Retzius-sparing robotic prostatectomy
Robotic removal of the prostate reached from behind the bladder, through the pouch between the bladder and the rectum, leaving the bladder and the tissues in front of the prostate in place. Many men regain urinary control sooner than after the standard approach.
Also called RS-RARP, Retzius-sparing RARP, Retzius sparing prostatectomy, Bocciardi approach, Posterior approach prostatectomy, Posterior robotic prostatectomy, Douglas approach prostatectomy, Prostatectomy from behind the bladder
- Where
- Hospital operating room
- Anesthesia
- General anesthesia (fully asleep)
- Time in the room
- About 2 to 4 hours
- Hospital stay
- Usually one night; some men go home the same day
- Going home with
- Urinary catheter for about 5 to 10 days; sometimes a small drain for a day
- Back to normal
- About 4 to 6 weeks
- Back to work
- Desk work in about 2 to 3 weeks; heavy physical work in about 6 weeks
Overview
A radical prostatectomy removes the whole prostate and the seminal vesicles, and the bladder is then sewn to the urethra, the tube that carries urine out. In the standard robotic operation, the surgeon first frees the bladder from the inside of the front belly wall and lets it drop back. This opens a space in front of the bladder and prostate, called the space of Retzius after the Swedish anatomist who described it. The Retzius-sparing approach does the same cancer operation without opening that space.
Instead, your surgeon reaches the prostate from behind the bladder, through a small opening in the pouch that sits between the bladder and the rectum, called the pouch of Douglas. Everything is done from that back door: the seminal vesicles, the back and sides of the prostate, the bladder neck, the front of the prostate and the urethra. The bladder stays attached to the belly wall, and the ligaments, muscle fibers and vein cluster in front of the prostate are left where they were. Surgeons Aldo Bocciardi and Antonio Galfano in Milan first described this approach in 2010, and it is sometimes called the Bocciardi approach.
Randomized trials and a Cochrane review have found that more men are dry in the first weeks and months after the Retzius-sparing approach. By one year, the difference becomes small, because most men in both groups regain control. Erection recovery appears similar. Some studies found cancer at the cut edge (a positive margin) somewhat more often, especially for cancers at the front of the prostate, while others did not.
It is a different way of seeing familiar anatomy, so it takes dedicated training, and fewer surgeons offer it. It also suits some prostates better than others. Large tumors at the front of the prostate, very large glands, and some large middle lobes can make it harder, and your surgeon may recommend the standard approach in those cases.
The parts of your body involved
The prostate sits below the bladder and in front of the rectum. In front of both lies the space of Retzius, between the back of the pubic bone and the bladder, filled with fat, veins and the supporting ligaments that hold the urethra and sphincter in place. Behind the bladder, the belly lining dips down into a pouch, the pouch of Douglas, just above the seminal vesicles and the rectum. The Retzius-sparing approach enters through that pouch, works up and around the prostate from behind, and leaves the front supports untouched.
- Prostate
A walnut-sized gland under the bladder with the urethra running through it. Most cancers start in its back part, which this approach reaches first.
- Space of Retzius
The space between the pubic bone and the front of the bladder and prostate. It holds fat, a cluster of veins, and ligaments that support the urethra. This approach leaves it closed.
- Pouch of Douglas
The lowest fold of the belly lining between the bladder and the rectum. In men it is also called the rectovesical pouch. It is the doorway for this approach.
- Seminal vesicles and vas deferens
The seminal vesicles are two small glands behind the prostate; the vas deferens tubes carry sperm. They sit just under the pouch and are the first structures freed.
- Urinary sphincter and front supports
The sphincter is the ring of muscle below the prostate that keeps you dry. The ligaments and muscle fibers in front help hold it in position, which is one theory for why sparing them helps early control.
- Erection nerves
Thin nerve bundles along the back and sides of the prostate. With this approach they are seen early and from behind.
Why it’s done
The reasons to remove the prostate are the same as for any radical prostatectomy. Your surgeon chooses the Retzius-sparing approach when your cancer and your anatomy suit it and when earlier urinary control is a priority for you.
- To cure cancer inside the prostate
For intermediate-risk and many high-risk cancers that have not spread, removing the whole prostate offers a long-term cure for most men.
- Earlier return of urinary control
In randomized trials, more men were dry within the first weeks to months after catheter removal than with the standard approach.
- The front supports stay in place
The ligaments, vein cluster and muscle in front of the prostate are not cut or tied, and the bladder is not dropped from the belly wall. Less disturbance around the sphincter is thought to explain the earlier control.
- A full report and simple follow-up
The whole prostate goes to the pathologist for an exact grade and stage, and the PSA blood test should fall to undetectable.
- Possibly simpler later surgery in front of the bladder
Some surgeons point out that an untouched space in front of the bladder may make later operations there, such as some groin hernia repairs, simpler. This has not been well studied.
