Evidence of trigonal denervation and reinnervation after radical retropubic prostatectomy

PURPOSE: Urinary incontinence continues to be a major consequence of radical prostatectomy. To understand the pathophysiology of this dysfunction we studied the impact of autonomic innervation of the superficial trigone on postoperative urinary continence. MATERIALS AND METHODS: To investigate nerve fiber density biopsies of the superficial trigone were obtained in 34 patients preoperatively as well as 6 weeks and 6 months postoperatively in 15 and 19, respectively. Specimens were Bouin fixed, paraffin embedded and processed for light microscopic immunohistochemical evaluation using an antibody against protein gene product 9.5, a general neuronal marker protein. In parallel we performed a comprehensive urodynamic evaluation, including determination of maximal urethral closure pressure and posterior urethral sensory threshold. RESULTS: Postoperatively protein gene product 9.5 immunoreactive nerve fiber density was generally decreased. However, nerve fiber density after 6 weeks of incontinence in 12 of 15 patients was only 7%, while 3 of 15 who were continent preserved 36% of initial nerve fiber density. After 6 months nerve fiber density in 19 patients increased in 3 with incontinence to 20% and in 16 with continence to 44% of intraoperative density. Urinary incontinence was associated with decreased trigonal innervation, a high sensory threshold and low maximal urethral closure pressure. CONCLUSIONS: Protein gene product 9.5 immunoreactive nerve fiber density corresponds with posterior urethral sensory threshold and urinary continence. Thus, preserving trigonal innervation and postoperative reinnervation may be important factors for achieving early postoperative urinary continence after radical prostatectomy.     

Preservation of Putative Continence Nerves during Radical Retropubic Prostatectomy Leads to More Rapid Return of Urinary Continence

Objectives. Urinary incontinence is a significant complication of radical pelvic surgery. A better understanding of the neuroanatomy of the rhabdosphincter has led to the modification of the radical retropubic prostatectomy to optimize the recovery of postoperative urinary control.Methods. Mock radical retropubic prostatectomy was performed on fresh cadavers to determine which surgical maneuvers could injure what may be the continence nerves. To assess the clinical significance of modifying the radical retropubic prostatectomy based on these anatomic studies, a contemporary series of 60 consecutive patients who underwent radical retropubic prostatectomy with continence nerve preservation was compared with a control group of 38 consecutive patients who had a standard anatomic radical retropubic prostatectomy.Results. At the level of the prostatic apex, both the pelvic and pudendal nerves gave intrapelvic branches that bilaterally coursed to the external urinary sphincter to enter at the 5 and 7 o’clock positions. The mock radical prostatectomy revealed that the nerves to the external urinary sphincter were most prone to injury when a right angle clamp was used to develop a plane between the posterior rhabdosphincter and anterior rectum and if the urethral anastomotic sutures were placed at the 5 and 7 o’clock positions. In addition, blunt dissection of the tips of the seminal vesicles injured the inferior hypogastric plexus. Modifications to preserve the continence nerves were incorporated in the anatomic radical prostatectomy. Although overall continence rates were similar for the two groups (98.3% for continence nerve-preserving radical prostatectomy versus 92.1% for standard prostatectomy), continence nerve preservation decreased the time to achieve continence.Conclusions. During radical retropubic prostatectomy, surgical maneuvers that avoid injury to the continence nerves resulted in the more rapid return of urinary control.     

