Abstract
To evaluate the safety and early functional outcomes of a urethral catheter–free protocol during extraperitoneal single-site robot-assisted radical prostatectomy (essRARP), enabled by suprapubic catheter (SPC) drainage placed through the existing incision, compared with urethral catheter (UC) drainage. We retrospectively analysed 217 consecutive men undergoing essRARP (June 2023–July 2025) at a single institution. Patients received either a urethral catheter–free protocol with SPC drainage (SPC/UC-free, n = 129) or UC drainage (UC, n = 88). In the SPC/UC-free group, after vesicourethral anastomosis and a negative 150 mL saline leak test, a 14-Fr SPC was inserted under direct vision via the existing incision (no additional skin punctures/incisions), and the UC was removed intraoperatively. Pain (VAS) was assessed on postoperative day 1, at discharge, and on catheter removal day. Immediate continence was defined as 0 pad/day within 24 h after catheter removal. Multivariable logistic regression identified predictors of immediate continence. Baseline and intraoperative characteristics were comparable before matching. In the unmatched cohort, pain scores were similar on postoperative day 1 and catheter removal day, but lower at discharge in the SPC/UC-free group (median [IQR] 1.0 [1.0–2.0] vs 1.5 [1.0–2.0]; P < 0.001). Immediate continence was higher in the SPC/UC-free group (57.4% [74/129] vs 25.0% [22/88]; P < 0.001). After propensity score matching, 87 matched pairs were identified, and the main findings remained directionally consistent, with the SPC/UC-free group showing lower discharge-day pain scores and a higher rate of immediate urinary continence. In multivariable logistic regression analysis, the urethral catheter-free protocol remained independently associated with immediate urinary continence (OR 3.94, 95% CI 2.07–7.48; P < 0.001). Two SPC/UC-free patients developed self-limiting gross haematuria; there were no urinary tract infections, urethral stricture, or readmissions. Urethral catheter–free drainage after essRARP using SPC via the existing incision improved early comfort and immediate continence without an evident short-term safety penalty.
Keywords: Single-site, Robot-assisted radical prostatectomy, Prostate cancer, Suprapubic catheter, Urethral catheter-free
Introduction
After robot-assisted radical prostatectomy (RARP), it is customary to insert a urethral catheter (UC) to facilitate urinary drainage and promote anastomotic healing. Nevertheless, UC utilization often leads to discomfort, such as persistent mechanical irritation of the urethra, penis, and perineum, potentially hindering patient recovery, early mobilization, and satisfaction. This practice may conflict with the tenets of enhanced recovery after surgery (ERAS). In light of the growing focus on patient-centered perioperative management, mitigating catheter-related complications post-RARP holds significant clinical significance [1].
As an alternative, the suprapubic catheter (SPC) has been introduced to reduce catheter-related discomfort.[2] Nevertheless, most existing SPC techniques require an additional suprapubic incision or puncture, which may increase postoperative pain, procedural trauma, and complication risks, thereby limiting their broader clinical adoption.[3–5] Therefore, whether urinary drainage can be achieved without an indwelling urethral catheter and without additional skin punctures remains a clinically meaningful question.
In this study, we introduce a urethral catheter-free technique using single-incision SPC placement during extraperitoneal single-site RARP (essRARP). The method avoids additional skin punctures or incisions and allows for intraoperative removal of the urethral catheter under direct visualization after confirming anastomotic integrity. We aimed to evaluate the safety, feasibility, and early functional outcomes of this technique compared with conventional UC management.
Materials and methods
Study population
This retrospective study included 217 patients diagnosed with prostate cancer who underwent extraperitoneal single-site robot-assisted radical prostatectomy (essRARP) at the First Affiliated Hospital of Guangzhou Medical University from June 2023 to July 2025. All surgeries were performed by a single experienced surgeon. Patients treated before December 2023 underwent conventional urethral catheterization (UC), whereas those treated thereafter received the SPC/UC-free protocol. Patients were divided into two groups: 129 patients received the urethral catheter-free technique (SPC/UC-free group), and 88 patients underwent conventional urethral catheter (UC group).
