Prognostic Implication Of Positive Apical Margin

The intimate anatomical relationship of the prostate to surrounding structures limits the ability to obtain wide surgical margins. Furthermore, the prostate lacks a true anatomical capsule, and normal condensation of fibromuscular tissue present in the posterolateral margin is not present at the apex.45 Stamey etal. also noted the absence of a defined capsule at the apex more than anywhere else in the prostate gland.3 McNeal suggested that cancer in the apex of the gland may represent invasion outside of the prostate because it is difficult to identify the capsule at the apex.2 Since the apex of the prostate does not have a well-defined capsular boundary, some investigators suggest that cancer in the apex of the prostate gland is equivalent to extraprostatic extension or a positive surgical margin.2'3

In addition to an absent well-defined capsule at this location, the method of pathological processing and surgical technique may contribute to the high incidence of a positive apical margin. Cephalad retraction with the Foley catheter may macerate the apical component of the surgical specimen, creating false-positive margins.

The importance of prostatic apex dissection in anatomical radical prostatectomy, as it relates to potency and urinary continence, is well established. The proximity of the rhabdo-sphincter must be preserved to minimize incontinence after prostatectomy. The anatomical location of the apex of the prostate deep in the pelvis, and the proximity with critical structures responsible for preservation of continence and sexual potency make the proper dissection of this area challenging. Before the anatomic approach, the high incidence of incontinence after radical prostatectomy had led patients and physicians to consider seriously alternatives to surgery even for the most appropriate candidates. Attempts to preserve the neurovascular bundles or maximal urethral length may compromise the extent of cancer excision, resulting in positive surgical margins at the apex.

Table 35.2. Location and frequency of positive surgical margin.

Sites of positive

Overall frequency of all

Frequency of solitary

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