What the Surgery Is Actually Doing

RP Surgical Techniques Compared

IPCSG Newsletter  ·  Surgical Technique Deep-Dive  ·  March 2026

A systematic comparison of radical prostatectomy techniques evaluated against the four things patients care about most: removing the cancer completely, checking the margins, preserving urinary control, and protecting erectile function. Suturing and nerve-sparing examined in technical detail.

Prepared for the IPCSG Newsletter  ·  March 2026

Bottom Line Up Front (BLUF)

Radical prostatectomy has four measurable goals that matter to patients: complete cancer removal, clear surgical margins, retained urinary continence, and preserved erectile function — the "Trifecta" or "Pentafecta" standard. No single surgical approach optimizes all four simultaneously; every technique involves trade-offs. Robot-assisted radical prostatectomy (RARP) is now the dominant approach worldwide (>90% of U.S. cases), achieving better functional outcomes than open surgery. Beyond the basic RARP platform, the critical differentiators are: (1) which approach to the space of Retzius — standard anterior versus Retzius-sparing — with the Retzius-sparing technique demonstrating dramatically better early continence but a more complex oncological profile; (2) how the urethra is reconnected after prostate removal, with the Van Velthoven single-knot running suture the current global standard and barbed sutures offering speed advantages; and (3) how the surgeon decides how much nerve tissue to spare, where the NeuroSAFE intraoperative frozen-section technique — validated in a Lancet Oncology Phase 3 trial published March 2025 — nearly doubles the rate of erectile function recovery without compromising cancer control. The anatomical reconstruction techniques (Rocco stitch posterior reconstruction, anterior suspension, total reconstruction) that surround the urethral anastomosis are equally important and have strong randomized trial support. The bottom line for patients: ask your surgeon which approach they use for each of these four decision points, why, and what their personal volume-based outcomes data show.

Part I: The Four Goals and How They Conflict

Before comparing techniques, it is essential to understand why optimizing all four patient goals simultaneously is genuinely difficult — not a matter of surgeon skill alone, but of anatomical proximity and surgical physics.

The prostate sits at a crossroads of critical structures. The urethra runs through its center. The neurovascular bundles (NVBs) — the paired nerve-and-artery structures responsible for erectile function — run along the posterolateral surface, pressed close to the prostate capsule in a fascial sheath that is sometimes only millimeters from malignant tissue. The urinary sphincter mechanism sits immediately below the prostate apex, and its integrity after the prostate is removed governs continence. The rectum lies immediately posterior.

The conflict is geometric: to ensure complete cancer removal with clear margins, the surgeon must excise tissue that may include or approach nerve tissue. To spare nerves, the surgeon must dissect close to the prostate — risking a positive margin. This is the central tension of radical prostatectomy, and it explains why every technique comparison in the literature involves a trade-off between oncological control and functional outcomes.

The surgical literature quantifies success using several standardized frameworks. The Trifecta requires: no biochemical recurrence (PSA undetectable), full urinary continence, and satisfactory erectile function. The more demanding Pentafecta adds negative surgical margins and absence of major complications. Published Pentafecta achievement rates at high-volume centers are typically 40–60% at two years — a sobering number that reflects the genuine difficulty of the surgery.

The Four Patient Goals — What the Literature Measures

• Cancer removal / Negative surgical margins (PSM rate): Positive surgical margins (cancer cells at the cut edge of the specimen) indicate residual tumor left in the body. PSM rates for RARP at high-volume centers: 10–25% overall; higher for pT3 (extracapsular extension) disease. PSM is associated with increased risk of biochemical recurrence but does not always require immediate intervention.
• Extracapsular extension assessment: The pathologist examines the specimen for capsular penetration, seminal vesicle invasion, and lymph node involvement (if dissected). This is done on the final surgical specimen — not during surgery in standard cases (NeuroSAFE provides intraoperative margin data at the NVB interface only).
• Urinary continence: Definitions vary across studies (from "zero pad use" to "one safety pad/day"), which makes comparisons difficult. By 12 months, most high-volume RARP series report 85–96% continence by the pad-free definition. Continence at 1 week after catheter removal ranges from 40% (standard approach) to over 90% (Retzius-sparing) depending on technique.
• Erectile function: Defined as IIEF-5 score ≥22 or "satisfactory intercourse" in most studies. At 12–18 months post-RARP with bilateral nerve-sparing in preoperatively potent men: 56–97% satisfactory function at high-volume expert centers; community-level results substantially lower. Unilateral nerve-sparing: 40–70%. Non-nerve-sparing: 5–15%.

