Impact of positive surgical margin location after radical prostatectomy: a network meta-analysis

Abstract Objective To perform a network meta-analysis comparing the impact of different positive surgical margin locations (Comparisons and intervention) on biochemical recurrence (Outcome) in patients undergoing radical prostatectomy (Population). Methods According to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, a protocol was registered (PROSPERO: CRD42022119025) and a search across four databases was conducted (the MEDLINE, Scopus, Embase and Cochrane). The primary outcome was biochemical recurrence (BCR). A network meta-analysis was conducted. Further subgroup analysis was performed to evaluate studies exploring robot-assisted radical prostatectomy (RALP). Results Our search yielded 1249 unique results; 22 studies were analysed. Anterior margins had the highest risk of BCR (HR 2.46, 95%CI 1.67–3.61, I 2 = 76%) followed by posterior (HR 2.29, 95%CI 1.43–3.66, I 2 = 0%), bladder base (HR 2.06, 95%CI 1.61–2.64, I 2 = 69%), apical (HR 1.88, 95%CI 1.51–2.35, I 2 = 59%), and posterolateral margins (HR 1.70, 95%CI 1.14–2.25, I 2 = 60%). Given significant heterogeneity, subgroup analysis was performed. In the RALP subgroup, anterior margins also demonstrated the highest recurrence risk (HR 3.74, 95%CI 2.47–5.66, I 2 = 0%), followed by apical (HR 2.43, 95%CI 1.97–8.00, I 2 = 0%), posterior (HR 2.23, 95%CI 1.47–3.38), base (HR 1.65, 95%CI 1.29–2.11, I 2 = 0%), and posterolateral margin (HR 1.54, 95%CI 1.07–2.22). Conclusions The risk of BCR after radical prostatectomy varies by PSM location, with the highest recurrence risk observed at anterior margins.