Background The learning curve for retzius sparing robotic radical prostatectomy is not fully understood. Objective This study attempts to identify the learning-curve across the first 130 cases of a single surgeon. Design, Setting, and Participants: All retzius sparing robotic radical prostatectomy cases performed by a single surgeon at a high-volume tertiary hospital between April 2019 and July 2022 were included. Outcome Measurements and Statistical Analysis: Outcome measures included positive surgical margin rate, complication rates and unplanned readmission to hospital, postoperative urinary continence, erectile function, and PSA measurement. Cases were divided chronologically into 3 groups and differences between groups assessed. Results and Limitation: 130 RS-RARP cases were identified. Differences were found between groups in several areas. Positive surgical margin rate fell between Group 1 (30.2%) and Group 3 (9.1%). Safety, post-operative continence, erectile function and PSA remained stable. Median patient age increased between group 1 (59yrs) and Group 3 (66.5yrs) (P = 0.04). Proportion of patients with stage > T2 increased between Group 1 (27.9%) and Group 2 (41.9%) (P = 0.036). Median console time increased between Group 1 (120 mins) and Group 2 (150 mins,) (P = 0.01). Median gland weight increased between Group 1 (28g) and Group 3 (35.5g) (P < 0.001). Conclusions The positive surgical margin rate improved over the learning curve, despite the complexity of cases increasing, reflected in older patients, larger prostates and higher stage disease. Safety and functional outcomes are excellent throughout. The learning curve might be facilitated by careful case selection favouring smaller prostates with less advanced disease. Patient Summary: We analysed the learning-curve for Retzius-sparing robotic radical prostatectomy. Across the first 130 cases positive surgical margin rate fell; safety and continence remained excellent. Selection of smaller and less advanced cases may facilitate learning.

Introduction: The aim of this study was to compare intraoperative and early post-operative outcomes between retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) versus standard approach for RARP (S-RARP). Patients and methods: All RARPs by a single surgeon were included and divided into two groups: (1) standard approach including combined anterior–posterior approach (S-RARP); (2) retzius-sparing posterior approach (RS-RARP). Allocation was based on prostate size and location of index lesion on MRI. Initial post-operative follow-up was at 6 weeks. Results: Overall, 169 RARPs were performed between March 2018 and October 2021: S-RARP = 99 versus RS-RARP = 70. There was no significant difference in pre-operative body mass index (BMI), prostate-specific antigen (PSA), International Society of Urological Pathology (ISUP) grade group and clinical T stage. Intraoperative differences were found in blood loss (300 versus 200 mL, p = 0.008), console time (180 versus 135 minutes, p < 0.001) favouring RS-RARP, with no differences in nerve-spare or lymph node dissection. Post-operatively, no difference was found in ISUP grade, pathological T stage, positive surgical margins, number of lymph nodes sampled, readmissions or complications. Gland size in the RS group was smaller (38 versus 29 g, p = 0.001). Early (6 weeks) post-op follow-up showed a significant difference between groups for both pad-free continence (35% versus 53%, p = 0.011) and social continence (79% versus 89%, p = 0.024), but no difference for erectile function recovery (27% versus 50% of baseline) and post-op PSA levels < 0.1 ng/mL (85% versus 93%). Conclusion: Even early in the learning curve, continence recovery, operative time and blood loss were significantly better for RS-RARP than S-RARP. Margin status and PSA levels are comparable to published literature for both groups. Standardised training in RS-RARP might help to improve the uptake of this novel technique. Level of evidence: 2.

Introduction: The learning curve for retzius sparing robotic radical prostatectomy is not fully understood. This study attempts to identify the learning-curve across the first 130 cases of a single surgeon. Methods: All retzius sparing robotic radical prostatectomy cases performed by a single surgeon between April 2019 and July 2022 were included. Cases were divided chronologically into 3 groups. Results: 130 RS-RARP cases were identified. Statistically significant differences were found between groups in several areas. Median patient age increased between group 1 (59yrs) and Group 3 (66.5yrs) (P=0.04). Proportion of patients with stage >T2 increased between Group 1 (27.9%) and Group 2 (41.9%) (P=0.036). Median console time increased between Group 1 (120 mins) and Group 2 (150 mins,) (P=0.01). Median gland weight increased between Group 1 (28g) and Group 3 (35.5g) (P<0.001). Positive surgical margin rate fell between Group 1 (30.2%) and Group 3 (9.1%). Conclusions: The complexity of cases increased over the learning curve, reflected in older patients, larger prostates and higher stage disease, but the positive surgical margin rate improved with experience. Safety and functional outcomes are excellent throughout. The learning curve might be facilitated by careful case selection favouring smaller prostates with less advanced disease.