Factors Associated with Recovery of Urinary Continence: A Multicenter Comparison of Pelvic Fascia-sparing and Standard Robotic-assisted Radical Prostatectomy.

Abstract

Background and objective: Pelvic fascia-sparing (PFS) approaches during robotic-assisted radical prostatectomy (RARP) may lead to faster and better recovery of urinary continence. However, direct comparisons are limited. We compared continence recovery across standard, anterior PFS (APFS), and posterior PFS (PPFS) RARP approaches.

Methods and surgical procedure: We conducted a multicenter retrospective study of 1155 RARP (593 standard, 332 PPFS, and 230 APFS) procedures performed between February 2012 and May 2024. Our primary outcome was urinary continence defined as the use of zero to one pad per day, identified from the Expanded Prostate Cancer Index Composite for Clinical Practice. Multivariable models evaluated the factors affecting early and long-term urinary continence.

Key findings and limitations: PPFS and APFS versus the standard approach were associated with improved urinary continence at 3 mo (90%, 83%, and 64%, respectively; p < 0.001), 12 mo (96%, 89%, and 84%, respectively; p < 0.001), and 20 mo (97%, 99%, and 90%, respectively; p < 0.001). In adjusted analyses, PPFS (odds ratio [OR] 3.71; confidence interval [CI] 2.27-6.07; p < 0.001) and APFS (OR 3.54; CI 1.97-6.37; p < 0.001) were associated with improved 3-mo continence compared with standard RARP. Similar results were observed for both PFS approaches at 12 mo. Only PPFS was associated with better long-term continence (20 mo: OR 3.00; CI 1.74-5.17; p < 0.001). However, PPFS had the highest positive surgical margins (standard: 29.5%; PPFS: 37.4%; APFS: 30.0%; p = 0.04). The sequential adoption of techniques from standard RARP to PPFS and then to APFS leads to disparate follow-up and sample sizes as a limitation.

Conclusions: PPFS and APFS were associated with better urinary continence recovery, although PPFS was found to have more positive surgical margins. Randomized trials are needed to validate our findings.

Patient summary: We compared the recovery rate of urinary continence after three surgical approaches with varying degrees of pelvic fascia sparing (PFS). Our findings suggest that PFS improves short- and long-term urinary continence compared with the standard approach.