The prevalence of urinary incontinence after RP can be influenced by preoperative patient characteristics, surgeon experience, surgical technique, and methods used to collect and report data.

One fundamental aspect for the surgeon is the perfect knowledge of the anatomy and the consequences of the removal of the prostate on the static system of the pelvis; therefore the aim of the reconstructive phase is to restore the pelvic anatomy and the urinary support system.

In this chapter we will focus on surgical tips during RARP to improve continence recovery.

As suggested by von Bodman et al. and Hakimi et al., both the membranous urethral length and volume on preoperative MRI, and a longer intraoperative urethra, are predictors of continence recovery [3, 4].

Another tip that has been correlated with higher continence rates at 3 months is the placement of the puboperiurethral stitch (12-in monofilament polyglytone suture on a CT-1 needle) after the ligation of the DVC [5] described this technique, which advantages are the anterior support to the striated sphincter and the stabilization of the posterior urethra that can aid in the preservation of the urethral length during the dissection of the prostatic apex.

Lei et al. in 2011 published the first description of selective suture ligation of the DVC during RARP [6]. In the first step an athermal, sharp division of prominent DVC components is performed to identify the avascular plane anterior to the urethra and the pillars of Walsh laterally. In the second step a selective suturing of DVC is performed followed by the anastomosis using a 3-0 Vicryl cut to 23 cm on a CT- 3 needle. This sequence minimizes instrument changes. The selective suture ligation of the DVC, compared to suture ligation prior to athermal DVC division, was associated with better urinary function and continence at 5 months, shorter operative times and similar positive surgical margins (PSM).

Anatomically, the bladder neck (BN) is represented by three muscular layers: the inner longitudinal layer, the middle circular layer and the outer longitudinal layer.

Careful dissection of the prostatovesical junction can maintain most of the circular muscle fibers of the BN, accelerating the return of urinary continence [7].

In our technique the BN is identified by a cessation of the fat extending from the bladder at the level of the prostato-vesical junction. The bladder is dissected off the prostate in the midline using a sweeping motion of the monopolar scissor while visualizing the bladder fibers. The full thickness of the posterior BN should be incised at the junction between the prostate and the bladder. The dissection is directed posteriorly and slightly cranially to expose the seminal vesicles.

Bladder neck preservation (BNP) is one variation of the BN dissection that has been associated with advantages like a lower risk of BN contracture [8] and earlier return to postoperative continence, but it has been postulated that it may increase the likelihood of PSM [9].

The first randomized, controlled, single blind trial comparing patients undergoing complete BNP with controls without preservation during ORP and RARP found that BNP was associated with significantly higher early and overall continence rates, and better quality of life outcomes without compromising cancer control [10]. In 2014, Lee et al. proposed a “graded” BNP during RARP, from grade 1 (wide BN dissection that necessitates BN reconstruction) to grade 4 (tight as possible BN dissection) [11]. The author underlined that a too distal dissection may compromise oncologic control by leaving residual prostatic tissue; a too proximal dissection may leave a large BN necessitating time-consuming BN reconstruction. In this study, BNP was an independent predictor of continence at 3 months, but not at 1 year; there was no difference among the four groups in PSM rates.

BNP is not possible in all patients. In these circumstances, some have shown improved urinary continence with bladder neck reconstruction (BNR). In case of large prostate and/or median lobes or previous endoscopic resection of prostate, a wide BN is frequently created.

In these cases, it is essential to protect the ureteral orifices and to reduce the BN diameter before the vesico-urethral anastomosis. The BN plication stitch (a single suture to plicate the BN in a figure of 8 fashion after the vesicourethral anastomosis) proposed by Lee et al. was associated with shorter mean time to reach total continence and higher total continence at 1 month and 12 months [12]. Patel’s team described a modified transverse plication for BNR: a bilateral plication over the lateral aspect of the bladder. The suture begins laterally and runs medially until the BN size matches that of the urethra [13].