There are 2 main approaches to perform robot-assisted radical prostatectomy (RARP), the standard “anterior” approach and the Retzius-sparing (RS) “posterior” approach. RS-RARP was first described by Galfano et al and allows the prostate gland to be removed from under the overlying detrusor apron, entirely avoiding the pubovesical ligaments.¹ This technique can also be performed in challenging surgical scenarios such as very large prostates, prostates with median lobes, post-transurethral prostatectomy (TURP) cases, kidney transplant recipients and for salvage prostatectomies.² An international survey on worldwide diffusion of RS-RARP showed that an increasing number of institutions have explored the feasibility and reproducibility of this approach with controversial results.³

Urinary incontinence has a massive impact on quality of life and treatment satisfaction after radical prostatectomy. The highest rates of urinary incontinence and associated bother are noted during the first 12 months after surgery. There is a wide variability of results reported in the literature, partly due to the lack of uniformity in defining, assessing and reporting continence outcomes after radical prostatectomy. Furthermore, capturing patient-reported outcome measures (PROMs) using validated questionnaires is far preferable to using physician reports with their inherent biases to evaluate functional outcomes after surgery.

The end points of our study were pentafecta outcomes (continence, potency, biochemical recurrence, complications and positive surgical margins), patient-reported outcome measures of functional recovery, quality of life and perioperative outcomes of RS-RARP and RARP. Patient- and physician-reported data on 483 patients were prospectively collected by the patient management software Carebit (Carebit Health Ltd, Brighton, United Kingdom), which was used to fully automate the generation, sending and recording of completed questionnaires by patients at each time interval.

All patients underwent surgery with the da Vinci® Surgical System using the 4-arm configuration by 3 experienced robotic surgeons (>500 prior minimally invasive radical prostatectomies). A 30-degree Trendelenburg position was used in all cases and pneumoperitoneum was induced by an open Hasson technique. Six trocars were placed in a fan array configuration, and low pressure surgery was possible with the use of the AirSeal® insufflation system.

In the RARP group, the transperitoneal anterior approach was performed as described by Menon et al⁴ or the Montsouris group.⁵ When indicated, a nerve-sparing procedure was performed with a posterolateral release of the neurovascular bundles. In the RS-RARP group, the posterior Retzius-sparing technique described by Galfano et al¹ was used with some modifications–not always using a peritoneal hitch stitch, but sometimes using a Pansadoro stitch to retract the bowel, and using a barbed suture for the anastomosis. When indicated, the nerve-sparing was performed using either an intrafascial or interfascial dissection, based on preoperative magnetic resonance imaging planning. The vesicoprostatic junction was isolated and sectioned, sparing the bladder neck when deemed oncologically safe. The vesicourethral anastomosis was performed with a van Velthoven technique using 3-zero barbed sutures in both groups.

The immediate urinary continence at catheter removal was better in the RS-RARP group (p=0.02), and there was no statistically significant difference in the immediate potency rate between the 2 groups (p=0.069, fig. 1). No significant differences in overall urinary symptoms (prevalence and bother) or erectile function were recorded at baseline and 1, 3, 6, 9 and 12 months after surgery between the 2 groups (fig. 2). A better quality of life was recorded in the RS-RARP group during the immediate postoperative course (p=0.004), while there was no difference at 3, 6, 9 and 12 months after surgery (fig. 3). However, after a detailed subscale analysis, we found less nocturnal urinary symptom prevalence (p=0.011) and bother (p=0.009) at 1 month after RS-RARP (fig. 4). The study also showed no differences in overall positive surgical margin (PSM) rates between the 2 groups (13.9% vs 15.6%, p=0.6), as well as no differences in T2, T3 and apical PSM rates. No significant differences in other functional or quality of life outcomes, perioperative parameters, complications or margin rates were found.

Figure 1. Immediate functional outcomes (continence and potency) between groups.

Figure 2. PROMS outcomes between groups at various time points. IEF-5, International Index of Erectile Function 5-Item Questionnaire.ICIQ-MLUTS, International Consultation on Incontinence Questionnaire-Male Lower Urinary Tract Symptoms Module.

Figure 3. EuroQol-5 Dimension (EQ-5D) index and visual analogue scale (VAS) scores between groups at various time points.

Figure 4. International Consultation on Incontinence Questionnaire-Male Lower Urinary Tract Symptoms Module (ICIQ-MLUTS) subscale analysis between groups at 1 month after surgery. b., bother. p., prevalence. Asterisk indicates difference was statistically significant.

The main strengths of our study are the large series of patients, the uniformity of the 2 groups with regard to the preoperative general, oncologic and functional features, including the proportions of high risk patients, the completeness of the data, including followup, the use of validated questionnaires providing high quality PROMs data, and no learning curve bias with the comparison of multiple high volume surgeons. These strengths make this study unique in the present literature.

RS-RARP showed better immediate continence rate and quality of life compared to standard RARP but with no differences recorded in other clinically relevant parameters at any other time point. The similarity in outcomes between groups lends support to the view that patients should choose their surgeon wisely rather than the specific technique used.