The impact of posterior reconstruction on the quality and ease of execution of vesico- urethral anastomosis during robot-assisted radical prostatectomy: results from a comparative non-randomized study

The impact of posterior reconstruction on the quality and ease of execution of vesico- urethral anastomosis during robot-assisted radical prostatectomy: results from a comparative non-randomized study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The impact of posterior reconstruction on the quality and ease of execution of vesico- urethral anastomosis during robot-assisted radical prostatectomy: results from a comparative non-randomized study Maria Chiara Sighinolfi, Simona Presutti, Giuseppe Pallotta, Antonio Silvestri, and 17 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8918811/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background and Objective Posterior reconstruction (PR) during radical prostatectomy was originally introduced to improve early urinary continence. Emerging evidence suggests PR may also facilitate vesico-urethral anastomosis (VUA) by reducing tension and enhancing anatomical alignment. This study aimed to assess the impact of PR on the quality and ease of VUA during robot-assisted laparoscopic prostatectomy (RALP). Methods Retrospective, single-center comparative study at Fondazione Policlinico Gemelli IRCCS, Rome, Italy. Included 271 patients with localized prostate cancer undergoing RALP between November 2023 and February 2025. PR introduced in October 2024 using a standardized two-layer technique. Primary outcomes: rate of cystogram use, urinary leakage, and emergency imaging due to suspect extravasation. Multivariable logistic regression was performed to identify independent predictors of leakage. Key Findings and Limitations Overall, 87 patients received PR, 184 did not; PR group had significantly lower cystogram use (34.5% vs. 52.7%, p=0.005) and leakage rates (6.7% vs. 71.8%, p<0.001). PR was independently associated with lower leakage risk (OR 0.18; 95% CI 0.04–0.80; p=0.024). No emergency cystograms required in either group. Limitations are the retrospective design, single-center setting, non-randomized allocation, relatively small sample size. Conclusions and Clinical Implications Posterior reconstruction improves anastomotic quality by reducing leakage and potentially simplifying VUA. Incorporating PR into standard RALP protocols may enhance perioperative outcomes and reduce the need for postoperative imaging. Further prospective, multi-center studies are warranted to confirm reproducibility. Robotic radical prostatectomy urinary leakage posterior reconstruction Introduction Radical prostatectomy (RP) has long been established as a primary surgical treatment for localized prostate cancer, with widespread adoption across open, laparoscopic, and robotic-assisted approaches. Despite its established oncological efficacy, radical prostatectomy may be associated with functional side effects, particularly regarding urinary continence and erectile function. While many patients recover well, urinary incontinence can persist in a subset of cases and may affect quality of life and postoperative satisfaction. One of the technical hurdles in radical prostatectomy is the vesico-urethral anastomosis (VUA), which demands precision and stability, particularly in the absence of supportive anatomical structures disrupted during prostate excision. In response to these functional challenges, particularly early urinary incontinence, a pivotal technique known as posterior reconstruction (PR) was introduced in the mid-2000s. Rocco and colleagues first described the restoration of the posterior rhabdosphincter during open radical retropubic prostatectomy as a means to anatomically support continence mechanisms. Their initial study demonstrated that restoring the posterior aspect of the rhabdosphincter significantly shortened the time to continence recovery after surgery [1]. This was followed by evidence of its benefit in minimally invasive surgery, where Rocco et al applied the same principles during transperitoneal videolaparoscopic RP and showed similarly improved functional outcomes [2]. The technique was subsequently adapted to robot-assisted radical prostatectomy (RARP), where enhanced visualization and instrument dexterity allowed for precise anatomical restoration. Gondo et al notably demonstrated that a double-layered posterior reconstruction during RARP led to a significantly faster recovery of continence in the early postoperative period [3], confirming the translatability and effectiveness of PR in robotic surgery. Building upon these early results, several systematic reviews and meta-analyses have rigorously evaluated the impact of PR on continence outcomes. A landmark review by Rocco and colleagues in 2012 synthesized available evidence and concluded that PR is associated with improved early return of continence after RP [4]. This was later substantiated and updated in a meta-analysis by Grasso et al. in 2016, which confirmed the superiority of PR in both open and robotic cohorts [5]. Additional studies, including those by Vis et al. [6] and Cui et al. [7], have expanded upon these findings, incorporating comparisons of various pelvic floor