Technical aspects of robot-assisted Retzius-sparing radical prostatectomy and perioperative outcomes of an initial case series

Background. Retzius-sparing robot-assisted radical prostatectomy is a modification of robot-assisted radical prostatectomy in which the prostate is removed through a posterior approach without entering the cave of Retzius. This technique is aimed at preserving the puboprostatic ligaments, dorsal venous complex, endopelvic fascia, and other structures involved in the support of the urethrovesical segment, and is associated with early recovery of urinary continence. Due to the specific surgical anatomy of this approach, standardization of the main operative steps and assessment of its reproducibility in clinical practice are required.

Aim. To analyze experience with Retzius-sparing robot-assisted radical prostatectomy at the University Urology Clinic of the the Moscow Multidisciplinary Clinical Centre “Kommunarka”, Moscow Healthcare Department, and to demonstrate key steps of the surgical technique.

Materials and methods. Between 2025 and the present, 30 Retzius-sparing robot-assisted radical prostatectomies have been performed at the University Urology Clinic using the da Vinci Xi robotic surgical system. Intraoperative parameters, early postoperative course, pathological findings, and continence recovery dynamics were analyzed.

Results. Mean operative time was 187.71 ± 32.66 min, and median blood loss was 30 mL. Median durations of urethral catheter drainage and postoperative hospital stay were 6 days. Pathological examination revealed pT2 disease in 92.9 % of cases and pT3a disease in 7.1 %. Gleason scores of 3 + 3 and 3 + 4 were identified with equal frequency, each accounting for 50.0 % of cases. The positive surgical margin rate was 28.6 %. Complete recovery of urinary continence was observed in 86 % of patients at 1 month and in 98 % at 3 months. The article also presents a step-by-step description of the surgical technique, including trocar placement, posterior access to the prostate, mobilization of the seminal vesicles, bladder neck dissection, urethral mobilization, and urethrovesical anastomosis formation.

Conclusion. The initial experience with Retzius-sparing robot-assisted radical prostatectomy at the University Urology Clinic confirms its technical feasibility and efficacy (achieving favorable early functional outcomes). At the same time, the positive surgical margin rate indicates the need for careful patient selection, standardization of key operative steps, and further assessment of the oncological safety of this approach in larger case series.

1. Malignant neoplasms in Russia in 2024 (incidence). Ed. by A.D. Kaprin, V.V. Starinsky, A.O. Shakhzadova, N.Yu. Zolotarev. Moscow: P.A. Herzen Moscow Medical Research Institute – branch of the National Medical Research Center of Radiology of the Ministry of Health of Russia, 2025.

2. EAU Guidelines, 2025. URL: http://uroweb.org/guidelines/compilations-of-all-guidelines

3. Pushkar D.Yu., Kolontarev K.B. Robot-assisted radical prostatectomy – functional result. Part II. Khirurgiya. Zhurnal im. N.I. Pirogova = Pirogov Russian Journal of Surgery. 2019;(4):80–6. (In Russ.). DOI: 10.17116/hirurgia201904180

4. Ficarra V., Novara G., Rosen R.C. et al. Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol 2012;62(3):405–17. DOI: 10.1016/j.eururo.2012.05.045

5. Walz J., Burnett A.L., Costello A.J. et al. A critical analysis of the current knowledge of surgical anatomy related to optimization of cancer control and preservation of continence and erection in candidates for radical prostatectomy. Eur Urol 2010;57(2):179–92. DOI: 10.1016/j.eururo.2009.11.009

6. Yaxley J.W., Gianduzzo T. Does a Retzius-sparing surgical technique improve urinary continence recovery after a robotassisted laparoscopic radical prostatectomy: results of a systematic review and meta-analysis of comparative studies. Prostate Cancer Prostatic Dis 2025;28(3):533–4. DOI: 10.1038/s41391-024-00881-5

7. Kodres-O’Brien S., Dall C., Sholklapper T., Kowalczyk K. Outcomes after pelvic fascia-sparing robot-assisted radical prostatectomy vs. standard robot-assisted radical prostatectomy. Mini-invasive Surg 2025;9:23. DOI: 10.20517/2574-1225.2024.121

8. Ferretti S., Dell’Oglio P., Ciavarella D. et al. Retzius-Sparing robotic-assisted prostatectomy: Technical challenges for surgeons and key prospective refinements. Res Rep Urol 2023;15:541–52. DOI: 10.2147/RRU.S372803

9. Gong W., Yan J., Cui Y. et al. Comparison of efficacy of Retzius-sparing radical prostatectomy versus standard radical prostatectomy in the treatment of prostate cancer: a systematic review and meta-analysis. Front Oncol 2025;15:1547687. DOI: 10.3389/fonc.2025.1547687

10. Nagasubramanian S., Leow J.J., Sooriakumaran P. Retzius-sparing robot-assisted radical prostatectomy. J Endourol 2025;39(S1):S27–34. DOI: 10.1089/end.2024.0616

11. Lambert E., Allaeys C., Berquin C. et al. Is it safe to switch from a standard anterior to Retzius-sparing approach in robot-assisted radical prostatectomy? Curr Oncol 2023;30(3):3447–60. DOI: 10.3390/curroncol30030261

12. Dalela D., Jeong W., Prasad M.A. et al. 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 2017;72(5):677–85. DOI: 10.1016/j.eururo.2017.04.029

13. Asimakopoulos A.D., Topazio L., De Angelis M. et al. Retzius-sparing versus standard robot-assisted radical prostatectomy: a prospective randomized comparison on immediate continence rates. Surg Endosc 2019;33(7):2187–96. DOI: 10.1007/s00464-018-6499-z

14. Jiang Y.L., Zheng G.F., Jiang Z.P. et al. Comparison of Retziussparing robot-assisted laparoscopic radical prostatectomy vs standard robot-assisted radical prostatectomy: a meta-analysis. BMC Urol 2020;20(1):114. DOI: 10.1186/s12894-020-00685-4

15. Xu J.N., Xu Z.Y., Yin H.M. Comparison of Retzius-sparing robot-assisted radical prostatectomy vs. conventional robot-assisted radical prostatectomy: An up-to-date meta-analysis. Front Surg 2021;8:738421. DOI: 10.3389/fsurg.2021.738421