Inclusion criteria: (1) histologically confirmed prostate cancer; (2) completion of essRARP.
Exclusion criteria: (1) prior malignancies; (2) previous transurethral resection of the prostate; (3) severe comorbidities (e.g., cardiovascular, respiratory, neurological, or urological diseases); (4) metastatic disease.
Ethical protocol and Informed consent
This study was approved by the Institutional Review Board (IRB #: ES-2024-102-01) at the First Affiliated Hospital of Guangzhou Medical University. Written informed consent was obtained from all patients before surgery, ensuring they were fully aware of the procedure, associated risks, and alternative treatments.
Data collection
Clinical data were obtained from electronic medical records and structured telephone follow-ups. Preoperative data included age, BMI, prostate-specific antigen (PSA) levels, Gleason score, and membranous urethral length (MUL). Intraoperative data encompassed blood loss, operative time, and nerve-sparing status. Postoperative outcomes included complications (e.g., urinary leakage, infections), pain scores, urinary continence, and hospital stay length. Continence recovery time was categorized as immediate (within 24 h after catheter removal), within 1 month, > 1 month to ≤ 3 months, or > 3 months after catheter removal, based on the first time point at which the patient achieved 0 pads/day. We adopted 0 pads/day as a deliberately strict definition of continence in order to reduce potential misclassification, because the commonly used 0–1 pad/day criterion may be influenced by individual pad-use habits and replacement frequency, which do not always correspond to the actual severity of urine leakage. This choice was made in the context of the known heterogeneity of continence definitions after radical prostatectomy. [6] Postoperative pain was assessed using a 10-point visual analogue scale (VAS), ranging from 0 (no pain) to 10 (worst pain), on postoperative day 1, at discharge, and on the day of catheter removal. Pain scores were recorded by nursing staff. All patients had a minimum follow-up duration of 7 months.
Surgical procedure
A 5 cm transverse incision was made 5 cm above the pubic symphysis, followed by dissection to the extraperitoneal space. An extraperitoneal single-site access system was deployed.7 (Fig. 1C) (Fig. 2).
Fig. 1.
Step-by-Step Extraperitoneal Port Placement Through a Single 5 cm Transverse Incision for essRARP All procedures were performed using the da Vinci Xi Surgical System. Patients were positioned in a modified Trendelenburg position. A 5 cm transverse incision was made 5 cm above the pubic symphysis for extraperitoneal access (Fig. 1A and B). An extraperitoneal single-site access device was installed, with the 12 mm camera port placed caudally and maintained at a 30° upward angle, while the cephalad 12 mm channel served as the assistant port (Fig. 1C). Postoperatively, both the pelvic drainage tube and SPC were secured within the same 5 cm incision (Fig. 1D).
Fig. 2.
SPC Placement Procedure Overview A 5 cm transverse incision is made 5 cm above the pubic symphysis for essRARP. Postoperatively, both the SPC and pelvic drainage tube are secured within the same 5 cm incision. At both ends of the incision, intracutaneous sutures of approximately 2–3 cm are placed. After tube removal (SPC or pelvic drainage tube), traction on the pre-placed sutures allows for closure of the primary wound
UC Group: After essRARP, vesicourethral anastomosis was performed using a bidirectional running technique with a barbed suture (3 –0 V-Loc™). An 18-Fr urethral catheter was inserted following completion of the anastomosis, and the balloon was inflated with 20 mL saline. In the UC group, the urethral catheter was kept in situ for 1–2 weeks before removal.
SPC/UC-free Group: After vesicourethral anastomosis, 150 mL of sterile saline was instilled via the urethra to assess anastomotic integrity. With no signs of leakage, a 14-Fr suprapubic catheter (SPC) was inserted under direct vision into the anterior bladder wall. Correct placement was confirmed by urine flow through the SPC, followed by balloon inflation with 4 mL saline. The urethral catheter was removed after confirming unobstructed drainage via the SPC. The SPC was removed on postoperative day 6.
