Secondary Logo

Journal Logo

Anatomic and technical considerations for optimizing recovery of urinary function during robotic-assisted radical prostatectomy

Vora, Anup A.*; Dajani, Daoud*; Lynch, John H.; Kowalczyk, Keith J.

doi: 10.1097/MOU.0b013e32835b0ae5
ROBOTICS: Edited by Jim Hu

Purpose of review The advent of robotic-assisted radical prostatectomy purported fewer complications including postprostatectomy incontinence (PPI). PPI is associated with worse quality of life. We evaluate recently reported robot-assisted radical prostatectomy surgical techniques aimed at limiting PPI, describe their anatomic basis and summarize their outcomes.

Recent findings RARP techniques to reduce PPI include bladder neck preservation, bladder neck reconstruction, urethral length preservation, periurethral suspension stitch, posterior reconstruction, combined anterior and posterior reconstruction, preservation of the endopelvic fascia, complete anterior preservation, selective suturing of dorsal venous complex and nerve sparing approach. Outcomes of reconstructive techniques seem to be conflicting, whereas outcomes of techniques aiming to preserve the native urinary continence system seem to hasten urinary function recovery. However, few of these techniques have been shown to affect long-term urinary continence.

Summary Surgical techniques preserving the natural urinary continence mechanism appear to improve short-term urinary continence, whereas techniques reconstructing pelvic anatomy have mixed results. The search for the ideal technique to minimize PPI remains hampered by the lack of prospective multi-institutional studies and the long-term follow up. Although reconstructive techniques are safe with few drawbacks, meticulous surgical technique and preservation of the natural continence mechanism should remain the mainstay of PPI prevention.

Department of Urology, Georgetown University Hospital, Washington, District of Columbia, USA

*Anup A. Vora and Daoud Dajani equally contributed to the writing of this article.

Correspondence to Keith J. Kowalczyk, MD, Department of Urology, Georgetown University Hospital, 3800 Reservoir Road NW, 1 PHC, Washington, DC 20007, USA. Tel: +1 202 444 4922; fax: +1 877 625 1478; e-mail: keith.kowalczyk@gunet,

Back to Top | Article Outline


Postprostatectomy incontinence (PPI) is a feared complication that leads to significant compromises in patient quality of life and serious psychosocial effects, regardless of oncologic and sexual function outcomes [1]. The advent of robotic surgery heralded a new dawn in radical prostatectomy with claims of lower rates of erectile dysfunction and urinary incontinence. Robotic-assisted radical prostatectomy (RARP) surgeons have strived not just for overall return of continence but also for earlier return of continence. Despite these efforts, loss of urinary control following RARP remains a problem, with incidences ranging from 2 to 87%. [1,2] Unfortunately, variations in outcomes reporting, definitions of urinary continence, methodology of data collection and patient selection have led to confusion regarding the large variation in reported PPI rates following RARP [3]. In addition, high expectations of men undergoing RARP may result in regret and PPI bother [4].

The wide range of incontinence outcomes despite the supposed finer dissection afforded by RARP has led RARP surgeons to try to better understand the cause of PPI. Although the physiologic mechanism of urinary continence following radical prostatectomy is not completely understood, both functional and anatomical changes associated with prostate removal lead to alterations in the urinary sphincter complex and pelvic floor musculature [5]. Improving urinary continence has driven the development of refined surgical techniques aimed at avoiding PPI. Within this review, we summarize the anatomical basis and outcomes of current surgical techniques aimed at improving urinary continence following RARP.

Box 1

Box 1

Back to Top | Article Outline


Anatomically, the bladder neck serves as an internal sphincter with three distinct muscular layers: the inner longitudinal layer, the middle circular layer and the outer longitudinal layer [6]. The longitudinal fibres of the bladder neck may be identified and isolated with meticulous dissection at the prostato-vesicual junction during RARP [7]. The outer longitudinal layer contributes anterior fibres to the pubovesical muscle and may contribute to the opening of the bladder neck during micturition. Posteriorly, the outer longitudinal fibres interdigitate with deep trigonal fibres and may aid in bladder neck closure. Therefore, although the bladder neck may not contribute to voluntary continence, it is intuitive that bladder neck preservation (BNP) may contribute to earlier return of urinary continence. However, published series analyzing outcomes of BNP at the time of open radical retropubic prostatectomy (RRP) and laparoscopic radical prostatectomy (LRP) have shown conflicting results, with some showing little benefit on continence and potential compromise of oncologic outcomes [8–12].

