Total en Bloc Urethra Preservation at Robot-Assisted Prostatectomy (ToP-RAP): A Prospective IDEAL Stage 1-2a Study.

Background/objective: Urinary continence recovery after robot-assisted radical prostatectomy remains variable despite technical refinements intended to preserve function. We describe Total en bloc Urethra Preservation at Robot-assisted Prostatectomy (ToP-RAP), a technique that preserves the entire intraprostatic urethra and avoids urethral transection, and report short-term functional and oncological outcomes.

Methods

Patients with PSA ≤ 15 ng/mL, prostate volume ≤ 80 mL, biopsy ISUP grade ≤ 3, and predefined selection criteria underwent surgery in this single-arm, two-center, IDEAL stage 1-2a development study (ClinicalTrials.gov NCT07678489). Surgical, perioperative safety, continence, and oncological outcomes based on PSA, imaging, and secondary treatment were assessed descriptively.

Results

The first 16 consecutive patients were treated between 02/2024 and 05/2025. Median age was 66 years (IQR 62-71), PSA was 6.7 ng/mL (IQR 4.7-9.6), and prostate volume was 33 mL (IQR 29-46). Biopsy ISUP grades 1, 2, 3 were in 19%, 44%, and 38% of patients, respectively. On MRI, 38% of patients had multifocal bilateral lesions. Urethral repair of ≤1 cm was required in 13% of patients. All patients underwent at least interfascial nerve sparing. One posterolateral positive surgical margin and one perioperative complication (fascial dehiscence) occurred, no further complications were observed within 90 days. Median follow-up was 7.2 months (IQR 6.1-10.7). No patient had PSA persistence, biochemical recurrence, or secondary treatment. Overall, 15 of 16 patients (94%) recovered urinary continence, and 94% did so within 5 days. Limitations include the small cohort and short follow-up.

Conclusions

Early findings support the feasibility and short-term safety of ToP-RAP. The observed early continence recovery warrants evaluation in larger cohorts with longer follow-up.