Part II: The Surgical Approach — How You Enter Matters Enormously

The first major technical decision is how the surgeon approaches the prostate. This is not merely a routing choice — it determines which anatomical structures are disrupted, what is preserved, and how quickly function returns. Three main approaches are used in robotic surgery.

Standard Transperitoneal Anterior Approach (the Historical Baseline)

The classic robotic approach follows the same anatomical path as Patrick Walsh's original open retropubic prostatectomy: the surgeon enters the pelvis through the abdomen, opens the space of Retzius (the pre-bladder space between the pubic bone and the bladder), divides the puboprostatic ligaments, controls the dorsal venous complex overlying the urethra, and dissects the prostate from anterior to posterior. This anterior dissection disrupts the hammock of tissue — the puboprostatic ligaments, the detrusor apron of the bladder, and the periurethral support structures — that the sphincter mechanism depends on for immediate support after the prostate is removed.

The advantages are excellent surgical exposure and a long track record. The limitations are predictable: because the retropubic space is opened and supportive structures are divided, early continence is poor. Most published series show approximately 50–70% continence at one month, recovering to 85–96% by 12 months.

Retzius-Sparing Approach (Posterior / Bocciardi Approach)

Developed by Galfano and Bocciardi in Milan beginning around 2010 and gaining widespread adoption through the 2020s, the Retzius-sparing (RS-RARP) approach enters the pelvis from a posterior direction — through the pouch of Douglas behind the bladder — without ever opening the space of Retzius. The puboprostatic ligaments, the detrusor apron, the arcus tendineus, and the entire anterior supporting hammock of the urinary sphincter remain completely intact throughout the operation. The prostate is dissected from its posterior and lateral attachments while the entire anterior pelvic floor structure remains undisturbed.

The functional result is striking. In one comparative study, urinary continence recovery rates at one week after catheter removal were 91.2% in the Retzius-sparing group versus 54.3% in the standard group (p < 0.001), with the advantage maintained at one, two, and three months, converging toward equivalence at six months. This near-immediate continence — patients leaving the hospital continent or nearly so — is the signature advantage of the Retzius-sparing approach and is supported by multiple meta-analyses and randomized trials.

The oncological concern is the trade-off. A 2025 AUA presentation comparing 1,155 RARPs across standard, Retzius-sparing, and Hood techniques concluded that pelvic fascia sparing approaches improve early urinary continence, but Retzius-sparing was associated with higher positive surgical margins. The mechanism is anatomical: operating from a posterior approach provides less direct visibility of the anterior prostate surface, which is the most common site of anterior tumors.

However, the picture is more nuanced than a simple "better continence, worse margins" conclusion. A two-year patient-reported outcomes study found no significant difference in positive surgical margin rate between Retzius-sparing and standard RARP (31% vs. 32%, p = 0.9), and five-year biochemical recurrence-free survival was not significantly different between the groups, with surgical approach not identified as a predictor of biochemical recurrence. The increased PSM length and anterior tumor location rate observed in the Retzius-sparing arm are concerning for specific tumor anatomies, however, and most centers exclude patients with large anterior tumors from Retzius-sparing approaches.

The Hood Technique (Anterior Pelvic Fascia-Sparing)

The Hood technique, developed more recently, attempts a middle path: it partially enters the space of Retzius but preserves the detrusor apron, arcus tendineus, and puboprostatic ligaments — the anterior "hood" of supportive tissue — while still providing the anterior exposure that makes oncological control at anterior tumor sites more straightforward. The 2025 AUA multi-center comparison found that both Retzius-sparing and the Hood technique improved early continence compared to standard RARP, with a randomized controlled trial now underway to formally compare their oncological and functional outcomes.

Criterion	Standard Anterior RARP	Retzius-Sparing RARP	Hood / Fascia-Sparing RARP
Oncological Control
Positive surgical margins (overall)	10–25% — well-established benchmark	Possibly higher in anterior tumors; equivalent in most studies at experienced centers	Under investigation; preliminary data comparable to standard
Anterior tumor control	Excellent — direct anterior exposure	Challenging — limited anterior visibility from posterior approach	Better than RS-RARP; inferior to standard for large anterior tumors
Biochemical recurrence-free survival (5-year)	No significant difference between approaches in most comparative studies	No significant difference vs. standard (Diamand et al., 2025)	Insufficient long-term data
Urinary Continence
Immediate (1 week post-catheter)	~40–55%	~88–92% — signature advantage	~70–85% — intermediate advantage
At 1 month	~60–70%	~90–95%	~80–90%
At 6–12 months	85–96% — converges with RS-RARP	90–97% — slight ongoing advantage	~90–95%
Erectile Function
Nerve-sparing opportunity	Good; NVB approach from anterior plane	Excellent; posterior plane naturally preserves NVB anatomy without anterior disruption	Good
Early potency (6 months, bilateral NS)	50–60%	68% in one comparative study	Data emerging
Surgical Logistics
Learning curve	50–100 cases for proficiency — established standard	Longer; anatomical orientation is reversed; 100–200+ cases	Intermediate; adds to standard technique
Suitability	All prostate anatomies; anterior tumors; large glands; prior pelvic surgery	Best: posterior/lateral tumors; normal-sized glands; no significant anterior tumor; no large median lobe	Intermediate; anterior tumors more manageable than with RS-RARP
RCT evidence quality	Highest — decades of data	Multiple RCTs; confirmed continence benefit; oncological debate ongoing	Limited; Phase 3 RCT underway (2025)

