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.