Intra-operative Diagnostic Techniques
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I do a very systematic biopsy before the operation.
I know exactly where the cancer is or get a good idea where the cancer is and we will design the operation for that particular cancer in that particular patient.
Now during the operation if the tissue separates very easily we're confident we're in the right place, there's no cancer there but if it doesn't and it's hard to dissect free I will do a frozen section where I will send some tissue off during the operation to check that there's no cancer outside the prostate.
I also do that routinely where we dissect the prostate from the neck of the bladder and from the urethra, the front of the prostate and the apex, the very front where often cancer can extend to.
This gets sent off and I really believe it's important and it helps patients because you will find that there may be unexpected cancer there during the operation and we will have that result back in 15 minutes so we can modify the operation, rather than waiting two or three days after the operation and finding out the cancer is unexpectedly beyond the confines of the prostate and at that stage it's too late to remove further tissue.
I'm very pleased to note the data published in the Journal of Urology on frozen sections2, taking extra tissues and they found and they found unexpected cancer and they went further and cleared it but these patients behaved like their cancer had been removed completely.
Some centres don't do this because it's a lot of trouble to go through but I've done this with my pathologist from day one with 3000 cases, they're very, very good at now, they do it in 15 minutes, it doesn't slow our operation up at all and patients when they have this, when they have this explained to them they understand that it's important and they all you know they all feel very confident that we're doing that additional work in theatre.
Intra-operative Diagnostic Techniques
Pre-operative planning
Dr Kooner performs a systematic biopsy before the operation so that the exact location of the cancer is known - or at least well mapped - and the surgical plan can be tailored to that specific cancer in that specific patient.
Frozen section during surgery
During the operation, if the tissue separates easily from the prostate it is a good sign that the surgical plane is clear of cancer. If the tissue is adherent or hard to dissect free, Dr Kooner performs a frozen section: tissue is sent to the pathologist during surgery to check for cancer at the surgical margin.
Frozen sections are also used routinely at key locations - where the prostate is dissected from the bladder neck and urethra, and at the front and apex of the prostate, which are common sites for cancer to extend.
Why this matters
Frozen-section results come back within 15 minutes without slowing down the operation. If unexpected cancer is found, the surgery can be modified immediately - for example, by removing additional tissue - rather than discovering a positive margin two or three days later when it is too late to act.
Published data in the Journal of Urology show that when extra tissue is taken on the basis of intra-operative frozen sections, patients with unexpected cancer at the margin can still achieve outcomes comparable to patients whose cancer was fully removed at the first pass2.
Why not every centre does it
Frozen-section analysis requires a dedicated pathology team during surgery and is more work than the standard approach, so not every centre offers it. Dr Kooner has worked with the same pathologist through 3,000 cases, with frozen-section turnaround of around 15 minutes. Patients consistently feel reassured when this additional work is performed during their operation.
References
- O. Windisch, M. Diana, D. Tilki, G. Marra, et al - Intraoperative technologies to assess margin status during radical prostatectomy – a narrative review - Prostate Cancer and Prostatic Diseases (2024) - https://doi.org/10.1038/s41391-024-00868-2
- Christian von Bodman, Marko Brock, Florian Roghmann - Intraoperative frozen section of the prostate decreases positive margin rate while ensuring nerve sparing procedure during radical prostatectomy - J Urol. 2013 Aug;190(2):515-20. doi: 10.1016/j.juro.2013.02.011. Epub 2013 Feb 13.