Part III: Reconstructing the Urethra — Suturing Techniques in Detail

Once the prostate is removed, the cut end of the urethra must be reconnected to the bladder neck — the vesicourethral anastomosis (VUA). This is often described as the most technically demanding step of the operation. The quality of this anastomosis directly affects early continence recovery (through both watertightness and sphincter preservation), risk of anastomotic leak, risk of bladder neck contracture, and ultimately long-term voiding function. How the surgeon sews the urethra matters enormously.

The Anatomical Goals of the Anastomosis

A good vesicourethral anastomosis must satisfy four requirements simultaneously. It must be tension-free — excessive tension causes ischemia and stricture. It must be watertight — leakage causes urinary extravasation, infection, and delayed continence. It must preserve sphincter anatomy — any stitch that catches the anterior sphincter muscle directly can cause mechanical incontinence. And it must achieve precise mucosal-to-mucosal apposition — bladder mucosa to urethral mucosa — to prevent stricture formation from fibrous ingrowth.

The anterior urethra — between the 9 o'clock and 3 o'clock positions — houses the functional striated sphincter, the rhabdosphincter. Stitches placed through or under tension against this anterior wall can permanently damage the sphincter mechanism. This has led to increasing interest in sphincter-sparing anastomosis techniques that deliberately avoid suturing the anterior urethra directly.

Van Velthoven Single-Knot Running Suture — The Global Standard

Introduced in 2003 by Roland Van Velthoven of Brussels, the Van Velthoven single-knot running suture is by far the most widely used anastomosis technique in minimally invasive prostatectomy worldwide. It uses two pre-tied sutures joined at a central knot, one running clockwise (left side) and one counterclockwise (right side) around the anastomosis, meeting anteriorly. The design functions as a winch — gentle traction on the free end brings the bladder neck down to the urethra as suturing progresses, maintaining approximation without knot-tying at multiple points.

Dr. Van Velthoven reported that the tightness of the wall and the good mucosal adjustment in this technique produced a very low urethral stenosis rate of just under 1% of cases, with mean anastomosis times of 16 minutes for experienced surgeons, 23 minutes for second-generation surgeons, and 30 minutes for trainees. The technique is teachable, reproducible, and has accumulated the largest safety and outcome dataset of any anastomosis method.

Barbed Sutures (V-Loc, Quill) — Speed with Comparable Outcomes

Barbed sutures — monofilament thread with microscopic barbs cut along its length that engage tissue as the suture is pulled through — eliminate the need for knot-tying, because the barbs hold tension along the entire suture length. For the vesicourethral anastomosis, barbed sutures (V-Loc 180 being the most studied) allow running closure without an assistant holding tension, reducing the surgeon's technical demands and shortening anastomosis time.

A 504-patient propensity score-weighted comparison of three VUA techniques found that anastomosis time was 13 minutes with the barbed V-Loc suture versus 28 minutes with the Van Velthoven technique (p < 0.05). Continence recovery was faster in the V-Loc group — on average 19–31 days shorter at one year of observation — though long-term continence rates at 12 and 18 months were comparable across all three groups.

A review of barbed suture techniques for VUA confirmed no evidence of increased tissue inflammation with barbed sutures and noted that randomized trials comparing barbed to standard monofilament sutures found no significant differences in urinary leakage rates or late bladder neck contracture rates. The consensus is that barbed sutures offer procedural efficiency with equivalent outcomes.

Interrupted Suture — Older Open Surgery Standard

The classical technique for open retropubic prostatectomy (Walsh technique) uses interrupted sutures — individual stitches, each independently tied — typically placed at 6, 5, 7, 4, 8, 3, 9, 2, 10, and 12 o'clock positions. This gives precise individual tension control at each point and avoids the "purse-string" risk of a continuous suture drawn too tight. A 2025 pragmatic randomized trial directly comparing interrupted versus running suture for VUA found no significant difference in continence recovery at 12 months between the two techniques, with both achieving comparable voiding function outcomes at all time points studied. Interrupted suture is technically more demanding in minimally invasive surgery and takes longer; running sutures have largely supplanted it in robotic and laparoscopic approaches.

