UROLOGICAL ONCOLOGY Detrusorrhaphy and Intrafascial Nerve-Sparing During Robot-Assisted Radical Prostatectomy on Recovery of Continence and Potency: Surgical Feasibility, One-Year Functional and Oncologic Outcomes Tae Young Shin, Yong Seong Lee* Purpose: To report the 1-year functional outcomes, oncologic outcomes, and postoperative complications in pa- tients who underwent modified robot-assisted radical prostatectomy (RARP) procedures for achieving early recov- ery of continence and potency postoperatively. Materials and Methods: This study included 165 patients who underwent RARP. Overall, 98 patients underwent RARP using our modified detrusorrhaphy and intrafascial nerve-sparing techniques (group 1) and 67 underwent standard RARP (group 2). Continence and potency rates were assessed at 1 week, 1, 3, 6, and 12 months after RARP. Oncologic outcomes comprised positive surgical margins (PSMs) and biochemical recurrence (BCR) rate. Results: The continence rates were 61.2% and 6.0%, 72.5% and 11.9%, 79.6% and 20.9%, 91.8% and 58.2%, and 97.9% and 74.6% at 1 week, 1, 3, 6, and 12 months in group 1 and 2, respectively. The potency rates were 66.3% and 11.9%, 78.6% and 38.8%, 85.7% and 50.8%, 92.9% and 70.2%, and 95.9% and 79.1% at 1 week, 1, 3, 6, and 12 months in group 1 and 2, respectively. Overall postoperative complication rates (< 10%) were similar between the groups. The PSMs rate was 17.4% and 16.4% in the two groups. The rate of PSMs in the cohort of patients with stage pT2 disease decreased to 13.6% and 12.5% in groups 1 and 2, respectively. BCR rate was 5.1% and 6.0% in groups 1 and 2, respectively. Conclusion: The use of detrusorrhaphy and intrafascial nerve-sparing techniques is safe and feasible, with our results demonstrating early return to continence and potency. Further studies should be conducted. Keywords: prostate cancer; robot-assisted radical prostatectomy; continence; nerve-sparing; erectile function INTRODUCTION Over the past decades, impaired urinary and sexual function has restricted the quality of life (QoL) of patients after radical prostatectomy.(1) Studies have de- scribed numerous surgical adaptations to improve the functional outcomes of radical prostatectomy and the use of advantageous robotic ergonomics and tools dur- ing robot-assisted radical prostatectomy (RARP) has allowed the introduction of various surgical techniques. (2–7) Still, the complications are unresolved after RARP, with incidences ranging from 10% to 69% at 1-year follow-up.(8,9) Particularly in increasing number of pa- tients who are younger, postoperative urinary inconti- nence and erectile dysfunction considerably influence patients’ QoL.(10) In our institution, we have implemented several surgi- cal techniques during RARP in an attempt to achieve early potency and continence. First, to preserve the entire neurovascular bundle (NVB), we focused on the modified clipless intrafascial nerve-sparing approach. Second, we performed a modified detrusorrhaphy tech- nique, which involves reinforcing the posterior detru- sor muscles using a zigzag flap during bladder neck reconstruction. The objective of the present study is to describe the detrusorrhaphy and clipless intrafascial Urology Department, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, An- yang, Korea. *Correspondence: Urology Department, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea. Tel: +82 31 380 3850. Fax: +82 31 380 3852. E-mail: novavia@hallym.or.kr. Received January 2020 & Accepted May 2020 nerve-sparing approaches and to evaluate the postop- erative 1-year functional and oncologic outcomes after RARP. MATERIALS AND METHODS Study population and design Between March 2015 and August 2018, 280 patients underwent RARP in our institution. All procedures were performed by one surgeon who had experience performing > 800 RARPs. Each patient preoperatively underwent multiparametric magnetic resonance imag- ing (mpMRI). This was a retrospective, non-randomized study. Medi- cal records of 280 patients who underwent RARP were retrospectively reviewed. Inclusion and exclusion crite- ria were: 1) we included 