Introduction:

Stress urinary incontinence and sexual dysfunction are long-term risks following radical prostatectomy (RP). Pelvic fascia sparing radical prostatectomy (PFS-RP) is associated with earlier and potentially better recovery of urinary function. However, preserving tissue over the anterior prostate may lead to more positive surgical margins and worse cancer control, especially for men with anterior tumor locations. We performed a multi-center analysis to assess cancer control for standard vs. PFS-RP.

Methods:

We retrospectively compared 896 patients who underwent standard vs. PFS-RP with two surgeons at Weill Cornell and Georgetown from 2015-2022. Anterior tumors were identified on MRI-targeted biopsy (with systematic cores). Anterior tumors were categorized as those above the horizontal axis of the urethra in the coronal plane. Excluding lesions diagnosed only on final pathology, we compared patients with anterior tumors to lesions in other areas. We then compared pathologic features of patients with anterior tumors who underwent standard vs PFS-RP and conducted regression analyses to evaluate factors associated with risk of biochemical recurrence.

Results:

Age, BMI, and prostate volume were similar between patients with anterior tumors (n=355) vs other tumors (n=236). Anterior patients who underwent PFS-RP patients (n=119) were less likely be upstaged to pT3 disease (p=0.002). However, they were more likely to have a positive surgical margin (PSM) (p=0.004) and specifically an anterior PSM (p<0.001). Cox regression showed biochemical recurrence (BCR) significantly associated with Gleason Group 4 (HR 8.73, 95% CI 1.79-42.65), Gleason Group 5 (HR 6.07, 95% CI 1.3-28.34) and pT3b disease (HR 2.86, CI 1.43- 5.71). BCR was also associated with positive focal margins (HR 2.9, 95% CI 1.63-5.16) and multifocal margins (HR 4.75, 95% CI 2.56-8.79).

Conclusion:

Patients with anterior tumors identified on MRI-targeted biopsy who underwent PFS-RP were more likely to have positive surgical margins. Positive focal and multifocal margins were associated with increased risk of biochemical recurrence. This highlights the need for careful patient selection for different surgical approaches and additional studies comparing long-term oncologic outcomes.

Funding: N/A