Update on Bladder Neck Preservation During Radical Retropubic Prostatectomy: Impact on Pathologic Outcome, Anastomotic Strictures, and Continence

OBJECTIVES: To preserve the bladder neck during radical prostatectomy in an attempt to maintain continence and decrease the incidence of anastomotic stricture without compromising the removal of cancer. METHODS: A retrospective analysis of 365 consecutive radical prostatectomies performed from December 1991 through January 1997 was carried out. The records were reviewed in regard to the pathology of the prostate. In addition, the incidence of anastomotic strictures was determined. Urinary function and continence was evaluated in 195 patients by a quality of life questionnaire. RESULTS: (1) Pathology: positive margins were found in 119 patients (32%). The bladder neck margin was positive in 27 (7%), but the bladder neck was the only positive margin in only 2 patients (0.5%). The mean Gleason score for patients with negative margins was 6.4, for those with positive margins 7.2, and for all those with bladder neck margin positive 7.7. The mean Gleason score for the 2 patients with a solitary positive margin at the bladder neck was 9.0. Of patients with a Gleason score less than 7, 81% had a negative margin, 19% had a positive margin, and 1% had tumor at the bladder neck. Of patients with a Gleason score 7 or more, 58% had a negative margin, 42% had a positive margin, and 11% had a positive bladder neck. Patients with a prostate-specific antigen value of less than 10 ng/mL were more likely to have a favorable pathology. (2) Anastomotic stricture: an anastomotic stricture occurred in 5 patients (1%). Three had a previous transurethral resection of the prostate (TURP) and therefore bladder neck preservation was not possible. (3) Urinary function: 88% of all responders did not wear pads 6 months or more after surgery. Seventy percent of patients did not wear pads less than 6 months after surgery. Ninety percent of patients believed that urinary function did not limit social, physical, or occupational activities. CONCLUSIONS: We believe that bladder neck preservation during radical prostatectomy does not compromise surgical margins. The incidence of anastomotic strictures is less than 1% in patients who have not had a previous TURP. The quality of life questionnaire indicates a high level of continence that may be related in part to preservation of the bladder neck.