208 patients with 1-year of fol- low-up and those who had preoperative continence and potency, defined as a Sexual Health Inventory for Men (SHIM) questionnaire score of ≥ 17, 2) patients with localized low-risk prostate cancer and Gleason score ≤ 7 (cT1–2N0M0) were evaluated, 3) exclusion criteria were any neoadjuvant hormonal treatment, prior radi- ation therapy, and previous history of urethral stricture and urinary incontinence, 4) we excluded nine patients who presented insufficient data and six patients who Urology Journal/Vol 18 No. 3/ May-June 2021/ pp. 314-321. [DOI: 10.22037/uj.v16i7.5915] Vol 18 No 3 May-June 2021 315 were transferred to our institution after being diagnosed with prostate cancer in other hospitals. Finally, 165 of the 208 patients were included in the study (Figure 1): those who underwent the detrusorrhaphy and intra- fascial NVB sparing techniques (group 1, 98 patients) between October 2016 and August 2018 and those who underwent standard RARP approach (group 2, 67 patients) between March 2015 and September 2016. The enrolled patients were divided into two subgroups according to a time criterion to compare the learning Detrusorrhaphy and nerve-sparing techniques-Shin et al. Figure 1. Study flow diagram. Figure 2. Operative steps. (A) Exposure of the prostate capsule by detaching the overlying periprostatic fascia and prostatic pedicles. (B) Further mobilization of the prostatic pedicles, including the neurovascular bundles, by using antegrade dissection (distal end of the prostatic pedicles, white arrow). (C) Combined blunt and sharp dissection of the neurovascular bundles as far distally to the apex as pos- sible until reaching the urethra (prostate capsule, white star; urethra, white arrow). (D) After complete prostate dissection, the preserved neurovascular bundles and prostatic pedicles are clearly visible and become thick. curve. The study protocol was approved by the Univer- sity Hospital Ethics Committee (No. 2018-05-012). Surgical techniques All patients underwent transperitoneal RARP. Patient positioning and port placement were those as described previously.(11) The da Vinci Xi Surgical System was used in all cases. Intrafascial nerve-sparing technique The endopelvic fascia was preserved in those with clin- ical stage ≤ T2c disease. Our intrafascial nerve-sparing technique essentially aims to preserve the surrounding periprostatic structures to the fullest extent. The prostate capsule is carefully exposed after detaching the over- lying fat and periprostatic fascia (Figure 2A). Arterial pulsations from the cavernous vessels within the NVB are easily recorded with further lateral dissection. These vessels are preserved by gently pushing them postero- laterally toward the rectum. The prostatic pedicles are further mobilized off the prostate capsule in an anteri- or direction until the most distal ends of the vascular pedicle (Figure 2B). The identified vascular pedicles are swept off the prostate, further mobilizing the NVBs, which are then gently eased out of the posterolateral surface of the prostate capsule with a combination of blunt and sharp dissection. We continued antegrade dis- section by peeling off the periprostatic fascia, NVBs, and the prostatic pedicle en bloc until reaching the ure- thra (Figure 2C). The use of monopolar electrocautery and clips is vigorously avoided during this dissection. If bleeding occurs from the periprostatic vessels, a brief increase in insufflation pressure can be applied to the bleeding source using hemostatic gauze, while slight venous bleeding is left uncontrolled. In cases of pul- satile arterial bleeding, ligation is performed with 4-0 V-Loc suture. The preserved NVBs are clearly visible after prostate dissection (Figure 2D). Bladder reconstruction and detrusorrhaphy tech- nique We designed the detrusorrhaphy technique which is designed for thickening and strengthening the detrusor muscles from the posterior bladder neck to the bilater- al dissected pedicles area. It was based on the theory that anatomically correct reconstructions would pro- vide functional reinforcement of the detrusor muscles. Our simple modification is different from conventional detrusorrhaphy.