Department of Urology, Veterans Health Service Medical Center, Seoul, Korea.
Department of Urology, National Health Insurance Service Ilsan Hospital, Goyang, Korea.
J Korean Med Sci. 2021 Oct 25;36(41):e256. doi: 10.3346/jkms.2021.36.e256.
There is no clear consensus on the optimal treatment with curative intent for patients with positive surgical margins (PSMs) following radical prostatectomy (RP). The aim of this study was to investigate the perceptions and treatment patterns of Korean urologists regarding the resection margin after RP.
A preliminary questionnaire was prepared by analyzing various studies on resection margins after RP. Eight experienced urologists finalized the 10-item questionnaire. In July 2019, the final questionnaire was delivered via e-mail to 105 urologists in Korea who specialize in urinary cancers.
We received replies from 91 of the 105 urologists (86.7%) in our sample population. Among them, 41 respondents (45.1%) had performed more than 300 RPs and 22 (24.2%) had completed 500 or more RPs. In the question about whether they usually performed an additional biopsy beyond the main specimen, to get information about surgical margin invasion during surgery, the main opinion was that if no residual cancer was suspected, it was not performed (74.7%). For PSMs, the Gleason score of the positive site (49.5%) was judged to be a more important prognostic factor than the margin location (18.7%), multifocality (14.3%), or margin length (17.6%). In cases with PSMs after surgery, the prevailing opinion on follow-up was to measure and monitor prostate-specific antigen (PSA) levels rather than to begin immediate treatment (68.1%). Many respondents said that they considered postoperative radiologic examinations when PSA was elevated (72.2%), rather than regularly (24.4%). When patients had PSMs without extracapsular extension (pT2R1) or a negative surgical margin with extracapsular extension (pT3aR0), the response 'does not make a difference in treatment policy' prevailed at 65.9%. Even in patients at high risk of PSMs on preoperative radiologic screening, 84.6% of the respondents said that they did not perform neoadjuvant androgen deprivation therapy. Most respondents (75.8%) indicated that they avoided nerve-sparing RP in cases with a high risk of PSMs, but 25.7% said that they had tried nerve-sparing surgery. Additional analyses showed that urologists who had performed 300 or more prostatectomies tended to attempt more nerve-sparing procedures in patients with a high risk of PSMs than less experienced surgeons (36.6% vs. 14.0%; = 0.012).
The most common response was to monitor PSA levels without recommending any additional treatment when PSMs were found after RP. Through this questionnaire, we found that the perceptions and treatment patterns of Korean urologists differed considerably according to RP resection margin status. Refined research and standard practice guidelines are needed.
根治性前列腺切除术（RP）后切缘阳性（PSMs）患者的最佳治愈性治疗方案尚无明确共识。本研究旨在探讨韩国泌尿科医生对 RP 后切缘的看法和治疗模式。
通过分析 RP 后切缘的各种研究，准备了一份初步问卷。8 位经验丰富的泌尿科医生对 10 项问卷进行了最终定稿。2019 年 7 月，通过电子邮件向韩国 105 位专门从事泌尿系统癌症治疗的泌尿科医生发送了最终问卷。
在我们的样本人群中，我们收到了 105 位泌尿科医生中的 91 位（86.7%）的回复。其中，41 位（45.1%）医生完成的 RP 手术超过 300 例，22 位（24.2%）医生完成的 RP 手术超过 500 例。在是否通常会进行额外的活检以获得手术时切缘侵犯的信息这一问题上，主要意见是如果没有残留癌的可疑迹象，就不会进行额外活检（74.7%）。对于 PSMs，阳性部位的 Gleason 评分（49.5%）被认为比切缘位置（18.7%）、多灶性（14.3%）或切缘长度（17.6%）更重要的预后因素。对于手术后出现 PSMs 的情况，大多数医生认为随访时应该测量和监测前列腺特异性抗原（PSA）水平，而不是立即开始治疗（68.1%）。许多医生表示，他们会在 PSA 升高时考虑进行术后影像学检查（72.2%），而不是定期检查（24.4%）。对于无包膜外侵犯（pT2R1）或包膜外侵犯阴性（pT3aR0）的手术切缘阳性患者，有 65.9%的医生表示治疗策略没有差异。即使在术前影像学检查中存在 PSMs 高风险的患者中，84.6%的医生表示他们不会进行新辅助雄激素剥夺治疗。大多数医生（75.8%）表示，在 PSMs 高风险的情况下，他们会避免进行保留神经的 RP，但 25.7%的医生表示他们已经尝试过保留神经的手术。进一步的分析表明，在 PSMs 高风险的患者中，进行 300 次或更多前列腺切除术的泌尿科医生比经验较少的医生更倾向于尝试保留神经的手术（36.6% vs. 14.0%； = 0.012）。
当 RP 后发现 PSMs 时，最常见的反应是监测 PSA 水平，而不建议进行任何额外的治疗。通过这份问卷，我们发现韩国泌尿科医生的看法和治疗模式因 RP 切缘状态的不同而有很大差异。需要进一步的研究和标准实践指南。
