Stepwise Description and Outcomes of Bladder Neck Sparing During Robot-Assisted Laparoscopic Radical Prostatectomy

Purpose: While bladder neck sparing may improve post-prostatectomy urinary continence, there is concern that it may lead to more positive surgical margins and compromise cancer control. We compared the continence and cancer control outcomes of bladder neck sparing vs nonsparing techniques during robot-assisted laparoscopic radical prostatectomy. Materials and Methods: Data were prospectively collected on 1,067 robot-assisted laparoscopic radical prostatectomies done from September 2005 through October 2011. We compared the procedures according to bladder neck sparing (791) and nonsparing (276). Continence was defined by zero pad responses on the EPIC (Expanded Prostate Cancer Index) item quantifying daily use. Biochemical recurrence was defined as prostate specific antigen 0.1 ng/ml or greater. Cox regression was performed to assess factors associated with post-prostatectomy continence and biochemical recurrence-free survival. Results: Median followup for bladder neck sparing vs nonsparing was 25.8 vs 51.7 months. Men treated with bladder neck sparing were more likely to have clinical T1c tumors (p <0.001) and less likely to have biopsy Gleason grade 6 or less disease (p = 0.023). They experienced fewer urinary leaks (p = 0.009) and shorter length of stay (p = 0.006). Regarding cancer control outcomes, there was no difference in bladder neck sparing vs nonsparing base (1.2% vs 2.6%, p = 0.146) and overall surgical margin positivity (each 13.8%, p = 0.985). On adjusted analyses bladder neck sparing vs nonsparing was associated with better continence (HR 1.69, 95% CI 1.43-1.99) and similar biochemical recurrence-free survival (HR 1.20, 95% CI 0.62-2.31, p = 0.596). Conclusions: Bladder neck sparing is associated with fewer urinary leak complications, shorter hospitalization and better post-prostatectomy continence without compromising cancer control compared to bladder neck nonsparing.