(12,13) The difference of the our detrusor- rhaphy technique is the use of zigzag suturing, which thickens and strengthens the deteriorated detrusor mus- cles during posterior dissection of the bladder (Figure 3). The conventional reconstruction method focuses on narrowing the bladder neck and suturing both wings of the dissected bladder. The aim of the detrusorrhaphy technique is to reconstruct the detrusor muscles while maintaining a physiologically and anatomically ide- al shape. This posterior reinforcement is based on the principles of Parsons and colleagues.(14) Pelvic lymph node dissection (PLND) PLND was performed in 88 patients (89.8%) and 61 pa- tients (91.0%) in group 1 and 2, respectively. Extended PLND until common iliac artery area was performed in patients with a risk of lymph node involvement of >5% in the Briganti nomogram.(15) A limited PLND until ob- turator fossa was performed in patients with an estimat- ed risk of <5%. Hem-o-Lok clips are used instead of cauterization to prevent lymphocele formation. Data collection and statistical analysis We assessed following demographic data: age, body mass index (BMI), American Society of Anesthesiol- ogist (ASA) score, prostate volume, PSA level, biopsy Gleason score, and D'Amico risk classification. Base- line sexual function before RARP was assessed with SHIM questionnaire and preoperative continence was evaluated using the International Prostate Symptom Score (IPSS) score. Postoperative complications were recorded and evaluated using the Clavien–Dindo clas- sification.(16) The primary end point was the postoperative function- al and oncologic outcomes. Postoperative functional Figure 3. Operative and schematic view of the detrusorrhaphy technique using a flap of dynamic detrusor cuff muscles (detrusor muscles, white arrow; bladder neck opening, white star). Detrusorrhaphy and nerve-sparing techniques-Shin et al. Urological Oncology 316 Vol 18 No 3 May-June 2021 317 and oncologic results were analyzed between the two groups. The catheter was removed at 1 week postoper- atively. We evaluated the potency rate using a SHIM questionnaire and continence rate using a pad test per day at 1 week and 1, 3, 6, and 12 months after RARP. We considered return to erectile function postoperative- ly as score of ≥ 4 on question 2 of the SHIM or the ability to have successful sexual intercourse. A patient was considered as continent if he applied “0 pad–” per day. Pathologic variables including pathologic stage, Gleason score, and positive surgical margins (PSMs) were evaluated. According to American Urological Association guidelines, biochemical recurrence (BCR) was defined as two consecutive PSA values of ≥ 0.2 ng/mL.(17) Continuous variables were reported as median values and interquartile ranges (IQRs), and categorical vari- ables of frequencies and proportions were reported as percentages. Patient characteristics with continuous variables were analyzed using student’s t-test and non- parametric Mann–Whitney test. Independent factors with categorical variables were analyzed using the chi-square test. Chi-square test was used to compare the rate of continence and potency between the groups. We evaluated the rates of PSMs in the two groups. The same analyses were performed in a subgroup of patients with a suspicion of posterolateral tumor at preoperative mpMRI. A P value of < .05 was considered to indicate a statistically significant difference. All statistical anal- yses were conducted using IBM® SPSS® Statistics Table 1. Demographic, preoperative, perioperative, and histopathologic data for groups 1 and 2 Demographic and preoperative Group 1 Group 2 P-value Patients, number 98 67 Age, median (IQR), year 60.5 (52.0–69.0) 61.5 (53–70.0) .685 BMI, median (IQR), kg/m2 25.4 (23.8–28.0) 25.8 (24.4–29.5) .927 ASA score, median (IQR) 2.0 (1.0–2.0) 2.0 (1.0–2.0) .875 Prostate volume, median (IQR), cc 39.6 (22.5–70.5) 38.5 (21.0–105) .435 PSA, median (IQR), ng/ml 6.9 (3.2–11.5) 7.5 (3.5–19.8) .075 Biopsy Gleason score, median (IQR) - 6 21 (21.4%) 16 (23.9%) .565 - 7 77 (78.6%) 51 (76.1%) .492 mpMRI site of tumor (%) - negative 14 (14.3%) 11 (16.4%) .459 - apical 21 (21.4%) 14 (20.9%) .667 - basal 10 (10.2%) 7 (10.4%) .728 - posterolateral 26 (26.5%) 18 (26.9%) .814 - anterior 8 (8.2%) 5 (7.5%) .452 - multiple 19 (19.4%) 12 (17.9%) .756 IPSS score, median (IQR) 12 (2.0–21.0) 13.5 (3.0–23.0) .475 SHIM score, median (IQR) 20.0 (17–25) 20.5 (17-25) .798 D’Amico risk group (%) - Low risk 77 (78.6%) 47 (70.2%) .645 - Intermediate risk 15 (15.3%) 13 (19.4%) .422 - High risk 7 (7.1%) 7 (10.4%) .785 Perioperative and histopathologic Operative time, median (IQR), min 230 (140–250) 210 (130–300) .522 Blood loss, median (IQR), ml 200 (80–600) 200 (100–600) .892 Blood transfusion rate (%) 1 (1.0%) 2 (2.9%) .535 Nerve sparing (%) - Bilateral 90 (91.8%) 59 (88.1%) .673 - Unilateral 5 (5.1%) 5 (7.5%) .495 - None 3 (3.1%) 3 (4.5%) .521 PLND (%) 88 (89.8%) 61 (91.0%) .348 - Extended PLND 8 (9.1%) 7 (11.5%) .255 - Limited PLND 80 (91.9%) 54 (88.5%) .282 Complications (%) - Clavien grade 1 - Clavien grade 2 8 (8.2%) 6 (9.0%) .592 - Clavien grade 3 0 0 Pathologic stage (%) - pT2 88 (89.8%) 56 (83.6%) .228 - pT3a 7 (7.1%) 7 (10.4%) .136 - pT3b 3 (3.1%) 4 (6.0%) .318 Pathologic Gleason score (%) - <6 20 (20.4%) 13 (19.4%) .785 - 7 73 (74.5%) 47 (70.2%) .682 - >8 5 (5.1%) 7 (10.4%) .115 PSMs rate (%) - overall 17 (17.4%) 11 (16.4%) .485 - among pT2 patients 12 (13.6%) 7 (12.5%) .755 - among pT3 patients 5 (50.0%) 4 (36.4%) .361 PSMs site (%) - apical 9 (52.9%) 5 (45.5%) .125 - posterolateral 5 (29.4%) 4 (36.3%) .355 - multifocal 3 (17.7%) 2(18.2%) .223 Positive PLND (%) 0 0 IQR, interquartile range; BMI, body mass index; ASA, American Society of Anesthesiologist; PSA, prostate–specific antigen; IPSS, Inter- national Prostate Symptoms Score; SHIM, Sexual Health Inventory for Men; PLND, pelvic lymph node dissection. Detrusorrhaphy and nerve-sparing techniques-Shin et al. for Windows, Version 22.0 (IBM Corp., Armonk, NY, USA). RESULTS Demographics Table 1 summarizes the baseline demographic, clinical, and pathological data for the 165 participants. No sig- nificant differences were observed between group 1 and 2 with respect to preoperative demographic and clinical data. Operative outcomes and complications Median operative time in groups 1 and 2 was 230 (IQR: 140–250) and 210 (IQR: 130–300) min, respectively. Total operating and console time were comparable be- tween the two groups. The estimated blood loss and overall complication rates (< 10%) were similar be- tween the groups (Table 1). No patient experienced any intraoperative complications. Up to 1 year post- operatively, none of the patients had urinary retention, and there were no complications, such as lymphocele, that required further procedures. None of the patients showed the positive pelvic lymphadenopathy findings. Continence outcomes Continence rates in groups 1 and 2 were 61.2% and 6.0%, 72.5% and 11.9%, 79.6% and 20.9%, 91.8% and 58.2%, and 97.9% and 74.6% at 1 week, 1, 3, 6, and 12 months of follow-up after RARP, respectively (Ta- ble 2). Up to 3 months, the continence recovery rate in group 1 was significantly higher than that in group 2 (P < .001). On learning curve analysis, a progressive change in the number of continent patients and the dif- ference in operative time between groups at each time point was not recorded. Continence was also assessed using the IPSS score, which revealed no significant between group differences in preoperative IPSS scores (12 and 13.5, respectively). The IPSS scores were com- parable between groups at 1, 3, 6, and 12 months of fol- low-up postoperatively (11.5 and 12.5, 10.5 and 12.5, 6.5 and 8.5, and 6.5 and 8.0, respectively; P > .05). Potency outcomes Potency rates in groups 1 and 2 were 66.3% and 11.9%, 78.6% and 38.8%, 85.7% and 50.8%, 92.9% and 70.2%, and 95.9% and 79.1% at 1 week, 1, 3, 6, and 12 months of follow-up after RARP, respectively (Table 2). Up to 3 months, the potency recovery rate in group 1 was sig- nificantly higher than that in group 2 (P < .05). Of the 98 patients, 84 were potent at 3 months. The remaining