Retzius-Sparing Robot-Assisted Robotic Prostatectomy: Past, Present, and Future - Beyond the Abstract

In this study, we aimed to highlight the evolution of Retzius-sparing robotic-assisted radical prostatectomy (RS-RARP), describe our technique and relevant anatomy, review studies comparing RS-RARP to standard RARP (S-RARP) with respect to oncologic and functional outcomes, and discuss areas of future study.

While radical prostatectomy is considered the gold standard treatment for prostate cancer, there are significant impacts on quality of life, particularly with respect to urinary incontinence.1,2 This surgery has undergone many transformations from its origins in the 1900s as an open perineal surgery to today where it’s primarily performed as a robotic procedure via a transperitoneal approach. Multiple modifications have been proposed to minimize incontinence associated with radical prostatectomy including the periurethral suspension stitch and preservation of urethral length and the bladder neck. In 2010, Galfano described the RS-RARP,3 which spares structures in the anterior pelvic compartment including the pubovesical ligaments, puboprostatic ligaments, endopelvic fascia, dorsal venous complex, and detrusor apron. All of these are thought to play important roles in continence and potency.

We reviewed nine studies comparing RS-RARP to S-RARP. The majority demonstrate superior continence outcomes for RS-RARP, which are maintained at one year in three of the four studies that had 12 months of follow-up. Sexual function outcomes were examined in two studies. When comparing EPIC-CP scores, Egan et al. (2020) found superior quality of life scores for RS-RARP at 12 months postoperatively.4 The existing evidence on oncologic outcomes is somewhat less robust compared to functional outcomes, but positive margin rates and biochemical recurrence-free survival rates appear to be similar.

RS-RARP is gaining traction as a popular technique for surgical removal of the prostate. However, multi-surgeon randomized studies with longer follow-up are needed to further assess functional superiority and oncologic safety. In addition, future studies should look beyond the “trifecta” of outcomes to examine other areas of importance to patients. For example, we found a lower risk of patient-reported penile shortening and inguinal hernia with RS-RARP vs. S-RARP.5 If future data continue to support improved outcomes for RS-RARP, this technique has the potential to become the new gold standard for prostate cancer management.

Written by: Meghan Davis, MD, MPH, Twitter: @MeghanDavisMD, Jillian Egan, MD, Twitter: @Egan_Jillian26, Keith Kowalczyk MD, Twitter: @KeithKow, Department of Urology, MedStar Georgetown University Hospital, Washington, DC


  1. Chen, Junchao, Clara Oromendia, Joshua A. Halpern, and Karla V. Ballman. "National trends in management of localized prostate cancer: A population based analysis 2004‐2013." The Prostate 78, no. 7 (2018): 512-520.
  2. Holt, James D., and Fereshteh Gerayli. "Prostate Cancer Screening." Primary Care: Clinics in Office Practice 46, no. 2 (2019): 257-263.
  3. Galfano, Antonio, Assunta Ascione, Salvatore Grimaldi, Giovanni Petralia, Elena Strada, and Aldo Massimo Bocciardi. "A new anatomic approach for robot-assisted laparoscopic prostatectomy: a feasibility study for completely intrafascial surgery." European urology 58, no. 3 (2010): 457-461.
  4. Egan, Jillian, Shawn Marhamati, Filipe LF Carvalho, Meghan Davis, John O’Neill, Harry Lee, John H. Lynch, Ryan A. Hankins, Jim C. Hu, and Keith J. Kowalczyk. "Retzius-sparing Robot-assisted Radical Prostatectomy Leads to Durable Improvement in Urinary Function and Quality of Life Versus Standard Robot-assisted Radical Prostatectomy Without Compromise on Oncologic Efficacy: Single-surgeon Series and Step-by-step Guide." European Urology (2020).
  5. Kowalczyk, Keith J., Meghan Davis, John O’Neill, Harry Lee, Joanna Orzel, Rachel S. Rubin, and Jim C. Hu. "Impact of Retzius-sparing Versus Standard Robotic-assisted Radical Prostatectomy on Penile Shortening, Peyronie’s Disease, and Inguinal Hernia Sequelae." European Urology Open Science 22 (2020): 17-22.
Read the Abstract