Objectives: The intraoperative finding of palpable tumor lesions has been described as a contraindication for nerve-sparing (NS) radical prostatectomy (RP). However, its evaluation is subjective. Especially in patients with a strong demand to regain postoperative erectile function, a surgeon might be reluctant to sacrifice neurovascular bundles (NVBs) based on this information. We investigated the use of frozen section (FS) analysis to monitor the safety and efficiency of NS during RP in patients with intraoperatively identified subcapsular tumor lesions.
Methods: In 83 of 608 patients, who underwent NS-RP, intraoperative FS was performed because of a lesion palpable close to the capsule. A wedge of 4cm in diameter including the lesion was cut off and stained differently for capsule and intraprostatic margin. In case of presence of carcinoma adherent to the capsule, the NVB was resected; otherwise, the NVB remained in situ.
Results: Patients with palpable tumor lesions had pT3 tumors in 36% and 61% had Gleason 4 pattern, compared to 18% and 42% for the control group. Carcinoma was found in 93% of the FS specimens. In 42% of the FS samples, tumor had contact with the capsule and 14% of secondary resected NVB specimens demonstrated a carcinoma invasion. In 52% NVBs could be preserved despite an ipsilateral nodule without negatively affecting the margin status. However, the false-negative rate of the FSs was 6%. Conversely, FSs set the intraoperative decision to remove the NVB in 42% of FS patients, resulting in an additional 36% of negative margins.
Conclusions: In patients with intraoperatively detected tumor lesions during a NS planned RP, FS objectively supports the decision of secondary NVB resection as well as preservation.