Other options
- Standard robotic prostatectomy
The prostate is reached from the front after dropping the bladder. It is the most widely done approach and may be preferred for large front tumors or very large prostates.
- Single-port robotic prostatectomy
The prostate is removed through one small cut. One single-port route goes through the bladder and, like Retzius-sparing surgery, leaves the space in front of the bladder closed.
- Open radical prostatectomy
The operation through one longer cut in the lower belly. Results are similar in experienced hands, with more blood loss and a slower early recovery.
- Active surveillance
For low-risk and some favorable intermediate-risk cancers, close monitoring with PSA tests, MRI and biopsies, treating only if the cancer changes.
- External beam radiation
Radiation aimed at the prostate from outside the body, often with hormone therapy for higher-risk cancers. Cure rates for many cancers are similar to surgery.
- Focal therapy
Treating only the cancer area with focused ultrasound or freezing, for carefully selected men, with fewer side effects but less certain long-term control.
Getting ready
Tick items off as you go. Your checklist is saved on this device only.
Weeks before
The week before
The day before
The morning of surgery
In the operating room, step by step
Press play or pick a step. Each drawing shows what your surgeon is doing at that moment. Your team may do some steps differently.
1. Going to sleep and tilting head-down
The anesthesiologist puts you fully to sleep and places a breathing tube. A catheter is placed into your bladder. Your arms are tucked and padded, and the table is tilted steeply so your head is lower than your feet. This lets the bowel slide up out of the pelvis, which matters even more in this approach, because the doorway is in the deepest part of the pelvis.
More detail
The tilt is usually about 25 to 30 degrees for most of the operation. The team pads every pressure point and protects your eyes. Your face may look puffy for a few hours afterward.
The surgeon sits at a console a few steps from you and moves every instrument with hand controls and foot pedals. The robot cannot move on its own or make decisions.
A camera on one arm gives the surgeon a bright, three-dimensional picture magnified about ten times, which helps them see small nerves and vessels.
The instruments are about the width of a pencil and bend like a wrist inside your body, so the surgeon can stitch and dissect through small openings.
A bedside assistant and a scrub nurse stay at the table, and the anesthesia team watches your breathing and blood pressure throughout. Most U.S. hospitals use the da Vinci system made by Intuitive.
After the operation
Right afterward
- The recovery room
You are watched for 1 to 2 hours. Your throat may be sore and your face puffy from the head-down position. Both settle within about a day.
- Walking the same evening
Nurses help you walk the evening of surgery. Walking eases gas pain and lowers the risk of blood clots.
- Eating and drinking
You can usually drink clear liquids the same day and eat light food by the next morning.
- Pain control
Most men do well with scheduled acetaminophen, sometimes with an anti-inflammatory medicine, and few opioid pills.
- Learning catheter care
A nurse shows you how to use the leg bag and night bag and how to keep the tip of the penis clean.
- Going home
Most men go home the next day. If a drain was placed, it usually comes out first.
At home
- Pain
Expect soreness at the cuts, most at the belly button, and shoulder-tip pain for 1 to 3 days. Walking and a heating pad help the gas pain.
- Wounds and showering
You can usually shower after 24 to 48 hours. Avoid baths, hot tubs and swimming until the cuts are healed and the catheter is out.
- Catheter care
Keep the bag below the bladder, wash the tip of the penis daily, use lubricant where the tube enters, and strap the tube to your thigh. Pink urine is common.
- Bladder spasms
Sudden cramps with urine leaking around the catheter are common and harmless. Ask about a spasm medicine if they are frequent.
- Diet and fluids
Eat normal food as your appetite returns and drink enough to keep urine light yellow.
- Bowels
Take a stool softener while on pain pills and avoid straining. Do not use enemas or suppositories unless your surgeon says so.
- Activity and lifting
Walk several times a day. Avoid lifting more than about 10 to 15 pounds, hard exercise and bicycle riding for about 6 weeks.
- Driving
Most surgeons ask you not to drive while the catheter is in or while you take opioid pain pills.
- Work
Desk work is often possible after about 2 to 3 weeks; heavy work after about 6 weeks.
- Pelvic floor and sex
Start Kegel exercises once the catheter is out, as your team teaches you. Sexual activity can resume when you feel ready, often with an erection recovery plan.
Recovery timeline
- Day 0Surgery day
Surgery takes about 2 to 4 hours. You wake with a catheter and take a short walk that evening.
- Day 1Going home
Most men go home the next day with a catheter and leg bag.
- Days 5 to 10Catheter out
The catheter is removed in clinic. Many men leak less in the first days than they expected, though nearly all leak some.
- Weeks 1 to 2Pathology results
Your surgeon reviews the grade, margins, seminal vesicles and lymph nodes with you.