Sphincter-Sparing Anterior Anastomosis — Avoiding the Critical 9-to-3 Zone

A recent innovation explicitly addresses the risk of anterior sphincter damage. Instead of suturing the anterior bladder neck to the anterior urethra (the 9 o'clock to 3 o'clock arc, where the rhabdosphincter lives), this technique sutures the anterior bladder neck to the already-ligated venous plexus overlying the sphincter — suspending the bladder from the plexus rather than directly engaging the anterior urethral muscle. A single-institution study of 448 men with this technique reported that 91% of patients were continent (zero pad use) one year after surgery, with no cases of retention or stricture requiring intervention.

This approach is particularly interesting because it addresses the mechanism of early post-RARP incontinence directly: disruption of sphincter geometry by anterior sutures. It remains to be validated in multicenter RCTs but represents the leading edge of anastomotic technique refinement.

Suture Technique	Anastomosis Time	Watertightness	Stricture Risk	Early Continence	Long-term Continence	Evidence Level
Van Velthoven running (standard)	16–28 min	Excellent	<1%	Standard benchmark	85–96%	Highest — 20+ years global data
Barbed (V-Loc / Quill)	12–17 min (faster)	Equivalent to VV	Equivalent	Slightly faster recovery (+19–31 days)	Equivalent at 12–18 months	Good — multiple comparative studies; no multicenter RCT
Interrupted (Walsh-style)	Longer; difficult in MIS	Excellent — individual tension control	Low	Equivalent to running	Equivalent at 12 months (2025 RCT)	Moderate — falling out of use in robotic surgery
Sphincter-sparing anterior	Similar to VV	Good	None reported in series	91% pad-free at 1 year in single series	Promising; multicenter data awaited	Emerging — single-institution data only
Modified VV with posterior musculofascial reconstruction (Gallucci / VV-G)	Similar to VV	Good	Low	Better early continence in prospective comparison	Equivalent or better	Moderate — prospective study data; no multicenter RCT

Part IV: Anatomical Reconstruction — What Surrounds the Suture Line

The anastomosis suture itself is only one component of the reconstructive step. A growing body of randomized trial evidence demonstrates that what surgeons do around the suture line — specifically how they reconstruct the supportive musculofascial anatomy of the posterior and anterior pelvis — significantly influences early continence recovery.

Posterior Reconstruction — The Rocco Stitch

Described for open prostatectomy by Rocco et al. and adapted for robotic surgery in 2007, posterior musculofascial reconstruction (PMFR) approximates the posterior musculofascial plate (the remnant of Denonvilliers' fascia) to the posterior urethral stump and perineal body, restoring the posterior support of the sphincter complex before the anastomosis is completed. In a more recent review, posterior reconstruction in RARP may result in better continence one week after removal of the catheter compared with RARP without reconstruction, though the benefit at three and twelve months is less clear. The Rocco stitch is widely adopted as a standard add-on to the anastomosis in robotic series, adding minimal operative time.

Anterior Reconstruction

Described by Patel and others for RARP, anterior reconstruction sutures the anterior bladder neck and detrusor to the anterior urethral stump and remnants of puboprostatic ligaments, restoring the anterior anatomical support of the sphincter. Total reconstruction — combining both anterior and posterior techniques — has been shown in multiple prospective series to facilitate faster and higher continence recovery compared with standard approach, posterior reconstruction alone, or anterior reconstruction alone. A large series of over 1,000 procedures of RARP with total reconstruction showed 79.66% of patients continent at three months after catheter removal.

Bladder Neck Preservation

Preserving as much bladder neck diameter and mucosa as possible — avoiding aggressive trimming that can compromise the proximal continence mechanism — is independently associated with improved early continence. Regardless of the chosen technique, protecting the bladder neck as high as possible has been found to preserve urinary continence. This requires identifying and preserving the circular smooth muscle fibers of the bladder neck while achieving clean proximal margins.

Puboprostatic Ligament Preservation

The puboprostatic ligaments anchor the urethra to the pubic bone and are divided in the standard approach to access the dorsal venous complex. Their preservation — possible in Retzius-sparing and Hood approaches and in some modifications of the standard approach — preserves the anterior urethral support geometry and is associated with improved early continence in RCT evidence. A systematic review of 39 randomized controlled trials on continence-sparing techniques found that preservation of the bladder neck and puboprostatic ligaments may contribute to better early continence recovery, although the evidence level is low.

