Randomized trial comparing an anterograde versus a retrograde approach to open radical prostatectomy: results in terms of positive margin rate

Objectives: Surgical technique, patient characteristics and method of pathological review may influence surgical margin (SM) status. Positive surgical margin (SM+) rates of 14% to 46% have been reported in different radical retropubic prostatectomy (RRP) series. We evaluated the effect of an anterograde versus retrograde approach to RRP and specifically focused on the incidence of SM+. Methods: From January 2003 to November 2007, we randomly assigned 200 patients with clinically localized prostate adenocarcinomas to undergo a retrograde (Group A) versus an anterograde (Group 13) open RRP. All RRPs were performed at our institution by 2 surgeons. For all 200 patients, we evaluated a panel of clinical and pathological variables relating to their association with SM status. Results: In Group A, 22% of cases after RRP showed a pT3 tumour and 39% of cases with a Gleason score >= 7 (4+3); in Group B, 20% of cases showed a p13 tumour and 37% of cases with a Gleason score >= 7 (4+3) (p >0.10). The incidence of SM+ was 18% in Group A and 14% in Group B (p = 0.0320). In Group A, 22.2% of cases with SM+ had multiple positive margins, whereas no cases in Group B showed multiple SM+. Regarding the localization of SM+, no difference was found between the 2 groups. In the multivariate analysis, only prostate-specific antigen (p = 0.0090 and p = 0.0020, respectively in the 2 groups) and pathological stage (p < 0.0001 in both groups) were significant and independently associated with SM+ occurrence. Conclusion: In our experience, the anterograde approach to open RRP is associated with lower SM+ rates and no risk of multiple SM+ when compared with the retrograde approach.