Guideline for Optimization of Surgical and Pathological Quality Performance for Radical Prostatectomy in Prostate Cancer Management

Guideline Objective

The objective of this document is to provide guidelines for surgical techniques for RP and concurrent PLND and for the handling of the surgical specimens in the operating room and laboratory, in order to achieve optimal benefit for the patient, with minimal risk of harm.

Patient Population

Adult males with potentially curable prostate cancer for whom RP is the preferred treatment option.

Risk Categories: Patients may be considered “low”, “intermediate”, or “high” risk for treatment failure (e.g., local recurrence, biochemical failure with prostate-specific antigen [PSA] relapse, emergence of metastatic disease) based on disease characteristics using the definitions proposed by D’Amico et al.

Patient Risk:

• Low Risk: PSA <10, Gleason ≤ 6, and clinical stage T1 or T2
• Intermediate Risk: PSA 10-20, and/or Gleason 7
• High Risk: PSA >20, Gleason ≥ 8, or clinical stage ≥T3

Research Question(s)

Surgical Questions

What are the recommended surgical procedures and outcomes for radical prostatectomy (RP), specifically:

1. What is the recommended extent of resection, and what is an acceptable positive margin rate?
2. What are the reported rates for surgical complications, specifically incontinence, erectile dysfunction, rectal injury, and blood transfusion, and does surgical technique (e.g., nerve sparing, bladder neck preservation) affect complication rates?
3. Under what circumstances should nerve-sparing techniques be used?
4. Which patients should receive pelvic lymph node dissection (PLND), and what is the recommended extent of PLND?

Pathological Questions

1. What are the recommended procedures for handling the RP specimen in the operating room and for handling and processing the RP specimen (with or without lymph nodes) in the pathology lab?
2. What diagnostic and prognostic elements should be included in the pathology report, what format should be used, and what reporting elements should be included?