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Page 8 of 10 Olivero et al. Mini-invasive Surg 2022;6:6 https://dx.doi.org/10.20517/2574-1225.2021.117

Several definitions have been proposed to evaluate erectile function after surgery: partial recovery, adequate
rigidity, the ability for intercourse, and sexual satisfaction. Some authors also expanded the definition from
[4]
couple sexual intercourse to sexual activity, including masturbation . We used the most used definition as
“erection sufficient for intercourse with or without the use of a PDE-5” [25-27] .

Another substantial difference of our work from the literature is that we included all patients submitted to
rs-RARP without selecting for NS-technique or age. As shown in the figures, trifecta outcome resulted
inversely proportional to patient’s age and correlated to the grade of NS adopted; ideally, in a selected
population of young patients treated with full NS, we can report trifecta rates around 66% in accordance
with the best results published.

A recent systematic review found a role in the recovery of continence and consequently in the trifecta rate
for the various anatomical reconstructions after RARP, finding that anterior and posterior reconstructions
together facilitate continence recovery in comparison to only one approach .
[28]

Our study is the first to investigate trifecta outcome after rs-RARP extensively. We relied on a significant
number of patients and sufficient follow-up time. In addition, we overcame the potential bias of the single
operator ability by including different surgeons.

Another strong point of this study is that other authors included very few high-risk prostate cancer
cases [6,7,26] . In our group, more than 24% of patients were classified high risk according to EAU risk group.
These are the patients who historically do not reach the trifecta outcome, and such a rate could limit the
result in our cohort.

Our study must be interpreted considering some limitations. First, our findings derived from a retrospective
review of prospectively collected observational data. Thus, our results must be interpreted considering the
limitations of such data. Second, the follow-up time of 24 months is relatively short, and only early
intermediate oncological results can be deducted.

Third, this study reports single-center experience where rs-RARP was ideated. In our center, only the
posterior approach is performed; this may not be translated to other centers where surgeons are not so
experienced in the Retzius-sparing approach. Confirmation studies in other centers and confrontation
studies between rs-RARP and anterior approach may be needed to obtain Level 1 evidence.

In conclusions, rs-RARP is associated with promising trifecta outcome rate. Age and NS technique are
independent predictors of trifecta outcomes. The Retzius-sparing approach should be considered a valid
surgical treatment for all PCa patients who want to optimize the balance between oncological and functional
outcomes.

DECLARATIONS
Authors’ contributions
Data analysis and manuscript drafting: Olivero A, Dell’Oglio P, Ambrosini F
Data research technical, and material support: Barbieri M, Palagonia E, Napoli G, Di Trapani D, Buratto C,
Martiriggiano M
Manuscript revision: Bocciardi AM, Galfano A, Petralia G, Strada E, Secco S