Effect of radical prostatectomy on sensory threshold and pressure transmission

PURPOSE: The mechanisms involved in post-radical prostatectomy incontinence remain unclear despite previous anatomical and functional studies. In addition, the factors responsible for the restoration of continence are not well studied. To improve our understanding of the alterations in continence mechanisms, we prospectively investigated the temporal changes in urodynamic parameters after radical prostatectomy. MATERIALS AND METHODS: Cystometry, urethral pressure profilometry and posterior urethral sensory threshold measurements were performed in patients undergoing radical prostatectomy. Preoperative pressure transmission was determined by the maximal urethral pressure divided by the maximal abdominal pressure during cough maneuvers at a bladder volume of 200 ml. Postoperative sensory threshold, pressure transmission (% of pressure transmission), maximal urethral closure pressure and functional sphincter length were measured 6 weeks and 6 months after prostatectomy. These parameters were compared between continent and incontinent patients. RESULTS: Preoperative and postoperative urodynamic studies were completed in 34 patients. The continence rate after 6 weeks was 18% (6 patients) and improved to 82% (28) after 6 months. Preoperatively sensory threshold was 16 +/- 11 mA. After 6 weeks and 6 months, respectively, sensory threshold was significantly higher in incontinent (84 +/- 11 mA., 70 +/- 8 mA.) compared to continent (65 +/- 8 mA., 41 +/- 12 mA.) patients. Preoperative proximal urethral sensory threshold was not correlated with degree of postoperative incontinence determined by pad tests. Pressure transmission was not different in continent and incontinent patients postoperatively. After 6 weeks and 6 months, respectively, pressure transmission was 77% and 91% in continent, and 37% and 58% in incontinent patients (p = 0.04, p = 0.03). Maximal urethral closure pressure was significantly higher in continent patients (35 +/- 6 cm. H2O) compared to incontinent patients (11 +/- 9 cm. H2O). Sphincter length decreased from 50 mm. preoperatively to 24 mm. after 6 weeks and 25 mm. after 6 months. There was no difference in sphincter length between continent and incontinent patients. CONCLUSIONS: Posterior urethral sensitivity and pressure transmission are impaired immediately after prostatectomy. An improvement in these parameters after 6 months is associated with the restoration of continence. These observations suggest that urinary continence after radical prostatectomy depends on the integrity of posterior urethral sensation and the efficiency of pressure transmission.     

经精囊面吊带悬吊膀胱颈技术在腹腔镜前列腺根治切除术中的应用

目的:探讨经精囊面吊带悬吊膀胱颈技术在腹腔镜前列腺癌根治术中的应用,评价其效果。方法:2013年10月~2014年6月,在12例前列腺癌根治手术中采用经精囊面吊带悬吊膀胱颈技术行膀胱颈离断。记录手术时间、术中出血量、膀胱颈切缘阳性率、术后短期尿控情况及术后并发症的发生。结果:12例患者,平均手术时间(98±21.5)min,平均术中出血量(134±26.4)ml。术后病理报告示膀胱颈切缘均为阴性。术后3个月仅1例发生轻度尿失禁。无尿漏、肾积水等并发症发生。结论:经精囊面吊带悬吊膀胱颈技术用于腹腔镜前列腺癌根治术中膀胱颈的离断安全性好,更好地保留了膀胱颈口,易于其与尿道的吻合,减少了术后并发症的发生。     

Early post-prostatectomy pelvic floor biofeedback

PURPOSE: We determined whether biofeedback enhanced pelvic floor exercises begun 6 weeks after radical prostatectomy improve the early recovery of continence. MATERIALS AND METHODS: We randomized 30 patients who underwent radical retropubic prostatectomy into a group that received 5 biofeedback sessions and a control group. RESULTS: Overall 87% of patients were pad-free at 6 months with similar results in the treatment and control groups (86% versus 88%). There was no statistically significant difference in pad test results or voiding diary records in the 2 groups. CONCLUSIONS: A treatment program of biofeedback enhanced pelvic floor exercises begun 6 weeks after radical retropubic prostatectomy did not significantly affect continence in this study.     

负压治疗联合盆底肌训练对前列腺癌根治术后患者控尿功能及性功能的影响

目的探讨负压治疗联合盆底肌训练对前列腺癌根治术后患者控尿功能及主观幸福感的影响。方法将中山大学附属第三医院2016年10月至2019年4月泌尿外科确诊为前列腺癌并行腹腔镜下前列腺癌根治术治疗的70例患者,按随机数字表法分为干预组和对照组各35例,其中对照组35例采用常规护理(盆底肌功能锻炼),干预组35例在常规护理基础上,术后6周起再增加负压治疗。比较对照组和干预组术后6周、10周、18周控尿功能恢复情况,同时进行国际勃起功能评分表(IIEF-5)评分及主观幸福感调查,观察其治疗效果。结果干预组术后6周、10周、18周尿失禁评分中位值分别2分、1分与0分,低于对照组的2分、2分与2分,提示干预组术后平均控尿功能恢复时间较对照组短,差异有统计学意义(P<0.05);此外干预组相比对照组,IIEF-5评分及主观幸福感评分上升速度较快,提示干预组术后勃起功能和生活质量改善情况明显优于对照组。结论负压治疗联合盆底肌训练对前列腺癌根治术后患者的控尿功能和性功能有明显改善,且缩短其恢复时间。     

