Research Article

Robotic Radical Prostatectomy and Urinary Continence: Posterior Reconstruction is Better

Goonewardene SS1*, Goggins A2, Kinsella J3 and Cahill D3
1The Royal Free Hospital and University College London
2Queens Medical School, Belfast
3The Royal Marsden, London

*Corresponding author: Goonewardene SS, Department of Urology, The Royal Free Hospital and University College London, London

Published: 02 Jul, 2016
Cite this article as: Goonewardene SS, Goggins A, Kinsella J, Cahill D. Robotic Radical Prostatectomy and Urinary Continence: Posterior Reconstruction is Better. Clin Oncol. 2016; 1: 1046.


Robotic radical prostatectomy; Anterior reconstruction; Posterior reconstruction; Continence outcomes


Robotic radical prostatectomy (RARP) is the gold standard for localised prostate cancer. However, a younger cohort are presenting with more locally advanced disease. Early continence following (RARP) is dependent on patient, surgeon and technical factors. Various techniques have been advocated to improve outcomes. A surgeon needs to audit outcomes as techniques are interpretation and execution dependant. Outcomes can then direct change for the better. The potential benefits of RARP are known [1] but what can be done to improve urinary outcomes using technical tips and tricks? This study assesses the modification of RARP using popularised techniques, with the intention of improving urinary continence (UC).
Various intraoperative technical modifications have been described with the goal of improving early return of continence following robot-assisted radical prostatectomy. Continence recovery relies on multiple factors [2]. Anterior suspension of posterior reconstruction sutures, similar to a bladder neck sling can be done for post prostatectomy incontinence [2]. Performing this suspension technique at the time of RARP may improve early continence recovery [2]. However, studies are –required to confirm this.


Between 2012 and 2014, 301 men were treated with RARP with evolving surgical techniques aimed at improving UC outcomes under a single surgeon. This patient data was from collected from a retrospective database with no randomisation involving 4 different techniques. Urethral length and bladder neck plication were not measured quantitatively, but rather outcomes of each technique conducted by analysis of outcomes. Group A had aRocco reconstruction incorporated as a mass technique with the anastomosis (n=530). Group B had a Rocco layer separate to the anastomosis and anterior reconstruction. Group C had separate Rocco and an anterior reconstruction. Group D had separate Rocco and anastomosis layers and posterior reconstruction (Table 1).


Mean age, DRE, clinical stage, PSA, MRI stage and Gleason Score, blood loss and operating time was similar between groups. What is clearly demonstrated from figure 2 and 3 is the fact that Group D-with posterior reconstruction clearly has an earlier time to continence and 100 %continence (pad free) compared to other techniques used, including those with anterior reconstruction. In contrast to this, other methods of anastomosis used, do not have. Outcomes that are comparable with this very often resulting in worsening continence rates or a longer time to continence. This can significantly impact a patients quality of life.


