EURURO Vol. 72 No. 5

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among posterior RARP patients, it is presumable that the
posterior approach allows more natural and/or complete
preservation of bladder neck and spares the space of
Retzius, as suggested earlier by Galfano et al’s and
Lim et al’s groups.
Second, while overall urinary function scores were
comparable in both arms, there was a beneficial impact
of the posterior approach on urinary bother scores. This
suggests that, while there seemed to be no differential
impact of the approach on urinary symptoms other than
incontinence, faster urinary continence recovery in the
posterior RARP arm may be associated with lower urinary
bother scores. Indeed, we noted a strong correlation
between urinary bother scores and 24-h pad weight at all
study time points in post hoc analyses (all p < 0.05; data not
shown), reinforcing previously reported associations be-
tween urinary continence and bother metrics Barry
et al have previously noted that 30% of Medicare
patients undergoing RP stated that urinary incontinence
was bothersome (‘‘moderate/big problem’’) 1 yr after
surgery and suggested that patients undergoing RARP
may be more likely to be bothered with incontinence
compared with open RP. On the contrary, we noted that only
15% and 13% of patients in the anterior and posterior RARP
groups, respectively, reported moderate dissatisfaction or
worse with their urinary function at 3 mo.
We noted comparable overall postoperative complica-
tion rates in the two study groups (12% in anterior vs 18% in
posterior RARP), with lymphocele (requiring percutaneous
drainage) being the most common complication overall (9/
120; 7.5%). While the overall PSM rate was greater in the
posterior arm (although not statistically significant), the
margins were predominantly focal (<2 mm), the prognostic
impact of which on oncological outcomes is yet to be proved
Nonfocal PSMs ( 2 mm) and, more importantly,
probability of BCRFS (0.91 in either arm) over median 1-
yr follow-up were comparable between the two arms.
Our study must be interpreted within the contexts of its
limitations. First, our results cannot be extrapolated to
patients with NCCN clinically high-risk prostate cancer, as
these men were excluded from the current trial. Second, this
trial was designed to determine time to continence and in
particular, early outcomes. Thus, it is too premature to
report on erectile function or long-term oncological out-
comes in this cohort. Third, we are required by law to
document treatment details in the electronic medical
record, and thus, were unable to blind patients or caregivers
involved in the trial. Finally, this was a single surgical team
study performed at an academic institution, and the results
may not be generalizable. While this was a pragmatic study,
with the only exclusions being patients with high-risk
cancer, longer follow-up is needed to ascertain if the
(nonstatistical) difference in positive margin rates will
translate into worse oncological outcomes.
That said, this study has notable methodological
strengths. We attempted to follow a pragmatic study
design, representative of patients undergoing RARP across
academic centers in the USA. Accordingly, we included all
eligible men with low–intermediate-risk prostate cancer
who opted for RARP in our study, involved different
residents and robotic surgery fellows with varying levels
of expertise, assessed important and quantifiable functional
outcomes, and routinely encouraged patients to return to
their presurgical activity level depending on their percep-
tion of functional recovery . Additionally, we sought to
focus on patient-reported outcomes (in terms of both
objective 24-h pad weights and subjective IPSS scores) and
adhered to the CONSORT-PRO statement, lending greater
validity to our findings. Lastly, the results presented here
mark the natural evolution of the technique at our center,
starting from the pilot study (unpublished data), with
ongoing subtle refinements as our experience with the
technique matures. To our knowledge, this is the first
randomized trial comparing the posterior and anterior
approaches, and it provides level 1 evidence supporting an
earlier return of continence in patients undergoing Retzius-
sparing prostatectomy.
5. Conclusions
Our study demonstrates earlier recovery of continence in
patients with clinically low–intermediate-risk prostate can-
cer, undergoing Retzius-sparing prostatectomy without a
compromise of perioperative outcomes. These results require
long-term validation and reproduction by other centers, as
well as studies on men with high-risk localized disease.
Author contributions: Deepansh Dalela had full access to all the data in
the study and takes responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Menon, Jeong, Abdollah, Sammon, Dalela.
Acquisition of data: Dalela, Prasad, Jamil.
Analysis and interpretation of data: Dalela, Karabon, Diaz.
Drafting of the manuscript: Dalela, Jeong, Menon.
Critical revision of the manuscript for important intellectual content: Dalela,
Jeong, Prasad, Sood, Abdollah, Diaz, Karabon, Sammon, Jamil, Baize,
Simone, Menon.
Statistical analysis: Dalela, Karabon, Diaz.
Obtaining funding: Menon.
Administrative, technical, or material support: Menon.
Supervision: Menon.
Other: None.
Financial disclosures: Deepansh Dalela certifies that all conflicts of
interest, including specific financial interests and relationships and
affiliations relevant to the subject matter or materials discussed in the
manuscript (eg, employment/affiliation, grants or funding, consultancies,
honoraria, stock ownership or options, expert testimony, royalties, or
patents filed, received, or pending), are the following: Firas Abdollah is a
consultant for GenomeDx Biosciences. All other authors have no disclosures.
Funding/Support and role of the sponsor: None.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at
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