Surgical Complications in a large series of Retzius-sparing robot-assisted radical prostatectomy: impact of surgical experience and technical modifications (1016 cases).

Robot-assisted radical prostatectomy (RARP) has become the standard surgical treatment for prostate cancer. The Retzius-sparing approach (RS-RARP) offers improved functional outcomes; however, detailed data on non-functional perioperative and postoperative complications remain limited. This study aimed to evaluate the incidence, spectrum, and management of complications following RS-RARP in a large series and to assess the impact of progressive technical modifications. We performed a retrospective analysis of a prospectively maintained database of 1016 consecutive patients who underwent RS-RARP between 2016 and 2025. Complications were recorded intraoperatively and postoperatively and graded using the Clavien-Dindo classification. Functional outcomes were excluded. Temporal changes in surgical technique and perioperative protocols were analysed in relation to trends in complications. A total of 199 complications were recorded, with an overall complication rate of 18.2%. Most complications were low-grade, while major complications (Grade ≥ III) occurred in a minority. The most frequent complications included urinary tract infection (4.5%), urinary retention (3.5%), and incisional hernia (3.15%). Symptomatic lymphocele occurred in 0.89% and urethral stricture in 0.98%. Life-threatening complications were rare (0.3%), with one perioperative mortality (0.1%). Few targeted technical modifications were introduced during the study period, including oral antibiotic prophylaxis to prevent urinary tract infections, adoption of a Pfannenstiel incision for specimen extraction to reduce hernia rates, implementation of peritoneal distraction with the aim of reducing lymphocele rates, and optimization of catheter management protocols. These changes were associated with a reduction in procedure-specific complications over time. Although functional outcomes are routinely emphasized, non-functional surgical complications should also be addressed during preoperative counselling. In this large series, most complications were infrequent and manageable, with rates influenced by ongoing technical refinements. While lymphocele and urinary retention may be more frequent with the Retzius-sparing approach, a lower incidence of de novo inguinal hernia was observed. Targeted technical modifications, including Pfannenstiel specimen extraction and oral cefixime prophylaxis, were associated with reductions in specific postoperative complications, highlighting the importance of continuous refinement of surgical technique and perioperative care in optimizing outcomes following RS-RARP.