Continence following nerve-sparing radical prostatectomy

Urinary incontinence after radical prostatectomy is a difficult postoperative problem and often is a major consideration in the selection of therapy for clinically localized disease. The occurrence of incontinence is unpredictable and the relationship of incontinence to operative technique is unclear. We compared urinary continence in 68 consecutive patients undergoing radical prostatectomy. In 34 patients nonnerve-sparing radical prostatectomy was performed and in 34 subsequent patients a nerve-sparing operation was done. Patient age, Gleason score and stage of the tumor, and operative time were not significantly different between the groups. In the nonnerve-sparing operated group there were 4 patients (12%) with total and 6 (18%) with stress incontinence requiring absorbent pads, compared to 0 and 2 (6%), respectively, in the nerve-sparing group. The postoperative functional urethral length in the nonnerve-sparing group was 1.9 +/- 0.6 cm. (standard deviation) and in the nerve-sparing group it was 2.3 +/- 0.5 cm., which was significantly different (p less than 0.05). The peak resting urethral pressure of the nonnerve-sparing group was 35.4 +/- 14.2 cm. water and in the nerve-sparing group it was 46.5 +/- 12.3 cm. water, which also was significantly different (p less than 0.05). The study indicates that preservation of the pelvic nerves during radical prostatectomy has a major role in the functional preservation of urinary continence.     

Seminal monolateral nerve-sparing radical prostatectomy in selected patients

INTRODUCTION: In recent years there has been a shift in prostate cancer stage with the majority of patients nowadays being operated with cT1c disease, prostate-specific antigen levels of <10 ng/ml, and a decreased rate of seminal vesicle invasion. Recent data suggest the role of preservation of the seminal vesicle in improving continence and/or potency. We describe our preliminary experience with seminal-sparing, unilateral nerve-sparing retropubic radical prostatectomy. PATIENTS AND METHODS: 21 selected patients with clinically localized prostate cancer underwent seminal unilateral nerve-sparing retropubic radical prostatectomy (seminal-sparing group, SSG). We compared the postoperative continence, erectile function and quality of orgasm results to those obtained in a control group (CG) of 21 patients who underwent unilateral nerve-sparing radical prostatectomy. Sexual function was evaluated preoperatively and 9 months postoperatively with the 5-item International Index of Erectile Function (IIEF-5) questionnaire and with other self-administered questionnaires. The quality of orgasm was evaluated 9 months postoperatively. RESULTS: 1 month postoperatively, 95 and 28% of the patients in the SSG and CG were continent (p<0.001). The median postoperative drop in IIEF-5 score was 5 points in SSG and 14.5 points in CG (p<0.0001). Nine months postoperatively, 90 and 62% of the patients in SSG and CG, respectively (p=0.05), maintained the ability to achieve orgasm. CONCLUSIONS: In our experience seminal-sparing radical prostatectomy showed good feasibility and improved early postoperative urinary continence, erectile function and quality of orgasm, without compromised cancer control.     

腹腔镜前列腺癌根治术术中实时盆底括约肌肌电监测的可行性研究

目的 通过在腹腔镜前列腺癌根治术中实时用NIM-ResponseTM肌电监测仪监测盆底括约肌电活动,了解控尿神经的分布,以便术中保护控尿神经,提高术后控尿效果;并对比手术前后患者控尿情况,评价实时监测技术在保护控尿神经方面的效果及意义.方法 80例前列腺癌患者临床分期为T2a~T3a纳入研究.将这些术前控尿正常的患者随机分成2组,每组40例.其中A组(神经监测组)利用NIM-ResponseTM肌电监测仪对以上患者腹腔镜前列腺癌根治术中盆底括约肌电活动进行术中实时监测.所有患者均采用气管全麻,避免术中使用肌松药.接地电极接于上臂,探测电极置于肛门括约肌及尿道括约肌.术中在前列腺邻近结构处以神经刺激探针以最高5 mA电流刺激和探测证实控尿神经在膀胱颈、前列腺、尿道周围行程及功能状态,通过避免电切电凝破坏控尿神经邻近结构达到保护其免受损伤的目的.B组(非神经监测组)行常规腹腔镜前列腺癌根治术.对比术前、术后拔尿管后24 h、术后3个月和术后6个月患者控尿情况,包括尿动力学检查、尿垫试验、膀胱镜检查.结果 术后两组拔尿管后24 h完全控尿率有显著差异(65.0%vs 37.5%,P<0.05)、术后3个月和术后6个月控尿率则无差异(80.0%vs 75.0%,P>0.05和92.5%vs 90.0%,P>0.05).术后30 d尿动力学检查证实80例患者前列腺部尿道控制带阻力消失,尿道闭合压正常存在,括约肌肌电正常存在.膀胱镜见40例患者尿道括约肌结构存在,镜下括约肌收缩功能良好.结论 腹腔镜前列腺癌根治术中采用盆底括约肌电活动实时监测,对控尿神经的解剖及功能分布有较强的准确性,可加快术后控尿功能恢复.     

