Editorial Comment on: Three-Layer Two-Step Posterior Reconstruction Using Peritoneum During Robot-Assisted Radical Prostatectomy to Improve Recovery of Urinary Continence: A Prospective Comparative Study by Ogawa et al.

The posterior reconstruction of the rhabdosphincter is a technical modification of the urethrovesical anastomosis that has been introduced by our group in open and minimally invasive surgery >15 years ago. ¹

The aim was to minimize the urethrosphincteric sliding after prostatectomy and to provide an appropriate fulcrum of contraction for the rhabdosphincter. Since our first article, >490 further studies have been published on this topic, with controversial results; however, according to three meta-analyses, the posterior reconstruction of the rabdoshpincter (PRR) leads to earlier continence recovery and reduction in anastomotic leakage. ^{1 –3}

Beyond articles reproducing the original technique, several other studies aimed to maximize the concept of posterior reinforcement. ⁴ Some of them propose to integrate posterior with anterior reconstruction, some others to include several reconstructive layers to improve early continence recovery. This is the case of the article of Ogawa S et al., ⁵ published on this issue of the Journal of Endourology, dealing with a novel change of the posterior reconstruction technique to improve early continence recovery. As in many other articles dealing with this topic, the proposed technique outperforms the original, with a more than double percentage of dry patients at 1 month after surgery. ^6,7 Of course, a single surgeon's experience with a limited sample size (48 patients) can only be suggestive of an interesting modification, but does not provide sufficient evidence to assess that this is the way to do. Particularly, the possibility of Rosenthal effect is pretty consistent and should be ruled out.

However, in this article, the anatomical basis and the principles are interesting and have been described clearly. Ogawa and colleagues have to be commended for spending a few lines explaining the way they measure and evaluate continence, very rigorously; The same apply for the continence definition, which was clear and reproducible.

In conclusion, the PRR is a concept that can be carried out in several different ways. Notwithstanding the pieces of evidence in the literature, there is no consensus whether this approach may lead to an improvement in earlier continence recovery, but also most of the detractors perform the PRR technique because it simplifies the execution of the anastomosis, provides a useful posterior support, particularly in case of oozing, and does not increase the risk of complications. ^{6 –8} It should be important to take advantage of the accurate definition and evaluation of continence of this study for further multicenter investigations to compare this with other surgical modifications [of our technique].