reconstruction techniques and their respective impacts on postoperative function. While the primary aim of PR has historically been to improve urinary continence outcomes, emerging evidence suggests it may also confer technical advantages beyond continence, particularly in facilitating the vesico-urethral anastomosis. By reapproximating the Denonvilliers’ fascia and supporting posterior anatomical structures, PR appears to stabilize the anastomotic site, potentially simplifying the reconstruction and improving its integrity. The objective of this study is to investigate the potential impact of posterior reconstruction on the quality and ease of vesico-urethral anastomosis during radical prostatectomy. Materials and methods This is a retrospective single-center comparative study conducted at a tertiary academic institution, the Fondazione Policlinico Gemelli Hospital IRCCS, Rome, Italy. Overall, 271 patients with localized prostate cancer who underwent robotic radical prostatectomy (RALP) were consecutively considered since November 2023. Patients signed a comprehensive informed consent for clinical and radiological data collection and analysis. All patients had a localized or locally advanced prostate cancer (PCa) diagnosis and were elected to surgery as the primary treatment. All RALP were carried out by five surgeons with Hugo RAS surgical system with a transperitoneal standard technique and a Van Velthoven vesico-urethral anastomosis (VUA). During surgery, a check for water-tightness of VUA was performed in all cases, accomplished with retrograde injection of saline and inspection of the pelvis. Afterwards, a retrograde cystogram prior to catheter removal was optional and suggested from the surgeon on an individual basis in difficult cases with challenging anastomotic suturing. Intervention Starting from September 2024, the PR was introduced as a standard technique for robotic radical prostatectomy. Posterior reconstruction is performed using a two layers technique, which involves first approximating the cut edge of Denonvilliers’ fascia to the rhabdosphincter, followed by suturing the posterior bladder neck to the posterior urethral wall [8]. In all cases, a barbed suture was used. Primary endpoint The primary endpoint is to compare the quality of the VUA before (November 2023 to September 2024) and after the introduction of the PR technique (October 2024 to February 2025). Outcome measures representative of ease of execution and quality of the anastomosis are: 1) the rate of patients who required an optional cystogram due to a difficult suturing of anastomosis; 2) the rate of leakage at retrograde cystogram; 3) the rate of patients who required an emergency cystogram due to suspicion of urinary extravasation. Statistical analysis Statistical analyses were conducted to compare baseline characteristics, intraoperative variables, histological findings, and postoperative outcomes between the Posterior and Non-posterior groups. Continuous variables were tested for normality using the Shapiro–Wilk test and reported as means with standard deviations (SD) or medians with interquartile ranges (IQR), as appropriate. Group comparisons were performed using the independent t-test for normally distributed variables and the Mann–Whitney U test for non-normally distributed variables. Categorical variables were summarized as frequencies and percentages, and comparisons were made using the Chi-square test or Fisher’s exact test, as appropriate. A p-value of less than 0.05 was considered statistically significant. A multivariable logistic regression model was used to assess the association between the type of reconstruction (posterior vs. non-posterior) and the occurrence of intraperitoneal leakage, which was the binary outcome variable. The primary predictor was the surgical technique (posterior reconstruction), while body mass index (BMI), age, final prostate volume at histological analysis, preoperative PSA levels, cancer stage >pTa2, and the Charlson Comorbidity Index were included as covariates to adjust for potential confounding factors. To select the most parsimonious and predictive model, the Least Absolute Shrinkage and Selection Operator (LASSO) method was applied. LASSO is a regularization technique that introduces a penalty proportional to the absolute values of the regression coefficients, effectively shrinking some coefficients to zero. This results in the exclusion of non-informative variables, thereby improving model interpretability and reducing the risk of overfitting—particularly useful in datasets with multicollinearity or a limited number of outcome events [9]. All analyses were conducted using Stata® 18 for MacOS (StataCorp LLC, College Station, TX, USA). Results Overall, 184 patients received a RALP without posterior reconstruction and 87 with PR. Baseline age, BMI, PSA did not differ significantly between groups. Prostate volume at final pathology was slightly higher in the non-PR group (42 vs 36 gr, p = 0.028); the PR group had a significantly higher proportion of patients with extracapsular disease (p = 0.005). A lower rate of cystogram usage (34.5% vs 52.7%, p = 0.005) was recorded with the introduction of posterior reconstruction and, once performed, a lower rate of urinary leakages (6.7% vs 71.8%, p < 0.001) was evident with PR. No symptoms related to delayed detection of extravasation were described in both groups, nor the need of an emergency cystogram to rule out this side effect. Table 1 summarizes outcomes stratified by presence/absence of posterior reconstruction (non-PR versus PR). The surgical technique (posterior reconstruction) was the only relevant inverse predictor of urinary leakage, after LASSO regularization excluding all other covariates. The logistic regression confirmed that PR was significantly associated with a lower risk of urinary leakage, with an odds ratio (OR) of 0.18, 95% confidence interval (CI) 0.04–0.80, and a p-value of 0.024. In this context, posterior reconstruction emerged as an independent predictor of leakage, supporting its primary influence regardless of patient- or disease-related factors (age, BMI, CCI, prostate volume). Discussion Vesicourethral anastomosis (VUA) is one of the most technically demanding steps during radical prostatectomy, a critical component whose quality directly influences the incidence of postoperative complications such as urinary leakage and long-term urinary incontinence [10]. Achieving a precisely aligned, watertight, tension-free, and stricture-free anastomosis is essential to preserve the integrity of the sphincter mechanism and to optimize functional recovery. Over the years, various techniques and tools have been proposed to refine this step, differing in suture type (e.g., barbed vs. non-barbed, monofilament vs. multifilament), suturing methods (e.g., interrupted vs. running sutures), and configuration (e.g., singleneedle vs. double-needle) [11–13], along with alternative direct and indirect approaches to reduce technical complexity. Given the impact of anastomotic quality on postoperative outcomes, efforts have been made to objectively assess and standardize this phase. Notably, Porpiglia et al [10] introduced the Anastomosis Quality Score to guide intraoperative decision-making and improve outcomes during robot-assisted radical prostatectomy (RARP). Certain anatomical and technical variables are recognized as risk factors for a more complex anastomosis, including disparities in diameter between the bladder neck and urethral stump, degree of bladder neck preservation, and absence of urethral stump protrusion—all of which can compromise approximation and increase suture tension [10]. Additionally, the steep Trendelenburg position commonly used during RARP contributes to a gravitational shift that may further widen the anatomical distance between the bladder neck and the urethral stump. This increased tension can render the anastomosis more challenging and potentially jeopardize its integrity, especially in the absence of posterior support. Posterior reconstruction (PR) was initially conceived to restore the anatomical structures contributing to continence, namely the rhabdosphincter and posterior support mechanisms. Since its introduction by Rocco et al [1,2], the technique has been widely adopted due to its positive impact on early continence recovery. Beyond its functional benefits, PR has now become an integral component of the standard technique in radical prostatectomy. It is cited as a key technical step in several authoritative resources, including the Hinman’s Atlas of Urologic Surgery [14], the ORSI (Orsi Academy) curriculum for robotic radical prostatectomy training [15], and Patel’s comprehensive textbook on robotic prostatectomy [8], where it is described as a routine part of the procedure. Importantly, PR may also provide technical advantages beyond continence. By reapproximating the Denonvilliers’ fascia and stabilizing the posterior bladder neck, PR effectively reduces the tension across the anastomotic site, thereby facilitating easier and more secure suturing. This tension-relieving function of posterior support has also been described in the context of intracorporeal neobladder reconstruction, where approximating the ileal reservoir to the urethral stump can be particularly demanding. Sighinolfi and the ERUS Scientific Working Group described specific strategies for ileo-urethral approximation, emphasizing the utility of posterior support to reduce tension and simplify the anastomosis [16]. Similarly, Rocco et al. reported on the benefits of posterior reconstruction in the setting of radical cystectomy and neobladder formation, highlighting improved anastomotic ease and functional outcomes [17,18]. The findings of the present study strengthen the hypothesis that posterior reconstruction serves not only a functional role in continence recovery but also a mechanical one in supporting the anastomosis. From the current analysis, this surgical strategy may reduce the occurrence of urinary extravasation. Furthermore, at multivariate analysis considering other variables likely to impact on tissue consistence and healing – such as age, BMI, CCI score, prostate volume – the posterior reconstruction remains the only inverse predictor of leakage. By acting as a scaffold between the bladder and urethra, PR may reduce anastomotic tension, improve suture handling, and facilitate a more efficient and secure reconstruction. These results support the notion that posterior reconstruction contributes