Retrotrigonal Layer Dissection from a Posterior Approach Enables Bladder Neck Preservation in Robot-Assisted Radical Prostatectomy.

BACKGROUND: We developed a novel surgical technique: dissection of the retrotrigonal layer from a posterior approach in robot-assisted radical prostatectomy (RARP). This approach enables earlier access to the posterior space during bladder neck dissection and helps preserve the bladder neck. We evaluated the safety and efficacy of this technique in terms of bladder neck preservation Methods: We retrospectively reviewed 238 consecutive patients who underwent RARP using this technique from August 2021 to September 2023. Key metrics included the success rate of accessing the posterior space prior to bladder neck opening during the dissection and the rate of bladder neck preservation. In addition, oncological and surgical safety, as well as continence recovery, were assessed. RESULTS: The median age and prostate-specific antigen level were 72 (65-75) years and 7.35 (5.40-11.5) ng/mL, respectively. In 153 (64%) patients, the posterior space was successfully accessed before bladder neck opening, with the success rate increasing from 56% in the series' first half to 72% in the second half (p = 0.015). The bladder neck was preserved in 120 (53%) patients, and this rate increased from 39% in the first half to 63% in the second half (p = 0.0004). Positive surgical margins at the junction between the prostate and bladder were observed in 10 cases (4%). Bladder neck preservation correlated with early continence recovery (hazard ratio 1.37 [95% confidence interval 1.03-1.83], p = 0.030). The grade 3 complication associated with this technique occurred in one case (0.5%). CONCLUSION: Retrotrigonal layer dissection from a posterior approach in RARP enhances the safety and ease of bladder neck dissection and aids in its preservation, potentially leading to improved continence recovery.

Long-term functional outcomes of vesicourethral anastomosis with bladder neck preservation and distal urethral length preservation after videolaparoscopic radical prostatectomy.

Introduction: Radical prostatectomy (RP) is the standard surgical treatment for localized prostate cancer (PCa), with excellent oncologic outcomes; however, complications such as post-prostatectomy incontinence could significantly affect quality of life. Aim: To provide data on long-term urinary functional outcomes of bladder neck preservation (BNP) combined with distal urethral length preservation (DULP) in patients treated with videolaparoscopic prostatectomy. Material and methods: In this retrospective study, data were analysed from 619 consecutive patients who underwent laparoscopic radical prostatectomy (LRP) due to localized prostate cancer between November 2014 and December 2018 in a single tertiary care centre in Poland. Of these patients, 227 had BNP and DULP during the procedure. Urinary continence status was assessed in patients at 3, 6, 12, and 18 months after LRP. Cancer resection was assessed by surgical margin status. Results: In the group with BNP and DULP, urinary continence recurred earlier than it did in the control group up to 3 months after surgery: 204 (89.8%) patients in this group were fully continent compared with 283 (72.2%) in the control group (p < 0.001). The difference was also significant after 6 months (95.1% vs. 80.6%, respectively; p < 0.001). Despite these early promising results, there was no difference in urinary continence recovery after 12 and 18 months. There was also no difference between the 2 groups regarding surgical margin status of the resected tissue. Conclusions: Our study showed that BNP combined with DULP is a safe procedure that helps to improve early urinary continence rates after surgery without altering the risk of positive surgical margin.

Holmium laser enucleation of prostate by using en-bloc and bladder neck preservation technique: technical consideration and influence on functional outcomes.

