V08-08: Bladder Neck Preservation during Robotic Prostatectomy: if the only concern is about positive surgical margins, there is no problem!
The post-prostatectomy recovery of continence is influenced by multiple factors, both pre- and intra/post-operative. The bladder neck preservation (BNP), more accurate during robot assisted radical prostatectomy (RARP), works on two anatomic components responsible for post-prostatectomy continence (internal and external sphincter). Moreover, BNP spares the zone of urothelial coaptation and provides primary resistance to the urine to maintain urinary continence. The risk of having a positive surgical margins (PSM) at the level of spared bladder neck may limit the indications of BNP during RARP. The purpose of this study is to evaluate the surgical and pathological outcome in prostate cancer patients underwent RARP with BNP.
We prospectively collected demographic, clinical, surgical and pathological data of patients underwent RARP with BNP, from January 2014 to December 2016. Moreover, our dedicated uro-pathologist performed a microscopic and macroscopic pathological analysis to evaluate the presence of alterations or continuous solutions of the capsule, specifically due to the surgical technique of BNP. BNP technique consisted of a complete dissection and preservation of the bladder neck and proximal urethra. We avoid any traction on the catheter balloon in order to better identify the bladder neck. With an athermal dissection of the plane between prostate and bladder we can minimize the traumatic effects on the longitudinal fibres of the bladder neck.
In order to have homogeneous data, from the total of 132 patients, we selected only the cases (88) performed by the same surgeon (FDM). Pathological stage was pT2a in 11 cases (12.5%), pT2b in 37 (42.1%), pT3a in 28 (31.8%) and pT3b in 12 patients (13.6%), with a lymph node involvement in 5 cases (5.7%). The definitive Gleason score was 6 in 10 cases (10.4%), 7 (3+4) in 30 (34.1%), 7 (4+3) in 20 (22.7%), 8 in 19 (21.,6%) and 9 in 9 patients (10.2%). In 5 patients (5.7%) there was a positive surgical margin at the level of bladder neck, but in all these cases there was also an involvement of the prostatic base (globally present in 14 cases). Pathological stage of the patients with bladder neck PSM was pT3a in 2 cases (40%) and pT3b in 3 (60%); in 3 cases (60%) there was a nodal involvement. Gleason score was 8 in 3 cases (60%) and 9 in 2 patients (40%). Nobody had alterations or continuous solutions of specimen external capsule, attributable to surgical technique BNP.
BNP during RARP is a safe oncological procedure. The bladder neck PSM are linked to neoplasia with adverse pathological features, rather than the BNP technique. BNP allows a more precise and accurate &[Prime]urethro-urethral&[Prime] anastomosis, avoiding any traction between urethral and bladder neck muscular layers and maintaining the urethral coaptation.