fourteen patients could achieve partial erections, but not sufficient for penetration, with or without the use of oral phosphodiesterase type 5 inhibitors agents. In these pa- tients, in the case of suspected seminal vesicle invasion or encountered adhesion between the NVB and pros- tate, a slightly wider dissection or unilateral extrafascial nerve-sparing approach was performed to avoid an iat- rogenic positive surgical margin. Pathologic findings and oncologic results Table 1 shows histopathologic data. The two groups had no differences in their pathologic stage (P > .05). The majority of patients (88 patients; 89.8%) in group 1 presented organ-confined disease; seminal vesicle in- vasion (pT3b) was identified in 3 of the patients (3.1%) and extraprostatic extension (pT3a) was found in 7 pa- tients (7.1%). The postoperative Gleason score 7 corre- sponded to 73 patients (74.5%) in group 1 (29 Gleason 3 + 4, 39.7%; 44 Gleason 4 + 3, 60.3%). Overall, 28 of 165 (16.9%) patients in the two groups revealed PSMs at postoperative pathology, without a significant difference between the two groups (groups 1 and 2: 17.4% and 16.4%, respectively; P > .05). The rate of PSMs in the cohort of patients with stage pT2 disease decreased to 13.6% (12 of 88 patients with pT2 stage) in group 1and 12.5% (7 of 56 patients with pT2 stage) in group 2, respectively (P > .05). The vast majority of PSMs was found to be apical margin 52.9% (9 patients) and 45.5% (5 patients) and posterolateral margin 29.4% (5 patients) and 36.3% (4 patients) in group 1 and 2, respectively. The PSMs in the posterolateral margin were seen in 9 patients in two groups. A subanalysis of patients with a suspicion of posterolateral tumor in preoperative mpMRI (26 and 18 patients in group 1 and 2) was performed. The poster- olateral PSMs were found in 5 (19.2%) of 26 patients in group 1 and 4 (22.2%) of 18 patients in group 2. It shows that there was no significant difference in poster- olateral PSMs rate between the two groups. The patients had a median follow-up period of 27 months (IQR: 17–36). BCR was seen in 5 cases (5.1%) and four cases (6.0%) in group 1 and 2, respectively. Median PSA level at the time of BCR was 0.3 (IQR: 0.2–0.95) ng/mL. Patients with BCR were analyz- ed with pelvic MRI, bone scintigraphy, and chest and abdominal computed tomography. No metastasis was observed in any case, and patients received adjuvant ra- diotherapy and/or androgen deprivation therapy. DISCUSSION The last decade has seen increased acceptance of RARP as s surgical treatment option for younger and sexually healthier patients with localized prostate cancer.(10) Al- though RARP is prioritized with consistent oncological outcomes and a lower risk of complications,(18) post- RARP urinary incontinence and erectile dysfunction still have remained the major complications and not shown a satisfactory reduction as expected. The physiological mechanisms related to post-prosta- tectomy urinary incontinence have not been fully eluci- dated. Potential causes of incontinence after RARP are Table 2. Continence and potency data at various follow-up points after catheter removal in groups 1 and 2 Time Patients achieving continence, N (%) P-value Patients achieving potency, N (%) P-value Group 1 (N=98) Group 2 (N=67) Group 1 Group 2 1 week 60 (61.2%) 4 (6.0%) < .001* 65 (66.3%) 8 (11.9%) < .001* 1 month 71 (72.5%) 8 (11.9%) < .001* 77 (78.6%) 26 (38.8%) < .001* 3 months 78 (79.6%) 14 (20.9%) < .001* 84 (85.7%) 34 (50.8%) .036* 6 months 90 (91.8%) 39 (58.2%) .026* 91 (92.9%) 47 (70.2%) .208 12 months 96 (97.9%) 50 (74.6%) .138 94 (95.9%) 53 (79.1%) .165 * significant at P < .05. Detrusorrhaphy and nerve-sparing techniques-Shin et al. Urological Oncology 318 Vol 18 No 3 May-June 2021 319 known to be due to the disruption of normal anatomic contributors to continence.(19) Studies have described numerous surgical adaptations to improve the conti- nence rate of patients.