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In robot-assisted radical prostatectomy (RARP), surgical techniques aimed at preserving urinary continence-such as bladder neck preservation, nerve sparing, and dorsal venous complex (DVC) preservation-are increasingly adopted to improve postoperative quality of life. However, whether an excessive emphasis on functional preservation compromises oncological outcomes remains unclear.

We retrospectively analyzed 235 consecutive patients who underwent RARP performed by a single experienced surgeon. Patients were stratified according to (1) extent of bladder neck preservation (< 8 mm, 8-16 mm, > 16 mm), (2) nerve-sparing status (bilateral, unilateral, none), and (3) degree of DVC preservation (long, standard, short). Urinary continence at 3 months postoperatively (≤ 1 safety pad/day), positive surgical margin (PSM) rates, and biochemical recurrence (BCR) were evaluated.

Bladder neck preservation was associated with improved early continence recovery without increasing PSM or BCR rates. Bilateral nerve sparing resulted in superior continence outcomes; higher PSM rates in the non-nerve-sparing group reflected a more advanced pathological stage. DVC preservation showed the strongest association with continence recovery; however, aggressive DVC preservation was associated with a significantly higher PSM rate, predominantly at the apical and anterior regions. No significant differences in BCR were observed among groups.

Bladder neck preservation and nerve sparing can improve urinary continence without compromising oncological outcomes when appropriately applied. In contrast, aggressive DVC preservation may increase the risk of positive surgical margins and should be performed cautiously with careful patient selection.