However, more recent studies show that BNP during RARP hastens continence without compromise on cancer control. Curto et al. [13] reported a series of 425 men undergoing LRP with BNP, with complete urinary continence achieved in 95% at 6 months. However, this study is limited by not evaluating the direct effect of BNP on urinary continence. However, Freire et al. [7] retrospectively compared 348 men undergoing BNP with 271 undergoing standard technique during RARP and noted significantly improved urinary function with BNP at 4 and 24 months (Table 1) [7,14–16]. Urinary continence was also significantly improved at 4 months (65.6 vs. 26.5%, P < 0.001). Importantly, there was no compromise in surgical margins when performing BNP, as suggested by RRP and LRP series [7]. Moreover, recent updates of this series demonstrate earlier recovery of continence throughout the 2-year follow-up interval, and no differences in PSA recurrence-free survival up to 5 years following RARP [17▪]. Even more recently, You et al. [14] confirmed improved early urinary continence with BNP compared with the standard technique, while Friedlander et al.[18] noted improved time to continence and fewer urine leaks with BNP without compromising cancer control.

Table 1

Table 1

Back to Top | Article Outline


BNP may not be possible in all patients [19]. In these circumstances, some have shown improved urinary continence with bladder neck reconstruction (Table 1). Lin et al. [15] published a series of 74 men undergoing RARP who did not undergo BNP for various reasons. In these men, plication of the bladder neck was performed, and 12.7% of men undergoing plication had urinary continence following catheter removal and 97.3% had urinary continence at 12 months, although results were not compared with a control group [15]. Similarly, Lee et al. [16] described a single bladder neck plication stitch to improve urinary continence. Following a change in technique to perform bladder plication, they noted shorter times to urinary continence with significantly increased odds of urinary continence at 1 month and 12 months in multivariate analysis [16].

Back to Top | Article Outline


Urinary continence following radical prostatectomy may be directly correlated to postoperative urethral length [20]. Hammerer and Huland [21] used urodynamic evaluation to confirm significantly longer urethral length in continent than in incontinent men following RRP. More recently, von Bodman et al. [22▪▪] performed an anatomic study measuring preoperative urethral length, urethral volume and proximity of levator muscle and membranous urethra following MRI in 967 men undergoing RRP. They found that urethral length, urethral volume and an anatomically close relationship between the levator muscle and membranous urethral were all significantly associated with recovery of urinary continence at 6 and 12 months [22▪▪].

Hakimi et al. [23] studied preoperative and intraoperative urethral length and its effect on postoperative urinary continence and quality of life in 75 men undergoing RARP. Unlike von Bodman et al.[22▪▪], they found no relationship between preoperative MRI urethral length and postoperative continence. However, on multivariate analysis, stretched and cut urethral length correlated with decreased time to urinary continence (P = 0.03 and P = 0.04, respectively). This implies that RARP techniques aimed at preserving urethral length as well as avoiding disturbance of the levator muscles can hasten urinary continence.

Using intraoperative transrectal ultrasound in 53 men undergoing LRP, Mizutani et al. [24] found that longer membranous urethral length had significantly higher continence rates at 1, 3 and 6 months following LRP, with no difference in positive surgical margin rates. Although there have not been any reports of utilizing intraoperative ultrasound during RARP to preserve urethral length, Hung et al.[25▪] recently described the feasibility of a robotically manipulated transrectal ultrasound system during RARP, which may aid surgeons in properly identifying the membranous urethra and maximizing urethral length.

Back to Top | Article Outline


During his initial description of anatomic RRP, Walsh [26] described reversal of the dorsal venous complex (DVC) suture through the symphysis pubis perichondrium to control venous bleeding and provide rhabdosphincter support. This periurethral suspension stitch (PSS) was subsequently found to hasten continence recovery [27,28]. The PSS has been applied to RARP by Patel et al. [29] (Fig. 1), who describe this technique in a prospective, nonrandomized trial of 237 RARP with PSS vs. 94 without PSS (Table 1). Urinary continence in men undergoing PSS was significantly improved 3 months postoperatively, whereas urinary continence at 1, 6 and 12 months remained similar. Therefore, it appears that although PSS may hasten urinary continence recovery, it does not affect long-term urinary continence. More studies are needed to evaluate the effect of PSS alone on the recovery of urinary continence following RARP.



