Surgical Endoscopy

, Volume 33, Issue 7, pp 2187–2196 | Cite as

Retzius-sparing versus standard robot-assisted radical prostatectomy: a prospective randomized comparison on immediate continence rates

  • Anastasios D. AsimakopoulosEmail author
  • Luca Topazio
  • Michele De Angelis
  • Enrico Finazzi Agrò
  • Antonio Luigi Pastore
  • Andrea Fuschi
  • Filippo Annino



Post-prostatectomy urinary incontinence is an adverse event leading to significant distress. Our aim was to evaluate immediate urinary continence (UC) recovery in a single-surgeon prospective randomized comparative study between the traditional robot-assisted laparoscopic radical prostatectomy (TR-RALP) and the Retzius-sparing RALP (RS-RALP), for the treatment of the clinically localized prostate cancer (PCa).


102 consecutive PCa patients were prospectively randomized to TR-RALP (57) or RS-RALP (45). Postoperative continence was defined as patient-reported absence of leakage or use of 0 pads/day. The immediate continence rate and 95% confidence interval (CI 95%) were calculated for each treatment. Univariable and multivariate logistic regressions were used to assess predictors of immediate continence following RALP. Continence rates from 1 to 6 months were calculated by Kaplan–Meier curves; log-rank test was used for the curve comparison. Two analyses were performed, considering a per-protocol (PP) population regarding all randomized patients that received nerve-sparing RALP and an Intention-To-Treat (ITT) population regarding all randomized patients that received RALP.


In the PP analysis, the rates of immediate continence were 12/40 (30%) (CI 95% 17–47%) for the TR-RALP and 20/39 (51.3%) (CI 95% 35–68%) for the RS-RALP (p = 0.05). In the ITT analysis, the corresponding rates were 12/57 (21%) (CI 95% 11–34%) for the TR-RALP and 23/45 (51%) (CI 95% 36–66%) for the RS-RALP (p = 0.001). Median time to continence was 21 days for the TR-RALP and 1 day for RS-RALP, respectively (p = 0.02). The relative Kaplan–Meier curves regarding continence resulted statistically different when compared with the log rank test (p = 0.02). In the multivariate analysis, lower age and the Retzius-sparing approach were significantly associated to earlier continence recovery.


The Retzius-sparing approach significantly reduces time to continence following RALP. Further studies are required to confirm the reproducibility of our results and investigate the role of the RS-RALP as an additional “protective” factor for postoperative continence in the elderly population.


Prostate cancer Randomized controlled trial Retzius Robot-assisted radical prostatectomy Urinary continence 


Compliance with ethical standards


Dr Asimakopoulos Anastasios, Dr Topazio Luca, Dr De Angelis Michele, Dr Finazzi Agrò Enrico, Dr Antonio Lugi Pastore, Dr Andrea Fuschi and Dr Annino Filippo have no conflicts of interest or financial ties to disclose.

Supplementary material

464_2018_6499_MOESM1_ESM.doc (418 kb)
Supplementary material 1 (DOC 418 KB)


