Background: Numerous continence-sparing radical prostatectomy techniques have been developed to enhance postoperative early continence recovery; however, evidence regarding the best approach remains controversial. The objectives are: to provide a critical appraisal of various prostatectomy techniques, based on the evidence of quality-assessed randomised control trials (RCT); to summarise the immediate continence and the early continence reported; to propose a new standardisation for continence outcomes reporting. Methods: Data acquired from five medical registries were reported to PRISMA standards. Evidence from published, English, full-text RCTs reporting postoperative urinary continence outcomes within 6 months from surgery were included. Heterogeneity of surgical techniques and continence definitions did not allow a meta-analysis. All RCTs were critically appraised and quality assessed. Results: 39 RCTs were included: 19/39 studies were low-quality RCTs, presenting small cohort, monocentric or single-surgeon data. The best RCT-supported evidence is in favour of RARP compared to LRP and of the Retzius-sparing technique over the traditional prostatectomy. Other techniques such as bladder neck and puboprostatic ligament preservation, posterior reconstruction with or without combination of anterior suspension technique and nerve-sparing approach seem to enhance EC. Oppositely, the endopelvic fascia preservation, bladder neck mucosa eversion/plication/slings and the selective ligature of dorsal venous complex were not significantly associated to early continence improvements. RCTs are lacking on pubovesical complex-sparing, seminal vesicle preservation, anterior reconstruction of the puboprostatic collar, musculofascial reconstruction, dorsal venous complex suspension to the periosteum of the pubic bone techniques. Conclusions: RARP and Retzius-sparing have high-quality evidence supporting their ability to enhance postoperative EC recovery. Nerve-sparing, bladder neck and puboprostatic ligament preservation may contribute to better EC recovery, although the evidence level is low. Further multicentre RCTs are needed to establish the optimal combination of standard surgical techniques. A new continence outcome-reporting standardisation was proposed.

Background: The prostatic urethra (PU) is conventionally resected during robot-assisted radical prostatectomy (RALP). Recent studies demonstrated the feasibility of the extended PU preservation (EPUP). Aims: To describe the histologic features of the PU. Methods: The PU was evaluated using cystoprostatectomy and RALP specimens. Cases of PU infiltration by prostate cancer or distortion by benign hyperplastic nodules were excluded. The thickness of the chorion and distance between the urothelium and prostate glands were measured. Prostate-specific antigen expression in the PU epithelium was evaluated with immunohistochemistry. Descriptive statistics were used. Results: Six specimens of PU were examined. Histologically, the following layers of the PU were observed: (1) urothelium with basal membrane, (2) chorion, and (3) prostatic peri-urethral fibromuscular tissue. The chorion measures between 0.2 and 0.4 mm. There is not a distinct urethral muscle layer, but rather muscular fibers that originate near the prostatic stroma and are distributed around the PU. This muscular tissue appears to be mainly represented in the basal and apical urethra, but not in the middle urethra. The mean distance between the chorion and prostatic glands is 1.74 mm, with significant differences between base of the prostate, middle urethral portion, and apex (2.5 vs. 1.49 vs. 1.23 mm, respectively). PSA-expressing cells are abundant in the PU epithelium, coexisting with urothelial cells. Conclusions: The exiguity of thickness of the PU chorion, short distance from glandular tissue, and coexistence of PSA-expressing cells in the epithelium raise important concerns about the oncologic safety of EPUP.

Introduction: The orthotopic neobladder is the type of urinary diversion (UD) that most closely resembles the original bladder. However, in the literature the urodynamic aspects are scarcely analysed. Objective: To provide the first systematic review (SR) on the urodynamic (UDS) outcomes of the ileal orthotopic neobladders (ONB). Continence outcomes are also presented. Methods: A PubMed, Embase and Cochrane CENTRAL search for peer-reviewed studies on ONB published between January 2001–December 2022 was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Results and Conclusion: Fifty-nine manuscripts were eligible for inclusion in this SR. A great heterogeneity of data was encountered. Concerning UDS parameters, the pooled mean was 406.2 mL (95% CI: 378.9–433.4 mL) for maximal (entero)cystometric capacity (MCC) and 21.4 cmH₂O (95% CI: 17.5–25.4 cmH₂O) for Pressure ONB at MCC. Postvoid-residual ranged between 4.9 and 101.6 mL. The 12-mo rates of day and night-time continence were 84.2% (95% CI: 78.7–89.1%) and 61.7% (95% CI: 51.9–71.1%), respectively.Despite data heterogeneity, the ileal ONB seems to guarantee UDS parameters that resemble those of the native bladder. Although acceptable rates of daytime continence are reported the issue of high rates of night-time incontinence remains unsolved. Adequately designed prospective trials adopting standardised postoperative care, terminology and methods of outcome evaluation as well as of conduction of the UDS in the setting of ONB are necessary to obtain homogeneous follow-up data and to establish UDS guidelines for this setting.