Initial incision of lateral pelvic fascia and early ligation of vascular pedicles during radical prostatectomy: potential to reduce positive margin rates

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Abstract
To report on our experience with a recently published technique to reduce positive margin (PM) rates (involving early incision of the lateral pelvic fascia, early release of the prostate and Denonvilliers' fascia off the rectum), with the additional modification of early ligation of the lateral vascular pedicles during radical retropubic prostatectomy (RP), as reducing PM rates continues to be an important oncological goal in RP. One hundred consecutive men (mean age 61 years, pretreatment prostate-specific antigen level 8.9 ng/mL, and estimated blood loss 502 mL) underwent RP by one surgeon. The initial dissection involves early incision of the lateral pelvic fascia and developing the plane between the prostate and underlying rectum, before any apical dissection. This incision can be made medial to the neurovascular bundles in a nerve-sparing procedure. After this plane is developed, the lateral vascular pedicles to the prostate are also divided. Once these same manoeuvres are used contralaterally, the prostate is lifted off of the rectum and held in place only by the apex and bladder neck. The apical/urethral dissection is then carried out conventionally, followed by dissection/transection of the seminal vesicles and the bladder neck. The pathological stage included T2a (11%), T2b (69%), T3a (17%), T3b (3%), and N+ (2%); 20 patients had capsular penetration, at the posterolateral (in 15) and anterior aspect (in five) of the gland. The PM rate for the 100 consecutive patients was 13%, with PMs at the apex in 10, the base in two and posterolateral gland in one. No patient had a PM at the site of capsular penetration. When patients were stratified by low-moderate risk (pT2 and Gleason sum < or = 7) vs high risk (pT3 or Gleason sum > 7), the PM rates were 7.9% and 29.2%, respectively. Initial dissection of the lateral pelvic fascia, including developing a "perirectal pocket", and early ligation of the lateral pedicles, resulted in a low PM rate during RP. This experience supports the previous observations that early development of the pre-rectal fat plane may allow for more precise dissection below all layers of Denonvilliers' fascia and with a wider margin of periprostatic tissue.