Back to Top | Article Outline


Rocco et al. [30] popularized posterior rhabdosphincter reconstruction (PR) during RRP. This technique reconstructs the posterior musculofascial plate by suturing the median raphe of the urethra to the remnants of Denonvillier's fascia posterior to the bladder. Theoretically, this restores anatomical length of the rhabdosphincter and posterior support by fixing the structure into its natural position. Rocco et al. [31] eventually applied this technique to LRP, and it was quickly adapted by multiple RARP surgeons with varying results (Table 2) [32–41,42▪]. Coelho et al. [32] and Brien et al. [33] found improvement in urinary continence at 1 and 3 months, respectively, without differences in long-term urinary continence. However, results of most remaining studies do not show a significant improvement in urinary continence following PR. In two retrospective studies, both Krane et al. [34] and Kim et al. [35] found no improvement in urinary continence and an increased risk in postoperative urinary retention in men undergoing PR. In a prospective, nonrandomized trial, Joshi et al.[36] also found no benefit of PR. Furthermore, two randomized control trials showed no statistical improvement in men undergoing PR alone [37] and in conjunction with PSS [38].

Table 2

Table 2

A recent systematic review by Rocco et al. [43▪▪] sought to clarify the effect of PR on urinary continence following RARP. Cumulative analysis showed that PR results in earlier return of urinary continence within 1 week [relative risk (RR) 1.79, P = 0.03] and 30–45 days (RR 1.57, P = 0.004), however there were no differences in urinary continence 90 days postoperatively. Cumulative analysis also suggested lower rates of postoperative urine leak (RR 0.45, P = 0.05). Although Kim et al. [35] found significantly higher rates of postoperative urinary retention following PR, the remaining studies found no differences in postoperative complications. Therefore, although PR may have little if any effect on continence, it may improve postoperative urinary leakage as well as facilitate the vesico-urethral anastomosis by attenuating tension during RARP with a few drawbacks. However, evidence from randomized controlled trials does not support its effectiveness in improving postoperative urinary continence rates.

Back to Top | Article Outline


Many RARP surgeons perform a combination of anterior and posterior reconstruction by performing a PSS in conjunction with posterior reconstruction (Table 2). Kalisvaart et al. [44] retrospectively noted improved urinary continence at 3 months with modified combined anterior and posterior reconstruction. However, this study suffers from small sample size, lack of correction for learning curve effect, as well as lack of long-term follow-up. Tan retrospectively studied urinary continence in 1900 men undergoing various techniques, including combined anterior and posterior reconstruction, along a single surgeon's learning curve. The first 214 underwent conventional anastomosis without reconstruction, the next 303 underwent anterior reconstruction, while the final 1383 underwent combined anterior andposterior reconstruction [39]. Bladder neck contracture rates were lower in men undergoing anterior reconstruction and combined anterior and posterior reconstruction vs. conventional anastomosis, whereas urinary continence was improved at all time points in men undergoing combined anterior and posterior reconstruction. However, differences in continence rates in this single-surgeon series do not account for likely learning curve effect over the study period.

Randomized controlled trials of combined anterior and posterior reconstruction vs. a standard anastomosis have been performed with conflicting results (Table 2). The same cohort studied by Menon et al. [38] and Sammon et al. [40] found no significant differences in early or late urinary continence in men undergoing combined anterior and posterior reconstruction vs. conventional anastomosis. Koliakos et al. [41], however, found improved urinary continence at 7 weeks in men undergoing combined anterior and posterior reconstruction, although long-term outcomes were not reported. Similarly, Hurtes et al. [42▪] noted significant urinary continence improvement in men undergoing combined anterior and posterior reconstruction vs. standard anastomosis at 1 and 3 months following RARP. However, there were no differences in continence at 6 months. In a recent meta-analysis, Ficarra et al. [45▪▪] found a small but significantly lower risk of urinary continence in men undergoing combined anterior and posterior reconstruction vs. standard anastomosis [odds ratio (OR) 0.4, P = 0.040]. In summary, similar to posterior reconstruction, it appears that combined anterior and posterior reconstruction may have a small impact urinary continence recovery; however, long-term outcomes are unknown and randomized controlled trials have not shown universal benefit. In addition, it is unknown whether the anterior or posterior support contributes to improved urinary continence in these studies, although it is the opinion of the authors that it is likely to be the PSS component that leads to improved urinary continence.