BACKGROUND: This study aimed to evaluate the efficacy and safety of holmium laser enucleation of prostate (HoLEP) by using en-bloc and bladder neck preservation technique on benign prostatic hyperplasia (BPH) and assess the influence of this procedure on urinary and sexual functional outcomes. METHODS: A total of 704 patients with BPH undergoing HoLEP were retrospectively analysed. Amongst them, 213 who met the sexual function assessment criteria were further assessed the influence of the technique on sexual functional outcomes. RESULTS: The mean operative time, resected prostate weight and mean estimated blood loss were 69.3±14.8 min, 53.4±17.6 g and 62.1±23.7 mL, respectively. The mean duration of catheterization after surgery and mean hospital stay were 2.1±1 and 5.4±3.6 days, respectively. The post-void residual volume, maximum urinary flow rate, international prostate symptom score and quality of life score were all significantly improved postoperation (P<0.05). Amongst the 213 patients with normal antegrade ejaculation before surgery, postoperative international index of erectile function scores slightly improved, although the difference was insignificant (P>0.05). The difference in the Erection Hardness Grading Scale before and after surgery was statistically insignificant (P>0.05). A total of 25 (11.7%) patients had retrograde ejaculation after surgery. CONCLUSIONS: HoLEP by an en-bloc and bladder neck preservation technique can obtain good functional outcome with small injury and high efficiency, especially for patients who need to preserve normal sexual function and anterograde ejaculation.

The Impact of Three Different Bladder Neck Reconstruction Techniques on Urinary Continence after Laparoscopic Radical Prostatectomy.

Objective: To evaluate the feasibility of three bladder neck reconstruction (BNR) techniques in laparoscopic radical prostatectomy (laparoscopic RP) and their effects on urinary continence. Methods: We retrospectively analyzed 121 patients with organ-confined prostate cancer, who underwent laparoscopic RP in our center from March to December 2018. Three BNR techniques-zero o'clock reconstruction (ZOR), six o'clock reconstruction (SOR), and three/nine o'clock reconstruction (T/NOR)-applied in patients with large bladder opening after prostate resection are described comprehensively. Demographic and perioperative data were collected and analyzed using Pearson's chi-square and one-way analysis of variance test. Multivariate analysis was performed to explore predictors that affected continence recovery in 24 hours, 1 month, 3 months, and 6 months after catheter removal. Results: Laparoscopic RP was performed in all patients, wherein 37, 35, 34, and 15 patients underwent bladder neck preservation, ZOR, SOR, and T/NOR techniques, respectively. There were more high-risk patients and larger mean prostate volume in groups with BNR techniques. Perioperatively, patients with reconstruction techniques had longer operation and anastomosis time, more estimated blood loss, and more positive margin status. Nevertheless, there was no significant difference among four groups regarding continence recovery in 24 hours, 1 month, 3 months, and 6 months after catheter removal. On multivariable analysis, positive apical margin and long anastomosis time were independent adverse predictors of continence recovery in 24 hours. Large prostate volume and positive apical margin were adverse factors of continence recovery at 1, 3, and 6 months. Conclusion: Three different kinds of BNR techniques were safe and feasible in laparoscopic RP and had no different impact on continence recovery. Positive apical margin, large prostate volume, and long anastomosis time were independent adverse predictors of continence.

Effect of Bladder Neck Preservation on Long-Term Urinary Continence after Robot-Assisted Laparoscopic Prostatectomy: A Systematic Review and Meta-Analysis.

This study aimed to evaluate the effect of bladder neck preservation (BNP) on long-term urinary continence after robot-assisted laparoscopic prostatectomy (RALP). We systematically searched the PubMed, Embase, and Cochrane Library databases to identify studies that assessed the difference in urinary continence and oncologic outcomes between patients who underwent RALP with BNP and those who underwent RALP without BNP. Four trials (1880 cases with BNP, 727 controls without BNP) were considered suitable for meta-analysis. BNP was associated with significantly better urinary continence outcomes at 3-4 months (odds ratio (OR), 2.88; 95% confidence interval (CI), 1.52-5.48; p = 0.001), 12 months (OR, 2.03; 95% CI, 1.10-3.74; p = 0.02), and 24 months (OR, 3.23; 95% CI, 1.13-9.20; p = 0.03) after RALP. There was no difference in the rate of overall positive surgical margin (PSM) (OR, 1.00; 95% CI, 0.72-1.39; p = 0.99) and that of PSM at the prostate base (OR, 0.49; 95% CI, 0.21-1.13; p = 0.09) between the two groups. The BNP technique during RALP leads to early return of urinary continence and long-term urinary continence without compromising the oncologic outcomes.

