Urinary continence recovery is an important outcome of prostatectomy, and patients eagerly await an early return. In this paper, we present a new surgical method to decrease postoperative urinary incontinence and promote a quicker continence recovery.

Here we demonstrate Clipless Anterior Structure PReserving Radical prostatectomy where we plan to preserve the structures anterior to the prostate, including the detrusor apron, arcus tendinous, puboprostatic ligament and anterior vessels. The patient in the video is a 71-year-old male with a 30cc prostate, a Gleason score of 3+3 and a PSA of 9.8. The prostate had a suspicious lesion in the right TZ. After posterior dissection and bilateral extended pelvic lymph node dissection, we moved ahead with bladder neck dissection. We used sharp cuts and monopolar cautery to develop the plane with the occasional use of bipolar to control significant bleeders. Slowly we could find the median lobe projecting into the bladder which we pulled with the help of 3-0 vicryl and transferred the fourth arm from the catheter to the vicryl sutures. This aided us in providing enough traction to define the posterior bladder neck. The posterior dissection was continued keeping the Denonvilliers fascia posteriorly and prostatic capsule anteriorly. Proceeding with the lateral dissection we were cognizant of the neurovascular bundles being close to the medial avascular plane. With some cold cuts and point coagulation we could tease off the nerves knowing that the tumour lies deep in the right transitional zone without compromising on the oncological outcome. We could get into the anterior intrafascial plane with sharp cutting and blunt dissection and avoiding cautery. The anterior hood structure with the DVC was carefully preserved making sure we did not open the venous plexus thus avoiding ligature. The procedure was clipless with minimal cautery providing an improved rate of continence and potency. We were close to the apex providing maximum urethral length and also acknowledging that the nerves converge here. Once the specimen is out, with 3-0 V loc we did posterior reconstruction with modified Roccos techniques using the perivesical tissue with the periurethral tissue in the first layer and urethra and posterior bladder wall as the 2nd layer. We completed the procedure after placing a 24 FR closed suction drain.

The console time was around 2 hours 30 minutes with approximately 200ml blood loss. On post-op day 3 he was discharged in stable condition. The final HPE was Gleason 3+3 disease and was organ-confined with margins uninvolved by the tumour. He was diaper-free in 15 days with a single safety pad.

The Clipless Anterior Structure PReserving(CASPER) technique preserves the musculofascial structures in front of the urethral sphincter complex, allowing for a quicker return of continence post-surgery, without affecting the rates of positive surgical margins.