Delayed recovery of urinary continence after laparoscopic radical prostatectomy

AIM: To study the rate at which patients regained urinary continence during our institution's early experience with laparoscopic radical prostatectomy. METHODS: The urinary continence of 34 patients was recorded at various intervals following laparoscopic radical prostatectomy. These data were compared with those from 49 patients who had undergone radical retropubic prostatectomy. RESULTS: For laparoscopic prostatectomy patients, 2.9% had regained urinary continence at 1 month, 29.4% at 3 months, 46.9% at 6 months, 56.0% at 9 months and 60.0% at 12 months. For retropubic prostatectomy patients, the corresponding rates were 22.4% at 1 month, 63.3% at 3 months, 84.1% at 6 months, 92.9% at 9 months and 92.9% at 12 months. Backward stepwise logistic regression analysis indicated that laparoscopic surgery itself significantly predicted urinary incontinence at every interval from 1 to 9 months following surgery (P < 0.05). CONCLUSION: Patients' postoperative recovery of urinary continence was not satisfactory in our early experience with laparoscopic radical prostatectomy. Further efforts to elucidate the reason for this poor functional outcome are mandatory before the procedure is accepted as part of standard practice.     

前列腺癌根治术中保护控尿功能的体会

目的：减少耻骨后前列腺癌根治术患者术后尿失禁发生率。方法：对16例B超前列腺癌患者行保护控尿功能的解剖性耻骨后前列腺癌根治术。结果：16例术后随访3个月-5年，平均13个月。膀胱控尿正常者13例，轻度压力性尿失禁者2例，严重尿失禁者1例。结论：在行耻骨后前列腺癌根治术时，认识尿道括约肌及其支配神经的解剖位置及结构，避免对其损伤可以减少术后尿失禁发生率。     

The role of pelvic floor exercises on post-prostatectomy incontinence

PURPOSE: Post-radical prostatectomy incontinence occurs in 0.5% to 87% of patients. This condition may be attributable to intrinsic sphincteric deficiency, and/or detrusor abnormalities. Previous studies of pelvic floor exercise (PFE) for improving post-prostatectomy incontinence have shown mixed results. We determined whether preoperative and early postoperative biofeedback enhanced PFE with a dedicated physical therapist would improve the early return of urinary incontinence. MATERIALS AND METHODS: A total of 38 consecutive patients undergoing radical prostatectomy from November 1998 to June 1999 were randomly assigned to a control or a treatment group. The treatment group of 19 patients was referred to physical therapy and underwent PFE sessions before and after surgery. Patients were also given instructions to continue PFE at home twice daily after surgery. The control group of 19 men underwent surgery without formal PFE instructions. All patients completed postoperative urinary incontinence questionnaires at 6, 12, 16, 20, 28 and 52 weeks. Incontinence was measured by the number of pads used with 0 or 1 daily defined as continence. RESULTS: Overall 66% of the patients were continent at 16 weeks. A greater fraction of the treatment group regained urinary continence earlier compared with the control group at 12 weeks (p <0.05). Three control and 2 treatment group patients had severe incontinence (greater than 3 pads daily) at 16 and 52 weeks. Of all patients 82% regained continence by 52 weeks. CONCLUSIONS: PFE therapy instituted prior to radical prostatectomy aids in the earlier achievement of urinary incontinence. However, PFE has limited benefit in patients with severe urinary incontinence 16 weeks after surgery. There is a minimal long-term benefit of PFE training since continence rates at 1 year were similar in the 2 groups.     

Posterior musculofascial plate reconstruction promotes early restoration of continence and prevents severe incontinence in patients undergoing laparoscopic radical prostatectomy

The objective of the present study was to assess the efficacy of posterior reconstruction of Denonvilliers' musculofascial plate for restoring urinary continence after laparoscopic radical prostatectomy. A total of 48 consecutive patients who underwent laparoscopic radical prostatectomy were retrospectively reviewed. Of them, 23 underwent laparoscopic radical prostatectomy without posterior reconstruction of Denonvilliers' musculofascial plate (group 1) and 25 underwent laparoscopic radical prostatectomy with posterior reconstruction of Denonvilliers' musculofascial plate (group 2). Patients' demographics were analyzed and continence rates between the two groups at 1, 3, 6 and 12 months after surgery were compared. Patients in group 2 had significantly larger prostates than in group 1. There were no significant differences between the two groups in terms of the other patient characteristics. The urinary continence rates were significantly higher in group 2 than in group 1 at 1, 3 and 12 months after surgery, and the rates of severe incontinence were significantly lower in group 2 at all time‐points considered. These findings suggest that posterior reconstruction of Denonvilliers' musculofascial plate helps in restoring early continence and decreasing severe incontinence in patients undergoing laparoscopic radical prostatectomy.     

