title: A multinational, multi-institutional study comparing positive surgical margin rates among 22393 open, laparoscopic, and robot-assisted radical prostatectomy patients.
abstract: BACKGROUND
  Positive surgical margins (PSMs) are a known risk factor for biochemical recurrence in patients with prostate cancer (PCa) and are potentially affected by surgical technique and volume.
  
  
  OBJECTIVE
  To investigate whether radical prostatectomy (RP) modality and volume affect PSM rates.
  
  
  METHODS
  Fourteen institutions in Europe, the United States, and Australia were invited to participate in this study, all of which retrospectively provided margins data on 9778 open RP, 4918 laparoscopic RP, and 7697 robotic RP patients operated on between January 2000 and October 2011.
  
  
  METHODS
  The outcome measure was PSM rate. Multivariable logistic regression analyses and propensity score methods identified odds ratios for risk of a PSM for one modality compared with another, after adjustment for age, preoperative prostate-specific antigen, postoperative Gleason score, pathologic stage, and year of surgery. Classic adjustment using standard covariates was also implemented to compare PSM rates based on center volume for each minimally invasive surgical cohort.
  
  
  CONCLUSIONS
  Open RP patients had higher-risk PCa at time of surgery on average and were operated on earlier in the study time period on average, compared with minimally invasive cohorts. Crude margin rates were lowest for robotic RP (13.8%), intermediate for laparoscopic RP (16.3%), and highest for open RP (22.8%); significant differences persisted, although were ameliorated, after statistical adjustments. Lower-volume centers had increased risks of PSM compared with the highest-volume center for both laparoscopic RP and robotic RP. The study is limited by its nonrandomized nature; missing data across covariates, especially year of surgery in many of the open cohort cases; lack of standardized histologic processing and central pathology review; and lack of information regarding potential confounders such as patient comorbidity, nerve-sparing status, lymph node status, tumor volume, and individual surgeon caseload.
  
  
  CONCLUSIONS
  This multinational, multi-institutional study of 22 393 patients after RP suggests that PSM rates might be lower after minimally invasive techniques than after open RP and that PSM rates are affected by center volume in laparoscopic and robotic cases.
  