Back to Top | Article Outline


Following cadaveric dissection identifying components of smooth muscle and pudendal nerve branches within the endopelvic fascia leading to the rhabdosphincter, Takenaka et al. [46] described a novel technique of endopelvic fascia preservation during RRP to improve urinary continence. van der Poel et al. [47] have subsequently applied this technique to RARP. In a prospective study of 151 men, they found that the extent of lateral fascial preservation was the strongest predictor of urinary continence at 6 and 12 months postoperatively [47]. These results have subsequently been replicated during RRP by Khoder et al. [48]. Further studies are needed to confirm the benefit of this technique in RARP. However, similar to BNP as well as urethral length preservation, it is likely that techniques that aim to maintain native continence mechanism are more important to preservation of urinary continence than reconstructive techniques.

Back to Top | Article Outline


Asimakopoulos et al.[49] describe the feasibility of complete periprostatic anatomy preservation during RARP. They hypothesize that due to continuity of the puboprostatic ligaments to the detrusor apron, it is not feasible to preserve the puboprostatic support structure unless the entire pubovesical complex (DVC, puboprostatic ligaments and detrusor apron) remains intact. The technique was performed on 30 men, all less than 60 years old and with good preoperative continence and potency. Urinary continence was 80% at catheter removal and 100% at 3 months. Future comparative studies are needed, especially given the demanding nature of this technique, particularly with a larger prostate size.

Back to Top | Article Outline


Selective suture ligation (SSL) of the DVC was first described by Walsh [26]. By selectively ligating the open venous channels of the DVC rather than taking the structure whole, surgeons can avoid damage to the surrounding levator muscle. Application of this technique during RRP is limited, given concerns of increased blood loss. However, pneumoperitoneum provided by laparoscopy makes this technique feasible. Porpiglia et al. [50] first described SSL during LRP in a prospective randomized study of 30 patients undergoing SSL vs. 30 patients undergoing complete ligation. SSL was associated with improved urinary continence at 3 months, although there were no differences at 1, 6 and 12 months. Lei et al. [17▪] first described SSL during RARP (Fig. 2). They retrospectively compared outcomes between 303 men undergoing standard DVC ligation and 240 men undergoing SSL. On a multivariate analysis, they found that SSL improved both overall urinary function scores and urinary continence at 5 months, although there were no differences at 12 months. Although men undergoing SSL experienced greater estimated blood loss (EBL), EBL remained low and there was no difference in transfusion rates. Thus, it appears that avoiding surrounding levator damage during DVC control by performing SSL may lead to earlier return to continence, although long-term continence remains unchanged. Again, further prospective studies are needed to confirm these results.



Back to Top | Article Outline


Although the rhabdosphincter receives direct innervation from the pudendal nerve [51], authors have noted an association between nerve-sparing approach and urinary continence. In a series of 602 RARP, Choi et al. [52▪] noted improved urinary continence and urinary function scores at 4 months in men undergoing bilateral nerve-sparing vs. non-nerve-sparing RARP. Urinary function scores remained higher in men undergoing bilateral nerve-sparing at 12 and 24 months, although urinary continence was similar [52▪]. Similarly, in a randomized trial of 200 men undergoing interfascial nerve-sparing vs. 200 men undergoing intrafascial nerve-sparing, Stolzenburg et al. [53] noted that intrafascial nerve-sparing was associated with improved urinary continence at 3 and 6 months, although with no difference at 12 months. Most recently, Suardi et al. [54] noted that bilateral nerve-sparing was an independent predictor associated with continence recovery in 1249 men undergoing RRP and with those undergoing bilateral nerve-sparing having a 1.8-fold higher chance of full continence recovery at 2 years of follow-up. Unlike previous studies reviewed, this is the only technique to show durable improved urinary continence at long-term follow-up.

