Biopsy results 👉 RARP

The bridge

The RARP page describes the operation in general — what it is, what it removes, what it preserves, what recovery looks like. This page reads that same operation through my biopsy findings. Same procedure, sharper questions: which nerve bundle is at risk, where the margin is going to be tight, what surgery would actually settle that imaging hasn't.

The findings that shape the surgical conversation

From the May 18 pathology plus the April 22 MRI:

• Grade Group 2 (Gleason 3+4=7). Significant cancer, but most of the volume is the less-aggressive pattern. On Grade Group alone, this is the second-lowest tier on a 1–5 scale.
• Intraductal carcinoma (IDC-P) in one sample. Adverse feature. Pushes the cancer's behavior toward more aggressive than the grade alone suggests.
• Cribriform pattern in two samples. Same direction. Most guidelines treat either of these features as a reason to choose definitive treatment over surveillance.
• 3 of 13 specimen containers positive. Two on the right — right mid PZPL and right lateral — plus the midline base (the core carrying the IDC-P). On biopsy, the left side came back clean — though MSK's June MRI re-read later flagged a small, lower-suspicion spot on the left (PI-RADS 4, ~0.8 cm) that the PSMA PET also lit up faintly. Whether that's a second small cancer or just inflammation is still unconfirmed (see nerve-sparing, below).
• April MRI on the right mid PZPL lesion: “No definite EPE but broad abutment on capsule.” Imaging didn't see cancer outside the prostate, but the lesion sat against the capsule along a wide area — which is the classic setup for microscopic EPE that imaging can't resolve. MSK's June re-read confirmed the same picture — still contained, only a mild capsular bulge with no clear break.

What this means for nerve-sparing

The neurovascular bundles run along the outside of the prostate, one on each side. Cancer location dictates which bundles a surgeon can preserve and which they may have to sacrifice for a clean margin.

The surgeon makes the final call intra-operatively, with the tissue actually in view. Imaging and biopsy give the planning picture; what they see on the day refines it.

What this means for margins

A positive surgical margin — cancer cells reaching the cut edge of the removed specimen — is a flag that some disease may have been left behind. With cancer hugging the capsule on the right, the surgeon's planning trade-off is sharp: take more tissue and risk the nerve bundle, or spare the nerve bundle and risk a positive margin.

A positive margin on its own doesn't automatically mean recurrence — many positive-margin patients never have cancer return. But it does shift the probability and is one of the factors that pushes toward adjuvant radiation and/or ADT after surgery.

What post-op pathology would actually settle

Biopsy samples a small fraction of the gland. The full surgical specimen gets sectioned and read in detail, which closes several questions the biopsy can only partly answer:

• True grade. The biopsy is 3+4. The full gland sometimes upgrades (more Gleason pattern 4 found than the needles caught) or — rarely — downgrades.
• EPE — yes or no. The capsule itself gets examined microscopically across the whole gland. The “broad capsular abutment” question stops being a probability and becomes a fact.
• Margin status. Whether the cut edges are clean.
• Seminal vesicle involvement. The vesicles get removed and examined too — seminal vesicle invasion bumps staging to T3b. This now has a specific target: the PET raised an unconfirmed question about the base of the left seminal vesicle, which surgery would settle outright.
• Lymph node status. If lymph nodes were sampled, whether any contained cancer.

That post-op report determines whether surgery alone is the end of treatment, or whether radiation and/or ADT need to be added.

The microscopic EPE question

Given confirmed cancer with broad capsular contact at the right mid PZPL — and a second positive site at the right lateral — the realistic worry isn't gross extension that imaging missed. It's microscopic extension below imaging resolution.

The standard pre-operative estimation tools, covered in the EPE deep-dive:

• Partin tables. Lookup table converting PSA + Gleason + clinical stage into probabilities of organ-confined disease, EPE, seminal vesicle invasion, and lymph node involvement.
• MSK / Briganti nomograms. Newer online calculators doing the same thing with more inputs.
• PSMA PET/CT. Now done (June 13): no spread beyond the prostate and no gross extension — though small-volume microscopic EPE remains below the resolution threshold, so it can't rule that out.

None of these answer the question definitively. They sharpen the probability. The definitive answer comes from post-op pathology — which is part of why surgery has the data-clarity edge described on the RARP page.