Part V: Nerve-Sparing — The Critical Decision That Determines Erectile Outcomes

Nerve-sparing is not a binary decision — it exists on a spectrum from no sparing (complete NVB excision bilaterally) through unilateral sparing to bilateral sparing, and within bilateral sparing from interfascial to intrafascial dissection planes. Each step on this spectrum represents a trade-off between oncological safety and functional preservation.

The Anatomy of the Neurovascular Bundle

The NVBs run in a fascial sheath on the posterolateral surface of the prostate, embedded between the prostatic fascia and the levator fascia. They are not visible macroscopically as discrete structures — the surgeon must identify and preserve a tissue plane, not an anatomical cord. Heat from energy devices (cautery, ultrasonic dissection) propagates several millimeters beyond the cutting edge and can thermally injure nerve fibers that appear intact. For this reason, cold-cut dissection — scissors or sharp dissection without energy — near the NVBs is critical, and many expert surgeons avoid energy entirely within 1–2 cm of the nerve tissue. The robotic da Vinci platform's superior optical magnification and instrument precision make this cold-cut technique more feasible than in open or standard laparoscopic surgery.

The Fundamental Problem: Surgeons Cannot See Cancer at the Margin

The core difficulty of nerve-sparing is that the surgeon cannot see — intraoperatively, in real time — whether cancer cells are at the prostate surface adjacent to the nerve. The standard preoperative plan (based on MRI, biopsy mapping, and risk stratification) guides the extent of nerve-sparing, but is imperfect. Studies consistently show that a substantial proportion of men who have non-nerve-sparing surgery because of presumed margin risk actually have organ-confined disease on final pathology — they lost their nerves unnecessarily. Conversely, nerve-sparing in some patients does risk leaving a positive margin.

"We tend to err on the side of oncological control. Many patients who have organ-confined disease on the definitive pathology have non-nerve-sparing surgery — we don't spare nerves when we could have." — Professor Greg Shaw, University College London; lead investigator, NeuroSAFE PROOF trial. Urology Times, 2025.

NeuroSAFE — Intraoperative Frozen Section to Resolve the Dilemma

The NeuroSAFE technique, developed by Schlomm et al. at the Hamburg Eppendorf University Hospital beginning in 2012, resolves the surgeon's dilemma by providing real-time intraoperative pathological feedback. After removing the prostate while maximally preserving the NVBs, the prostate is immediately transported to pathology, where sections from the posterolateral surface (the NVB interface) are snap-frozen, sectioned, stained, and examined microscopically — in approximately 20–25 minutes while the patient remains on the table. If the margin adjacent to the nerve is clear, the NVB is preserved and the anastomosis proceeds. If positive, the surgeon excises the NVB on the affected side (secondary resection) to achieve oncological clearance.

This approach transforms nerve-sparing from a preoperative gamble into an intraoperative real-time decision. The March 2025 NeuroSAFE PROOF Phase 3 randomized controlled trial — the first properly randomized evaluation of this technique — is now the pivotal evidence base.

NeuroSAFE PROOF results (Lancet Oncology, March 2025; 381 patients, 5 UK NHS centers):

NeuroSAFE PROOF — Key Trial Results (Lancet Oncology, 2025)

• Bilateral nerve-sparing rate: 82.1% with NeuroSAFE vs. 56.4% with standard RARP — a 45% relative increase in nerve-sparing surgery
• No or mild erectile dysfunction at 12 months: 39% (NeuroSAFE) vs. 23% (standard RARP) — a 70% relative improvement
• Severe erectile dysfunction at 12 months: 38% (NeuroSAFE) vs. 56% (standard RARP)
• Erections sufficient for intercourse at 12 months: 32% vs. 18% — nearly double
• Benefit was greatest in men who would NOT have received bilateral nerve-sparing under standard preoperative planning — exactly the patients most at risk of unnecessary functional loss
• Positive surgical margins: 21% small PSM in NeuroSAFE vs. 13% in standard — more small PSMs, but fewer large/multifocal PSMs (14% vs. 16%), suggesting the secondary resection option allows rescue when margins are found
• PSA persistence and biochemical recurrence at 12 months: Small, non-statistically significant numerical differences; 12 months acknowledged as early for definitive oncological conclusions
• Continence: Early benefit at 3 and 6 months in NeuroSAFE group; equivalent long-term rates at 12 months
• Operative time: 174 min (NeuroSAFE) vs. 131 min (standard) — 43 minutes longer
• Trial conclusion: "This supports using the NeuroSAFE technique during RARP to guide nerve-sparing and prostate cancer care guidelines should be updated accordingly."