An early return to continence, was supported by use of periurethral suspension stitch, bladder neck plication and posterior reconstruction of the rhabdosphincter [3]. However, this paper concluded robotic prostatectomy is still in evolution. Technical modifications resulting in improved oncological and functional outcomes are the result of increasing surgical experience and procedure understanding [3]. The importance of posterior urethral support was confirmed by Dal Moro et al [4]. To determine whether a novel intraoperative technique of complete reconstruction of the posterior urethral support (CORPUS) improves early urinary continence after robotic-assisted radical prostatectomy [4]. In a prospective study, patients were assigned to complete reconstruction or Rocco's standard reconstruction [4]. Technical Considerations within the CORPUS group includedfibers of the bilateral portions of the puborectalis muscle were used to create a sort of posterior hammock for the urethra. The very early continence rate of the CORPUS patients was significantly improved compared with that of patients undergoing Rocco's standard technique [4]. With the basic principle of restoring a patient's anatomy to its original state postoperatively, Ali et al attempted to identify technical aspects of total anatomical reconstruction that led to early return of urinary continence after robot-assisted laparoscopic prostatectomy [5]. Patients who underwent RARP also had total anatomic reconstruction with the additions of a circum-apical urethral dissection, a dynamic detrusor cuff trigonoplasty, and placement of a suprapubic catheter [5]. This demonstrated reconstructing the pelvic anatomy and supporting bladder structures leads to an earlier return to continence. However larger randomized trials will need to confirm these key steps [5]. Coelho et al also describe a modified technique for PR of the rhabdosphincter during RARP and report its impact on early recovery of urinary continence and on cystographic leakage rates [6]. The modification allows a reinforced watertight closure of the posterior anastomotic wall. Shorter interval to recovery of continence and lower incidence of cystographic leaks were demonstrated with this technique when compared to RARP with no reconstruction [6]. Mendoza et al. [7] looked at bladder plication on continence outcomes after RARP. After completing the vesicourethral anastomosis, a 3-0 monocryl single suture was used to plicate the bladder neck [7]. The stitch is placed 2 cm proximal to the bladder neck near the 3 and 9 o'clock positions and tied. This plication creates a funnel configuration such that the more distal bladder neck remains narrow during bladder filling [7].The bladder plication is a simple and effective technical modification for improving urinary incontinence after RARP [7]. Borin et al reviewed how urethral length affects return to continence. A longer length was found to be beneficial [8].

Table 1

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Table 1
Definition of groups.
The primary outcome measure was urinary continence. This was assessed at 8 weeks, 3, 6,9 and 12 months post operatively. The measured outcome for urinary continence was zero pad usage at patient interview. If patients were using pads, they were deemed as not continent. We used descriptive statistics (ANOVA and Chi-squared test)to compare surgical variables across the 4 groups. Positive surgical margins were defined as any margin, with areas of positivity.


In conclusion, objective assessment of urinary continence is better than subjective assessment. Patient reported outcomes are the gold standard. The overall conclusion, is that with improved technical ability and a good surgical team, good outcomes can be achieved. At the same time, in line with literature, posterior reconstruction, bladder neck reconstruction and longer urethral length can also contribute to improved continence.


  1. Gandaglia G, Suardi N, Gallina A, Zaffuto E, Cucchiara V, Vizziello D, et al. How to optimize patient selection for robot-assisted radical prostatectomy: Functional outcome analyses from a tertiary referral center. Journal of Endourology. 2014; 28: 792-800.
  2. Agrawal V, Ghazi A, Joseph J. Anterior suspension of posterior reconstruction suture-a novel technique to improve early return of urinary continence following robot-assisted radical prostatectomy. Journal of Urology. 2015; e405-e406.
  3. Giedelman C, Macek P, Lunelli L, Mascle L, Ahallal Y, Sanchez-Salas R, et al. Robotic radical cystectomy. Tips and tricks in pelvic lymphadenectomy and neurovascular bundles preservation. Journal of Urology. 2013; e764.
  4. Dal Moro F, Crestani A, Valotto C, Zattoni F. CORPUS--novel COmplete Reconstruction of the Posterior Urethral Support after robotic radical prostatectomy: preliminary data of very early continence recovery. Urology. 2014; 83: 641-647.
  5. Tewari A, Ali A, Ghareeb G, Ludwig W, Metgud S, Theckumparampil N, et al. Improving time to continence after robot-assisted laparoscopic prostatectomy: augmentation of the total anatomic reconstruction technique by adding dynamic detrusor cuff trigonoplasty and suprapubic tube placement. J Endourol. 2012; 26: 1546-1552.
  6. Coelho R, Chauhan S, Orvieto MA, Sivaraman A, Palmer KJ, Coughlin G, 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.
  7. Mendoza PJ, Sharma S, Natale R, Monahan K, Walicki M, Schwab CW, et al. Bladder neck plication stitch: A novel technique during robot assisted radical prostatectomy (RARP) to improve recovery of urinary continence. Journal of Endourology. 2010; 24: A89.
  8. Borin JF, Skarecky DW, Narula N, Ahlering TE. Impact of urethral stump length on continence and positive surgical margins in robot-assisted laparoscopic prostatectomy. Urology. 2007; 70: 173-177.