Functional and Oncological Outcomes of Novel Anterior, Retzius‐Sparing, and Conventional Anterior Approaches in Robot‐Assisted Radical Prostatectomy: A Comparative Cohort Study

OBJECTIVES: To compare functional and oncological outcomes among the novel anterior approach, the Retzius-sparing approach, and the conventional anterior approach for robot-assisted radical prostatectomy. METHODS: This retrospective cohort study included 585 patients who underwent robot-assisted radical prostatectomy between September 2017 and August 2022 at Jichi Medical University Saitama Medical Center. Among them, 173, 109, and 303 patients underwent the novel anterior approach, the Retzius - sparing approach, and the conventional anterior approach, respectively. Urinary continence recovery was evaluated as the primary endpoint, while postoperative inguinal hernia incidence and oncological outcomes, including surgical margins and biochemical recurrence-free survival, were assessed as secondary endpoints and compared using Kaplan-Meier methods. RESULTS: Patient characteristics did not differ across groups except for surgeon's experience and follow-up duration. Both the Retzius-sparing approach and the novel anterior approach were associated with earlier recovery of complete continence (HR = 3.10, 95% CI 2.26-4.26; HR = 1.60, 95% CI 1.25-2.04) and a lower incidence of inguinal hernia (HR = 0.34, 95% CI 0.19-0.62; HR = 0.23, 95% CI 0.13-0.42) compared with the conventional anterior approach. Biochemical recurrence-free survival did not differ significantly among the three approaches, despite the higher rate of positive surgical margins in the Retzius-sparing approach. CONCLUSIONS: The novel anterior approach and the Retzius-sparing approach may offer functional advantages over the conventional anterior approach, while oncological outcomes appear comparable across groups in this retrospective cohort. These hypothesis-generating findings suggest the need for further prospective studies with longer follow-up.