- Weeks 2 to 6Early control
This is when the Retzius-sparing approach shows its main advantage: in trials, more men were dry or nearly dry in these early weeks.
- Weeks 6 to 12First PSA test
Your first PSA after surgery should be undetectable.
- 3 to 6 monthsContinued recovery
Most men have little or no leakage. Erection recovery is slower and often just beginning.
- 1 to 2 yearsLong-term recovery
By one year, urinary control is usually similar to the standard approach, with most men dry. Erections can keep improving for 2 years or more.
What it feels like
For most men, the days in the hospital and the catheter week feel the same as after any robotic prostatectomy. The difference men notice is in the weeks after the catheter comes out.
Choosing an approach
Hearing that there is more than one way to do the same operation can be unsettling. Some men worry that choosing faster continence means accepting more cancer risk.
What helpsAsk your surgeon to show you on your MRI where the cancer is and why this approach suits it. Ask how often they find cancer at the cut edge with each approach.
Waking up
A scratchy throat, grogginess, puffy eyelids, and a constant urge to pee from the catheter.
What helpsTell the nurse early about nausea or pain. The catheter urge usually fades within a day.
Shoulder-tip pain
A sharp ache at the top of the shoulders from leftover gas, usually lasting 1 to 3 days.
What helpsWalk often, use a heating pad on the shoulder, and take acetaminophen on schedule.
The catheter week
The tube tugs, the tip of the penis gets sore, and bladder spasms can come in waves.
What helpsStrap the tube with some slack, use lubricant, avoid constipation, and ask about spasm medicine.
The day the catheter comes out
Many men are pleasantly surprised by how much control they have in the first days, while others leak more than they hoped and feel let down after reading about early continence.
What helpsBring pads anyway. Remember that the advantage is an average across many men, and your own pace may differ. Kegel exercises and a pelvic floor therapist help either way.
Erections and intimacy
Erections are usually weak at first, even with nerve sparing, and orgasm is dry. This can be hard to talk about.
What helpsAsk for an erection recovery plan, and talk openly with your partner about other ways to be close while the nerves recover.
Waiting for the pathology and PSA
Many men who chose this approach worry most about the margin result.
What helpsAsk ahead of time what a positive margin would mean for you and what the next steps would be. Most men with a positive margin are watched with PSA tests rather than treated right away.
How well it works
Success is the same as for any prostatectomy: clear margins, an undetectable PSA, and good recovery of urinary and sexual function. The extra goal of this approach is getting control back sooner.
- Early urinary control
In the first randomized trial, from the Vattikuti Urology Institute in Detroit, about 7 in 10 men were dry within a week of catheter removal with the Retzius-sparing approach, compared with about 5 in 10 with the standard approach. By one year, most men in both groups were dry.
- The pathology report
The lab reports the grade group, stage, margins and lymph nodes. Pooled studies suggest positive margins may be somewhat more common with this approach, especially in early experience and for front tumors.
- PSA after surgery
The PSA should become undetectable within about 6 to 12 weeks. A later rise to 0.2 ng/mL or higher, confirmed on a second test, suggests cancer has come back.
- Sexual function
Erection recovery appears similar to the standard approach and depends mostly on age, erections before surgery and nerve sparing.
- Long-term control
Because the long-term difference in continence is small, the main reason to choose this approach is a faster return to normal life in the first months.
Risks
Every operation has risks. These are the ones people ask about most, with honest odds where good numbers exist. Your surgeon’s own results matter more than averages.
Common
Most men leak some after the catheter comes out, though on average less and for a shorter time than after the standard approach.
Erections weaken or stop for a while. Recovery depends on age, erections before surgery and nerve sparing, and can take 1 to 2 years.
Orgasm still happens but is dry. You cannot father a child naturally. This is permanent.
Shoulder-tip pain and bloating for 1 to 3 days.
Common while the catheter is in, and usually gone once it is out.
Less common
Cancer cells at the cut edge. Some studies found this somewhat more often with the Retzius-sparing approach, mostly for cancers at the front of the prostate. It does not always mean cancer was left behind, and it is usually watched with PSA tests.
Urine can seep through the join while it heals. It usually seals if the catheter stays a little longer.
Fluid can collect after lymph node removal. A large one may need draining.
Scar tissue can narrow the join months later, causing a weak stream. It is usually treated with a short scope procedure.
A groin bulge can appear in the first year or two after any prostatectomy. Some studies suggest it may be less common after the Retzius-sparing approach.
Uncommon. Walking, leg sleeves and sometimes blood thinner shots lower the clot risk; infections are treated with antibiotics.
Rare
The rectum lies right beside the work area. A small tear is rare and usually repaired during surgery.
Blood loss is usually low, and a transfusion is rarely needed.
Rare, and usually repaired right away.
If the anatomy or the cancer makes the back approach unsafe, your surgeon may open the space in front and finish with the standard approach, or very rarely convert to open surgery.
