Ponthieu A, Delgrande J, Ivaldi A
Centre d'Urologie Castellane, Marseille.
Prog Urol. 1996 Apr;6(2):250-5; discussion 255-6.
Between 35 to 45% of radical prostatectomies (RP) will show positive margins and approximately 50% of patients with positive margins will progress following RP. Peroperative diagnosis of positive margin possibly can improve the currability of RP. We report here the incidence and management of positive urethral margins diagnosed by frozen sections during radical prostatectomy.
Frozen sections were performed systematically to analyse the surgical margins during 130 RP performed for localized prostate cancer from january 1989 to december 1993. Peroperative analysis of distal (urethral) and proximal (bladder neck) margins, as well as posterior (Denonvilliers fascia) margins, and every surrounding tissue that was macroscopically abnormal were performed.
Analysis of the distal margins showed no prostatic gland in 68 cases (52%), normal prostatic glands in 56 cases (43%) and neoplastic prostate glands in 6 cases (5%). Further urethral sections with frozen section analysis were performed in 62 cases until the distal margin was free of prostatic glands. Three out of six patients with positive urethral margins had another positive margin that was excised as well. Five out of six patients with positive urethral margins were pT3, NO, MO and one pT2, NO, MO. In the group of patients, with positive urethral margins, the average preoperative PSA serum level was 37 ng/ml and the average tumor weight was 14 g. Postoperative pelvic radiation therapy (45 grays) was performed in 5 of these patients. The mean follow-up is 36 months (12-68). PSA serum level is undetectable in 4 cases, and 0.4 ng/ml in 1 case. Urinary PSA level is undetectable in 5 out of 6 cases.
Peroperative analysis of surgical margins, and particularly urethral margins, during RP allows to a better staging and to perform any tumor excision complement if possible. Surgical margins analysis when performed during surgery should help for the choice of the most adapted surgical procedure. In our experience, nerve-sparing RP are performed only when surgical margins are negative on frozen sections.
35%至45%的根治性前列腺切除术（RP）会出现切缘阳性，切缘阳性的患者中约50%在RP后会病情进展。术中对切缘阳性进行诊断可能会提高RP的治愈率。我们在此报告根治性前列腺切除术中经冰冻切片诊断的尿道切缘阳性的发生率及处理情况。
1989年1月至1993年12月期间，对130例因局限性前列腺癌行RP的患者，系统地进行冰冻切片以分析手术切缘。术中对远端（尿道）和近端（膀胱颈）切缘、后方（Denonvilliers筋膜）切缘以及肉眼可见异常的周围组织进行分析。
远端切缘分析显示，68例（52%）无前列腺组织，56例（43%）有正常前列腺组织，6例（5%）有肿瘤性前列腺组织。对62例患者进一步进行尿道冰冻切片分析，直至远端切缘无前列腺组织。6例尿道切缘阳性患者中有3例还有其他阳性切缘，也一并切除。6例尿道切缘阳性患者中，5例为pT3、N0、M0，1例为pT2、N0、M0。在尿道切缘阳性的患者组中，术前血清PSA平均水平为37 ng/ml，肿瘤平均重量为14 g。其中5例患者术后接受了盆腔放疗（45格雷）。平均随访36个月（12 - 68个月）。4例患者血清PSA水平不可测，1例为0.4 ng/ml。6例中有5例尿PSA水平不可测。
RP术中对手术切缘，尤其是尿道切缘进行分析，有助于更好地分期，并在可能的情况下进行肿瘤切除补充。手术中进行切缘分析应有助于选择最适合的手术方式。根据我们的经验，仅在冰冻切片显示手术切缘阴性时才进行保留神经的RP。