Transurethral resection of the prostate with preservation of the bladder neck decreases postoperative retrograde ejaculation.

INTRODUCTION: Even though transurethral resection of the prostate (TURP) is the standard surgical treatment for benign prostatic hyperplasia (BPH), there is a high rate of postoperative retrograde ejaculation. AIM: To evaluate the effectiveness of TURP with preservation of the bladder neck in comparison with that of standard TURP. MATERIAL AND METHODS: This is a retrospective study. 137 men with BPH were divided into two groups: TURP with preservation of the bladder neck and standard TURP were performed respectively in group A and group B. The patients were evaluated preoperatively and at 3, 6 and 12 months after surgery by International Prostate Symptom Score (IPSS), health-related quality of life (HRQL) score, maximum urinary flow rate (Qmax), postvoid residual urine volume (PVR) and the rate of complications including retrograde ejaculation. RESULTS: There was no statistically significant difference between groups in terms of the operative duration, catheterization period, hemoglobin decrease, and hospital stay. At the 3-month follow-up, the rates of incontinence and retrograde ejaculation in group A were lower than those in group B. At the 6- and 12-month follow-ups, the difference in the frequency of retrograde ejaculation remained constantly stable whereas the incontinence rates were similar in both groups. The IPSS, HRQL score, Qmax, PVR and the rate of complications including hematuria, clot retention, urinary tract infection, urethral stricture, and bladder neck contracture evaluated at 3, 6 and 12 months also displayed a very similar response in the two groups. CONCLUSIONS: Comparable with standard TURP, TURP with preservation of the bladder neck appears to provide a satisfactory clinical outcome in decreasing early postoperative incontinence and lowering the rate of retrograde ejaculation.

How robotic surgery is changing our understanding of anatomy.

The most recent revolution in our understanding and knowledge of the human body is the introduction of new technologies allowing direct magnified vision of internal organs, as in laparoscopy and robotics. The possibility of viewing an anatomical detail, until now not directly visible during open surgical operations and only partially during dissections of cadavers, has created a 'new surgical anatomy'. Consequent refinements of operative techniques, combined with better views of the surgical field, have given rise to continual and significant decreases in complication rates and improved functional and oncological outcomes. The possibility of exploring new ways of approaching organs to be treated now allows us to reinforce our anatomical knowledge and plan novel surgical approaches. The present review aims to clarify some of these issues.

Complete bladder neck preservation promotes long-term post-prostatectomy continence without compromising midterm oncological outcome: analysis of a randomised controlled cohort.

PURPOSE: The only RCT available on complete bladder neck preservation (cBNP) during radical prostatectomy reported superior continence and QoL outcomes in the first 12 months after cBNP. We provide the first data on long-term urinary continence, QoL and biochemical recurrence (BCR) after complete bladder neck preservation in a randomised controlled cohort. METHODS: After approval by IRB, 199 men recruited for the randomised, controlled single-blind Heidelberger cBNP Study had prostatectomy performed with (cBNP) or without (noBNP) complete bladder neck preservation. Only men with renewed consent for this follow-up were evaluated for continence, QoL outcomes and BCR by ICIQ-SF self-assessment questionnaire, Pad-use/day and PSA levels. Students-t test, Pearson´s Chi-square, Fishers exact test and multiple logistic regression analyses were applied. RESULTS: Mean follow-up was approx. 4 years. There were no significant differences in baseline characteristics between responders/non-responders or between study groups. We noted significantly higher continence rates (p = 0.004), less pad-use (p < 0.001), reduced frequency (p = 0.023) and amount (p = 0.009) of urine loss, and higher QoL outcomes (p = 0.012) after cBNP. A younger age positively influenced continence (OR = 0.91), but the multivariate analysis found cBNP to be the only independent predictor of continence (p = 0.008; OR = 8.1). pT stage was the only predictor for positive surgical margins (PSM; p < 0.001). There was no significant difference in pT stage (p = 0.23) or BCR (p = 0.63) between study groups and also no significant correlation between BCR and presence (p = 0.26) or localisation (p = 0.11) of PSM, nerve sparing (p = 0.70), surgeon (p = 0.41), preoperative PSA (p = 0.53) or pT stage (p = 0.17). No cancer-related death was noted. CONCLUSIONS: Results of this first follow-up on a prospective randomised controlled cohort demonstrate that cBNP is associated with significantly higher continence and QoL outcomes without compromising cancer control making cBNP a novel objective during radical prostatectomy.

