An integrated Posterior-Anterior-Lateral (PAL) approach for robot-assisted radical prostatectomy: a propensity-matched comparison with the anterior technique

Robot-assisted radical prostatectomy (RARP) can be performed through anterior, posterior, or lateral approaches. We developed a structured Posterior-Anterior-Lateral (PAL) operative sequence and compared its perioperative and functional outcomes with the conventional anterior approach for RARP. This retrospective, single center, propensity-matched (1:2) study included 46 nonmetastatic prostate cancer patients in PAL RARP and 222 in conventional anterior approach RARP. The PAL approach involved posterior preparation, limited anterior access, and definitive lateral dissection with standardized seminal vesicle–based traction. The primary endpoints were safety and early functional outcomes (urinary continence). Secondary endpoints included complication rates, erectile function recovery and oncologic outcomes. PAL approach was associated with higher urinary continence rates at 3 and 6 months (p < 0.05) and overall faster recovery (log-rank p = 0.0016), along with a lower rate of bladder neck reconstruction (8.7% vs 29.3%, p = 0.010). Operative time was shorter (123.5 vs. 127.5 min, p = 0.017), with comparable blood loss and complication rates. Positive surgical margin rates, lymph node metastasis, 12-month biochemical recurrence, and major complication rates did not differ significantly between groups. Erectile function recovery was high in PAL (80.0% vs. 61.1%) but was not statistically significant. The PAL approach is technically feasible and safe, with favourable early outcomes. This technique may provide a workflow-based integration of existing surgical approaches that facilitates improved exposure and accuracy while preserving key anatomical structures, potentially improving functional outcomes and maintaining oncologic control. Prospective studies with longer-term follow-up are necessary to validate these early findings.