However, some authors have not noted such an association between urinary continence and nerve-sparing approach. Marien and Lepor [55] concluded that bilateral nerve-sparing was not associated with continence in 1100 men undergoing RRP. They noted although 60% of men regained potency, 97% regained continence at 24 months. However, all men in the study underwent either bilateral or unilateral nerve-sparing, and results were not compared with men undergoing non-nerve-sparing. In addition, the direct effect of nerve-sparing approach on urinary outcomes was not addressed. Similarly, Pick et al. [56] retrospectively reviewed outcomes in 592 men undergoing RARP and found that there was no significant difference in continence rates between nerve-sparing approaches at 1, 3 and 12 months. However, the retrospective nature and relatively smaller sample size than studies showing nerve-sparing benefit limit these conclusions.

These authors have previously noted improved potency in men undergoing nerve-sparing with limited traction and delicate dissection of the neurovascular bundle [57,58]. In this same cohort of patients, we also noted improved urinary continence, with men undergoing nerve-sparing without traction having better urinary function at 5 months. In a multivariate analysis, bilateral nerve-sparing vs. nonlateral/unilateral nerve-sparing was associated with improved overall urinary function scores as well as continence 12 months postoperatively (both P ≤ 0.035) [59]. Therefore, we believe it is likely a combination of neural preservation as well as delicate tissue handling during nerve-sparing that preserves urinary continence.

Back to Top | Article Outline


Urinary incontinence remains a feared complication following radical prostatectomy regardless of approach. Numerous surgical techniques based on the anatomy and physiology of the urinary tract have been proposed in order to improve these outcomes, although further multi-institutional studies with more patients and longer follow-up are needed to confirm the benefit of these techniques. Techniques aimed at preservation and nondistortion of the natural anatomy, such as BNP, urethral length preservation, endopelvic fascia preservation, and selective ligation of the DVC, seem to improve short-term urinary continence rates in most studies without conflicting evidence. Other techniques aimed at reconstruction of the pelvic anatomy, such as PR and combined anterior and posterior reconstruction, have had conflicting results and have largely not been supported by randomized controlled trials. We believe that a meticulous surgical technique and avoiding disruption of the natural continence mechanism remains the most important variable in the preservation of postoperative urinary function. Although reconstructive techniques may hasten urinary recovery in some patients, and are relatively easy to perform and are associated with few complications, there is no substitute for a meticulous surgical technique that obviates the need for such reconstructive procedures.

Back to Top | Article Outline



Back to Top | Article Outline

Conflicts of interest

There are no conflicts of interest.

Back to Top | Article Outline


Papers of particular interest, published within the annual period of review, have been highlighted as:

  • ▪ of special interest
  • ▪▪ of outstanding interest

Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 101–102).

