Purpose: To evaluate the impact of modifications to anatomical apical dissection including a puboprostatic open-collar technique, which visualizes the lateral aspect of the apex and dorsal vein complex (DVC) covering the rhabdosphincter while preserving the puboprostatic collar, on positive surgical margin (PSM) and continence recovery.

Methods: One-hundred-and-sixty-seven patients underwent gasless single-port retroperitoneoscopic radical prostatectomy using a three-dimensional head-mounted display system. Sequentially modified surgical techniques comprised puboprostatic open-collar technique, sutureless transection of the DVC, retrograde urethral dissection, and anterior reconstruction. The associations of these modifications with PSM and continence recovery were assessed.

Results: The puboprostatic open-collar technique, sutureless DVC transection, and retrograde urethral dissection were significantly associated with lower apical PSM (P=0.003, 0.003, and 0.010, respectively). The former two also showed similar associations in 84 patients with anterior apical tumor (P=0.021 and 0.030, respectively). Among 92 patients undergoing all of these three procedures, overall and apical PSM rates were 13.0% and 3.3%, respectively. Retrograde urethral dissection (odds ratio [OR] 2.73, P=0.004) together with nerve sparing (OR 2.77, P=0.003) and anterior apical tumor (OR 0.45, P=0.017) were independently associated with immediate continence recovery. A multivariable model for 3-month continence recovery included anterior apical tumor (OR 0.28, P=0.003) and puboprostatic open-collar technique (OR 3.42, P=0.062). Immediate and 3-month continence recovery rates were 56.3% and 85.4%, respectively, in 103 patients undergoing both the puboprostatic open-collar technique and retrograde urethral dissection.

Conclusion: Novel anatomical apical dissection utilizing a puboprostatic open-collar technique may favorably impact on both apical surgical margin and continence recovery.