Introduction of posterior reconstruction technique during robotic assisted radical prostatectomy at a tertiary center: results on the self-perception of anastomotic quality and ease of execution

Background and objective: The posterior reconstruction (PR) during robot-assisted radical prostatectomy (RARP)-as originally described by Rocco F and coworkers-has been introduced in 2006 aiming to restore anatomical disruption occurring after radical prostatectomy and to improve continence recovery. The original open technique has been adapted to laparoscopy and to robotics thereafter. The approximation achieved after PR may also reduce the anastomotic tension-while tying the suture - and thus enhance the anatomical alignment. The Rocco's stitch was introduced by October 2024 at a tertiary robotic center previously unfamiliar to the technique; therefore, a comparative study to assess the impact of PR on the self-perceived quality and easiness of VUA of robotic surgeons was performed. Methods: This is a retrospective, single-center comparative study performed at Fondazione Policlinico Gemelli IRCCS, Rome, Italy. The Rocco Stitch was introduced in October 2024 using the standardized two-layer technique. Cases before and after the introduction of PR were retrieved from a prospectively maintained database (Protocol ID 7314) and 271 patients undergoing RARP between November 2023 and February 2025 were evaluated. Post-operative cystogram was performed when deemed necessary (7-9 PO day), based on the surgeon's ease of anastomosis execution and final perceived quality. The primary outcome of the study is the rate of cystogram use; the overall rate of urinary leakage and the need for additional imaging due to suspect urine extravasation are secondary endpoint. Multivariable logistic regression was performed to identify independent predictors of leakage. Key findings and limitations: Overall, 87 patients received PR, 184 did not; PR group had significantly lower cystogram use (34.5% vs. 52.7%, p = 0.005). Considering the whole cohort (w/out cystogram), 67 out of 184 (37%) patients before PR introduction had a urinary leakage whereas 2 out of 87 (2.2%) patients who underwent PR had extravasation. No emergency cystograms was required in either group. PR was independently associated with lower leakage risk (OR 0.18; 95% CI 0.04-0.80; p = 0.024) among other factors as age, BMI, CCI, prostate volume. Catheter removal occurred in 17 (SD 13) PO day compared with 8 (SD 5) PO day before and after PR introduction, respectively. Limitations are the retrospective design, single-center setting, non-randomized allocation, relatively small sample size. Conclusions and clinical implications: In our experience, the introduction of PR led to an improved surgeon's confidence toward vesico-urethral anastomosis; when assessed through cystogram, PR significantly decreases the rate of urinary extra-vasation. Incorporating PR into standard RARP protocols may enhance perioperative outcomes and reduce the need for postoperative imaging. Further prospective, multi-center studies are warranted to confirm reproducibility.