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Impact of transperitoneal anterior, retzius-sparing, extraperitoneal, transvesical and perineal approaches on urinary continence recovery after robot-assisted radical prostatectomy: a systematic review and meta-analysis of comparative studies

Prostate Cancer and Prostatic Diseases volume 28, pages 328–341 (2025)Cite this article

Subjects

Abstract

Background

Urinary incontinence significantly impacts on health-related quality of life of patients undergoing radical prostatectomy. In the last decades, several approaches (extraperitoneal, Retzius-sparing (RS), perineal and, transvesical) for robot-assisted radical prostatectomy (RARP) have proposed with the aim to improve functional outcomes in comparison with transperitoneal, anterior ones.

Methods

We performed a systematic review and meta-analysis of studies published in English language, in the last ten years, comparing the different approaches used to perform RARP. We included only studies reporting urinary continence rates at different follow-up time points. From each eligible study, we extracted the number of analyzed patients; the study design; the continence definition; and, when available, immediate, 1-, 3-, 6-, and 12-mo urinary continence rates. Statistical analyses were performed using RevMan version 5.4 (Cochrane Collaboration, Oxford, United Kingdom, UK). The Odds Ratio (OR) with 95% confidence intervals (CIs) was calculated using the generic inverse variance. A p value of <0.05 was set as significance level when comparing studies.

Results

The meta-analyses of studies comparing anterior, transperitoneal RARP and RS-RARP in terms of immediate (OR = 3.73; 95% CI: 2.17–6.43; p < 0.0001), 1-mo (OR = 4.16; 95% CI: 2.68–6.48; p < 0.00001), 3-mo (OR 4.71; 95% CI: 3.70–6.00; p < 0.0001), 6-mo (OR 4.12; 95% CI: 2.95–5.75; p < 0.00001) and 12-mo (OR = 3.25; 95% CI: 1.76–5.99; p < 0.00001) urinary continence rates showed a statistically significant advantage in favor of RS approach. However, a sub-analysis of Randomized Controlled Trials showed overlapping urinary continence rates between the two approaches at 6-mo (OR = 1.99; 95% CI: 0.90–4.42; p = 0.09) and 12-mo (OR = 1.36; 95% CI: 0.43–4.31; p = 0.60) after surgery. The meta-analysis of studies comparing extraperitoneal and transperitoneal approaches showed that 6-mo urinary continence rates were overlapping between the two approaches (OR = 1.18; 95% CI: 0.85–1.65; p = 0.32). The meta-analysis of studies comparing single-port (SP) and multi-port (MP) RARP showed comparable 6-mo urinary continence rates (OR = 0.93; 95% CI 0.65–1.33; p = 0.69).

Conclusions

Within the limitations of mainly low to moderate quality of evidence, the RS  approach offers significant advantages compared to an anterior, transperitoneal, approach in terms of urinary continence recovery at different follow-up time points in patients who underwent MP-RARP. MP perineal and transvesical approaches need to be further tested and might be of interest in the setting of SP-RARP. Our meta-analysis showed comparable results between SP- and MP-RARP in terms of urinary continence rates.

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Fig. 1: PRISMA flow diagram.
Fig. 2: Forest plot of immediate urinary continence rates after catheter removal in 10 studies comparing RS-RARP versus anterior RARP.
Fig. 3: Forest plot of 1-mo urinary continence rates in 11 studies comparing RS-RARP versus anterior RARP.
Fig. 4: Forest plot of 3-mo urinary continence rates in 15 studies comparing RS-RARP versus anterior RARP.
Fig. 5: Forest plot of 6-mo urinary continence rates in 12 studies comparing RS-RARP versus anterior RARP.
Fig. 6: Forest plot of 12-mo urinary continence rates in 18 studies comparing RS-RARP versus anterior RARP.
Fig. 7: Forest plot of 6-mo urinary continence rates in 3 studies comparing extraperitoneal versus transperitoneal RARP.
Fig. 8: Forest plot of 3-mo urinary continence rates in 6 studies comparing MP versus SP-RARP.

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  1. Twitter: @FicarraVincenzo

Authors and Affiliations

  1. Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy

    Vincenzo Ficarra

  2. Department of Human and Pediatric Pathology “Gaetano Barresi”, Urologic Section, University of Messina, Messina, Italy

    Marta Rossanese, Romito Ilaria & Ettore Di Trapani

  3. Urology Unit, Academic Medical Centre “Santa Maria della Misericordia”, Udine, Italy

    Gianluca Giannarini

  4. Department of Urology, Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium

    Alexandre Mottrie

  5. ORSI Academy, Ghent, Belgium

    Alexandre Mottrie

  6. Department of Urology, Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany

    Christian Thomas

  7. Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany

    Felix Chun

  8. Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy

    Antonio Galfano

  9. VUI Center for Outcomes Research, Analysis, and Evaluation, Henry Ford Health System, Detroit, MI, USA

    Firas Abdollah

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Contributions

VF 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: VF. Acquisition of data: VF, MR, IR. Analysis and interpretation of data: VF, MR, IR. Drafting of the manuscript: RF. Critical revision of the manuscript for important intellectual content: RF, GG, AM, CT, FC, AG, FA, EDiT. Statistical analysis: VF, IR. Obtaining funding: None. Administrative, technical, or material support: None. Supervision: RF, GG, AM, CT, FC, AG, FA, EDiT. Other: None.

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Ficarra, V., Rossanese, M., Ilaria, R. et al. Impact of transperitoneal anterior, retzius-sparing, extraperitoneal, transvesical and perineal approaches on urinary continence recovery after robot-assisted radical prostatectomy: a systematic review and meta-analysis of comparative studies. Prostate Cancer Prostatic Dis 28, 328–341 (2025). https://doi.org/10.1038/s41391-025-00943-2

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