The impact of posterior reconstruction on the quality and ease of execution of vesico- urethral anastomosis during robot-assisted radical prostatectomy: results from a comparative non-randomized study

Background and Objective Posterior reconstruction (PR) during radical prostatectomy was originally introduced to improve early urinary continence. Emerging evidence suggests PR may also facilitate vesico-urethral anastomosis (VUA) by reducing tension and enhancing anatomical alignment. This study aimed to assess the impact of PR on the quality and ease of VUA during robot-assisted laparoscopic prostatectomy (RALP). Methods Retrospective, single-center comparative study at Fondazione Policlinico Gemelli IRCCS, Rome, Italy. Included 271 patients with localized prostate cancer undergoing RALP between November 2023 and February 2025. PR introduced in October 2024 using a standardized two-layer technique. Primary outcomes: rate of cystogram use, urinary leakage, and emergency imaging due to suspect extravasation. 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) and leakage rates (6.7% vs. 71.8%, p<0.001). PR was independently associated with lower leakage risk (OR 0.18; 95% CI 0.04–0.80; p=0.024). No emergency cystograms required in either group. Limitations are the retrospective design, single-center setting, non-randomized allocation, relatively small sample size. Conclusions and Clinical Implications Posterior reconstruction improves anastomotic quality by reducing leakage and potentially simplifying VUA. Incorporating PR into standard RALP protocols may enhance perioperative outcomes and reduce the need for postoperative imaging. Further prospective, multi-center studies are warranted to confirm reproducibility.