  
  RESULTS
  In this study, we compared the effectiveness of different types of surgery for prostate cancer by looking at the rates of cancer cells left at the margins of what was removed in the operations. We compared open, keyhole, and robotic surgery from many centers across the globe and found that robotic and keyhole operations appeared to have lower margin rates than open surgeries. How many cases a center and surgeon do seems to affect this rate for both robotic and keyhole procedures.
authors.affiliation: Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden. Electronic address: sooriakumaran@gmail.com.
authors.forename: Prasanna
authors.initials: P
authors.lastname: Sooriakumaran
authors.affiliation: Department of Urology, Montefiore Medical Center, New York, NY, USA.
authors.forename: Abhishek
authors.initials: A
authors.lastname: Srivastava
authors.affiliation: Department of Urology, Weill Cornell Medical College-New York Presbyterian Hospital, New York, NY, USA; Department of Urology, Medical University of Vienna, Vienna, Austria.
authors.forename: Shahrokh F
authors.initials: SF
authors.lastname: Shariat
authors.affiliation: Prostate Cancer Centre, St. Vincent's Clinic, Sydney, Australia.
authors.forename: Phillip D
authors.initials: PD
authors.lastname: Stricker
authors.affiliation: Department of Urology, University of California-Irvine School of Medicine, Irvine, CA, USA.
authors.forename: Thomas
authors.initials: T
authors.lastname: Ahlering
authors.affiliation: Department of Urology, Royal Surrey County Hospital, Guildford, UK.
authors.forename: Christopher G
authors.initials: CG
authors.lastname: Eden
authors.affiliation: Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Peter N
authors.initials: PN
authors.lastname: Wiklund
authors.affiliation: Department of Urology, L'Institut Mutualiste Montsouris, Paris, France.
authors.forename: Rafael
authors.initials: R
authors.lastname: Sanchez-Salas
authors.affiliation: Department of Urology, Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Mottrie
authors.affiliation: Department of Urology, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: David
authors.initials: D
authors.lastname: Lee
authors.affiliation: Department of Uro-oncology, University of Cambridge, Cambridge, UK; Uro-oncology Research Group, Cancer Research UK, Cambridge Research Institute, Cambridge, UK.
authors.forename: David E
authors.initials: DE
authors.lastname: Neal
authors.affiliation: Department of Urology, Montefiore Medical Center, New York, NY, USA.
authors.forename: Reza
authors.initials: R
authors.lastname: Ghavamian
authors.affiliation: Department of Urology, Semmelweis University, Budapest, Hungary.
authors.forename: Peter
authors.initials: P
authors.lastname: Nyirady
authors.affiliation: Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Andreas
authors.initials: A
authors.lastname: Nilsson
authors.affiliation: Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Stefan
authors.initials: S
authors.lastname: Carlsson
authors.affiliation: Department of Urology, Weill Cornell Medical College-New York Presbyterian Hospital, New York, NY, USA.
authors.forename: Evanguelos
authors.initials: E
authors.lastname: Xylinas
authors.affiliation: Department of Urology, St. Vincent's Hospital, Linz, Austria.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Loidl
authors.affiliation: Department of Urology, Medical University of Vienna, Vienna, Austria.
authors.forename: Christian
authors.initials: C
authors.lastname: Seitz
authors.affiliation: Department of Urology, Saint John of God Hospital, Vienna, Austria.
authors.forename: Paul
authors.initials: P
authors.lastname: Schramek
authors.affiliation: Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
authors.forename: Claus
authors.initials: C
authors.lastname: Roehrborn
authors.affiliation: Department of Urology, L'Institut Mutualiste Montsouris, Paris, France.
authors.forename: Xavier
authors.initials: X
authors.lastname: Cathelineau
authors.affiliation: Department of Urology, University of California-Irvine School of Medicine, Irvine, CA, USA.
authors.forename: Douglas
authors.initials: D
authors.lastname: Skarecky
authors.affiliation: Uro-oncology Research Group, Cancer Research UK, Cambridge Research Institute, Cambridge, UK.
authors.forename: Greg
authors.initials: G
authors.lastname: Shaw
authors.affiliation: Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
authors.forename: Anne
authors.initials: A
authors.lastname: Warren
authors.affiliation: Prostate Cancer Centre, St. Vincent's Clinic, Sydney, Australia.
authors.forename: Warick J
authors.initials: WJ
authors.lastname: Delprado
authors.affiliation: Prostate Cancer Centre, St. Vincent's Clinic, Sydney, Australia.
authors.forename: Anne-Marie
authors.initials: AM
authors.lastname: Haynes
authors.affiliation: Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands.
authors.forename: Ewout
authors.initials: E
authors.lastname: Steyerberg
authors.affiliation: Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands.
authors.forename: Monique J
authors.initials: MJ
authors.lastname: Roobol
authors.affiliation: Department of Urology, Weill Cornell Medical College-New York Presbyterian Hospital, New York, NY, USA.
authors.forename: Ashutosh K
authors.initials: AK
authors.lastname: Tewari
mesh_terms: D000368:Aged; D001315:Australia; D005060:Europe; D061847:Hospitals, High-Volume / Q000706:statistics & numerical data; D061846:Hospitals, Low-Volume / Q000706:statistics & numerical data; D006801:Humans; D010535:Laparoscopy / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D018365:Neoplasm, Residual / Q000453:epidemiology*; D011468:Prostatectomy / Q000379:methods* / Q000706:statistics & numerical data*; D011471:Prostatic Neoplasms / Q000601:surgery*; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000706:statistics & numerical data*; D014481:United States
keywords: Laparoscopic; Margins; Open; Radical prostatectomy; Robotic