Maximal anatomic bladder neck preservation at the prostatic origin (MANO) in robotic radical prostatectomy: does prostate size matter?

Prostate size has traditionally been considered a determinant of surgical difficulty and postoperative outcomes in radical prostatectomy. Larger glands often present challenges in bladder neck dissection, with potential implications for continence and oncological safety. We describe the maximal anatomic bladder neck preservation at the prostatic origin (MANO) technique, designed to enable safe circumferential dissection at the true bladder neck origin irrespective of gland size. This retrospective study analyzed 341 patients undergoing nerve-sparing robotic-assisted radical prostatectomy (RALP) with the MANO technique between 2017 and 2023. Patients were stratified into three groups by MRI-estimated prostate volume: < 30 cc (n = 83), 30-50 cc (n = 147), and > 50 cc (n = 111). Perioperative, pathological, functional, and oncological outcomes were compared. Continence was defined as 0-1 pad/day, assessed at 3, 12, and 24 months. Larger prostates were associated with older age and higher preoperative PSA (p < 0.05). Mean operative time increased with gland size (165.2 vs. 191.5 min, p < 0.001), and hospital stay was longer for > 50 cc prostates (p = 0.003). Blood loss showed a non-significant increase with prostate size. Pathological stage, Gleason grade, and margin status were comparable across groups. Early continence at 3 months was similar (≈71% across cohorts, p = 0.607), with > 85% continent at 12 months in all groups. Biochemical recurrence rates did not differ significantly (p = 0.630). Complications were infrequent, with no ureteric injuries reported. The MANO technique enables safe bladder neck preservation across all prostate sizes. Despite increased operative complexity in larger glands, functional and oncological outcomes remain equivalent. This approach may standardize bladder neck management in RALP and support improved continence recovery irrespective of prostate volume.