Hostile male pelvis and its impact on robot-assisted radical prostatectomy outcomes

A “hostile male pelvis” describes unfavorable pelvic anatomy that impairs surgical access during robot-assisted radical prostatectomy (RARP). Key factors include narrow pelvic diameters and increased dorsal venous complex (DVC) volume. This research aims to define the “hostile male pelvis” with the aforementioned variables to identify individuals who would have an increased risk of positive surgical margins (PSMs) after RARP. The population tested consisted of males who were diagnosed with organ-confined prostate cancer, irrespective of their Gleason score, who were eligible for radical surgical treatment, who underwent RARP at a single tertiary high-volume center (Ludwik Rydygier Collegium Medicum, Poland), and who were operated on by an experieced surgeon between March 2023 and March 2025. MRI-derived pelvic diameters—anatomic, robotic (RC), and diagonal conjugates—and DVC volume were assessed. The associations of these genes with PSM at the prostatic apex were analyzed. The study included 117 adult males. PSM occurred in 19.2% of the patients. RC provided high sensitivity (0.87), whereas DVC volume offered high specificity (0.76) for predicting PSM. At the estimated optimal cutoff point (RC: 9.95 cm, DVC: 15.65 cm 3 ), the baseline PSM probability was 25.9%. A DVC volume >15.65 cm 3 significantly increased the PSM risk (OR = 1.24, 95% CI: 1.05–1.52; p = 0.028), with each 1 cm 3 increment increasing the OR by 24%. RC and DVC volume may predict apical PSM, supporting their role in defining the “hostile male pelvis”.