(5–7) We developed the zigzag de- trusorrhaphy technique, which is specially designed for thickening and strengthening the detrusor muscles from the posterior bladder neck to the bilateral dissected pedicles area. Performing bladder neck narrowing us- ing zigzag suturing with the detrusorrhaphy technique achieves morphologically and fundamentally different results when compared to using the classic tennis rac- quet procedure, which simply uses a side by side stitch to narrow the wide-opened bladder neck. When dissect- ing the base of the prostate, the tissue around the pros- tate and bladder neck is very tight and the boundaries are unclear. We inevitably deteriorate a large amount of detrusor muscle. Our modified procedure aims to re- construct the detrusor muscles to maintain a physiologi- cally and anatomically ideal form. The aspect of the de- trusorrhaphy technique involves dynamic detrusor cuff detrusorrhaphy, which supports the proximal urethra and bladder neck with contractile detrusor tissue and constricts this outlet.(20) Reconstruction of our detrus- orrhaphy technique is thought to prevent hypermobili- zation of the bladder neck area, thereby reducing stress urinary incontinence, and is considered important for the recovery of continence. Our results revealed early continence rates of 61.2%, 72.5%, 79.6%, 91.8%, and 97.9% at 1 week, 1, 3, 6, and 12 months of follow-up after RARP, respectively. These results are consistent with those of other studies demonstrating the benefits of early recovery of urinary continence, although dis- crepancies exist in surgical techniques and continence definitions vary. A nonrandomized single-arm study by Porpiglia et al. achieved similar continence rates (71.8%, 77.8%, 89.3%, 94.4%, and 98.0%) at 1 day, 1, 4, 12, and 24 weeks, respectively, after catheter re- moval.(11) Recent studies have suggested that the course of NVBs is more involved than that previously described by Walsh.(21) Tewari et al. described a hammock-like nerve distribution on which the prostate rests, reveal- ing that NVB is more a network of multiple finely dispersed nerves than a distinct structure.(22,23) Further- more, Eichelberg et al. showed that only 46%–66% of all nerves were found in the classical posterolateral location relative to the prostate, while 21%–29% were identified on the anterolateral surface.(24) Nerve-spar- ing is an important step in radical prostatectomy that determines the functional outcomes of the procedure. We have performed antegrade nerve-sparing, which was similar to the method initially reported by Kursh et al.(25) In developing our athermal clipless intrafascial NVB sparing technique, we focused on two technical principles to spare the NVBs. Our antegrade intrafas- cial approach included completely eliminating the use of monopolar electrocautery (athermal). Additionally, we dissected the NVBs off the prostate in a medial to lateral direction without ligating the vascular pedicles by Hem-o-Lok clips (clipless). It is possible to elimi- nate bulk clipping of the pedicles by dividing the pedi- cle vessels as they enter the prostate. We believe that these factors may result in more viable tissue preserva- tion within the NVBs. Our clipless technique is similar to that described by Chien et al.(26) The risk of PSMs is highly possible when using the method of following the posterior plane laterally and anteriorly. However, our technique did not seem to af- fect the oncologic results. The overall PSMs rate (group 1 and 2: 17.4% and 16.4%, respectively) was higher than that noted in a previously reported study.(27) How- ever, the PSMs rate in the cohort of patients with pT2 stage (group 1 and 2: 13.6% and 12.5%, respectively) was similar or lower than that noted in another study. (28) In the subanalysis of posterolateral PSMs, the poste- rolateral PSMs were found in 5 (19.2%) of 26 patients in group 1 and 4 (22.2%) of 18 patients in group 2. It shows that there was no significant difference in pos- terolateral PSMs rate between the two groups. Using a validated sexual function questionnaire at 1 week after RARP, we found that the patients returned to 66.3% of their baseline preoperative sexual function scores, which then increased to 78.6%, 85.7%, 92.9%, and 95.9% at 1, 3, 6, and 12 months, respectively. This is a favorable outcome compared with other series of RARP using the same validated questionnaire, in which the percentage of patients reporting a return to baseline sexual function was 53.1%, 69.9%, 82.3%, and 86.7% at 1, 3, 6, and 12 months, respectively.