前列腺癌根治术后电针联合提肛训练对改善尿控的研究

目的 探讨电针辅助提肛锻炼对前列腺癌根治术后患者尿失禁治疗的效果和意义.方法 2008年9月至2009年9月接受前列腺癌根治术并完整随访的患者109例,年龄48～79岁.按照术前患者意愿分为两组:治疗组40例,拔除导尿管1周后,在提肛锻炼的同时加用电针辅助治疗;对照组69例,术后只应用提肛锻炼帮助尿控恢复.随访术后尿控情况,记录相关临床特征,进行ICI-Q-SF量表评分,并进行相关统计学分析.结果 治疗组和对照组尿控曲线差异具有统计学意义(P=0.029).两组尿控率差异从术后4周起逐渐明显,至术后6周差异最大(P=0.023),其后差异逐渐缩小,至术后16周基本无差异.ICI-Q-SF评分量表显示的两组患者主观尿失禁感受也与尿控率情况相符合.结论 前列腺癌根治术后电针辅助提肛锻炼可以明显缩短患者尿控恢复时间.     

Evaluation of pelvic floor muscle strength before and after robotic-assisted radical prostatectomy and early outcomes on urinary continence

The aim of the study was to evaluate the effect of pelvic floor muscle (PFM) assessment and training before and after robot-assisted laparoscopic radical prostatectomy (RARP) in improving PFM strength and urinary continence. We performed an analysis of a database of patients who underwent robot-assisted laparoscopic radical prostatectomy (RARP) performed by two urologists from 2011 to 2013. Pelvic floor muscle (PFM) activation and strength were graded by a trained pelvic floor physiotherapist. Patients were given an exercise program, grouped according to the strength of their pelvic floor as graded by assessment, to complete before and after surgery. PFM strength was recorded preoperatively, 4 days post-catheter removal and 4 weeks post-catheter removal. Continence was recorded at 4 weeks postop and was defined as the requirement of no continence aids. A total of 98 patients had RARP and a preoperative physiotherapy assessment plus postoperative appointments at around 1 and 4 weeks post-RARP. The majority of men improved their PFM strength regardless of preoperative strength with no significant predictors of postoperative strength found. Age was the only significant predictor of postoperative incontinence. In this pilot study, a majority of patients increased their pelvic floor strength with time. Pelvic floor physiotherapy is an important modifiable patient factor, which does have an impact in improving patients’ urinary continence by strengthening the pelvic floor muscles. Patient age influences response to pelvic floor physiotherapy.     

Urinary continence after radical retropubic prostatectomy: a modification in the technique of apical dissection

Urinary incontinence impairs the quality of life for patients following radical prostatectomy. We retrospectively reviewed the records of 36 patients who underwent radical retropubic prostatectomy between 1987 and 2002, and achieved the time from operation until urinary continence. A modification in the technique of apical dissection was introduced in 1999 and applied in 12 cases of consecutive radical prostatectomy. The principles for this technique were based on sharp division of the dorsal vein complex, continuous suturing cut edges of lateral pelvic fascia, and anterior anastomotic sutures including lateral pelvic fascia as well as urethra and bladder neck. None of the patients undergoing the new technique used pads at 6 months. With introduction of this technique, the rate of continence at 12 months increased from 58.3 to 100.0%. Our results suggest that the surgical technique of apical dissection is an important factor associated with postprostatectomy in continence.     