  1. 1.
    Cambio AJ, Evans CP (2006) Minimising postoperative incontinence following radical prostatectomy: considerations and evidence. Eur Urol 50(5):903–913 (discussion 913)Google Scholar
  2. 2.
    Freire MP, Weinberg AC, Lei Y, Soukup JR, Lipsitz SR, Prasad SM, Korkes F, Lin T, Hu JC (2009) Anatomic bladder neck preservation during robotic-assisted laparoscopic radical prostatectomy: description of technique and outcomes. Eur Urol 56(6):972–980Google Scholar
  3. 3.
    Tan HJ, Xiong S, Laviana AA, Chuang RJ, Treat E, Walsh PC, Hu JC.. Tan HJ, Xiong S, Laviana AA, Chuang RJ, Treat E, Walsh PC, Hu JC (2016) Technique and outcomes of bladder neck intussusception during robot-assisted laparoscopic prostatectomy: a parallel comparative trial. Urol Oncol 34(12):529.e1–529.e7Google Scholar
  4. 4.
    John H, Hauri D (2000) Seminal vesicle-sparing radical prostatectomy: a novel concept to restore early urinary continence. Urology 55(6):820–824Google Scholar
  5. 5.
    Rocco B, Gregori A, Stener S, Santoro L, Bozzola A, Galli S, Knez R, Scieri F, Scaburri A, Gaboardi F (2007) Posterior reconstruction of the rhabdosphincter allows a rapid recovery of continence after transperitoneal videolaparoscopic radical prostatectomy. Eur Urol 51(4):996–1003Google Scholar
  6. 6.
    Tewari AK, Bigelow K, Rao S, Takenaka A, El-Tabi N, Te A, Vaughan ED (2007) Anatomic restoration technique of continence mechanism and preservation of puboprostatic collar: a novel modification to achieve early urinary continence in men undergoing robotic prostatectomy. Urology 69(4):726–731Google Scholar
  7. 7.
    Patel VR, Coelho RF, Palmer KJ, Rocco B (2009) Periurethral suspension stitch during robot-assisted laparoscopic radical prostatectomy: description of the technique and continence outcomes. Eur Urol 56(3):472–478Google Scholar
  8. 8.
    van der Poel HG, de Blok W, Joshi N, van Muilekom E (2009) Preservation of lateral prostatic fascia is associated with urine continence after robotic-assisted prostatectomy. Eur Urol 55(4):892–900Google Scholar
  9. 9.
    Asimakopoulos AD, Annino F, D’Orazio A, Pereira CF, Mugnier C, Hoepffner JL, Piechaud T, Gaston R (2010) Complete periprostatic anatomy preservation during robot-assisted laparoscopic radical prostatectomy (RALP): the new pubovesical complex-sparing technique. Eur Urol 58(3):407–417Google Scholar
  10. 10.
    Porpiglia F, Fiori C, Grande S, Morra I, Scarpa RM (2009) Selective versus standard ligature of the deep venous complex during laparoscopic radical prostatectomy: effects on continence, blood loss, and margin status. Eur Urol 55(6):1377–1383Google Scholar
  11. 11.
    Coelho RF, Chauhan S, Palmer KJ, Rocco B, Patel MB, Patel VR (2009) Robotic-assisted radical prostatectomy: a review of current outcomes. BJU Int 104(10):1428–1435Google Scholar
  12. 12.
    Krupski TL, Saigal CS, Litwin MS (2003) Variation in continence and potency by definition. J Urol 170(4 Pt 1):1291–1294Google Scholar
  13. 13.
    Galfano A, Di Trapani D, Sozzi F, Strada E, Petralia G, Bramerio M, Ascione A, Gambacorta M, Bocciardi AM (2013) Beyond the learning curve of the Retzius-sparing approach for robot-assisted laparoscopic radical prostatectomy: oncologic and functional results of the first 200 patients with ≥ 1 year of follow-up. Eur Urol 64(6):974–980Google Scholar
  14. 14.
    Donovan JL, Peters TJ, Abrams P, Brookes ST, de la Rosette JJ, Schäfer W (2000) Scoring the short form ICSmaleSF questionnaire. J Urol 164:1948–1955Google Scholar
  15. 15.
    Asimakopoulos AD, Miano R, Galfano A, Bocciardi AM, Vespasiani G, Spera E, Gaston R (2015) Retzius-sparing robot-assisted laparoscopic radical prostatectomy: critical appraisal of the anatomic landmarks for a complete intrafascial approach. Clin Anat 28(7):896–902Google Scholar
  16. 16.
    Schulz KF, Altman DG, Moher D, for the CONSORT Group. (2010) CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. Ann Int Med 152:726–732Google Scholar