In both groups, during the procedure, neurovascular bundles were preserved when oncologically appropriate, at the surgeon’s discretion. Routine ROCCO posterior reconstruction and anterior reconstruction were performed to ensure optimal anatomical and functional recovery [8].
Postoperative Management: In both groups, a cystogram was performed on the day of catheter removal to assess anastomotic integrity. If no anastomotic leakage was detected, the catheter(s) were removed. In the SPC/UC-free group, the wound was closed by tightening the previously placed suture tails.
Statistical analysis
Statistical analysis was conducted using SPSS version 27.0. Continuous variables were compared using Student’s t-test or the Mann–Whitney U test, as appropriate, and categorical variables were analyzed using the chi-square test or Fisher’s exact test. Categorical variables with multiple levels (e.g., Gleason score and clinical T stage) were compared as overall distributions between groups. Pain scores were treated as non-normally distributed ordinal variables and are presented as median and interquartile range (IQR). Between-group comparisons of pain scores were performed using the Mann–Whitney U test at each prespecified time point. A two-sided P-value < 0.05 was considered statistically significant. Propensity score matching was additionally performed using age, BMI, PSA, membranous urethral length, prostate volume, Gleason score, and clinical T stage as matching covariates. Patients were matched 1:1 using nearest-neighbor matching with a caliper of 0.2. Baseline characteristics and perioperative outcomes were then compared in both the unmatched and matched cohorts. To identify independent predictors of immediate urinary continence, multivariable logistic regression analysis was performed with age, PSA, Gleason score, clinical T stage, prostate volume, membranous urethral length, nerve-sparing status, and surgical group entered as covariates. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated.
Results
Baseline characteristics
In the unmatched cohort, baseline characteristics were generally comparable between the SPC/UC-free and UC groups, with no statistically significant between-group differences in demographic or preoperative variables (Table 1). After propensity score matching, 87 matched pairs were identified. Baseline characteristics were generally better balanced in the matched cohort, although a small residual imbalance remained for Gleason score (P = 0.042), with cT stage also showing borderline imbalance (P = 0.054) (Table 1).
Table 1.
Preoperative characteristics and intraoperative parameters
| Variables | Before PSM | After PSM | ||||
|---|---|---|---|---|---|---|
| SPC/UC-free (n = 129) | UC (n = 88) | P a | SPC/UC-free (n = 87) | UC (n = 87) | P | |
| Age (years), (median (IQR)) | 70.00 (66.00, 75.00) | 71.50 (68.00, 75.00) | 0.169 | 70.00 (66.00, 75.00) | 71.00 (68.00, 75.00) | 0.080 |
| BMI, (median (IQR)) | 23.72 (22.00, 25.50) | 24.17 (21.76, 25.88) | 0.800 | 23.50 (21.85, 25.71) | 24.09 (21.73, 25.86) | 0.856 |