Call your care team or go to the emergency room if
- Fever of 101°F (38.3°C) or higher, or shaking chills.
- No urine draining into the bag for more than 1 to 2 hours, especially with lower belly pain. Check the tubing for kinks first, then call.
- The catheter falls out or slips partway out. Call your surgeon right away and do not let anyone put in a new one without speaking to your surgeon.
- Thick blood or clots in the urine that do not clear, or that block the catheter.
- Swelling, pain or warmth in one calf or thigh. Call 911 for sudden shortness of breath or chest pain.
- Belly pain that keeps getting worse, a swollen belly, repeated vomiting, or no gas or bowel movement for 3 days.
- Redness spreading from a cut, pus, or a wound that opens.
- After the catheter is out: you cannot pass urine at all, or you have new pain and swelling in the lower belly, groin or leg.
Questions to ask your surgeon
- Is my cancer a good fit for the Retzius-sparing approach, given where it sits on my MRI?
- How large is my prostate, and do I have a middle lobe that would make this approach harder?
- How many Retzius-sparing prostatectomies have you done?
- What are your positive margin rates with this approach compared with the standard one?
- What are your results for early and one-year urinary control?
- Will you remove lymph nodes?
- Can you spare the nerves on one or both sides?
- What would make you switch to the standard approach during surgery?
- How long will I have the catheter?
- When will I get my pathology results and first PSA?
Words you may hear
- Pneumoperitoneum
- The gas-filled belly that makes keyhole surgery possible. Carbon dioxide is pumped in through a thin needle or the first port until the belly wall lifts like a tent (usually at a pressure of 12 to 15 mmHg), giving the camera and instruments room to work. The gas is let out at the end, and the little that remains is absorbed and breathed out over a day or two; it can cause shoulder-tip ache in the meantime.
- Space of Retzius
- The space between the pubic bone and the front of the bladder and prostate, holding fat, veins and supporting ligaments.
- Retzius-sparing
- Removing the prostate without opening the space of Retzius, by working from behind the bladder.
- Pouch of Douglas
- The lowest fold of the belly lining between the bladder and the rectum, used as the doorway in this approach.
- Bocciardi approach
- Another name for Retzius-sparing prostatectomy, after one of the surgeons who first described it.
- Dorsal venous complex
- A cluster of veins on the front of the prostate. In this approach it is usually left untouched.
- Denonvilliers fascia
- A thin layer between the back of the prostate and the rectum.
- Bladder neck
- The bottom opening of the bladder, where it joins the prostate.
- Anastomosis
- The new join between the bladder neck and the urethra.
- Urinary continence
- Being able to hold urine without leaking.
- Positive margin
- Cancer cells touching the cut edge of the removed prostate.
- Nerve sparing
- Peeling the erection nerves off the prostate and leaving them in the body.
- Kegel exercises
- Squeezing and relaxing the pelvic floor muscles to strengthen urinary control.
Common questions
Will I definitely be dry right away?
No. Most men still leak some at first. On average, more men are dry early with this approach than with the standard one, but each man's recovery is different.
Is the cancer operation the same?
Yes. The same organs are removed and the same lymph nodes can be taken. Only the path to the prostate differs. Some studies found slightly more positive margins, which is why tumor location matters in choosing it.
Why doesn't every surgeon do it this way?
It requires learning a different view of the anatomy, the long-term benefit is small, and it is less suitable for some cancers and prostates. Many excellent surgeons use the standard approach with steps of their own to protect continence.
Does it affect erections?
Erection recovery appears similar to the standard approach. Your age, erections before surgery and how much nerve tissue can be kept matter most.
Can I have radiation later if I need it?
Yes. Radiation to the area where the prostate was can be given after this approach, just as after the standard one.
Does the robot do the operation?
No. Your surgeon controls every movement from the console. The robot holds the camera and instruments steady and moves only with your surgeon's hands.
Sources this page draws on
- European Urology, A new anatomic approach for robot-assisted laparoscopic prostatectomy: a feasibility study for completely intrafascial surgery (Galfano, Bocciardi and colleagues) (2010)
- European Urology, A pragmatic randomized controlled trial examining the impact of the Retzius-sparing approach on early urinary continence recovery after robot-assisted radical prostatectomy (Dalela, Menon and colleagues) (2017)
- Cochrane Database of Systematic Reviews, Retzius-sparing versus standard robotic-assisted laparoscopic prostatectomy for the treatment of clinically localized prostate cancer (2020)
- American Urological Association and American Society for Radiation Oncology, Clinically Localized Prostate Cancer: AUA/ASTRO Guideline (2022)
- European Association of Urology, EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer
Written November 2026. This page explains what usually happens. It is not medical advice and does not replace a conversation with your own surgeon, whose plan for you comes first.