Contemporary methods for surgical margin assessment in radical prostatectomy: a systematic review and meta-analysis of diagnostic test accuracy

INTRODUCTION: Surgical treatment of prostate cancer often leads to adverse outcomes such as erectile dysfunction and urinary incontinence. Nerve-sparing surgery aims to minimize these complications but may increase the risk of incomplete cancer removal. Intraoperative surgical margin assessment assists in balancing oncologic control with functional preservation. This systematic review and meta-analysis evaluated the technologies used for intraoperative margin assessment during radical prostatectomy. EVIDENCE ACQUISITION: A literature review was conducted in February 2025. All included studies involved patients with prostate cancer undergoing nerve-sparing radical prostatectomy in which intraoperative surgical margin assessment was performed. The primary outcome was the comparative diagnostic test accuracy of commercially available assessment methods. EVIDENCE SYNTHESIS: A total of 47 studies were included in the qualitative synthesis, of which 24 were eligible for the meta-analysis of diagnostic test accuracy. These included 11 studies on intraoperative frozen section analysis, seven validating the NeuroSAFE protocol, and six evaluating fluorescence confocal microscopy. A key finding was the demonstration that fluorescence confocal microscopy is non-inferior to the NeuroSAFE protocol. However, limitations such as inconsistent data reporting substantially reduced the number of studies eligible for quantitative analysis. CONCLUSIONS: This study offers a comprehensive evaluation of intraoperative surgical margin assessment techniques employed during radical prostatectomy. Evidence from the NeuroSAFE randomized controlled trial confirms the clinical utility of this protocol, while our findings demonstrate that confocal microscopy provides comparable diagnostic performance. Collectively, these results support their broader clinical implementation. Nonetheless, definitive conclusions will require higher-quality evidence and standardized reporting in future research.