V4-06: Technique and outcomes of maximal urinary muscle preservation during robotic assisted radical prostatectomy
Surgical techniques that reduce urinary incontinence after radical prostatectomy (RP) are not well known. Some studies suggest bladder neck preservation and preoperative membranous urethral length may correlate with better postoperative continence. Here we describe technique and outcomes for a novel approach to robotic RP that combines intraprostatic urethral preservation (IPUP) with Mohs-like bladder neck preservation (MBNP) to achieve maximal urinary muscle preservation.
35 consecutive prostate cancer patients electing robotic RP with a single surgeon underwent maximal urinary muscle preservation (IPUP + MBNP) regardless of comorbidity or oncologic severity. Following complete BNP, frozen sections were assessed from the bladder neck circumferentially and repeated as needed to ensure absence of prostate tissue or cancer, analogous to a Mohs dermatologic excision. IPUP was performed along the surgical plane between the prostatic urethra muscle and the transition zone, entering the outer intraurethral muscular layer upon deeper intraprostatic dissection (“telescoping”) to ensure a prostate-free urethra. Measured outcomes include length of spared intraprostatic urethra, incidence of intraoperative bladder neck continence prior to anastamosis (absent leakage despite filling of the transected bladder), surgical margin positivity, postoperative PSA detection and continence recovery.
Continence of the transected bladder neck prior to anastomosis was observed in 77% of patients. The median intraprostatic urethra length spared was 4 cm on stretch (range 2.5-6.0 cm). Most (70%) patients had high risk pathology (>pT3 and/or Gleason >8). 7 (20%) patients had positive surgical margins, including 2 (6%) at the apex and 1 (3%) at the bladder neck. With a median follow up of 6 months (range 1-17.7 months), 2/35 (6%) patients had a detectable PSA >0.1, including 1/33 (3%) patients without lymph node metastases. Half of all patients had immediate social continence (
Maximal urinary muscle preservation by combined IPUP and MBNP is a novel approach that achieves excellent continence outcomes among unselected robotic RP patients, without compromise in oncologic outcomes. Rates of positive surgical margins and early biochemical relapse appear acceptable even with high risk disease, although additional study with longer follow up is needed.