Back to Top | Article Outline


1. Stanford JL, Feng Z, Hamilton AS, et al. Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA 2000; 283:354–360.
2. Foote J, Yun S, Leach GE. Postprostatectomy incontinence. Pathophysiology, evaluation, and management. Urol Clin North Am 1991; 18:229–241.
3. Litwin MS, Lubeck DP, Henning JM, Carroll PR. Differences in urologist and patient assessments of health related quality of life in men with prostate cancer: results of the CaPSURE database. J Urol 1998; 159:1988–1992.
4. Schroeck FR, Krupski TL, Sun L, et al. Satisfaction and regret after open retropubic or robot-assisted laparoscopic radical prostatectomy. Eur Urol 2008; 54:785–793.
5. Song C, Doo CK, Hong JH, et al. Relationship between the integrity of the pelvic floor muscles and early recovery of continence after radical prostatectomy. J Urol 2007; 178:208–211.
6. Kingsnorth AN, Skandalakis PN, Colborn GL, et al. Embryology, anatomy, and surgical applications of the preperitoneal space. Surg Clin North Am 2000; 80:1–24.
7. Freire MP, Weinberg AC, Lei Y, et al. Anatomic bladder neck preservation during robotic-assisted laparoscopic radical prostatectomy: description of technique and outcomes. Eur Urol 2009; 56:972–980.
8. Deliveliotis C, Protogerou V, Alargof E, Varkarakis J. Radical prostatectomy: bladder neck preservation and puboprostatic ligament sparing -- effects on continence and positive margins. Urology 2002; 60:855–858.
9. Srougi M, Nesrallah LJ, Kauffmann JR, et al. Urinary continence and pathological outcome after bladder neck preservation during radical retropubic prostatectomy: a randomized prospective trial. J Urol 2001; 165:815–818.
10. Marcovich R, Wojno KJ, Wei JT, et al. Bladder neck-sparing modification of radical prostatectomy adversely affects surgical margins in pathologic T3a prostate cancer. Urology 2000; 55:904–908.
11. Lowe BA. Comparison of bladder neck preservation to bladder neck resection in maintaining postrostatectomy urinary continence. Urology 1996; 48:889–893.
12. Aydin H, Tsuzuki T, Hernandez D, et al. Positive proximal (bladder neck) margin at radical prostatectomy confers greater risk of biochemical progression. Urology 2004; 64:551–555.
13. Curto F, Benijts J, Pansadoro A, et al. Nerve sparing laparoscopic radical prostatectomy: our technique. Eur Urol 2006; 49:344–352.
14. You YC, Kim TH, Sung GT. Effect of bladder neck preservation and posterior urethral reconstruction during robot-assisted laparoscopic radical prostatectomy for urinary continence. Korean J Urol 2012; 53:29–33.
15. Lin VC, Coughlin G, Savamedi S, et al. Modified transverse plication for bladder neck reconstruction during robotic-assisted laparoscopic prostatectomy. BJU Int 2009; 104:878–881.
16. Lee DI, Wedmid A, Mendoza P, et al. Bladder neck plication stitch: a novel technique during robot-assisted radical prostatectomy to improve recovery of urinary continence. J Endourol 2011; 25:1873–1877.
17▪. Lei Y, Alemozaffar M, Williams SB, et al. Athermal division and selective suture ligation of the dorsal vein complex during robot-assisted laparoscopic radical prostatectomy: description of technique and outcomes. Eur Urol 2011; 59:235–243.

The first series to describe in detail utilization of SSL of the DVC during RARP, and is accompanied by a video describing the technique in detail.

18. Friedlander DF, Alemozaffar M, Hevelone ND, et al. Stepwise description and outcomes of bladder neck sparing during robot-assisted laparoscopic radical prostatectomy. J Urology 2012; 188:1754–1760.
19. Huang AC, Kowalczyk KJ, Hevelone ND, et al. The impact of prostate size, median lobe, and prior benign prostatic hyperplasia intervention on robot-assisted laparoscopic prostatectomy: technique and outcomes. Eur Urol 2011; 59:595–603.
20. Presti JC Jr, Schmidt RA, Narayan PA, et al. Pathophysiology of urinary incontinence after radical prostatectomy. J Urol 1990; 143:975–978.
21. Hammerer P, Huland H. Urodynamic evaluation of changes in urinary control after radical retropubic prostatectomy. J Urol 1997; 157:233–236.
22▪▪. von Bodman C, Matsushita K, Savage C, et al. Recovery of urinary function after radical prostatectomy: predictors of urinary function on preoperative prostate magnetic resonance imaging. J Urol 2012; 187:945–950.

A very interesting study describing the anatomic changes in urethral length and volume following prostatectomy and association with postoperative urinary function.

23. Hakimi AA, Faleck DM, Agalliu I, et al. Preoperative and intraoperative measurements of urethral length as predictors of continence after robot-assisted radical prostatectomy. J Endourol 2011; 25:1025–1030.
24. Mizutani Y, Uehara H, Fujisue Y, et al. Urinary continence following laparoscopic radical prostatectomy: association with postoperative membranous urethral length measured using real-time intraoperative transrectal ultrasonography. Oncol Lett 2012; 3:181–184.
25▪. Hung AJ, Abreu AL, Shoji S, et al. Robotic transrectal ultrasonography during robot-assisted radical prostatectomy. Eur Urol 2012; 62:341–348.

