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Financial Impact of Positive Surgical Margins During Radical Prostatectomy and the Odds of Receiving Adjuvant Radiation Therapy.

Radical prostatectomy (RP) remains the standard therapy for the treatment of men with localized prostate cancer because it is associated with a clear survival benefit and longer life expectancy. As technology has advanced, many urologists have transitioned away from open RP and have quickly adopted minimally invasive technology to first perform laparoscopic RP and now robotic-assisted laparoscopic RP in attempts to minimize the morbidity associated with this procedure. Although this technology has led to better perioperative outcomes, such as a reduction in hospital length of stay and lower odds of requiring blood transfusions, oncological and functional outcomes such as continence and erectile dysfunction remain similar for surgeons experienced with either approach.1 One aspect of RP that is often variable is a positive surgical margin (PSM) on final pathological examination. Rates of PSMs may change on the basis of certain factors, such as surgical technique (open vs minimally invasive), tumor aggressiveness, and surgeon experience. Some evidence does suggest that PSM rates are lower with robotic-assisted RP vs open RP (13.8% vs 22.8%).2 However, data comparing these 2 modalities are often difficult to interpret because many of these studies are nonstandardized in terms of pathological review, nerve-sparing status, tumor volume, and surgeon experience. Positive surgical margins are often associated with a more-advanced stage or aggressive disease, with rates as high as 60% for pT3 disease.2 However, 1 known modifiable risk factor as a source of potentially avoidable PSMs is the surgeon experience. A multi-institutional study by Bravi et al3 found that for both organ-confined and non–organ-confined disease, surgeons with more experience with robotic-assisted RP had a higher rate of negative margins. When comparing surgeons performing their first 10 operations with those with at least 250 prior operations, the rate of PSMs decreased from 16.7% to 9.6% in organ-confined disease and from 38.4% to 24.9% in non–organ-confined disease.2 Although this finding may speak to the greater need for centralization of care at high-volume centers for these procedures, it is essential to note that biochemical recurrence rates were not found to be different for these surgeons despite their level of experience.3 Management of PSMs after RP remains a clinical challenge because the exact outcome on a patient’s long-term survival is debatable. Although PSMs are associated with biochemical recurrence, adverse pathological features of the disease, such as advanced stage and grade group, are likely associated with more meaningful prostate cancer–specific end points.4 For example, Mithal et al4 retrospectively analyzed more than 4000 men who underwent RP, and those with a PSM were twice as likely to have biochemical recurrence as those without a PSM. However, when controlling for pathological characteristics such as Gleason score, prostate-specific antigen level, and tumor stage, other end points, such as the development of castration resistance, metastatic sites, and cancerspecific mortality, were not associated with PSMs.4 Studies such as this highlight the need for clinicians to consider the entirety of the patient and to stratify risk according to tumor characteristics and clinical scenario before recommending adjuvant therapies after RP with a PSM. Although the oncological outcome is difficult to determine, PSMs often do lead to adjuvant therapy, specifically radiation therapy (RT). Martini and colleagues5 queried the US National Cancer Database to answer an important question regarding the financial outcomes of a PSM in terms of further treatment for prostate cancer. The authors specifically looked at the end point of adjuvant RT after prostatectomy. After controlling for tumor characteristics, which may also prompt the decision for adjuvant RT, men with PSMs had nearly 4 times the chance of undergoing adjuvant RT (odds ratio, + Related article