The earliest recorded prostate cancer surgery dates back over 100 years. In 1901, the Frenchman Proust performed a transperineal prostatectomy, and in 1904, the American Young performed a prostate cancer surgery (1). Due to the limitations of medical technology at that time, the mortality risk of radical prostatectomy for radical prostate cancer surgery was as high as 30% (2). Starting from the 1940s, radical prostatectomy through the posterior pubic approach began to be applied in clinical practice. In the 1980s, Professor Walsh conducted research on the pelvic floor anatomy of the prostate and proposed a posterior pubic nerve-preserving prostatectomy, elevating the prostate cancer surgery technology to a new level. Before this, the S-RARP surgery had become the classic method for radical prostatectomy (3).

Although the radical prostatectomy through the posterior pubic approach significantly reduced intraoperative bleeding and improved postoperative urinary control and sexual function, 7% of patients still needed diapers one year after the operation (3). To achieve more minimally invasive and better functional recovery, urologists have been exploring more treatment methods and new technologies. After 1990, laparoscopic technology was applied in the field of urology. In 1997, Schuessler et al. (4) reported laparoscopic radical prostatectomy (LRP), and by 2000, German Binder and Kramer (5) first performed robot-assisted laparoscopic radical prostatectomy, using the clear 3D vision and flexible robotic arms of the robot to achieve better surgical results and develop the VIP technology. However, whether it is the classic open nerve-preserving radical prostatectomy or the surgical techniques of the robot era, both patients and doctors still face the problem of early urinary incontinence after the operation. The proportion of postoperative urinary incontinence one month after the operation varies from 10% to 50%, which is one of the main problems affecting the quality of life of patients after the operation (6). In 2010, Professor Bocciardi from Italy proposed a new robotic surgical approach, opening the peritoneum behind the bladder and in front of the rectum in the Douglas fossa, and completely removing the prostate. This technique was named the robot-assisted laparoscopic radical prostatectomy with Retzius space preservation (Retzius-sparing RARP, RS-RARP), and is generally referred to as the posterior approach prostatectomy. The posterior approach has better immediate urinary control and 3-month and 6-month urinary control than traditional robot-assisted prostatectomy (7). By 2020, the EAU Prostate Cancer Diagnosis and Treatment Guidelines recommended the posterior approach surgery as one of the surgical methods for prostate cancer (8).

The posterior approach surgery has obvious advantages in immediate and early urinary control after the operation. However, when transitioning from the standard anterior approach surgery to the posterior approach surgery, surgeons often face difficulties such as limited surgical space, few surgical anatomical landmarks, and changes in surgical habits. Therefore, at present, the adoption rate of posterior approach prostate cancer surgery in Europe is not high, and the number of units and doctors performing posterior approach surgery in China is relatively small, and it is even less frequently carried out routinely. The center where I work began to perform posterior approach prostate cancer surgery in 2023, and so far, we have completed over 100 posterior approach robot-assisted laparoscopic radical prostatectomies, and now we have routinely carried out posterior approach surgery. Therefore, in this study, we compared two groups of prostate cancer patients who received different surgical approaches to evaluate their surgical outcomes.

