Perioperative, oncological, and functional outcomes of intrafascial versus extrafascial retzius-sparing robot-assisted radical prostatectomy: a real-world retrospective cohort study

To compare perioperative, oncological, and functional outcomes between intrafascial (IF) and extrafascial (EF) techniques in Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) performed beyond the learning curve. This retrospective study analyzed 188 patients with localized prostate cancer (LPCa) who underwent RS-RARP between May 2021 and July 2023 at the urology departments of the Chinese PLA General Hospital. Patients were stratified into an IF group ( n = 72) and an EF group ( n = 116) based on the clinical T stage of the tumor and patient preference. All surgeries were performed by experienced surgeons (> 100 RS-RARP cases). Perioperative outcomes, positive surgical margin (PSM) rates, biochemical progression-free survival (bPFS), urinary continence (UC) recovery, and the EPIC-26 urinary incontinence and sexual scores were analyzed. No significant differences were observed in operative time, estimated blood loss, postoperative length of hospital stay, or complication rates (all P > 0.05). Regarding oncological outcomes, after multivariable adjustment, EF RS-RARP was associated with a lower hazard of biochemical recurrence (HR = 0.12, 95% CI: 0.06–0.22, P < 0.001) and lower odds of PSM (OR = 0.16, 95% CI: 0.06–0.42, P < 0.001). In terms of functional outcomes, there were no statistically significant differences between the two groups in UC recovery rates or EPIC-26 urinary incontinence scores at 3, 6, or 12 months postoperatively (all P > 0.05). However, compared with the IF group, the EF group had significantly lower EPIC-26 sexual domain scores at 3 months (13.8 [1.1, 22.2] vs. 22.2 [4.2, 30.5], P = 0.001) and 12 months (18.0 [9.7, 27.7] vs. 40.3 [22.2, 57.0], P < 0.001), and a significantly higher proportion of patients exceeded the MCID at 12 months (100% vs. 79.2%, P < 0.001). In this real-world cohort, after multivariable adjustment, EF RS-RARP was associated with lower PSM and BCR hazards and comparable long-term UC recovery versus IF RS-RARP. These findings suggest that EF RS-RARP may be an option for patients with LPCa who do not prioritize erectile function preservation; however, given inherent allocation bias, prospective studies are warranted to validate these results.