| PSA (ng/ml), (median (IQR)) | 10.80 (7.57, 18.14) | 13.16 (9.50, 19.30) | 0.154 | 10.42 (7.52, 18.00) | 13.00 (9.42, 19.06) | 0.186 |
| MUL (mm), (median (IQR)) | 9.04 (8.39, 10.22) | 9.04 (8.36, 10.03) | 0.553 | 9.00 (8.39, 10.16) | 9.04 (8.36, 10.15) | 0.774 |
| Prostate Volume (ml), (median (IQR)) | 35.55 (26.59, 49.10) | 36.74 (22.90, 55.84) | 0.806 | 35.00 (23.70, 45.50) | 36.07 (22.30, 56.26) | 0.398 |
| Gleason Score (n, %) | 0.065 | 0.042 | ||||
| 6 | 22 (17.10%) | 5 (5.70%) | 17 (19.54%) | 5 (5.75%) | ||
| 7 | 71 (55.00%) | 58 (65.90%) | 49 (56.32%) | 58 (66.67%) | ||
| 8 | 24 (18.60%) | 17 (19.30%) | 14 (16.09%) | 17 (19.54%) | ||
| 9 | 9 (7.00%) | 8 (9.10%) | 5 (5.75%) | 7 (8.05%) | ||
| 10 | 3 (2.30%) | 0 (0.00%) | 2 (2.30%) | 0 (0.00%) | ||
| cT stage (n, %) | 0.283 | 0.054 | ||||
| cT1 | 4 (3.10%) | 2 (2.30%) | 4 (4.60%) | 2 (2.30%) | ||
| cT2 | 88 (68.20%) | 58 (65.90%) | 59 (67.82%) | 58 (66.67%) | ||
| cT3 | 26 (20.20%) | 25 (28.40%) | 15 (17.24%) | 25 (28.74%) | ||
| cT4 | 11 (8.50%) | 3 (3.40%) | 9 (10.34%) | 2 (2.30%) | ||
| Blood Loss (ml), (median (IQR)) | 30.00 (20.00, 50.00) | 50.00 (20.00, 50.00) | 0.133 | 30.00 (20.00, 50.00) | 50.00 (20.00, 50.00) | 0.185 |
| Operative Time (min), (median (IQR)) | 140 (120.00, 195.00) | 156 (115.00, 194.25) | 0.592 | 140 (120, 194) | 155 (115, 194) | 0.549 |
| Positive surgical margin, (n, %) | 16 (12.40%) | 8 (9.10%) | 0.587 | 9 (10.34%) | 7 (8.05%) | 0.600 |
| Length of Hospital Stay Postoperatively (day), (median (IQR)) | 3 (2, 4) | 3 (2, 5) | 0.230 | 3 (2, 5) | 3 (2, 5) | 0.356 |
| Nerve-sparing status, n (%) | 0.090 | 0.226 | ||||
| No Nerve spare | 88 (68.20%) | 63 (71.60%) | 61 (70.11) | 62 (71.26%) | ||
| Uni Nerve spare | 22 (17.10%) | 20 (22.70%) | 15 (17.24%) | 20 (22.99%) | ||
| Bil Nerve spare | 19 (14.70%) | 5 (5.70%) | 11 (12.64%) | 5 (5.75%) | ||
SPC = suprapubic catheter; UC = urethral catheter; BMI = body mass index; PSA = prostate specific antigen; n = number; IQR = interquartile range; MUL: membranous urethral length, cT stage = clinical Tumor stage, PSM = propensity score matching
A Statistical test performed: Mann–Whitney U test, chi-square test of independence
Intraoperative parameters
Intraoperative and perioperative parameters were similar between groups in both the unmatched and matched cohorts, with no significant differences in operative time, estimated blood loss, postoperative hospital stay, or nerve-sparing status (Table 1).
Pain scores
In the unmatched cohort, VAS pain scores were similar between groups on postoperative day 1 and on the day of catheter removal, but were lower in the SPC/UC-free group at discharge (median [IQR] 1.0 [1.0–2.0] vs. 1.5 [1.0–2.0]; P < 0.001). This pattern remained similar after propensity score matching, with significantly lower discharge-day pain scores in the SPC/UC-free group (median [IQR] 1.0 [1.0–2.0] vs. 2.0 [1.0–2.0]; P = 0.013), whereas pain scores on postoperative day 1 and catheter removal day remained comparable (Table 2).
Table 2.
