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Evolving Pathologic Outcomes in a Contemporary Cohort of Patients Undergoing RALP at a Small Academic Institution
Urszula Kowalik, MD, Scott D. Perrapato, DO, Brian Irwin, MD, Mark K. Plante, MD, FRCS(C), FACS.
University of Vermont Medical Center, Burlington, VT, USA.

Background: Robotic-assisted laparoscopic radical prostatectomy (RALP) is currently the standard surgical approach for the treatment of clinically localized prostate cancer. We sought to evaluate the resultant pathologic findings in patients undergoing RALP with focus on Gleason grade, positive surgical margins, and features of pathologically locally advanced disease including extra-prostatic extension (EPE or pT3a) or seminal vesicle invasion (SVI or pT3b) at our academic center.
Methods: An IRB approved retrospective review of 224 consecutive patients who underwent RALP at University of Vermont Medical Center (UVMMC) from 2013 to 2015 was completed examining both pre-operative biopsy and post-operative whole-mount pathologic specimen assessments.
Results: Post-operative pathologic review revealed that 58% (129/224) of patients had organ-confined disease (pT2A, pT2B, or pT2C), while 42% (95/224) of patients were staged as pT3A or pT3B. Two patients were excluded from Gleason grading because they received prior androgen deprivation therapy. Overall Gleason grading showed that 8% (19/222) had Gleason 6, 80% (177/222) had Gleason 7, 5% (11/222) had Gleason 8 and 7% (15/222) had Gleason 9 disease on final pathologic review. In comparison with pre-operative biopsy, a total of 40 patients were down-graded (23 from G8 to G7, 14 from G7 to G6, 2 from G9 to G8 and one from G10 to G9) and 22 were up-graded (14 from G6 to G7, 5 from G7 to G8, and 3 from G8 to G9). Among the entire cohort, 59 patients were found to have tertiary pattern 5 disease.  Of the 42% of patients with features of locally advanced disease, 41% (39/95) had SVI and 83% (91/95) had EPE. Overall, 25% of patients were reported to have positive surgical margins. Only 8% of patients with organ-confined disease were found to have a positive surgical margin compared to 46% in patients with locally advanced disease.
Conclusions: Pathologic review of the past three years of patients undergoing RALP at UVMMC suggest a paradigm shift away from primary surgical treatment of patients with low risk disease, with 93%(206/222) of patients undergoing RALP meeting criteria for intermediate and high risk disease. This shift toward operating on higher risk patients does not appear to compromise our rates of surgical margin positivity when compared with previous reports ranging from 6.5-32% in series with larger percentages of low risk patients.


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