Improved Early Urinary Continence After Robot-Assisted Radical Prostatectomy Using a Modified Vesicourethral Anastomosis with Posterior Musculofascial Reconstruction: A Prospective Comparative Study

Introduction: Post-prostatectomy incontinence (PPI) remains a major functional concern after robot-assisted radical prostatectomy (RARP). Posterior musculofascial reconstruction (PMFR) has been shown to facilitate early urinary continence (EUC), but variations in technique may further improve outcomes. We evaluated whether a modified vesicourethral anastomosis (VUA) incorporating simultaneous PMFR with a single barbed suture [pontine VUA (P-VUA)] may facilitate continence recovery compared with the standard Van Velthoven anastomosis (ST-VUA). Materials and Methods: This prospective study included patients undergoing RARP between January 2021 and December 2023. Allocation was based on surgeon preference. UC was defined as the use of no pads or one dry safety pad per day and was assessed at 10, 30, 90, 180, and 365 days after catheter removal. Multivariable logistic regression was performed to evaluate factors associated with 30-day continence. Time to continence was additionally analyzed using Kaplan–Meier methods. Results: This prospective comparative study included 157 patients undergoing robot-assisted radical prostatectomy (RARP) between January 2021 and December 2023 (76 ST-VUA, 81 P-VUA). Baseline and pathological characteristics were comparable between groups. Catheterization time was significantly shorter in the P-VUA group (5.0 ± 1.1 vs. 6.7 ± 1.4 days, p < 0.001). Continence rates were higher in the P-VUA group at 10 days (72.8% vs. 55.3%, p = 0.03), 30 days (84.0% vs. 68.4%, p = 0.035), 90 days (92.6% vs. 76.3%, p = 0.007), 180 days (93.8% vs. 82.9%, p = 0.044), and 365 days (97.5% vs. 86.8%, p = 0.015). Kaplan–Meier analysis demonstrated a shorter time to continence in Group P (log-rank p = 0.0037). In multivariable analysis, P-VUA was independently associated with higher odds of 30-day continence (OR 6.38, 95% CI 2.08–19.63, p = 0.001). Conclusions: The study suggests that the P-VUA technique was associated with faster recovery of urinary continence compared with ST-VUA in this prospective, non-randomized cohort. These findings support the hypothesis that integrating anatomical reconstruction principles into the anastomotic step may enhance functional outcomes after RARP. However, the results should be interpreted with caution, given the study design and sample size, and require confirmation in larger, preferably randomized studies.