Postoperative pain scores, urinary continence and complications
| Variables | Before PSM | After PSM | ||||
|---|---|---|---|---|---|---|
| SPC/UC-free (n = 129) | UC (n = 88) | P | SPC/UC-free (n = 87) | UC (n = 87) | P | |
| VAS pain score, POD1, (median (IQR)) | 2.0 (2.0–2.0) | 2.0 (2.0–2.0) | 0.271 | 2.0 (2.0–2.0) | 2.0 (2.0–2.0) | 0.262 |
| VAS pain score, discharge day, (median (IQR)) | 1.0 (1.0–2.0) | 1.5 (1.0–2.0) | < 0.001 | 1.0 (1.0–2.0) | 2.0 (1.0–2.0) | 0.013 |
| VAS pain score, catheter removal day, (median (IQR)) | 1.0 (1.0–1.0) | 1.0 (1.0–1.0) | 0.618 | 1.0 (1.0–1.0) | 1.0 (1.0–1.0) | 0.509 |
| Urinary continence b | ||||||
| Immediate urinary continence, (n, %) | 74 (57.40%) | 22 (25.00%) | <0.01 | 52 (59.77%) | 22 (25.29%) | < 0.001 |
| ≤ 1 Month, (n, %) | 31 (24.00%) | 23 (26.10%) | 0.848 | 6 (6.90%) | 15 (17.24%) | 0.036 |
| 1 Month and ≤ 3 Months, (n, %) | 14 (10.90%) | 19 (21.60%) | 0.049 | 9 (10.34%) | 18 (20.69%) | 0.060 |
| > 3 Months, (n, %) | 32 (24.80%) | 31 (35.20%) | 0.132 | 20 (22.99%) | 32 (36.78%) | 0.047 |
| Readmission, (n, %) | 0 (0.00%) | 0 (0.00%) | - | 0 (0.00%) | 0 (0.00%) | - |
| Gross hematuria, (n, %) | 2 (1.55%) | 0 (0.00%) | 0.241 | 2 (2.30%) | 0 (0.00%) | 0.155 |
| Anastomotic leakage, (n, %) | 0 (0.00%) | 0 (0.00%) | - | 0 (0.00%) | 0 (0.00%) | - |
| Urethral stenosis, (n, %) | 0 (0.00%) | 0 (0.00%) | - | 0 (0.00%) | 0 (0.00%) | - |
| Urinary retention, (n, %) | 0 (0.00%) | 0 (0.00%) | - | 0 (0.00%) | 0 (0.00%) | - |
| Re-catheterization, (n, %) | 0 (0.00%) | 0 (0.00%) | - | 0 (0.00%) | 0 (0.00%) | - |
ᵇ Urinary continence was consistently defined as the use of 0 pads/day. Continence recovery categories indicate the time to first achievement of continence after catheter removal and are mutually exclusive
Urinary continence
In the unmatched cohort, Immediate urinary continence was 57.4% (74/129) in the SPC/UC-free group and 25.0% (22/88) in the UC group (P < 0.001) (Table 2). Continence recovery within ≤ 1 month was 24.0% (31/129) and 26.1% (23/88), respectively (P = 0.848). Continence recovery within > 1 month to ≤ 3 months was 10.9% (14/129) and 21.6% (19/88), respectively (P = 0.049). The proportion of patients requiring > 3 months to achieve continence was 24.8% (32/129) and 35.2% (31/88), respectively (P = 0.132).
After propensity score matching, immediate urinary continence remained significantly higher in the SPC/UC-free group than in the UC group (59.77% [52/87] vs. 25.29% [22/87], P < 0.001). Continence recovery within ≤ 1 month was 6.90% (6/87) and 17.24% (15/87), respectively (P = 0.036). Continence recovery within > 1 month to ≤ 3 months was 10.34% (9/87) and 20.69% (18/87), respectively (P = 0.060). The proportion of patients requiring > 3 months to achieve continence was 22.99% (20/87) and 36.78% (32/87), respectively (P = 0.047). These categories represent the time to first achievement of continence and are mutually exclusive.
Postoperative complications
Two patients in the SPC/UC-free group developed self-limiting gross hematuria, and no additional intervention was required. There were no cases of anastomotic leakage, urinary retention, re-catheterization, urinary tract infection, urethral stricture, or hospital readmission in either group. No suprapubic catheter-related adverse events were observed other than the above-mentioned transient gross hematuria.
