Total periurethral reconstruction with preservation of "Hood" structures promotes early recovery of urinary continence in extraperitoneal single-port robot-assisted radical prostatectomy

Abstract

Urinary incontinence is a complex complication of radical prostatectomy (RP), with early urinary continence (UC) recovery influenced by surgical methods. This study evaluated the efficacy and safety of total periurethral reconstruction preserving "Hood" structures on early UC recovery in extraperitoneal single-port robot-assisted laparoscopic RP (sp-RARP). We analyzed perioperative data from 12 extraperitoneal sp-RARP cases employing the novel technique between July 2023 and July 2024. Continence rates and oncologic results at 24 h, 1 week, 4 weeks, and 3 months post-catheter removal were recorded. The technique involves anastomosing the lateral levator ani muscle and median dorsal raphe at the "Hood" structures base to the posterior detrusor apron (DA) of the bladder neck (BN) for parachute-style dorsal support before vesicourethral anastomosis (VUA). The anterior DA of BN is anastomosed to the prostate fascia and DA rim above the urethral stump for anterior fixation after VUA. Median and interquartile range (IQR) are used for continuous non-normally distributed variables. The median reconstruction and surgical time were 13.5 (IQR, 11.0-21.5) min and 152 (IQR, 141.25-180) min. No transitions to open surgery or additional auxiliary trocars were necessary. No serious complications occurred during the perioperative period. Continence rates at 24 h, 1 week, 4 weeks, and 3 months post-catheter expulsion were 41.67% (5/12), 66.67% (8/12), 75.00% (9/12), and 91.67% (11/12). The novel technique shows promising early UC recovery following extraperitoneal sp-RARP without increasing complications or compromising oncologic outcomes, suggesting it is a feasible and effective surgical method.

Keywords: Hood technique; Single-port surgery; periurethral reconstruction; robot-assisted laparoscopic radical prostatectomy (RARP); urinary continence (UC).

Figure 1

Prostate dissociation phase. (A) The internal urethral orifice was preserved whenever possible during the BN dissection; (B) the anatomical structures involved after preservation of Hood structures prior to reconstruction work. AT, arcus tendineus; BN, bladder neck; DA, detrusor apron; DVC, deep venous complex; DF, Denonvillier fascia; EPF, endopelvic fascia; IUO, internal urethral orifice; US, urethral stump; MDR, median dorsal raphe; PF, prostatic fascia; P, prostate.

Figure 2

Surgical procedure of the reconstruction phase. (A) The parachute-style running suture manner of the posterior support; (B) the suture was tightened sequentially with the decreasing pneumoperitoneum pressure and aspirator; (C) the vesicourethral anastomosis was finished by another V-loc suture; (D) the anterior detrusor muscle of bladder neck was anastomosed to rim of “Hood” structures with the rest of the suture.

Video 1

Complete surgical procedures for the total periurethral reconstruction with preservation of “Hood” structures in extraperitoneal single-port robot-assisted radical prostatectomy.