Positive surgical margins with radical retropubic prostatectomy: Anatomic site-specific pathologic analysis and impact on prognosis

Objectives. To correlate the extent and location of positive surgical margi ns after radical prostatectomy with disease progression. Methods. Data on 495 patients who underwent radical prostatectomy by one su rgeon were analyzed. All radical prostatectomy specimens were sectioned ent irely using 2 to 3-mm step sections by one pathologist. One hundred fifty-o ne patients (30.5%) had one or more positive surgical margins and were subj ected to further detailed analysis. Recurrence was defined as a serum prost ate-specific antigen (PSA) level of 0.2 ng/mL and rising on at least two po stoperative measurements. Results. The mean follow-up was 25.3 months (range 3 to 73). The overall re currence rate was 13.3%. Neoadjuvant hormonal treatment was given to 37 (25 %) of those with a positive margin. Patients with positive surgical margins had a significantly higher incidence of recurrence compared with those wit h negative margins (27.8% versus 6.9%, P = 0.001). The recurrence rate for various locations was 29% apex/urethra, 30% posterior, 33% anterior, 36% la teral, 48% posterolateral, and 57% bladder neck. Time to recurrence was sho rter in patients older than 70 years (P <0.055); with a preoperative PSA gr eater than 10 ng/mL (P <0.0001); with a biopsy Gleason score greater than 7 (P = 0.02); with a prostatectomy Gleason score greater than 7 (P <0.001); with seminal vesicle invasion (P = 0.0001); having more than 1 location of a positive margin (P = 0.002); or having a positive margin at the bladder n eck (P = 0.0003) or the posterolateral surface of the prostate (P = 0.02) c ompared with other locations. Multivariate proportional hazards analyses in dicated that age older than 70 (P = 0.005), a prostatectomy Gleason score o f 7 (P = 0.015) or 8 to 10 (P = 0.003), and positive margin(s) at the bladd er neck (P = 0.003) were independently associated with a shorter time to re currence among patients with a positive margin. Conclusions. In our study, among patients with positive surgical margins, t hose with multiple positive margins, or a margin involving the bladder neck or the posterolateral surface of the specimen carried a higher risk of pro gression. A positive margin at the bladder neck appears to be the most sign ificant adverse prognostic indicator. This information may help in decision s regarding additional therapy. UROLOGY 54: 682-688, 1999. (C) 1999, Elsevi er Science Inc.