Multivariable logistic regression for immediate urinary continence
In the multivariable logistic regression model including age, PSA, Gleason score, clinical T stage, prostate volume, MR-measured membranous urethral length, nerve-sparing status, and surgical group, the SPC group remained independently associated with higher odds of immediate urinary continence compared with the UC group (OR 3.94, 95% CI 2.07–7.48, P < 0.001). In addition, non–nerve-sparing was independently associated with lower odds of immediate urinary continence compared with bilateral nerve-sparing (OR 0.29, 95% CI 0.09–0.91, P = 0.034), whereas unilateral nerve-sparing did not reach statistical significance (OR 0.42, 95% CI 0.12–1.47, P = 0.176). Age showed a borderline association with immediate urinary continence (OR 0.95, 95% CI 0.91–1.00, P = 0.054), while PSA, Gleason score, clinical T stage, prostate volume, and MR-measured membranous urethral length were not significantly associated with the outcome (Table 3).
Table 3.
Multivariable logistic regression for immediate urinary continence
| Variables | OR | 95% CI | P value |
|---|---|---|---|
| Age (years) | 0.95 | 0.91–1.00 | 0.054 |
| PSA (ng/mL) | 0.99 | 0.97–1.01 | 0.377 |
| Gleason score | 0.95 | 0.62–1.45 | 0.802 |
| Clinical T stage | 0.67 | 0.38–1.17 | 0.159 |
| Prostate volume (mL) | 1.00 | 0.99–1.02 | 0.567 |
| Membranous urethral length (mm) | 1.15 | 0.94–1.42 | 0.173 |
| Nerve-sparing (non vs. bilateral) | 0.29 | 0.09–0.91 | 0.034 |
| Nerve-sparing (unilateral vs. bilateral) | 0.42 | 0.12–1.47 | 0.176 |
| Surgical group (SPC/UC-free vs. UC) | 3.94 | 2.07–7.48 | < 0.001 |
Outcome: immediate urinary continence. Reference categories: bilateral nerve-sparing for nerve-sparing status; UC group for surgical group. OR = odds ratio; CI = confidence interval
Propensity score-matched analysis
After propensity score matching, 87 matched pairs were identified. Baseline characteristics were generally more balanced in the matched cohort, although a small residual imbalance in Gleason score remained. In the matched analysis, the SPC/UC-free group remained associated with lower discharge-day pain scores and a higher rate of immediate urinary continence, while overall perioperative safety outcomes remained comparable between groups (Tables 1 and 2).
Discussion
Urethral catheter is usually employed following radical prostatectomy to ensure adequate bladder drainage and anastomotic healing [1]. However, it frequently induces catheter-related lower urinary tract symptoms (LUTS) [9], such as penile irritation and perineal pain, which may hinder patient comfort. The advent of SPC, first introduced by Tewari et al. [2] in 2008 as an alternative drainage strategy, offers a renewed opportunity to reconsider urethral catheter-free recovery by aiming to mitigate the adverse effects associated with LUTS. Subsequently, Ghani et al. [3] (2013) provided a detailed, step-by-step SPC placement guide, which required an additional suprapubic stab incision to anchor the bladder. Prasad et al. [4] (2014), in a randomized controlled trial, using two separate suprapubic incisions, found no advantage over UC in pain or complications, with longer operative times. Morgan et al. [5] (2016) reported more SPC-related emergency visits, further questioning the clinical advantages of SPC techniques. Notably, most previously described SPC protocols required an additional suprapubic incision; avoiding extra skin punctures or incisions is desirable to maximise patient comfort and align with ERAS principles. Therefore, we implemented a urethral catheter-free technique. A single, horizontal 5 cm incision—approximately 5 cm superior to the pubic symphysis—originally created as the robotic access point for specimen retrieval, was utilised to place both the SPC and pelvic drainage tube under direct visualisation, thereby obviating the need for any additional skin punctures. Following confirmation of correct SPC positioning, adequate drainage, and the absence of urinary leakage, the urethral catheter was removed intraoperatively. Patients were subsequently transferred to recovery without a urethral catheter in situ.
In the present cohort, pain outcomes differed mainly at discharge. The SPC/UC-free group had lower discharge-day pain scores than the UC group in both the unmatched and matched analyses. However, pain scores on postoperative day 1 and on the day of catheter removal were similar between groups. Although the discharge-day difference reached statistical significance, the absolute between-group difference was modest and should therefore be interpreted cautiously in terms of clinical significance. Nevertheless, these findings suggest that avoiding an indwelling urethral catheter may provide some improvement in postoperative comfort.