The 2024 systematic review and meta-analysis of 14 studies (7,505 NeuroSAFE patients across 15,446 total patients) confirmed that the increased number of nerve-sparing surgeries with NeuroSAFE, together with reduced PSMs, non-inferior biochemical recurrence, and low adverse event rates, implies that NeuroSAFE is an oncologically safe technique associated with improved erectile function.

NeuroSAFE — Limitations Patients Should Understand

• Not universally available: Requires a pathology team capable of rapid frozen section processing in the operating room or immediately adjacent. Currently limited to high-volume specialist centers. Not standard in most U.S. community hospitals.
• Adds operative time: ~40 minutes of anesthesia for the pathology turnaround. This has patient safety implications for comorbid patients.
• Not for everyone: Patients with frankly high-risk disease and clearly indicated non-nerve-sparing surgery do not benefit. Most appropriate for patients where nerve-sparing candidacy is uncertain — the "borderline" patient.
• Oncological follow-up is short: 12-month PSA data are reassuring but not definitive. Five-year data are awaited.
• The 3% BCR/PSA persistence numerical difference in the trial (NeuroSAFE vs. standard) requires long-term follow-up to determine whether it is clinically meaningful or within the noise of short-term variation.

Degrees of Nerve Preservation: Bilateral vs. Unilateral vs. Non-Sparing

A meta-analysis of 8 cohort studies (2,499 patients) found that nerve-sparing was beneficial for recovery of urinary continence (RR 0.46; p = 0.045) and erectile function during RARP. A larger meta-analysis found that avoiding damage to the nerves around the prostate improves urinary continence in the first six months after surgery; after this time, there is no statistically significant difference in continence between men who had nerves removed and those who had them saved. This is a nuanced result: nerve-sparing accelerates continence recovery without necessarily changing the ultimate long-term continence rate — another argument for nerve-sparing as broadly beneficial even beyond erectile function.

For erectile function specifically, the gradient is stark: bilateral nerve-sparing in preoperatively potent men at expert centers achieves 60–90% satisfactory erections at 12–18 months. Unilateral nerve-sparing achieves 40–70%. Non-nerve-sparing achieves 5–15%. In one single-surgeon series with novel nerve-sparing and endopelvic fascia preservation, 97% of bilateral nerve-sparing patients and 80% of unilateral nerve-sparing patients achieved satisfactory erectile function, with 96% achieving pad-zero urinary continence by one year.

The Intrafascial vs. Interfascial Distinction

Within nerve-sparing, the dissection plane matters. Interfascial dissection cuts between the prostatic fascia and the levator fascia — outside the prostatic fascia, inside the NVB sheath. Intrafascial dissection cuts directly on the prostate capsule, within the prostatic fascia — the most nerve-preserving plane possible but the one with the highest risk of a positive margin if tumor is near the capsule. Intrafascial dissection is appropriate only for very low-risk disease; interfascial is the standard for most nerve-sparing cases.

Part VI: Emerging and Adjunct Technologies

Fluorescence-Guided Nerve Identification (ICG)

Indocyanine green (ICG) fluorescence imaging — already widely used in robotic surgery for lymphatic mapping — is being investigated for real-time visualization of neural structures during prostatectomy. A 2025 study found that ICG fluorescence-assisted nerve-sparing RARP had a favorable impact on lower urinary tract symptoms. This approach aims to make nerve tissue directly visible rather than inferred from fascial anatomy alone. It remains investigational and requires specialized near-infrared camera systems available on newer da Vinci Xi and da Vinci 5 platforms.

Augmented Reality and 3D Reconstruction

Three-dimensional reconstruction of prostate MRI data, superimposed on the live surgical field as augmented reality, allows the surgeon to "see through" the prostate surface to the location of cancer foci and their relationship to the capsule and NVBs in real time. Porpiglia and colleagues at Turin have published on HA3D (Hyper-Accuracy Three-Dimensional) reconstruction with augmented reality RARP, demonstrating improved margin rates and nerve-sparing precision compared to standard RARP. This technology is at the leading edge of deployment in specialty centers and is not yet routine.

da Vinci 5 Force Feedback

As discussed in companion IPCSG articles, the da Vinci 5 system (launched 2024) includes integrated force feedback — the first FDA-approved surgical robot with this capability. During dissection near the NVBs and during anastomosis suture placement, force feedback allows the surgeon to feel when suture tension is becoming excessive, potentially reducing sphincter trauma from an over-tensioned anastomosis and NVB thermal injury from tissue handling. Published data show approximately 20% reduction in peak applied force in clinical use; the implications for nerve-sparing outcomes are being studied.