The Impact of Lateral Bladder Neck Preservation on Urinary Continence Recovery After Robot-Assisted Radical Prostatectomy.

OBJECTIVE: Urinary incontinence is one of the most bothersome adversities after robot-assisted radical prostatectomy (RARP). The aim of this study was to investigate the urinary continence recovery and the effect of various surgical techniques. MATERIALS AND METHODS: We previously reported that posterior rhabdosphincter reconstruction and nerve-sparing were independent predictors of urinary continence recovery 1 month after catheter removal in 199 patients who underwent RARP. Retrospectively, we further reviewed those 199 patients for urinary continence recovery at 3 months or later after RARP. The relationships of urinary continence with perioperative findings, including surgical procedures, were evaluated at 3 to 12 months after RARP. The Fisher exact test and Mann-Whitney rank sum test were used for evaluating variables between the groups. Multivariate logistic regression analysis was performed to investigate the association between urinary continence and perioperative factors. RESULTS: On univariate analyses, surgeon experience, lateral bladder neck preservation (BNP), anterior reconstruction, and posterior reconstruction were significantly associated with urinary continence recovery 3 months after RARP, but only lateral BNP was independently associated with urinary continence recovery in a multivariate analysis. Similarly, on univariate analyses, surgeon experience, lateral BNP, and posterior reconstruction were significantly associated with continence recovery at 6 months or later after surgery. However, multivariate analyses showed that only lateral BNP was significantly associated with urinary continence recovery 6 months or later after surgery. CONCLUSION: Although the lateral BNP technique did not affect immediate urinary continence recovery, this procedure was significantly associated with continence recovery 3 months or later after RARP.

Combined bladder neck preservation and posterior musculofascial reconstruction during robotic assisted radical prostatectomy: effects on early and long term urinary continence recovery.

BACKGROUND: To evaluate the effects of combined bladder neck preservation and posterior reconstruction techniques on early and long term urinary continence in patients treated by robotic assisted radical prostatectomy (RARP). METHODS: Two-hundred ninety-two patients who previously underwent radical prostatectomy were retrospectively selected for a case-control study, excluding those with anastomotic strictures and significant perioperative complications and re-called for a medical follow-up visit after their consent to participate the study. They were divided in 3 different groups according to the surgical technique previously received: radical retropubic prostatectomy (RRP) combined with bladder neck preservation (BNP), RARP with bladder neck resection, and RARP combined with BNP and posterior musculofascial reconstruction (PRec). Functional and oncologic outcomes evaluation were integrated by a questionnaire on urinary continence status, abdominal ultrasound scan, uroflowmetry and post-void urine volume measurement. Urinary continence definition included the terms "no pad" or "safety pad". RESULTS: Two hundred thirty-two patients responded to the phone call interview and were enrolled in the study. They presented comparable age, prostate volume and BMI. Differences in comorbidities, ASA score and medications, did not influence the postoperative functional results, focused on continence outcome. Early urinary continence was achieved in 49.38% and 24.73% of patients who previously underwent RARP + BNP + PRec and simple RARP respectively (p = 0.000)as well as late 12-months urinary continence was obtained in 92.59% and 79.56% of patients.(p = 0.01). Late urinary continence in the RRP + BNP group was comparable to the result obtained in the simple RARP group. The potential effects of nerve sparing technique on urinary continence have not been evaluated. CONCLUSIONS: The combined technique of RARP + BNP + PRec seems to be effective to determine early and long term significant effects on urinary continence of patients with comparable body mass index, age and prostate volume. No statistically significant differences were found between the simple RARP and the RRP + BNP groups.