A notable finding of this study was the higher rate of immediate urinary continence in the SPC/UC-free group.[3, 10] This earlier recovery pattern also helps explain the distribution of continence recovery across later follow-up intervals. Because more patients in the SPC/UC-free group achieved continence immediately after catheter removal, fewer remained at risk of first recovery within the later ≤ 1 month and > 1 to ≤ 3 month intervals. Therefore, the differing proportions across these later time categories likely reflect a temporal shift toward earlier continence recovery rather than a contradictory pattern. Importantly, this advantage remained evident after propensity score matching, supporting the robustness of the observed early continence benefit. In addition, expanded multivariable logistic regression analysis including age, PSA, Gleason score, clinical T stage, prostate volume, MR-measured membranous urethral length, nerve-sparing status, and surgical group showed that the urethral catheter-free technique remained independently associated with immediate urinary continence (Table 3). Given that membranous urethral length and nerve-sparing status were incorporated into the multivariable model, and that all procedures were performed by a single surgeon using a standardised technique, major anatomical and technical confounders are less likely to fully account for the observed difference [11]. Representative cystograms obtained on the day of catheter removal suggested possible differences in postoperative bladder configuration between groups (Fig. 3). In the UC group, the bladder appeared more inferiorly positioned with a tendency toward retroversion, whereas in the SPC/UC-free group the bladder appeared relatively elevated and more anteriorly oriented. Because cystography was performed in only a subset of patients, these imaging observations should be interpreted as illustrative and hypothesis-generating rather than as definitive group-level evidence. We further hypothesise that the observed early continence advantage may relate to the balloon-anchored SPC, which can functionally tether the anterior bladder wall to the abdominal wall and help maintain a more elevated, anterior bladder position. This configuration could reduce tension across the vesicourethral anastomosis and may resemble, in part, the anatomic support described in Retzius-sparing approaches [12]. Besides, we observed little apparent postoperative need for mirabegron in the SPC/UC-free group, although this was not a prespecified endpoint and was not formally analysed. In addition, during urethral catheterisation, urine may occasionally leak through the space between the urethral catheter and the urethral mucosa.[13] In contrast, the urethral catheter-free protocol avoids this potential source of peri-anastomotic irritation, which may partly contribute to the observed early continence advantage in the SPC/UC-free group.[14, 15].
Safety should be considered alongside these potential functional advantages. In our cohort, two patients in the SPC/UC-free group developed self-limiting gross hematuria, which resolved spontaneously after delaying SPC removal by three days. Hematuria may have been partly related to bladder wall puncture during SPC placement; however, no additional intervention was required. No urethral stricture, urinary leakage, urinary tract infection, urinary retention, re-catheterization or readmission occurred in either group. Postoperative cystography revealed no anastomotic leakage or urinary extravasation, and no patient developed urethral stricture during the 7-month follow-up. These findings are broadly consistent with previous reports supporting the short-term safety of SPC-based drainage after RARP.[16].
Fig. 3.
Postoperative day 1 cystograms comparing bladder configuration between SPC/UC-free and UC groups. (A, C) SPC/UC-free group; (B, D) UC group. (A) Anteroposterior view of SPC/UC-free patient showing the lowest bladder point 5.05 mm below the superior margin of the pubic symphysis (pubic symphysis height 33.89 mm; 5.05 mm / 33.89 mm =0.149). (B) Anteroposterior view of UC patient showing the lowest bladder point 30.91 mm below the superior margin of the pubic symphysis (pubic symphysis height 38.76 mm; 30.91 mm / 38.76 mm =0.797). (C) Lateral view of SPC/UC-free patient demonstrating an anteriorly tilted bladder; distance from anterior bladder wall to abdominal wall = 41.40 mm. (D) Lateral view of UC patient revealing a retroverted, inferiorly positioned bladder; distance from anterior bladder wall to abdominal wall = 83.96 mm.
