Preservation of Endopelvic Fascia: Effects on Postoperative Incontinence and Sexual Function – A Randomized Clinical Trial

Background Urinary incontinence and sexual dysfunction are common after robot-assisted radical prostatectomy (RALP). New surgical techniques to improve these functions after the operation are under evaluation for example, preservation of endopelvic fascia during RALP. However, the benefits of this technique have not been critically scrutinized in a randomized setting. Aim In this study, we compared endopelvic fascia preserving operation with the standard surgical procedure in a randomized trial at the Tampere University Hospital, Finland. Methods A total of 158 men with localized prostate cancer and scheduled for RALP were randomized 1:1 into endopelvic fascia–preserving RALP or a control group that is, standard operation. All operations were performed by a single surgeon. Outcomes Urinary and sexual function were evaluated by the Expanded Prostate Cancer Index Composite-26 questionnaire at baseline and 3, 6, and 12 months after the surgery. Results There was no difference in urinary incontinence or sexual function between the groups at any time point (urinary incontinence domain at 12 months after RALP for fascia preserving and control group 73.6 ± 3 vs 78.9 ± 2.5 and sexual domain 43 ± 3.2 vs 40.3 ± 3, respectively). Clinical and pathologic tumor characteristics, duration of surgery, blood loss, rate of complications, and time to hospital discharge were similar between the study arms. Compliance of filling out the Expanded Prostate Cancer Index Composite-26 questionnaire varied from 91% to 98%, with no difference between study arms. Clinical Implications Based on our results, endopelvic fascia preservation alone during RALP is not recommended over the standard surgical method. Strengths & Limitations This is a randomized clinical study with sufficient statistical power. As a limitation, only a minority of participants underwent magnetic resonance imaging before the operation, thus we could not evaluate the role of urethral length or shape of the prostate. Urinary and sexual function results are based on questionnaires filled out by the patients, however, participants completed the surveys independently unassisted by health care personnel. Conclusion Endopelvic fascia–preserving RALP does not improve urinary continence or sexual function as compared with the standard surgical technique. Future studies aiming to improve functional outcomes after RALP should focus on evaluating other technique modifications. Siltari A, Riikonen J, Murtola TJ. Preservation of Endopelvic Fascia: Effects on Postoperative Incontinence and Sexual Function – A Randomized Clinical Trial. J Sex Med 2021;18:327–338.