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Assisted Laparoscopic Radical Prostatectomy Specimen Removal

Removing the specimen with traction during robotic radical prostatectomy

Serkan Altinova, Abidin Egemen Isgoren, Ziya Akbulut, Muhammed Fuat Ozcan, Abdullah Erdem Canda, Ali Fuat Atmaca, Mevalana Derya Balbay

Key words: Prostate cancer, radical prostatectomy, specimen, traction


Purpose: Our aim was to show if removing the specimen with traction during robot assisted laparoscopic radical prostatectomy cause positive surgical margin or not.

Materials and Methods: 169 patients with localized prostate cancer who were performed robot assisted laparoscopic radical prostatectomy were included in the study between 2009-2011. Patients were divided into 2 groups. Patients’ characteristics, preop and postop evaluation were recorded.

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Results: There were 111 and 58 patints in group 1 (with traction) and group 2 (without traction), respectively. Patients’ ages, follow up time, body mass indexes (BMI), prostate spesific antigen (PSA) values, preop and postop Gleason score values, pathological stage, positive surgical margin rates and biochemical PSA reccurrence rates were evaluated. There was no statistically significant difference between groups for age, preop PSA values, BMI, preop and postop Gleason scores, positive surgical margin rates and biochemical reccurrence rates. There was significant difference between prostate weight, tumor volume and clinical stage between groups. (

Conclusions: Removing the specimen with traction during robot assisted laparoscopic radical prostatectomy does not cause positive surgical margin. The incision can be as small as possible for cosmetic sight.


Robot-assisted laparoscopic radical prostatectomy (RALP) has become the most preferred surgical technique for localized prostate cancer. One of the most important factor pointing out the oncologic success is the surgical margin status.(1) Positive surgical margin (PSM) status may be related both with the surgeon, surgical technique and disease burden. (1,2 ) Our aim was to evaluate the effect of traction, probably the cause of PSM, during the specimen removal. Ther are many studies comparing the PSM acording to techniques, pathologic findings and clinical stage but we found none acording the technique of specimen removal. (3)

Materials and Methods

169 patients who were performed RALP for localized prostate cancer between 2009 and 2011 were included in this study. All the patients were evaluated and Ethic Committee permission were given for each. The reason why we planned this study was the patients with postoperative PSM (positive surgical margin) but no PSA (prostate spesific antigen) reccurrence. Patients were randomized as two groups, A and B, acording to their status of traction was done or not while removing the specmen. Traction can be defined as removing the specimen from a small incision that may let the specimen removed by traction. No traction can be defined as removing the traction from an incision larger than prostate that make easy removing the specimen without any difficulty.

Student-t test was used for follow-up, age, BMI (body mass index), PSA, prostate weight and tumor volume. Chi-square test was used for Gleason grade, stage, SMI (surgical margin invasion) and BCR (biochemical reccurrence rates). All the values were calculated as mean and SD. SPSS 16 was used.


Group A (traction group) had 111 patients while group B (no-traction group) had 58. There was statistically significant difference between groups for prostate weight, tumor volume and clinical stage. Age, BMI, preoperative PSA levels, biopsy Gleason score, prostatectomy Gleason score, pathological stage, SMI status and BCR were similar for both groups. Patients’ preoperative and postoperative characteristics are summerized in table 1 and 2. Although there are pT0 patients in both groups we have to say that we have given no additional therapy like androgen deprivation therapy preoperatively.


Nowadays robot-assisted laparoscopic radical prostatectomy is the main surgical technique for localized prostate cancer. In the United States 85% of radical prostatectomies are performed robotically. (4) Generally PSM rates after different techniques for radical prostatectomy seems to be equal but sometimes surgical technique may effect the rates.(5,6) Oncologic outcomes of robotic surgery are generally similar with laparoscopic and open surgery (7-10) although there are some other results suggesting that the rates are different for the techniques. (11-13) The well known object is that the PSM may be related with disease burden, surgeon and also the technique. Robotic surgery has some differences from laparoscopic surgery. The adventages of robotic surgery are related both with the patient and the surgeon. This provides a comfortable operation for the surgeon. In order to find out if traction may cause a PSM, we randomised the patients into two groups as traction or non-traction. We believe that traction may cause a damage on the prostate capsula and show a pseudopositive surgical margin. In our study PSM rates are similar in both groups. Higher tumor volume and stage can effect PSM rates. (2) Although traction group has higher tumor volume rates and lower clinical stage PSM rates are similar. Also prostatectomy Gleason scores are similar for both groups. All the operations were performed by the same person as PSM rates can differ among surgeons performance. Some outhors have described “ Capsular Incision Index” to show the damages on the capsula that may cause pseudopositive surgical margin.(2). We beleive, because of the traction made by the fourth arm of the robot may cause pseudopositive surgical margin, pahologist must reveal that if there is a positive margin coloured with the ink they use, they must also see the capsula of the prostate. If no, this may not be really a positive margin. This is very important as sometimes may affect the extra therapy options. In order not to give any unneccesssary treatment both the surgeon and the pathologist must be very careful as this may not only increase the morbidity but also the cost.


Surgical margin status after radical prostatectomy is an important topic. Surgical technique is important in order not to cause a positive surgical margin but pathlogical findings are maybe more important for the possible additional treatment. Removing the specimen with traction during robot assisted laparoscopic radical prostatectomy does not cause positive surgical margin. The incision can be as small as possible for cosmetic sight.


