜 RP 居中（16.3%），开放式 RP 最高（22.8%）；尽管在统计调整后差异仍然存在，但有所改善。与腹腔镜 RP 和机器人 RP 相比，低容量中心的 PSM 风险更高。该研究存在一定的局限性，包括非随机性质、多个协变量缺失数据（尤其是许多开放式队列病例的手术年份）、缺乏标准化的组织学处理和中央病理审查、以及缺乏关于潜在混杂因素（如患者合并症、神经保留状态、淋巴结状态、肿瘤体积和个别外科医生的手术量）的信息。
这项针对 22393 例 RP 后患者的多国家、多机构研究表明，与开放式 RP 相比，微创技术后的 PSM 发生率可能更低，并且腹腔镜和机器人病例中的 PSM 发生率受中心手术量的影响。
在这项研究中，我们通过观察手术切除标本边缘处残留癌细胞的比率来比较不同类型的前列腺癌手术的效果。我们比较了全球许多中心的开放式、微创手术和机器人手术，发现机器人和微创手术的切缘率似乎低于开放式手术。中心和外科医生的手术量似乎会影响机器人和微创手术的切缘率。