A novel technique for approaching the endopelvic fascia in retropubic radical prostatectomy, based on an anatomical study of fixed and fresh cadavers

OBJECTIVE: To present the anatomical basis and details of a technique for an approach to the endopelvic fascia devised to preserve urinary continence. PATIENTS, MATERIALS AND METHODS: For cross-sectional macroscopic observation, seven formalin-fixed specimens of the male pelvic contents including the pelvic wall were serially sectioned at a 5-mm thickness. Semi-serial sections from eight other specimens were examined histologically. Eight fresh cadavers were dissected to mimic the various steps in a retropubic radical prostatectomy. After approaching the endopelvic fascia in an anatomically determined manner to reach the paraprostatic space, the pubic bone was removed and nerves near the rhabdosphincter dissected. To assess the clinical implication of this approach, we examined the time to achieve continence in 23 consecutive patients who had a radical retropubic prostatectomy using the new technique. RESULTS: Sectional macroscopic observation depicted the fascia of the levator ani as a definite structure adherent to but not fused with the lateral pelvic fascia. The thin fascia overlying the levator ani fascia and lateral pelvic fascia represented the true endopelvic fascia. Microscopically, the lower part of the fascia of the levator ani was rich in smooth muscle, which interdigitated with the framework of the rhabdosphincter. In fresh cadavers, the levator ani muscle was removed laterally still covered by its fascia, without visualizing the muscle fibres. Small branches from the pudendal nerve entered the rhabdosphincter. The mean (sd, range) distance from the lowest point of the endopelvic fascia to the point where the sphincteric branch entered the rhabdosphincter was 5.5 (1.8, 3-8) mm. The continence rate at 1, 3, 6 and 9 months after surgery using the new technique was 44%, 83%, 96% and 100%, respectively. CONCLUSIONS: Preserving the fascia of the levator ani helps to protect the levator ani muscle, rhabdosphincter and pudendal nerve branches to the rhabdosphincter. In retropubic radical prostatectomy, this anatomical approach to the endopelvic fascia should preserve or allow the earlier recovery of urinary continence.     

Early recovery of urinary continence after laparoscopic versus retropubic radical prostatectomy: evaluation of preoperative erectile function and nerve-sparing procedure as predictors

The aim of this study was to evaluate preoperative erectile function and attempted nerve-sparing procedure as predictors for early recovery of urinary continence after retropubic and laparoscopic radical prostatectomy. Patients were divided into two groups according to surgical approach (retropubic or laparoscopic) and learning curve for laparoscopic approach: group 1—retropubic approach (37 patients operated on from April 2000 to June 2006), group 2—laparoscopic approach (109 patients operated on from April 2003 to June 2006). We assessed state of urinary continence at 1, 3, 6, and 12 months after removal of the urinary catheter. Overall rates of urinary continence were 18%, 49%, 68%, and 80% at 1, 3, 6, and 12 months, respectively. Between groups 1 and 2, no statistically significant differences in recovery of urinary continence were evident, being 27% versus 15% at 1 month, 54% versus 47% at 3 months, 77% versus 65% at 6 months, and 91% versus 77% at 12 months in groups 1 and 2, respectively. An attempted nerve-sparing procedure (one or both neurovascular bundles) was statistically associated with urinary continence at 3 month, and International Index of Erectile Function-5 (IIEF-5) score (≥14) was identified as a significant factor predicting urinary continence at 6 months after laparoscopic radical prostatectomy. Younger age tended to result in early recovery of urinary continence after retropubic radical prostatectomy.     

Urinary continence and pathological outcome after bladder neck preservation during radical retropubic prostatectomy: a randomized prospective trial

PURPOSE: Bladder neck preservation during radical prostatectomy has been advocated for improving urinary continence. We compared bladder neck preservation and resection in a randomized trial, looking at continence rates and surgical cancer control. MATERIALS AND METHODS: Patients with stage T1c-T2c prostate cancer underwent radical retropubic prostatectomy with maximal preservation of the external urinary sphincter. Bladder neck preservation or resection was chosen by chance during surgery. Urinary continence (1 or no protective pad daily) was assessed by interview 2 days after catheter removal, and 2 and 6 months after surgery. The surgeon, pathologist and interviewer were the same throughout. Neither patient nor interviewer knew which procedure was done. Planned enrollment was 120. RESULTS: Enrollment was stopped after 70 patients because surgical margins were positive only at the bladder neck in 10% of the preservation group but in none of the resection group (p = 0.08). Each group was assigned 35 patients but the bladder neck could not be preserved in 4 and 1 died, leaving 31 in the preservation group and 38 in the resection group. There were no statistically significant differences between groups in early or late urinary continence rates. Two days after catheter removal, and 2 and 6 months after surgery the respective rates were 79%, 87% and 95% with resection, and 67%, 87% and 97% with preservation. CONCLUSIONS: In our opinion bladder neck preservation during radical retropubic prostatectomy does not improve urinary continence and might compromise cancer control. The external sphincter appears more important for continence after radical prostatectomy.