(29) The limitations of this study are the retrospective na- ture, the small sample size, and only one surgeon per- forming the surgeries at a single institution. The design of this study is not a randomized study. Basically, the two groups could not be extracted at the same time, which could result in potential selection bias and run- ning curve bias in patients using the modified surgical methods. However, we believe that these biases can be minimized because the operator has already performed more than 800 RARPs from 2007 to the present and the modified surgical methods are not challenging tech- niques. Although our data are still maturing, our initial results have shown early recovery of urinary continence and potency. Longer follow-ups on a larger number of patients comparing two concomitant cohorts of patients undergoing our techniques is necessary to evaluate post- operative recovery of urinary continence and potency in a standardized fashion. Furthermore, preexisting co- morbidities such as diabetes mellitus and smoking his- tory, prostate weight, BMI, D'Amico risk classification, and nerve-sparing bilaterality, which could potentially affect the continence and potency status,(30) were not recorded. Therefore, we should perform multivariate analysis using various other factors in future studies. CONCLUSIONS The use of the detrusorrhaphy and intrafascial nerve-sparing approach during RARP helped to achieve early recovery of continence and potency without com- promising oncologic outcomes. The detrusorrhaphy and intrafascial nerve-sparing techniques are safe and feasible. Our findings should be validated to assure re- producibility of the measurement in a prospective com- parative study. ACKNOWLEDGEMENT No competing financial interests exist. CONFLICT OF INTEREST The authors report no conflict of interest. REFERENCES 1. Willis DL, Gonzalgo ML, Brotzman M, Feng Z, Trock B, Su LM. Comparison of outcomes Detrusorrhaphy and nerve-sparing techniques-Shin et al. between pure laparoscopic vs robot-assisted laparoscopic radical prostatectomy: a study of comparative effectiveness based upon validated quality of life outcomes. BJU Int. 2012;109:898–905. 2. Menon M, Shrivastava A, Bhandari M, Satyanarayana R, Siva S, Agarwal PK. Vattikuti Institute prostatectomy: technical modifications in 2009. Eur Urol. 2009;56:89– 96. 3. Patel VR, Schatloff O, Chauhan S, et al. The role of the prostatic vasculature as a landmark for nerve sparing during robot-assisted radical prostatectomy. Eur Urol. 2012;61:571–6. 4. Basiri A, de la Rosette JJ, Tabatabaei S, Woo HH, Laguna MP, Shemshaki H. Comparison of retropubic, laparoscopic and robotic radical prostatectomy: who is the winner? World J Urol. 2018;36:609–21. 5. Vora AA, Dajani D, Lynch JH, Kowalczyk KJ. Anatomic and technical considerations for optimizing recovery of urinary function during robotic-assisted radical prostatectomy. Curr Opin Urol. 2013;23:78–87. 6. Basiri A, Hosseini Sharifi SH. Revisiting vesicourethral anastomosis during open radical retropubic prostatectomy; a simple and reproducible technique: a single center experience with 200 cases. Urol J. 2019;16:475–7. 7. Kohjimoto Y, Yamashita S, Kikkawa K, et al. The association of length of the resected membranous urethra with urinary incontinence after radical prostatectomy. Urol J. 2020;17:146–51. 8. Kumar A, Tandon S, Samavedi S, Mouraviev V, Bates AS, Patel VR. Current status of various neurovascular bundle-sparing techniques in robot-assisted radical prostatectomy. J Robot Surg. 2016;10:187–200. 9. 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;62:405–17. 10. Penson DF, Feng Z, Kuniyuki A, et al. General quality of life 2 years following treatment for prostate cancer: what influences outcomes? results from the prostate cancer outcomes study. J Clin Oncol. 2003;21:1147–54. 