After obtaining approval from the ethics committee, a retrospective analysis was conducted on patients who underwent radical prostatectomy at the First Affiliated Hospital of Gannan Medical University from October 2019 to March 2025. Inclusion criteria: (1) No severe cardiovascular, pulmonary or systemic diseases, and physically capable of undergoing surgery; (2) Expected survival time >10 years and willing to undergo postoperative follow-up; (3) Diagnosed with prostate cancer through pathological examination; (4) Local early-stage or partially locally advanced patients with no tumor metastasis; (5) No radiotherapy or chemotherapy before the surgery. Exclusion criteria: (1) Having contraindications for laparoscopic surgery (such as tumor metastasis, hematological diseases, cardiac or pulmonary dysfunction, etc.); (2) Complicated with mental disorders, cognitive impairments, etc., and unable to cooperate with treatment; (3) Having urinary incontinence, infections, etc. before the surgery; (4) Complicated with other primary tumors or other severe underlying diseases; (5) Having a history of complex pelvic surgeries in the past. A total of 120 patients operated by one surgical team were divided into two groups. Patients with prostate cancer before 2023 were classified into Group 1 based on inclusion and exclusion criteria. Patients with prostate cancer after 2023 were divided into Group 1 and Group 2 based on the different surgical approaches. The 60 patients in the first group underwent surgery using the S-RARP technique, and the 60 patients in the second group underwent surgery using the RS-RARP technique. The collected clinical data included height, weight, age, BMI, preoperative neoadjuvant therapy, prostate-specific antigen (PSA) level, pathological prostate volume, clinical stage; the collected perioperative and postoperative follow-up data included total hospital stay, operation time, hemoglobin difference, postoperative drainage situation, positive rate of surgical margins, perioperative complications, postoperative urinary incontinence (considered as urinary control recovery if using no more than 1 pad within 24 h) (8), biochemical recurrence (BCR) situation (continuous two postoperative PSA levels >0.2 ng/mL). On the day of extubation, patients were reminded by phone to come to the outpatient clinic to observe urinary incontinence, and the urinary control status and postoperative PSA levels of the patients were recorded at 1 week, 1 month, 3 months and 6 months after the operation, with a median follow-up time of 11 (6–23) months.

With the improvement of living standards, people naturally develop a desire for a higher quality of life. More and more prostate cancer patients are no longer satisfied with tumor control alone, but also demand to retain sexual function and early recovery of urinary control after surgery. For urologists, our thinking needs to shift to meeting patients' needs for urinary control and sexual function recovery without affecting tumor control. In this study, we retrospectively analyzed the case data of prostate cancer patients who underwent RS-RARP and RARP, and found that the method of preserving the Retzius space was related to the early recovery of urinary control.

In 2010, Professor Bocciardi from Italy proposed a new robotic surgical approach. The peritoneum was opened in the Douglas fossa behind the bladder and in front of the rectum, and the prostate was completely removed. This surgical approach is different from the traditional anterior approach surgery. The traditional anterior approach surgery uses the bladder as a landmark, separates the anterior wall of the bladder and enters the posterior space of the pubic bone (Vattikuti-style as an example), then removes the prostate. This surgical method will damage some important structures in the anterior cavity, including nerve and blood vessel bundles, Aphrodite veil, pelvic fascia, Santorini plexus, pubocervical ligament, and all the structures that are believed to play a role in maintaining erection and sexual function (9–11). The posterior approach Douglas space follows a complete intra-fascial plane and does not dissect the anterior cavity (12). It bypasses the related anatomical structures related to urinary incontinence, such as the Retzius space. Therefore, this technique was named the robot-assisted laparoscopic radical prostatectomy with Retzius preservation (Retzius-sparing RARP, RS-RARP), and is generally referred to as posterior approach prostatectomy. This technique simulates the earliest transperineal approach prostatectomy. Prostatectomy is performed through the intra-fascial or inter-fascial plane. Due to its complete preservation of important structures in the anterior cavity and more preservation of the bladder neck muscles, good urinary control was achieved after surgery. By 2020, the EAU prostate cancer diagnosis and treatment guidelines recommended posterior approach surgery as one of the surgical methods for prostate cancer.

The superior performance of RS-RARP in urinary control has led more and more urologists to try this surgical method. The related research has also increased. In terms of urinary control, multiple centers' high-quality randomized controlled study data have confirmed that RS-RARP has significant advantages in immediate and early urinary control. The results of Qiu X et al.'s one-year follow-up in a randomized controlled, single-blind trial showed that one week after extubation, the urinary control of the posterior approach group was significantly higher than that of the anterior approach group (p < 0.05) (13). The study by Mani et al. showed that the early recovery of the posterior approach (Bocciardi) approach had significant advantages, but there was no significant difference between the two groups after more than 6 months (14). Asimakopoulos A D et al.'s study also showed that the posterior approach was superior to the traditional robotic prostatectomy in immediate urinary control, at 3 months and 6 months after surgery (15). Among the 60 patients in the posterior approach group of this study, the immediate urinary continence rate was 71.7%, significantly higher than that of the anterior approach group. Moreover, the urinary continence rates within 1 week and 1 month were also higher than those of the anterior approach group. Similar conclusions were drawn, which were consistent with those of other high-quality studies (16–18).

