The importance of anatomical reconstruction for continence recovery after robot assisted radical prostatectomy: a systematic review and pooled analysis from referral centres.

INTRODUCTION Urinary incontinence is one of the most scared sequelae of robot assisted radical prostatectomy (RARP). Therefore, different surgical modifications, aimed to restore the original anatomy, were proposed to overcome this issue. The purpose of this study is to assess which is the best reconstruction technique (posterior only: PR; anterior only: AR; total: TR) compared to the standard approach for continence recovery after RARP in a tertiary care centre. EVIDENCE ACQUISITION After establishing an a priori protocol, a systematic electronic literature search was conducted in May 2019. The article selection proceeded in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and was registered (PROSPERO registry number 131667). The risk of bias and the quality assessment of the included studies were performed. Simple pooled analysis was performed for continence rates according to the definition of continence (0 pad vs. 0-1 pad) and the different types of reconstruction at 1, 4, 12, 24, 52 weeks after RARP. Complication rate, operative and console time and estimated blood loss were pooled. Two-side test of proportion and T-test were used to compare rates and mean, respectively. EVIDENCE SYNTHESIS Six studies meeting the inclusion criteria were found and included in the analysis. All the included studies were of "poor" or "good" quality. A high or moderate risk of bias was recorded. TR showed higher continence recovery rates, compared to their anterior reconstruction counterpart at 1, 4, 12, 24, 52 weeks (p <0.001 at all time-points). At 12 weeks TR showed the highest continence rates (p<0.001), followed by AR and PR. No statistically significant differences were recorded regarding anastomosis-related complication rates (anastomosis stricture p=0.08; urine leakage p=0.1). CONCLUSIONS In patients undergoing RARP, TR facilitates a faster and higher continence recovery compared to standard approach or PR or AR only.