Systematic Review of Studies Reporting Positive Surgical Margins After Bladder Neck Sparing Radical Prostatectomy.

PURPOSE OF REVIEW: Bladder neck preservation (BNP) during radical prostatectomy (RP) has been proposed as a method to improve early recovery of urinary continence after radical prostatectomy. However, there is concern over a possible increase in the risk of positive surgical margins and prostate cancer recurrence rate. A recent systematic review and meta-analysis reported improved early recovery and overall long-term urinary continence without compromising oncologic control. The aim of our study was to perform a critical review of the literature to assess the impact on bladder neck and base margins after bladder neck sparing radical prostatectomy. EVIDENCE ACQUISITION: We carried out a systematic review of the literature using Pubmed, Scopus and Cochrane library databases in May 2017 using medical subject headings and free-text protocol according to PRISMA guidelines. We used the following search terms: bladder neck preservation, prostate cancer, radical prostatectomy and surgical margins. Studies focusing on positive surgical margins (PSM) in bladder neck sparing RP pertinent to the objective of this review were included. EVIDENCE SYNTHESIS: Overall, we found 15 relevant studies reporting overall and site-specific positive surgical margins rate after bladder neck sparing radical prostatectomy. This included two RCTs, seven prospective comparative studies, two retrospective comparative studies and four case series. All studies were published between 1993 and 2015 with sample sizes ranging between 50 and 1067. Surgical approaches included open, laparoscopic and robot-assisted radical prostatectomy. The overall and base-specific PSM rates ranged between 7-36% and 0-16.3%, respectively. Mean base PSM was 4.9% in those patients where bladder neck sparing was performed, but only 1.85% in those without sparing. Bladder neck preservation during radical prostatectomy may increase base-positive margins. Further studies are needed to better investigate the impact of this technique on oncological outcomes. A future paradigm could include modification of intended approach to bladder neck dissection when anterior base lesions are identified on pre-operative MRI.

Bladder neck preservation improves time to continence after radical prostatectomy: a systematic review and meta-analysis.

Bladder neck preservation (BNP) during radical prostatectomy (RP) may improve postoperative urinary continence, although its overall effectiveness remains controversial. We systematically searched PubMed, Ovid Medline, Embase, CBM and the Cochrane Library to identify studies published before February 2016 that assessed associations between BNP and post-RP urinary continence. Thirteen trials (1130 cases and 1154 controls) assessing BNP versus noBNP (or with bladder neck reconstruction, BNR) were considered suitable for meta-analysis, including two randomized controlled trials (RCT), six prospective and five retrospective studies. Meta-analysis demonstrated that BNP improved early urinary continence rates (6 mo, OR = 1.66; 95% CI, 1.21-2.27; P = 0.001) and long-term urinary continence outcomes (>12 mo, OR = 3.99; 95% CI, 1.94-8.21; P = 0.0002). Patients with BNP also had lower bladder neck stricture frequencies (OR = 0.49; 95% CI, 0.29-0.81; P = 0.006). Anastomotic leak rates, positive surgical margins and biochemical failure rates were comparable between the two groups (P>0.05). There were no differences in baseline characteristics except for a smaller average prostate volume (WMD = -2.24 ml; 95% CI, -4.27 to -0.22; P = 0.03) in BNP patients. Our analyses indicated that BNP during RP improved early recovery and overall long-term (1 year) urinary continence and decreased bladder neck stricture rates without compromising oncologic control.

