Prostate cancer is the second most common malignancy in men. Although novel surgical approaches have been developed, robust clinical evidence remains limited. Despite being associated with lower morbidity compared to radiotherapy, radical prostatectomy can still result in complications such as bleeding, bladder injury, and transient urinary incontinence, particularly when the bladder neck is positioned below the pubic symphysis. Furthermore, current literature identifies preservation of the neurovascular bundles as a key protective factor against urinary incontinence in patients undergoing prostatectomy [1].
Since its introduction in 2000, robot-assisted laparoscopic radical prostatectomy has become the most widely used and preferred surgical procedure for the treatment of prostate cancer. Several modifications of the surgical approach and technical advancements have been proposed to improve continence outcomes [1–3]:
• Preservation: Retzius space, bladder neck, seminal vesicles (not routinely recommended), neurovascular bundle(s), puboprostatic ligaments, maximal urethral length, endopelvic fascia, and detrusor apron.
• Reconstruction:
Posterior urethral support: Denonvilliers’ fascia, pubourethral ligament, endopelvic fascia, levator ani, and arcus tendineus fascia
Anterior puboprostatic support: puboprostatic ligament and detrusor apron
Combined (total) reconstruction
Bladder neck reconstruction
• Surgical modifications of traditional techniques: Continuous suturing, barbed sutures, and suprapubic catheter placement
Although various robotic approaches and strategies for prostatectomy have been developed, none has been conclusively shown to be superior in reducing urinary incontinence rates, partly due to significant heterogeneity in the available literature.
Therefore, a technique designed to integrate these strategies described in the literature was developed: total-sparing transvesical robot-assisted radical prostatectomy.

This prospective study included 50 patients eligible for radical prostatectomy. The technique involves a less steep Trendelenburg position, pneumoperitoneum maintained at 12 mmHg, and a longitudinal bladder incision with preservation of innervation and vascularization. Demographic and clinical data were collected, along with functional outcomes, including urinary continence, erectile function, and surgical margin status.

The mean age was 66 years. The mean prostate volume was 51 g, and the mean tumor size was 7 mm.
Patients were staged as T1–T2b, with ISUP grades up to 5 on biopsy. 
The mean console time was 2 hours and 30 minutes, the median hospital stay was 2 days, and the mean catheterization time was 7 days.
Urinary continence at catheter removal was 66.7% (0–1 pad), increasing to 98% at 30 days. Erectile function was preserved in 28% of patients at 7 days, and 63% resumed satisfactory sexual activity by 30 days.
PSA at 45 days was <0.03 ng/mL in all patients.
No blood transfusions were required, and no major complications were observed.

The causes of urinary incontinence are multifactorial. Achieving optimal continence outcomes requires careful dissection and meticulous anatomical reconstruction following specimen removal. These initial results with the total-sparing transvesical technique are promising and appear to support these objectives. Randomized studies with longer follow-up are essential to statistically validate its benefits and to assess its impact on quality of life.

Ficarra V, Novara G, Rosen RC et al. Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol 2012; 62:405–417
Arroyo C, Martini A, Wang J, Tewari AK. Anatomical, surgical and technical factors influencing continence after radical prostatectomy. Ther Adv Urol. 2019; 8;11:1756287218813787.
Fonseca J, Moraes-Fontes MF, Sousa I, et al. Membranous urethral length is the single independent predictor of urinary continence recovery at 12 months following Retzius-sparing robot-assisted radical prostatectomy. J Robot Surg 2024; 29: 230.