Modified extrafascial radical retropublic prostatectomy technique decreases frequency of positive surgical margins in T2 cancers < 2 cm(3)

Objectives: In an effort to decrease the frequency of postoperative positiv e surgical margins (+SM), a modified extrafascial radical prostatectomy tec hnique was developed and evaluated. Methods: 402 consecutive radical prostatectomy specimens removed for clinic al stage T2 cancers from 1987 to 1994 were histologically examined prospect ively for tumor volume, extraprostatic extension and +SM. Surgical techniqu e modification was introduced in 1990. We compared the histologic status an d biological outcome of the prostatectomy cases in 1987-1989 (n = 166) to t hose treated from 1990 to 1994 (n = 236). Results: The two series were comparable in (1) clinical stage and preoperat ive (PSA, (2) tumor volume, grade and location, and (3) capsular penetratio n, seminal vesicle and lymph node status. +SM fell from 32 to 25% overall, but for 146 (36%) prostates with a tumor volume <2 cm(3), +SM fell from 21 to 6% which was statistically significant. Outcome measured by biological p rogression showed a decrease from 33% for +SM to 13% for -SM for cases with a tumor volume <2 cm(3). For cancer volumes >2 cm(3), the incidence of +SM did not vary significantly. We describe the anatomic details necessary for exposure of periprostatic fascias and extrafascial dissection at (1) the p rostatourethral junction which ensures wide excision of the anterior and ap ical aspect of the prostate, (2) the posterior and apical area (development of the prerectal space), lateral and posterior areas at the base of the pr ostate which ensures wide excision of the rectoprostatic fascia (Denonvilli ers's fascia) and lateral prostatic fascia. Conclusions: Differences in surgical technique probably accounted for the s ignificant decrease in +SM for those T2 cancers with volumes less than or e qual to 2 cm(3) which represents 36% of the T2 cancers in our series. Recen t screening with PSA (T1c cancers) increases the incidence of these cancers less than or equal to 2 cm(3). This modified uni- or bilateral anatomic ex trafascial prostatectomy with improved +SM and biological progression rates for T2 cases should be evaluated for T1c cases. Copyright (C) 2000 S. Karg er AG, Basel.