The posterior approach surgery has obvious advantages in immediate and early urinary control after surgery. However, when transitioning from the standard anterior approach surgery to the posterior approach surgery, surgeons often face difficulties such as limited surgical space, few surgical anatomical landmarks, and changes in surgical habits. Therefore, at present, the adoption rate of posterior approach prostate cancer surgery in Europe is not high (19–21). In China, the number of units and doctors performing posterior approach surgery is relatively small, and it is even less frequently carried out. The center where our team is located began to implement posterior approach prostate cancer surgery in 2023. Through technological improvement, up to now, we have successfully completed over 100 posterior approach robot-assisted laparoscopic radical prostatectomy surgeries. We have now routinely carried out posterior approach surgeries and have become one of the early and few units in China to routinely perform such surgeries. In the practice of posterior approach surgeries, our team, through practical experience and reflection on posterior approach surgeries, proposed a surgical approach for the prostate divided into three layers, and achieved good surgical results and excellent urinary control effects. We have realized that by dividing the prostate into three layers, it is possible to better find the surgical planes, establish surgical anatomical landmarks, and avoid surgical complications. Now, we introduce the method as follows: We divide the globular prostate into three layers. The first layer is the posterior plane between the Denonvillier fascia and the rectum. The second layer is the lateral plane between the prostate capsule and the fascia. The third layer is the anterior plane between the prostate and the anterior fibromuscular stroma band. The vas deferens and seminal vesicle are the first important anatomical landmark during the surgery. After exposing the Douglas fossa and revealing the vas deferens and seminal vesicle, we do not first free the seminal vesicle and vas deferens, but instead, along their surface, we free them into the bottom of the prostate. The anterior plane of the Denonvillier fascia and the anterior plane of the rectum is a natural loose anatomical plane. Using the robotic arm to pull the vas deferens and performing blunt dissection of the Denonvillier fascia to enter the posterior plane between the prostate and the Denonvillier fascia (technique within the fascia) or into the anterior plane of the rectum (technique outside the fascia), then we free the vas deferens and seminal vesicle gland. The surgical difficulty lies in transitioning from the first layer to the second layer. This is also the part where NVB attaches and blood vessels enter the prostate. Using the anatomical “scalpel” technique to handle the area where NVB enters the prostate, to achieve precise coagulation, it is recommended to set the energy level at less than 30 watts of electrocoagulation, with a short duration (less than 1 s), and try to avoid using electrocoagulation near the nerve and blood vessel bundles (5−10 mm). The bladder neck is another important anatomical landmark during the surgery. The urinary catheter helps to better locate the bladder neck. By blunt and sharp dissection of the bladder prostate muscle and the muscles around the bladder neck, the shape of the bladder neck can be well revealed, regardless of the size of the prostate. The posterior approach can retain all the internal urethral sphincters of the prostate, while the anterior approach may sever the muscle of the bladder-prostate connection at 2–6 o'clock and 8–12 o'clock. The male urinary control mechanism mainly relies on the muscle tension of the urethral internal sphincter and the pelvic floor muscle complex and the function of the pubocervical urethral ligament suspension. Therefore, the posterior approach has better early urinary control function. By dissecting the seminal vesicle and vas deferens, revealing the Denonvillier fascia, through the method of transitioning from the first layer to the second layer, the lateral plane upward to the bladder neck, the anterior plane between the Denonvillier fascia and the rectum, and the lateral plane of the prostate, the anterior plane between the prostate and the anterior fibromuscular stroma band can be well completed the surgery. This study has many limitations. Firstly, it is a non-randomized, single-center, retrospective study, which inevitably has selection bias. Secondly, the sample size involved is small and the follow-up time for tumors is short. The results of this study still need to be verified by larger sample sizes and further randomized controlled studies.

In conclusion, robot-assisted laparoscopic posterior approach radical prostatectomy has a significant advantage over the traditional anterior approach in terms of early urinary control recovery, but a longer follow-up period is needed to confirm its oncological safety.