A feasibility study of a new robotic-controlled intraoperative transrectal ultrasound probe. Although these authors use the system to delineate the plane of dissection between prostate and rectum and also for neurovascular bundle preservation, such a system could also aid in maximizing urethral length.

26. Walsh PC. Anatomic radical prostatectomy: evolution of the surgical technique. J Urol 1998; 160:2418–2424.
27. Noguchi M, Kakuma T, Suekane S, et al. A randomized clinical trial of suspension technique for improving early recovery of urinary continence after radical retropubic prostatectomy. BJU Int 2008; 102:958–963.
28. Sugimura Y, Hioki T, Yamada Y, et al. An anterior urethral stitch improves urinary incontinence following radical prostatectomy. Int J Urol 2001; 8:153–157.
29. Patel VR, Coelho RF, Palmer KJ, Rocco B. Periurethral suspension stitch during robot-assisted laparoscopic radical prostatectomy: description of the technique and continence outcomes. Eur Urol 2009; 56:472–478.
30. Rocco F, Carmignani L, Acquati P, et al. Restoration of posterior aspect of rhabdosphincter shortens continence time after radical retropubic prostatectomy. J Urol 2006; 175:2201–2206.
31. Rocco B, Gregori A, Stener S, et al. Posterior reconstruction of the rhabdosphincter allows a rapid recovery of continence after transperitoneal videolaparoscopic radical prostatectomy. Eur Urol 2007; 51:996–1003.
32. Coelho RF, Chauhan S, Orvieto MA, et al. Influence of modified posterior reconstruction of the rhabdosphincter on early recovery of continence and anastomotic leakage rates after robot-assisted radical prostatectomy. Eur Urol 2011; 59:72–80.
33. Brien JC, Barone B, Fabrizio M, Given R. Posterior reconstruction before vesicourethral anastomosis in patients undergoing robot-assisted laparoscopic prostatectomy leads to earlier return to baseline continence. J Endourol 2011; 25:441–445.
34. Krane LS, Wambi C, Bhandari A, Stricker HJ. Posterior support for urethrovesical anastomosis in robotic radical prostatectomy: single surgeon analysis. Can J Urol 2009; 16:4836–4840.
35. Kim IY, Hwang EA, Mmeje C, et al. Impact of posterior urethral plate repair on continence following robot-assisted laparoscopic radical prostatectomy. Yonsei Med J 2010; 51:427–431.
36. Joshi N, de Blok W, van Muilekom E, van der Poel H. Impact of posterior musculofascial reconstruction on early continence after robot-assisted laparoscopic radical prostatectomy: results of a prospective parallel group trial. Eur Urol 2010; 58:84–89.
37. Sutherland DE, Linder B, Guzman AM, et al. Posterior rhabdosphincter reconstruction during robotic assisted radical prostatectomy: results from a phase II randomized clinical trial. J Urol 2011; 185:1262–1267.
38. Menon M, Muhletaler F, Campos M, Peabody JO. Assessment of early continence after reconstruction of the periprostatic tissues in patients undergoing computer assisted (robotic) prostatectomy: results of a 2 group parallel randomized controlled trial. J Urol 2008; 180:1018–1023.
39. Tan G, Srivastava A, Grover S, et al. Optimizing vesicourethral anastomosis healing after robot-assisted laparoscopic radical prostatectomy: lessons learned from three techniques in 1900 patients. J Endourol 2010; 24:1975–1983.
40. Sammon JD, Muhletaler F, Peabody JO, et al. Long-term functional urinary outcomes comparing single- vs double-layer urethrovesical anastomosis: two-year follow-up of a two-group parallel randomized controlled trial. Urology 2010; 76:1102–1107.
41. Koliakos N, Mottrie A, Buffi N, et al. Posterior and anterior fixation of the urethra during robotic prostatectomy improves early continence rates. Scand J Urol Nephrol 2010; 44:5–10.
42▪. Hurtes X, Roupret M, Vaessen C, et al. Anterior suspension combined with posterior reconstruction during robot-assisted laparoscopic prostatectomy improves early return of urinary continence: a prospective randomized multicentre trial. BJU Int 2012; 110: 875–883.

One of the two randomized controlled trials of anterior and posterior reconstruction showing early improved continence, whereas previous trials have not shown a difference.

