Bladder Neck Dissection During Robotic-assisted Laparoscopic Radical Prostatectomy

Abstract

The approach to the bladder neck (BN) is the first critical step of antegrade laparoscopic radical prostatectomy. Its identification can be difficult in some cases and a mistake at this point of the surgery can compromise the rest of the operation, influencing the next steps of dissection as well as the anastomosis. Because of the complexity of the continence mechanism, the value of preserving the BN during radical prostatectomy is still debated, even if there is some evidence for an earlier return to continence in the cases where it is preserved. Preservation of the BN does not seem to be correlated with a higher risk of positive margins, even if some authors suggest that a wide resection of the bladder neck decreases the positive surgical margin rate. In our opinion, an accurate dissection of the BN and its preservation, especially of the posterior wall, could improve the early return to continence. The use of the robotic assistance allows us to perform a fine dissection and preservation of the bladder neck when this is indicated. In this chapter we describe our technique and some tricks to perform a safe dissection of the bladder neck, exploring the anatomy and a step-by-step surgical procedure for several different situations.