Apical margins after robot-assisted radical prostatectomy: Does technique matter?

Background and Purpose: The apex is the most common site of an involved surgical margin after robot-assisted radical prostatectomy. We assessed the impact of two surgical techniques for dorsal vein control on surgical margins rates. Patients and Methods: From August 2005 to January 2008, 480 patients underwent robot-assisted radical prostatectomy at Roswell Park Cancer Institute. The Roswell Park Cancer Institute Quality Assurance robotic prostatectomy database was reviewed to identify all patients with prostate cancer at the apex on final pathologic evaluation. The rate of positive apical margins was compared between two surgical techniques. Group 1 consisted of 145 patients who underwent apical dissection after cold incision of the dorsal venous complex (DVC) without previous suture ligation, and group 2 consisted of 158 patients who underwent suture ligation of the DVC before apical dissection. Results: Of 480 patients, 303 (63%) patients had prostate cancer in the apex. Age, body mass index, prostate-specific antigen level, and clinical stage were similar in both groups. The overall apical positive margin rate was 5%. Group 1 patients had an apical positive margin rate of 2%, while group 2 patients had a positive margin rate of 8% (P = 0.02). Mean operative blood loss estimated by the attending anesthesiologist was 331 mL and 268 mL in group 1 and group 2, respectively (P = 0.044). One patient in group 1 needed blood transfusion. Conclusions: Cold incision of the DVC before suture ligation reduces the rate of apical margin involvement during robot-assisted radical prostatectomy.