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Olivero et al. Mini-invasive Surg 2022;6:6 https://dx.doi.org/10.20517/2574-1225.2021.117 Page 3 of 10

All patients prior to the surgery answered self-administered validated questionnaire, the International Index
[19]
of Erectile Function (IIEF-5) , to assess the baseline sexual function.
In the present study, we only included patients with preoperative IIEF-5 scores of > 16. In addition, all
patients analyzed were continent before rs-RARP. All patients provided informed consent.

Surgical technique and functional rehabilitation
All RS-RARP procedures were performed with a four-arm da Vinci Si Surgical System (Intuitive Surgical,
Sunnyvale, CA, USA) with a transperitoneal approach. Eight different urologists with different grades of
experience performed the surgeries. All the surgeons had completed the learning curve and had completed
at least 40 cases. The assistant was often a resident or a urologist in the learning curve phase. Patients were
[9]
placed in the 30° Trendelenburg position. Six laparoscopic trocars were used as previously described . The
type of nerve sparing (NS) performed during the rs-RARP was reported according to the Pasadena
Consensus Panel . In the surgical report, the surgeon defined a grade of NS for each side of the gland
[20]
(intra-fascial, inter-fascial, or extra-fascial/no nerve-sparing technique). We considered full NS intra-fascial
at least on one side and intra- or inter-fascial on the other, partial NS inter-fascial bilaterally, and minimal
or no NS for extra-fascial or no NS on one side. Therefore, all types of NS were included in the analysis.

All patients started pelvic floor muscle exercises immediately after the supra-pubic catheter removal and
were recommended to continue during the follow-up. In addition, all patients were advised to use
phosphodiesterase-5 (PDE-5) inhibitors after surgery regularly, at least three times/week, until recovery of
sexual function. A vacuum device was not routinely recommended.

Follow-up and outcomes definition
Our primary goal was to determine the trifecta rate 24 months after rs-RARP.

Urinary continence was defined as the use of no pads (score 0) in the last four weeks.

Potency was defined as the ability to obtain and maintain a proper erection for sexual intercourse in more
than 50% of the attempts, with or without PDE-5 inhibitors.

The biochemical recurrence (BCR) was defined as two consecutive prostatic specific antigen (PSA)
measurements of > 0.2 ng/mL after the surgery.

During follow-up, serum PSA measurement and clinical evaluation were carried out at 3, 6, and 12 months,
and then every six months for three years. Before clinical evaluations, questions about potency and urinary
function were assessed.

Statistical analyses
Medians and interquartile ranges (IQR) and frequencies and proportions were reported for continuous and
categorical variables, respectively.

To identify predictors of trifecta outcome, a multivariable logistic regression model testing for trifecta
outcome was performed. Adjustment variables consisted of age, body max index (BMI), PSA, comorbidities
(reported as the Charlson score), prostate volume, pathological International Society of Urological
Pathology (ISUP) grade, pathological tumor stage (pT), and nerve-sparing technique. The R software
environment for statistical computing and graphics (version 3.6.3) was used for all statistical analyses. All