  17. 17.
    Ficarra V, Novara G, Artibani W, Cestari A, Galfano A, Graefen M, Guazzoni G, Guillonneau B, Menon M, Montorsi F, Patel V, Rassweiler J, Van Poppel H (2009) Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies. Eur Urol 55(5):1037–1063Google Scholar
  18. 18.
    Heesakkers J, Farag F, Bauer RM, Sandhu J, De Ridder D, Stenzl A (2017) Pathophysiology and contributing factors in postprostatectomy incontinence: a review. Eur Urol 71(6):936–944Google Scholar
  19. 19.
    Sanda MG, Dunn RL, Michalski J, Sandler HM, Northouse L, Hembroff L, Lin X, Greenfield TK, Litwin MS, Saigal CS, Mahadevan A, Klein E, Kibel A, Pisters LL, Kuban D, Kaplan I, Wood D, Ciezki J, Shah N, Wei JT (2008) Quality of life and satisfaction with outcome among prostate-cancer survivors. N Engl J Med 358(12):1250–1261Google Scholar
  20. 20.
    Prabhu V, Sivarajan G, Taksler GB, Laze J, Lepor H (2014) Long-term continence outcomes in men undergoing radical prostatectomy for clinically localized prostate cancer. Eur Urol 65(1):52–57Google Scholar
  21. 21.
    Donovan JL, Hamdy FC, Lane JA, Mason M, Metcalfe C, Walsh E, Blazeby JM, Peters TJ, Holding P, Bonnington S, Lennon T, Bradshaw L, Cooper D, Herbert P, Howson J, Jones A, Lyons N, Salter E, Thompson P, Tidball S, Blaikie J, Gray C, Bollina P, Catto J, Doble A, Doherty A, Gillatt D, Kockelbergh R, Kynaston H, Paul A, Powell P, Prescott S, Rosario DJ, Rowe E, Davis M, Turner EL, Martin RM, Neal DE, ProtecT Study Group* (2016) Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med 375(15):1425–1437Google Scholar
  22. 22.
    Barry MJ, Gallagher PM, Skinner JS, Fowler FJ Jr (2012) Adverse effects of robotic-assisted laparoscopic versus open retropubic radical prostatectomy among a nationwide random sample of medicare-age men. J Clin Oncol 30(5):513–518Google Scholar
  23. 23.
    Yanagida T, Koguchi T, Hata J, Yabe M, Sato Y, Akaihata H, Kawashima Y, Kataoka M, Ogawa S, Kumagai S, Kumagai K, Haga N, Kushida N, Ishibashi K, Aikawa K, Kojima Y (2014) Current techniques to improve outcomes for early return of urinary continence following robot-assisted radical prostatectomy. Fukushima J Med Sci 60(1):1–13Google Scholar
  24. 24.
    Galfano A, Ascione A, Grimaldi S, Petralia G, Strada E, Bocciardi AM (2010) A new anatomic approach for robot-assisted laparoscopic prostatectomy: a feasibility study for completely intrafascial surgery. Eur Urol 58(3):457–461Google Scholar
  25. 25.
    Dalela D, Jeong W, Prasad MA, Sood A, Abdollah F, Diaz M, Karabon P, Sammon J, Jamil M, Baize B, Simone A, Menon M (2017) A pragmatic randomized controlled trial examining the Impact of the Retzius-sparing approach on early urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol 72(5):677–685Google Scholar
  26. 26.
    Mandel P, Graefen M, Michl U, Huland H, Tilki D (2015) The effect of age on functional outcomes after radical prostatectomy. Urol Oncol 33(5):203.e11–203.e18Google Scholar
  27. 27.
    Menon M, Dalela D, Jamil M, Diaz M, Tallman C, Abdollah F, Sood A, Lehtola L, Miller D, Jeong W (2018) Functional recovery, oncologic outcomes and postoperative complications after robot-assisted radical prostatectomy: an evidence-based analysis comparing the Retzius sparing and standard approaches. J Urol 199(5):1210–1217Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Anastasios D. Asimakopoulos
    • 1
    • 2
    Email author
  • Luca Topazio
    • 1
  • Michele De Angelis
    • 1
  • Enrico Finazzi Agrò
    • 2
  • Antonio Luigi Pastore
    • 3
  • Andrea Fuschi
    • 1
    • 3
  • Filippo Annino
    • 1
  1. 1.Department of UrologyUsl Toscana Sud Est, San Donato HospitalArezzoItaly
  2. 2.Department of Experimental Medicine and Surgery, UOC of UrologyUniversity of Rome Tor VergataRomeItaly
  3. 3.Department of Medico-Surgical Sciences and Biotechnologies, Urology UnitSapienza University of RomeLatinaItaly

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