Investigating the mechanism underlying urinary continence using dynamic MRI after Retzius-sparing robot-assisted radical prostatectomy

Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) exhibits better postoperative urinary continence than conventional RARP (C-RARP) via the anterior approach. However, the reasons behind this are unknown. Herein, early postoperative urinary incontinence and anatomical differences of 51 propensity score-matched C-RARP and RS-RARP cases were compared. Dynamic magnetic resonance imaging (MRI) was performed before and after surgery to examine the pelvic anatomical changes under abdominal pressure. The median urine loss ratios in the early postoperative period after C-RARP and RS-RARP were 11.0% and 1.0%, respectively. Postoperative MRI revealed that the anterior bladder wall was fixed in a higher position after RS-RARP compared with its position after C-RARP. Dynamic MRI after C-RARP showed that cephalocaudal compression of the bladder while applying abdominal pressure caused the membranous urethra to expand and the urine to flow out. After RS-RARP, the rectum moved forward during abdominal pressure, and the membranous urethra was compressed by closure from behind. This is the first study using dynamic MRI to reveal the importance of high attachment of the anterior bladder wall for the urethral closure mechanism during abdominal pressure. RS-RARP, which can completely preserve this mechanism, is less likely to cause stress urinary incontinence compared with C-RARP.