Part VII: Questions Patients Should Ask Their Surgeon

Informed Consent Checklist — What to Ask Your Surgeon

1. Which surgical approach do you use — standard anterior, Retzius-sparing, or Hood — and why for my specific anatomy and tumor location? If I have an anterior tumor, is Retzius-sparing still on the table?
2. What is your personal positive surgical margin rate for patients at my risk stage (pT2 vs. pT3), and how does it compare to published benchmarks?
3. What anastomosis technique do you use — Van Velthoven running, barbed suture, or other — and do you perform posterior musculofascial reconstruction (Rocco stitch) and/or anterior reconstruction?
4. Am I a candidate for nerve-sparing, and on which sides? What is your preoperative planning tool — MRI alone, biopsy mapping, PSMA-PET?
5. Does your center offer NeuroSAFE? Given the Lancet Oncology Phase 3 trial results, if I am in the "borderline" nerve-sparing category, am I a candidate?
6. What is your personal 12-month continence rate by pad-free definition, at your case volume? What is your 12-month erectile function recovery rate for bilateral nerve-sparing patients with my preoperative potency level?
7. How many RARPs do you perform per year? The learning curve is 50–100 cases for basic proficiency, and outcomes continue to improve well beyond 250 cases. Volume matters.
8. What penile rehabilitation protocol do you use? Early phosphodiesterase-5 inhibitor therapy (daily low-dose sildenafil or tadalafil), vacuum erection device therapy, and other neuroprotective approaches started in the first weeks after surgery are strongly associated with better long-term erectile function recovery.