Laparoscopic radical prostatectomy with bladder neck preservation: positive surgical margin and urinary continence status.

INTRODUCTION: Preservation of the bladder neck (BN) has been controversial, as limited excision of the bladder neck may result in incomplete resection of the disease. Moreover, the urinary continence rate may not be improved. AIM: To evaluate the effect of bladder neck sparing on urinary continence, and surgical margins status in prostate cancer (PCa) patients treated with laparoscopic radical extraperitoneal prostatectomy. MATERIAL AND METHODS: A retrospective analysis of 295 consecutive patients who had undergone laparoscopic radical extraperitoneal prostatectomy for clinically localised prostate cancer in a single institution was performed. Positive surgical margin (SM(+)) and urinary continence status at 3, 6, and 12 months were evaluated. RESULTS: The distribution of SM(+) for pT2, pT3, and pT4a was 15.3% (27/176), 49.1% (58/118), and 100% (1/1), respectively. Overall, there were 55.61%, 80.61%, and 84.69% of men continent at 3, 6, and 12 months, respectively. However, when limiting the analysis to those who did not receive adjuvant radiotherapy within 12 months following surgery, urinary continence rates were 59.23%, 85.86%, and 90.21% at 3, 6, and 12 months, respectively. Preoperative prostate-specific antigen (PSA) and pathological T stage were identified as significant predictors of positive surgical margins. CONCLUSIONS: Laparoscopic radical extraperitoneal prostatectomy with bladder neck preservation has been a safe procedure which has resulted in good functional outcome. We observed a relatively high incidence of positive surgical margins which could be attributed to a large number of extracapsular disease cases.

A comparison of bladder neck preservation and bladder neck reconstruction for urinary incontinence after radical retro pubic prostatectomy.

BACKGROUND: Prostate cancer is the sixth most common cancer worldwide and will include about 30% of all malignancies in men. Since the initial report of the anatomic radical prostatectomy, refinements in the surgical technique have been made. Several studies show that bladder neck preservation (BNP) during radical prostatectomy makes improve early return of urinary continence, erectile function or both. However, some clinical trials have suggested little difference between the return of continence while using modifications. In this study, we compared outcomes of BNP and bladder neck reconstruction (BNR) during radical retropubic prostatectomy (RRP). MATERIALS AND METHODS: This prospective study was performed on 60 patients at a referral university hospital from March 2010 to March 2012. Study population was all patients candidate for RRP (RRP in this period. All patients divided into two groups, A and B (30 patients in each group). Group A (n = 30) who preserved bladder neck (BNP) and Group B (n = 30) who had BNR. Prostate specific antigen (PSA) before and at 2, 6, 9, 12 and18 months after surgery, anastomotic stricture symptoms, positive bladder neck margin, Gleason score and urine incontinence were compared between two groups. Also, we compared bladder neck contracture, urinary continence and positive surgical margin rates after BNP and BNR while retropubic prostatectomy in 24 months period follow-up. RESULTS: The mean age of the patients was 61.81 ± 7.15 years (range, 50-74 years). After a follow-up period of 24 months, the PSA rising was not different between the two groups. After 2 months, 19 (63.33%) of patients in A group and the same number in B group were continent (P = 0.78). Stricture of the bladder neck at the anastomosis site requiring transurethral dilation occurred in 7 (23.33%) and 3 (10.0%) patients in groups A and B, respectively (P = 0.04). CONCLUSION: Although there was no difference in prevalence and duration of return of urinary continence after the operation between two groups, but results of our study showed that stenosis of the bladder neck was lower in BNP. Hence in the group of BNP, need for further operation and overflow incontinency due to the obstruction of urinary tract will be less likely than BNR and patients have better long time (24 months) urinary continence.