  1. Wiezer AZ, Strope S, Wood DP. Margin control in robotic and laparoscopic prostatectomy: What are the REAL oucomes. Urol Oncol. 2010; 28:210-14.
  2. Hong H, Mel L, Taylor J, Wu Q, Reeves H. Effects of robotic-assisted laparoscopic prostatectomy on surgical pathology specimens. Diagn Pathol. 2012; 7:24-30.
  3. Tewari A, Sooriakumaran P, Bloch DA, Seshadri-Kreaden U, Hebert AE, Wiklund P. Positive surgical margin and perioperative complication rates of primary surgical treatments for prostate cancer: A systematic review and meta-analysis comparing retropubic, laparoscopic and robotic prostatectomy. Eur Urol. 2012; 62:1-15.
  4. Lowrance WT, Parekh DJ. The rapid uptake of robotic prostatectomy and its collateral effects. Cancer. 2012; 118:4–7.
  5. Philippou P, Waine E, Rowe E. Robot-assisted laparoscopic prostatectomy versus open: comparison of the learning curve of a single surgeon. J Endourol. 2012; 26:1002-08.
  6. Coelho RF, Rocco B, Patel MB, et al. Retropubic, laparoscopic and robot-assisted radical prostatectomy: a criticai review of outcomes reported by high volume centers. J Endourol. 2010; 24:2003-15.
  7. Parsons JK, Bennett JL. Outcomes of retropubic, laparoscopic, and robotic-assisted prostatectomy. Urology. 2008; 72:412–16.
  8. Ficarra V, Novara G, Fracalanza S, et al. A prospective, non-randomized trial comparing robot-assisted laparoscopic and retropubic radical prostatectomy in one European institution. BJU Int. 2009; 104:534–39.
  9. Schroeck FR, Sun L, Freedland SJ, et al. Comparison of prostate-specific antigen recurrence-free survival in a contemporary cohort of patients undergoing either radical retropubic or robot-assisted laparoscopic radical prostatectomy. BJU Int. 2008; 102:28–32.
  10. Laurila TA, Huang W, Jarrard DF. Robotic-assisted laparoscopic and radical retropubic prostatectomy generate similar positive margin rates in low and intermediate risk patients. Urol Oncol. 2009; 27:529–33.
  11. Williams SB, Chen MH, D’Amico AV, et al. Radical retropubic prostatectomy and robotic-assisted laparoscopic prostatectomy: likelihood of positive surgical margin(s) Urology. 2010; 76:1097–1101.
  12. Cathcart P, Murphy DG, Moon D, Costello AJ, Frydenberg M. Perioperative, functional and oncological outcomes after open and minimally invasive prostate cancer surgery: experience from Australasia. BJU Int. 2011; 107(Suppl 3):11–19.
  13. Magheli A, Gonzalgo ML, Su LM, et al . Impact of surgical technique (open vs laparoscopic vs robotic-assisted) on pathological and biochemical outcomes following radical prostatectomy: an analysis using propensity score matching. BJU Int. 2011; 107:1956–62.

Table 1. Preoperative characteristics of patients

Total (n:169) Traction Group (n:111. 65.7%) No-Traction Group (n:58. 34.3%) P value
Follow-up, mo, Mean±SD 33.85±8.45 38.62±6.30 24.72±2.26 <0.001*
Age, Mean±SD 61.11±6.65 61.22±6.81 60.91±6.40 0.822
BMI, Mean±SD 26.90±2.97 27.07±2.99 26.50±2.92 0.522
Preoperative PSA, Mean±SD 8.5±5.73 8.88±6.25 7.76±4.56 0.084
Prostate Weight, Mean±SD 53.20±19.13 50.22±17.39 58.91±21.10 0.037*
Tumor Volume, cc, Mean±SD 7.85±1.62 8.80±1.90 6.05±8.54 0.029*
Biopsy Gleason Score, n(%) 0.336
≤ 6 121 (71.6) 84 (49.7)(75.7) 37 (21.9)(63.8)
3+4 26 (15.4) 15 (8.9)(13.5) 11 (6.5)(19)
4+3 9 (5.3) 4 (2.3)(3.6) 5 (3)(8.6)
>7 13 (7.7) 8 (4.7)(7.2) 5 (3)(8.6)
Clinical Stage, n(%) < 0.001*
cT1 78 (46.2) 78 (46.2)(70.3)
cT2 91 (53.8) 33 (19.5)(29.7) 58 (34.3)(100)

Table 2. Patients’ postoperative findings

Total (n:169) Traction Group (n:111. 65.7%) No-Traction Group (n:58. 34.3%) P value
Prostatectomy Gleason Score, n(%) 0.462
pT0 9 (5.3) 6 (3.6)(5.4) 3 (1.7)(5.2)
≤ 6 92 (54.4) 66 (39.2)(59.5) 26 (15.4)(44.8)
3+4 40 (23.7) 23 (13.6)(20.7) 17 (10.1)(29.3)
4+3 16 (9.5) 9 (5.3)(8.1) 7 (4.2)(12.1)
>7 12 (7.1) 7 (4.1)(6.3) 5 (3)(8.6)
Pathological Stage, n(%) 0.064
pT0 8 (4.7) 5 (3)(4.5) 3 (1.7)(5.1)
pT2 123 (72.8) 75 (44.4)(67.6) 48 (28.4)(82.8)
pT3a 38 (22.5) 31 (18.4)(27.9) 7 (4.1)(12.1)
SMI 0.746
Negative 142 (84) 94 (55.6)(84.7) 48 (28.4)(82.8)
Positive 27 (16) 17 (10.1)(15.3) 10 (5.9)(17.2)
BCR 11 (6.5) 8 (4.7)(7.2) 3 (1.8)(5.2) 0.611


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