Collectively, these procedural refinements—including extraperitoneal direct visualization, bladder fixation via balloon anchorage, one incision SPC and immediate tract sealing through pre-placed sutures—may underlie the observed low incidence of complications and support the viability of urethral catheter free in our study. In our opinion, for the majority of early-stage prostate cancer patients with preserved preoperative urethral sphincter function, no history of urinary incontinence, favourable intraoperative vesicourethral anastomosis and no requirement for bladder-neck reconstruction, a urethral catheter-free technique may offer improved postoperative comfort and better early continence outcomes. Therefore, routine urethral catheter may not be necessary for all patients undergoing RARP.
This study has several limitations. First, it was a single-center retrospective study with a non-randomized, time-based allocation design, so selection bias and residual confounding cannot be fully excluded despite propensity score matching and multivariable adjustment. Second, although all patients had a minimum follow-up of 7 months, the study primarily focused on very early and early postoperative functional outcomes, and therefore does not allow firm conclusions regarding sustained mid- or long-term benefit. Third, all procedures were performed using an extraperitoneal single-site robotic approach by a single experienced surgeon, which may limit the generalizability of our findings to standard multiport RARP settings.
Despite these limitations, the study provides clinically relevant evidence on a novel urethral catheter-free strategy during essRARP. The surgical technique and perioperative management were highly standardized, all procedures were performed by a single experienced surgeon, and the main findings were supported by both propensity score-matched analysis and multivariable adjustment. These results support the feasibility and potential early functional benefit of this approach and justify further prospective evaluation.
Conclusion
The urethral catheter-free technique using single-incision suprapubic catheter placement during essRARP appears to be safe and feasible. Compared with conventional urethral catheterization, this approach was associated with improved immediate urinary continence and lower discharge-day pain scores, without an evident increase in short-term complications. These findings mainly support a potential benefit in early postoperative recovery, whereas the mid- and long-term functional implications remain to be determined in prospective multicenter studies with longer follow-up.
Author contributions
Di Gu and Binghao Zeng had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Conceptualization and Methodology: Binghao Zeng, Yubo Wang, Xinci Ning, Qingfeng Yu, Zhuyinjun Zong, Mingzhao Li, Shancheng Ren, Guohua Zeng, and Di Gu. Investigation: Binghao Zeng, Yubo Wang, Xinci Ning, Qingfeng Yu, Zhuyinjun Zong, Viktor Stankov and Mingzhao Li. Formal Analysis and Data Curation: Binghao Zeng, Yubo Wang, Xinci Ning, Qingfeng Yu, Zhuyinjun Zong. Writing – Original Draft: Binghao Zeng, Yubo Wang, Zhuyinjun Zong, Xinci Ning. Writing, Review and Editing: Binghao Zeng, Yubo Wang, Xinci Ning, Qingfeng Yu, Zhuyinjun Zong, Mingzhao Li, Yongda Liu, Chao Cai, Jiehui Zhong, Tao Xie, Jianfeng Liang, Jianhao Wu, Xuezhi Long, Yueting Huang, Viktor Stankov, Shancheng Ren, Guohua Zeng, and Di Gu. Visualization: Zhuyinjun Zong, Yubo Wang. Rating Scale Review and Collection: Yan Zhao. Resources, Supervision, Project Administration: Guohua Zeng, Shancheng Ren, Di Gu.
Data availability
The dataset generated and analysed during the present study are not publicly available as the conditions of the ethics approval do not permit public archiving of the data but are available from the corresponding author on reasonable request.
Declarations
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Binghao Zeng, Yubo Wang, Xinci Ning and Zhuyinjun Zong contributed equally to this work.
Change history
10/15/2026
A Correction to this paper has been published: https://doi.org/10.1007/s11701-026-04051-8
Contributor Information
Shancheng Ren, Email: renshancheng@gmail.com.
Guohua Zeng, Email: gzgyzgh@vip.sina.com.
Di Gu, Email: sveong@163.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The dataset generated and analysed during the present study are not publicly available as the conditions of the ethics approval do not permit public archiving of the data but are available from the corresponding author on reasonable request.