Verified Sources and Formal Citations

1. Ficarra V, et al. Retzius-sparing vs. standard robot-assisted radical prostatectomy for clinically localised prostate cancer: a comparative study. Prostate Cancer and Prostatic Diseases. 2023;26(3):568–574. doi:10.1038/s41391-022-00625-3
   https://pubmed.ncbi.nlm.nih.gov/36443438/
2. Diamand A, et al. Retzius-sparing versus standard robot-assisted laparoscopic prostatectomy: A two-year patient-reported and oncological assessment. The Prostate. 2025. doi:10.1002/pros.24807
   https://onlinelibrary.wiley.com/doi/10.1002/pros.24807
3. Wald G, et al. Recovery of Urinary Continence after RARP: A Multicenter Comparison of Retzius-Sparing, Hood and Standard Techniques. Presented at: 2025 American Urological Association Annual Meeting. Las Vegas, NV. April 2025.
   UroToday AUA 2025 Summary
4. Dinneen E, Almeida-Magana R, Al-Hammouri T, et al. Effect of NeuroSAFE-guided RARP versus standard RARP on erectile function and urinary continence in patients with localised prostate cancer (NeuroSAFE PROOF): a multicentre, patient-blinded, randomised, controlled phase 3 trial. The Lancet Oncology. 2025;26(4):447–458. doi:10.1016/S1470-2045(25)00091-9
   https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(25)00091-9/fulltext
5. Kroon LJ, et al. Neurovascular Structure-adjacent Frozen-section Examination (NeuroSAFE) During Radical Prostatectomy: A Systematic Review and Meta-analysis. European Urology Oncology. Published online December 2024. doi:10.1016/j.euo.2024.12.008
   https://www.sciencedirect.com/science/article/pii/S2588931124002906
6. [UCL News]. Twice as many men recover erectile function after improved prostate cancer surgery. University College London News. March 24, 2025.
   https://www.ucl.ac.uk/news/2025/mar/twice-many-men-recover-erectile-function-after-improved-prostate-cancer-surgery
7. [Urology Times]. NeuroSAFE procedure for RARP leads to improved erectile function. Urology Times. 2025.
   https://www.urologytimes.com/view/neurosafe-procedure-for-rarp-leads-to-improved-erectile-function
8. Wiatr T, Belch L, Gronostaj K, et al. Van Velthoven single-knot running suture versus Chlosta's running suture versus single barbed suture V-Loc for vesicourethral anastomosis in laparoscopic radical prostatectomy: a retrospective comparative study. Wideochirurgia i Inne Techniki Małoinwazyjne. 2022;17(1):214–225. doi:10.5114/wiitm.2021.105851
   https://pmc.ncbi.nlm.nih.gov/articles/PMC8886460/
9. [Van Velthoven R]. Van Velthoven suturing after laparoscopic radical prostatectomy is effective, easily learned. Urology Times. [EAU multicenter series, 5,158 patients; stenosis rate <1%; anastomosis time by training level]
   https://www.urologytimes.com/view/van-velthoven-suturing-after-laparoscopic-radical-prostatectomy-effective-easily-learned
10. Van Velthoven RF, Ahlering TE, Peltier A, Skarecky DW, Clayman RV. Technique for laparoscopic running urethrovesical anastomosis: the single knot method. Urology. 2003;61(4):699–702. [Original Van Velthoven description]
    https://pubmed.ncbi.nlm.nih.gov/12670548/
11. [Fankhauser CD, Afferi L, Antonelli A, Mattei A]. Anterior sphincter-sparing suturing of the vesicourethral anastomosis during RARP. European Urology Open Science. 2023. [448 patients; 91% pad-free at 1 year; no retention/stricture]
    https://www.eu-openscience.europeanurology.com/article/S2666-1683(23)00181-7/fulltext
12. [Anonymous, 2025 Randomized Trial]. A Pragmatic Randomized Trial Comparing Suturing Techniques for VUA: One-Year Voiding Function Outcomes After Radical Prostatectomy. Journal of Clinical Medicine. June 2025;14(11):3934. [Interrupted vs. running suture — equivalent outcomes at 12 months]
    https://www.mdpi.com/2077-0383/14/11/3934
13. [Checcucci E, et al.] Surgical techniques to preserve continence after robot-assisted radical prostatectomy. Frontiers in Surgery. October 2023. doi:10.3389/fsurg.2023.1289765 [Comprehensive review of BNP, total reconstruction, Rocco stitch, NVB sparing evidence]
    https://www.frontiersin.org/journals/surgery/articles/10.3389/fsurg.2023.1289765/full
14. Casale P, et al. Continence-sparing techniques in radical prostatectomy: a systematic review of randomized controlled trials. Journal of Endourology. 2023;37(11):1088–1104. [39 RCTs; RARP and RS-RARP highest evidence; BNP, PPL preservation lower evidence]
    https://pubmed.ncbi.nlm.nih.gov/37597197/
15. Liu Y, Deng X, Qin J, et al. Erectile function, urinary continence and oncologic outcomes of neurovascular bundle sparing RARP for high-risk prostate cancer: a systematic review and meta-analysis. Frontiers in Oncology. 2023;13:1161544. doi:10.3389/fonc.2023.1161544 [8 cohort studies, 2,499 patients; NS beneficial for continence RR 0.46 and EF]
    https://www.frontiersin.org/journals/oncology/articles/10.3389/fonc.2023.1161544/full
16. Reeves F, Preece P, Kapoor J, et al. Preservation of the neurovascular bundles is associated with improved time to continence after radical prostatectomy but not long-term continence rates: results of a systematic review and meta-analysis. European Urology. 2015;68(4):692–704.
    https://www.ncbi.nlm.nih.gov/books/NBK292451/
17. Xiang P, Du Z, Guan D, et al. Is there any difference in urinary continence between bilateral and unilateral nerve sparing during radical prostatectomy? A systematic review and meta-analysis. World Journal of Surgical Oncology. 2024;22:66. doi:10.1186/s12957-024-03340-6
    https://pmc.ncbi.nlm.nih.gov/articles/PMC10885481/
18. [Gunge N, et al.] Effect of ICG fluorescence-assisted new nerve-sparing of RARP on lower urinary tract symptoms. International Journal of Urology. 2025;32(3):285–292. doi:10.1111/iju.15644
    [Cited in: Current Urology Reports review of next-generation nerve-sparing techniques, 2025]
19. Hashimoto T, et al. Novel nerve-sparing robot-assisted radical prostatectomy with endopelvic fascia preservation and long-term outcomes for a single surgeon. Scientific Reports. January 2024. doi:10.1038/s41598-024-51598-3 [96% pad-zero continence; 97% BNS EF; 80% UNS EF at 1 year]
    https://www.nature.com/articles/s41598-024-51598-3
20. Gong W, Yan J, Cui Y, Zhang D, Ma Y. Comparison of efficacy of Retzius-sparing radical prostatectomy versus standard radical prostatectomy in the treatment of prostate cancer: a systematic review and meta-analysis. Frontiers in Oncology. 2025;15:1547687. doi:10.3389/fonc.2025.1547687
    https://www.frontiersin.org/journals/oncology/articles/10.3389/fonc.2025.1547687/full
21. Yaxley JW, Gianduzzo T. Does a Retzius-sparing surgical technique improve urinary continence recovery after RARP? A systematic review and meta-analysis of comparative studies. Prostate Cancer and Prostatic Diseases. 2025;28:533–534. doi:10.1038/s41391-024-00881-5
    https://www.nature.com/articles/s41391-024-00881-5

This article was prepared as educational content for the Informed Prostate Cancer Support Group (IPCSG) newsletter. It does not constitute medical advice. All outcome data are drawn from peer-reviewed literature as cited. Individual patient outcomes vary substantially based on preoperative function, tumor characteristics, surgeon experience, and center volume. Patients should discuss surgical approach selection and technique preferences directly with their surgeon in the context of their own clinical picture.