Minor modifications in apical dissection of radical retropubic prostatectomy in patients with clinical stage T2 prostate cancer reduce positive surgical margin incidence

Objectives. To describe modifications in the apical dissection of radical retropubic prostatectomy (RRP) in men with palpable disease that reduce the incidence of positive apical surgical margins. Positive surgical margins occur in up to 45% of patients undergoing RRP, even in contemporary series. The apex is the most common site of positive margins, and patients with palpable (clinical Stage T2) disease are more likely to have positive surgical margins than patients with nonpalpable (clinical Stage T1c) disease. Methods. Ninety-five men, 48 to 77 years old (mean age 59.6) with clinical Stage T2 tumors underwent RRP between October 1998 and May 2001. Surgical modifications included identification of the prostatic urethral junction by dissection of the levator ani muscle from the prostate and partial transection of the puboprostatic ligaments; variable division of the membranous urethra 1 to 3 mm distal to the prostatic urethral junction; division of prostatic ischial ligaments before dividing the catheter and posterior membranous urethra; and division of the neurovascular bundle at the urogenital diaphragm before liberating the prostate from the rectum. Results. Positive surgical margins occurred in only 8 (8.4%) of 95 patients, even though tumor extended beyond the prostatic capsule in 55% of cases. Only 2 (2.1%) of the 95 patients had isolated positive apical surgical margins. Urinary continence was not adversely affected by these modifications. Conclusions. Easily applied modifications in the apical dissection of RRP significantly reduce the incidence of positive apical margins in patients with clinical Stage T2 prostate cancer.