Radical prostatectomy remains a gold standard treatment option for localized prostate cancer, with >90, 000 operations performed annually in the USA [1]. Although the adoption of robotic-assisted radical prostatectomy (RARP) improved the overall safety profile over open radical prostatectomy in terms of bleeding, transfusions, and complications [2], there remains ample opportunity to improve the recovery of functional outcomes. For instance, 14–25% of men report permanent, bothersome leakage after radical prostatectomy, decreasing quality of life [3].

Recovery of continence following RARP is predicated on the preservation of integral deep pelvic anatomic structures. The continence mechanism requires a functional interplay between smooth and voluntary muscles of the bladder neck, detrusor apron, and urethral sphincters, as well as their respective ligamentous connections (puboprostatic ligaments and arcus tendinous), and the surrounding neurovascular bundles (NVBs) [4]. Key surgical factors expedite continence recovery, including preservation of the membranous urethra length and the supportive rhabdosphincter [5].

Anatomic studies have driven procedural modifications to reduce complications and enhance postoperative quality of life, such as bladder neck preservation and minimization of damage to the rhabdosphincter [6,7]. The posterior approach to pelvic fascia-sparing (PPFS) RARP, or Retzius sparing, avoids the disruption of the retropubic space, preserving ligamentous attachments completely, including those anterior to the bladder neck, to enhance continence recovery (Fig. 1A and 1B) [8]. Previous studies demonstrated early recovery of postoperative urinary continence within 1 wk to 3 mo following catheter removal, but evidence is inconclusive surrounding the long-term impact PPFS has on improving urinary continence [[9], [10], [11]]. The anterior approach to pelvic fascia sparing (APFS) is a modification that dissects into the space of Retzius, but preserves the detrusor apron, arcus tendinous, puboprostatic ligament, and some anterior vessels, leaving a “hood” comprising supportive structures for urinary continence recovery (Fig. 1C) [12].

APFS, when compared across series, seemed to offer similar continence benefits to PPFS, while maintaining the more customary anterior visualization of the standard approach [12]. However, a multicenter, head-to-head comparison of APFS versus PPFS has not been performed to explore a causal mechanism of urinary continence. Moreover, evidence remains mixed on whether pelvic fascia-sparing (PFS) techniques enhance long-term urinary continence. Herein, we present an observational series comparing continence recovery after standard, PPFS, and APFS RARP with varying degrees of PFS, to facilitate treatment decision-making.