Posterior Approach to Endopelvic Neurovascular Total Sparing Robotic-Assisted Radical Prostatectomy Improves Recovery of Erectile Function

Background and Objective: A posterior approach to endopelvic neurovascular total sparing (PATENTS) during robotic-assisted radical prostatectomy (RARP) may improve recovery of sexual function through preservation of anterolateral periprostatic tissue. We compared RARP erectile function recovery with PATENTS vs the conventional anterior nerve-sparing approach. Methods: We conducted a single surgeon retrospective review of 495 RARP (278 anterior nerve-sparing, 217 PATENTS) performed during 2015 to 2025, with initiation of PATENTS in 2022. Our primary outcome was erectile function recovery defined as erections sufficient for sexual activity (at least masturbation/foreplay) from the Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP). Cox proportional hazard models evaluated factors affecting recovery of erectile function. Key Findings and Limitations: PATENTS patients were older (median 66 vs 64 years; P = .002) and more likely to have clinically significant cancer at diagnosis (95.8% vs 86.0%; P = .003). Despite shorter follow-up (5 months [IQR 3-15] vs 10 [3-21], P < .001), PATENTS was associated with shorter duration to erections sufficient for intercourse ( P = .022). In adjusted analyses, PATENTS was associated with improved erections firm enough for intercourse (hazard ratio [HR] 2.3, confidence interval [CI]: 1.45-3.68, P < .001), erections firm enough for sexual activity (HR 1.5, CI: 1.21-1.96, P < .001), and any partial erections (HR 1.4, CI: 1.13-1.63, P < .001). There were no differences in margin status ( P = .234) or adverse events ( P = .933). Study limitations include single surgeon, retrospective study design. Conclusions and Clinical Implications: PATENTS facilitated recovery of erectile function without compromising surgical margins or adverse events. Prospective, multisurgeon series are needed to validate our findings.