title: Neurovascular structure-adjacent frozen-section examination (NeuroSAFE) increases nerve-sparing frequency and reduces positive surgical margins in open and robot-assisted laparoscopic radical prostatectomy: experience after 11,069 consecutive patients.
abstract: BACKGROUND
  Intraoperative frozen-section analysis allows real-time histologic assessment of surgical margins (SMs) and identification of candidates for nerve-sparing (NS) procedures.
  
  
  OBJECTIVE
  To examine the efficacy and oncologic safety of a systematic neurovascular structure-adjacent frozen-section examination (NeuroSAFE) during NS radical prostatectomy (RP).
  
  
  METHODS
  From January 2002 to June 2011, 11 069 consecutive RPs were performed at the University Medical Center Hamburg-Eppendorf. Of these, 5392 (49%) were conducted with NeuroSAFE.
  
  
  METHODS
  Our NeuroSAFE approach included the whole laterorectal circumference of the prostate to determine the SM status of the complete neurovascular tissue-corresponding prostatic surface.
  
  
  METHODS
  The impact of NeuroSAFE on NS frequency, SM status, and biochemical recurrence (BCR) was analyzed by chi-square test, and by Kaplan-Meier analyses in propensity score-based matched cohorts.
  
  
  CONCLUSIONS
  Positive SMs (PSMs) were detected in 1368 (25%) NeuroSAFE RPs, leading to a secondary resection of the ipsilateral neurovascular tissue. Secondary wide resection resulted in conversion to a definitive negative SM (NSM) status in 1180 (86%) patients. In NeuroSAFE RPs, frequency of NS was significantly higher (all stages: 97% vs 81%; pT2: 99% vs 92%; pT3a: 94% vs 72%; pT3b: 88% vs 40%; p<0.0001) and PSM rates were significantly lower (all stages: 15% vs 22%; pT2: 7% vs 12%; pT3a: 21% vs 32%; p<0.0001) than in the matched non-NeuroSAFE RPs. In propensity score-based comparisons, NeuroSAFE had no negative impact on BCR (pT2, p=0.06; pT3a, p=0.17, pT3b, p=0.99), and BCR-free survival of patients with conversion to NSM did not differ significantly from patients with primarily NSM (pT2, p=0.16; pT3, p=0.26). The accuracy of our NeuroSAFE approach was 97% with a false-negative rate of 2.5%. The major limitations of this study are its retrospective nature and relatively short follow-up.
  
  
  CONCLUSIONS
  NeuroSAFE enables real-time histologic monitoring of the oncologic safety of a NS procedure. Systematic NeuroSAFE significantly increases NS frequencies and reduces PSMs. Patients with a NeuroSAFE-detected PSM could be converted to a prognostically more favorable NSM status by secondary wide resection.
authors.affiliation: Martini-Clinic, Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. tschlomm@uke.uni-hamburg.de
authors.forename: Thorsten
authors.initials: T
authors.lastname: Schlomm
authors.forename: Pierre
authors.initials: P
authors.lastname: Tennstedt
authors.forename: Caroline
authors.initials: C
authors.lastname: Huxhold
authors.forename: Thomas
authors.initials: T
authors.lastname: Steuber
authors.forename: Georg
authors.initials: G
authors.lastname: Salomon
authors.forename: Uwe
authors.initials: U
authors.lastname: Michl
authors.forename: Hans
authors.initials: H
authors.lastname: Heinzer
authors.forename: Jens
authors.initials: J
authors.lastname: Hansen
authors.forename: Lars
authors.initials: L
authors.lastname: Budäus
authors.forename: Stefan
authors.initials: S
authors.lastname: Steurer
authors.forename: Corinna
authors.initials: C
authors.lastname: Wittmer
authors.forename: Sarah
authors.initials: S
authors.lastname: Minner
authors.forename: Alexander
authors.initials: A
authors.lastname: Haese
authors.forename: Guido
authors.initials: G
authors.lastname: Sauter
authors.forename: Markus
authors.initials: M
authors.lastname: Graefen
authors.forename: Hartwig
authors.initials: H
authors.lastname: Huland
mesh_terms: D000368:Aged; D016616:Cryoultramicrotomy; D018572:Disease-Free Survival; D005629:Frozen Sections; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D060787:Neoplasm Grading; D009364:Neoplasm Recurrence, Local / Q000473:pathology / Q000601:surgery; D011467:Prostate / Q000294:innervation; D017430:Prostate-Specific Antigen / Q000097:blood; D011468:Prostatectomy / Q000379:methods*; D011471:Prostatic Neoplasms / Q000473:pathology* / Q000601:surgery*; D012189:Retrospective Studies; D012371:Robotics / Q000379:methods*; D016896:Treatment Outcome
chemical_list: D017430:Prostate-Specific Antigen