To explore the intrafascial and extrafascial techniques of Retzius-sparing robot-assisted radical prostatectomy (Rs-RARP) in the treatment of localized prostate cancer.

From August 2022 to August 2023, 30 cases of Rs-RAPR were performed by the same senior surgeon in the Department of Urology, the Third Affiliated Hospital of Sun Yat-sen University, 20 low and medium-risk patients with D'Amico risk stratification who underwent intrafascial surgery and 10 high-risk patients underwent extrafascial surgery. All surgeries were performed by the da Vinci robotic system. The surgical method was after establishing the robotic platform, the Douglas fossa was revealed, and then the vas deferens and seminal vesicles were freed. Intrafascial techniques: the urethra can be exposed after bluntly pushing away the anterior layer of denonvillier’s fascia close to the back of the prostate, dissecting the lateral ligament laterally, and mobilizing the front under the Aphrodite veil. Extrafascial techniques: cutting the anterior layer of Denonvillier’s fascia sharply behind the prostate, dissecting the lateral ligament laterally to open the pelvic fascia, and mobilizing above the Aphrodite veil to expose the urethra. Finally, the bladder neck and posterior urethra are continuously anastomosed with double-needle barbed sutures.

All 30 patients with Rs-RARP were completed, there was no conversion to open and traditional surgery, and no serious complications occurred in the perioperative period. The operation time, intraoperative blood loss, bladder neck urethral anastomosis time and urinary catheter indwelling time were shorter in patients with complete intrafascial surgery than in patients with extrafascial surgery (P<0.05). The postoperative pathology of 30 patients showed pT₂ 12 cases, pT_3a 12 cases, and pT_3b 6 patients. 2 patients with intrafascial and extrafascial T₃ stage were found to have positive surgical margins, respectively, and 1 patient in each group had biochemical recurrence (PSA>0.2 ng/ml). The urinary continence rates of the two groups were 55% and 10% immediately after removal of the catheter (P<0.05), and the continence rate after 1 month was 80% and 60% (P>0.05). The IEEF-5 scores of the two groups were 20% and 0% ≥18 months after surgery, and 35% and 20% in 3 months after surgery.

The treatment of localized prostate cancer with Rs-RARP is safe and feasible, and it is recommended to choose intrafascial technology for intermediate and low-risk Pca patients, and the extrafascial technique for local high-risk patients. The short-term follow-up effect of tumor control, urinary continuation, and erectile function recovery is satisfactory, and the long-term effect requires further follow-up.