11. Porpiglia F, Bertolo R, Manfredi M, et al. Total anatomical reconstruction during robot- assisted radical prostatectomy: implications on early recovery of urinary continence. Eur Urol. 2016;69:485–95. 12. Walsh PC, Marschke PL. Intussusception of the reconstructed bladder neck leads to earlier continence after radical prostatectomy. Urology. 2002;59:934–8. 13. Tan G, Srivastava A, Grover S, et al. Optimizing vesicourethral anastomosis healing after robot-assisted laparoscopic radical prostatectomy: lessons learned from three techniques in 1900 patients. J Endourol. 2010;24:1975–83. 14. Parsons JK, Marschke P, Maples P, Walsh PC. Effect of methylprednisolone on return of sexual function after nerve-sparing radical retropubic prostatectomy. Urology. 2004;64:987–90. 15. Briganti A, Larcher A, Abdollah F, et al. Updated nomogram predicting lymph node invasion in patients with prostate cancer undergoing extended pelvic lymph node dissection: the essential importance of percentage of positive cores. Eur Urol 2012;61: 480–7. 16. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13. 17. Cookson MS, Aus G, Burnett AL, et al. Variation in the definition of biochemical recurrence in patients treated for localized prostate cancer: the American Urological Association Prostate Guidelines for Localized Prostate Cancer Update Panel report and recommendations for a standard in the reporting of surgical outcomes. J Urol. 2007;177:540–5. 18. Froehner M, Novotny V, Koch R, Leike S, Twelker L, Wirth MP. Perioperative complications after radical prostatectomy: open versus robot-assisted laparoscopic approach. Urol Int. 2013;90:312–5. 19. Tewari AK, Ali A, Ghareeb G, et al. Improving time to continence after robot-assisted laparoscopic prostatectomy: augmentation of the total anatomic reconstruction technique by adding dynamic detrusor cuff trigonoplasty and suprapubic tube placement. J Endourol. 2012;26:1546–52. 20. Moinzadeh A, Shunaigat AN, Libertino JA. Urinary incontinence after radical retropubic prostatectomy: the outcome of a surgical technique. BJU Int. 2003;92:355–9. 21. Walsh PC, Donker PJ. Impotence following radical prostatectomy: insight into etiology and prevention. J Urol. 1982;128:492–7. 2 2. Tewari AK, Ali A, Metgud S, et al. Functional outcomes following robotic prostatectomy using athermal, traction free risk-stratified grades of nerve sparing. World J Urol. 2013;31:471–80. 23. Tewari AK, Srivastava A, Huang MW, et al. Anatomical grades of nerve sparing: a risk- stratified approach to neural-hammock sparing during robot-assisted radical prostatectomy (RARP). BJU Int. 2011;108:984–92. 24. Eichelberg C, Erbersdobler A, Michl U, et al. Nerve distribution along the prostatic capsule. Eur Urol. 2007;51:105–10. 25. Kursh ED, Bodner DR. Alternative method of nerve-sparing when performing radical retropubic prostatectomy. Urology. 1988;32:205–9. 26. Chien GW, Mikhail AA, Orvieto MA, et al. Modified clipless antegrade nerve preservation in robotic-assisted laparoscopic radical prostatectomy with validated sexual function evaluation. Urology. 2005;66:419–23. Detrusorrhaphy and nerve-sparing techniques-Shin et al. Urological Oncology 320 27. Patel VR, Sivaraman A, Coelho RF, et al. Pentafecta: a new concept for reporting outcomes of robot-assisted laparoscopic radical prostatectomy. Eur Urol. 2011;59:702– 7. 28. Srougi V, Bessa J Jr, Baghdadi M, et al. Surgical method influences specimen margins and biochemical recurrence during radical prostatectomy for high-risk prostate cancer: a systematic review and meta-analysis. World J Urol. 2017;35:1481–8. 29. de Carvalho PA, Barbosa JABA, Guglielmetti GB, et al. Retrograde release of the neurovascular bundle with preservation of dorsal venous complex during robot-assisted radical prostatectomy: optimizing functional outcomes. Eur Urol. 2018;S0302:30481–0. 30. Jiang DG, Xiao CT, Mao YH, et al. Impact and predictive value of prostate weight on the outcomes of nerve sparing laparoscopic radical prostatectomy in patients with low risk prostate cancer. Urol J. 2019;16:260–6. Detrusorrhaphy and nerve-sparing techniques-Shin et al. Vol 18 No 3 May-June 2021 321