Introduction: Pre-operative membranous urethral length (MUL) is a well-known non-modifiable factor predicting continence recovery after surgery, but there are also refinements in surgical techniques to optimize early continence after robotic-assisted radical prostatectomy (RARP). These include modifications in apical dissection to maximize urethral length and maximizing preservation of periurethral structures responsible for urethral stability.
Methods: We reviewed data of patients who underwent RARP between January 2018 and October 2021. MUL, anterior Retzius sparing approach and continence (pads) 6-weeks after surgery were recorded. We present five surgical scenarios often encountered while planning the apical dissection in RARP: non urethral preservation, half-supported full or non-full-length urethral preservation, full length unstable urethra, full length stable urethra and full-length stable preservation in the context of unusual apical anatomy. All patients consented to data storage and video-recording.
Results: Following on from the video footage of this surgical scenarios, we present 342 patients for quantitative analysis. Those patients with a MUL >10mm had 9.7 increased chance of being completely dry at 6-weeks (OR 9.7 CI95% 2.2 – 42.1). Those patients with a MUL >10mm who also had anterior Retzius sparing their chances increased by a further 4.3 (OR 4.3 IC95% 2.1– 8.8).
Conclusions: The apical approach in a RARP can be planned and tailored for each case depending on both patients and tumour anatomy to optimize urethral stability post-RARP and early continence recovery. We advocate both preservation of urethral length and those structures responsible for urethral stability.