43▪▪. Rocco B, Cozzi G, Spinelli MG, et al. Posterior musculofascial reconstruction after radical prostatectomy: a systematic review of the literature. Eur Urol 2012; 62:779–790.

An excellent meta-analysis by Rocco et al. [43▪▪], who initially described posterior reconstruction in RRP patients. In a cumulative analysis, they note a small but signficant improvement in short-term continence rates. They conclude, quite correctly, that better designed studies are needed to prove the merit of this technique.

44. Kalisvaart JF, Osann KE, Finley DS, Ornstein DK. Posterior reconstruction and anterior suspension with single anastomotic suture in robot-assisted laparoscopic radical prostatectomy: a simple method to improve early return of continence. J Robot Surg 2009; 3:149–153.
45▪▪. Ficarra V, Novara G, Rosen RC, et al. Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol 2012; 62:405–417.

Another excellent meta-analysis summarizing overall urinary function outcomes reported following RARP.

46. Takenaka A, Hara R, Soga H, et al. A novel technique for approaching the endopelvic fascia in retropubic radical prostatectomy, based on an anatomical study of fixed and fresh cadavers. BJU Int 2005; 95:766–771.
47. van der Poel HG, de Blok W, Joshi N, van Muilekom E. Preservation of lateral prostatic fascia is associated with urine continence after robotic-assisted prostatectomy. Eur Urol 2009; 55:892–901.
48. Khoder WY, Schlenker B, Waidelich R, et al. Open complete intrafascial nerve-sparing retropubic radical prostatectomy: technique and initial experience. Urology 2012; 79:717–721.
49. Asimakopoulos AD, Annino F, D’Orazio A, et al. Complete periprostatic anatomy preservation during robot-assisted laparoscopic radical prostatectomy (RALP): the new pubovesical complex-sparing technique. Eur Urol 2010; 58:407–417.
50. Porpiglia F, Fiori C, Grande S, et al. Selective versus standard ligature of the deep venous complex during laparoscopic radical prostatectomy: effects on continence, blood loss, and margin status. Eur Urol 2009; 55:1377–1385.
51. Strasser H, Bartsch G. Anatomy and innervation of the rhabdosphincter of the male urethra. Semin Urol Oncol 2000; 18:2–8.
52▪. Choi WW, Freire MP, Soukup JR, et al. Nerve-sparing technique and urinary control after robot-assisted laparoscopic prostatectomy. World J Urol 2011; 29:21–27.

A large retrospective review of prospectively collected data showing clear benefit of bilateral nerve-sparing up to 2 years following surgery.

53. Stolzenburg JU, Kallidonis P, Do M, et al. A comparison of outcomes for interfascial and intrafascial nerve-sparing radical prostatectomy. Urology 2010; 76:743–748.
54. Suardi N, Moschini M, Gallina A, et al. Nerve-sparing approach during radical prostatectomy is strongly associated with the rate of postoperative urinary continence recovery. BJU Int 2012 [Epub ahead of print].
55. Marien TP, Lepor H. Does a nerve-sparing technique or potency affect continence after open radical retropubic prostatectomy? BJU Int 2008; 102:1581–1584.
56. Pick DL, Osann K, Skarecky D, et al. The impact of cavernosal nerve preservation on continence after robotic radical prostatectomy. BJU Int 2011; 108:1492–1496.
57. Kowalczyk KJ, Huang AC, Hevelone ND, et al. Stepwise approach for nerve sparing without countertraction during robot-assisted radical prostatectomy: technique and outcomes. Eur Urol 2011; 60:536–547.
58. Alemozaffar M, Duclos A, Hevelone ND, et al. Technical refinement and learning curve for attenuating neurapraxia during robotic-assisted radical prostatectomy to improve sexual function. Eur Urol 2012; 61:1222–1228.
59. Kowalczyk KJ, Huang AC, Hevelone ND, et al. Effect of Minimizing Tension During Robotic Assisted Laparoscopic Radical Prostatectomy on Urinary Function Recovery. World Journal of Urology 2012 (in press).

continence; outcomes; robotic-assisted radical prostatectomy; techniques

© 2013 Lippincott Williams & Wilkins, Inc.