to surgical quality by simplifying one of the most complex aspects of the procedure. A watertight anastomosis is at the very basis of an uneventful course [19]; to date, retrograde cystogram is the mostly used examination to rule out urinary leakage [20]. According to center’s practice, the exam could be performed on a regularly basis or it could be limited to cases with challenging anastomosis in which the surgeon deems it necessary, as in our clinical practice. Thus, we choose the need for a cystogram as part of the primary endpoint, hypothesizing a reduction of cystogram exams with implementing PR practice; however, recognizing the weakness of this variable, prone to surgeon’s subjective evaluation, we choose to rule out the presence of undiagnosed leakage by considering the rate of urgent VUA assessment for suspicious unrecognized leakage – such as emergency cystogram or CT scan with cystography step. This study is not devoid of limitation. The relatively small sample size could be seen as the first one; the single center feature may raise concerns about the reproducibility of our outcomes. The different background of surgeons could be interpreted as another limitations, however, we should emphasize that all surgeons had already completed their learning curve for RALP (at least 50 robotic procedures). Opposite, the use of a new robotic system, the Hugo RAS, could be seen as a point of strength and novelty, and the current series confirms that routinary surgical steps are reproducible also on the Medtronic technology. To note, Hugo RAS was settled up by the end of 2022 at the Policlinico Gemelli and all surgeons have already achieved expertise – in terms of both knowledge and practice - with this new system [21–23]. Conclusions The Rocco Stitch - firstly described in 2006 for open radical prostatectomy - proved to be an effective and widespread technique contributing to improve post-prostatectomy continence recovery. From the current series, the PR may also improve the watertightness of the vesico-urethral anastomosis; by enhancing approximation and reducing tension, it provides support for sutures and therefore could be useful to reduce catheterization and to prevent urinary leakage. Declarations Author Contribution Conceptualization and study design: M.C.S., B.R. / Data curation: G.P., S.P., A.S., S.A. / Formal analysis: S.T. / Investigation: G.P., M.C.S., S.P., A.S., E.S., V.C., L.R., B.G., F.R., P.R., F.T., A.T., R.B., C.G., E.P. / Methodology: M.C.S., B.R., G.P. / Writing: G.P., M.C.S. / Supervision: B.R. References Rocco F, Carmignani L, Acquati P, Gadda F, Dell'Orto P, Rocco B, Bozzini G, Gazzano G, Morabito A. Restoration of posterior aspect of rhabdosphincter shortens continence time after radical retropubic prostatectomy. J Urol. 2006 Jun;175(6):2201-6. doi: 10.1016/S0022-5347(06)00262-X. PMID:16697841. Rocco B, Gregori A, Stener S, Santoro L, Bozzola A, Galli S, Knez R, Scieri F, Scaburri A, Gaboardi F. Posterior reconstruction of the rhabdosphincter allows a rapid recovery of continence after transperitoneal videolaparoscopic radical prostatectomy. Eur Urol. 2007 Apr;51(4):996–1003. doi: 10.1016/j.eururo.2006.10.014. Epub 2006 Oct 23. PMID: 17079070. 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Online ahead of print.PMID: 39455408 Rocco B, Sighinolfi MC, Sarchi L, Assumma S, Turri F, Sangalli M, Gaia G, Grasso A, Dell'Orto P, Calcagnile T, Piacentini I, Coelho RF, Terzoni S, Panio E, Moscovas MC, Patel V. First case of robotassisted radical cystectomy and intracorporeal neobladder reconstruction with the Hugo RAS system: step-by-step surgical setup and technique. J Robot Surg. 2023 Oct;17(5):2247–2251. doi: 10.1007/s11701-023-01629-4. Epub 2023 Jun 9.PMID: 37294418 Tables Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files tabelleroccostitchword.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Polyclinic","correspondingAuthor":false,"prefix":"","firstName":"Filippo","middleName":"","lastName":"Turri","suffix":""},{"id":599008497,"identity":"4eb0e399-383f-4322-ac90-473bf55ced14","order_by":20,"name":"Bernardo Cesare Maria Rocco","email":"","orcid":"","institution":"Agostino Gemelli University Polyclinic","correspondingAuthor":false,"prefix":"","firstName":"Bernardo","middleName":"Cesare Maria","lastName":"Rocco","suffix":""}],"badges":[],"createdAt":"2026-02-19 15:42:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8918811/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8918811/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104400853,"identity":"47c6fa41-77f4-4ee4-9e95-388e08c3c292","added_by":"auto","created_at":"2026-03-11 12:11:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":481232,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8918811/v1/a256e223-bace-482d-870a-9cb1dc428312.pdf"},{"id":103862914,"identity":"2daab590-1d82-45ea-b499-e9c26a59c05d","added_by":"auto","created_at":"2026-03-03 20:42:05","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":26833,"visible":true,"origin":"","legend":"","description":"","filename":"tabelleroccostitchword.docx","url":"https://assets-eu.researchsquare.com/files/rs-8918811/v1/06f473c0111235721d4a7008.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The impact of posterior reconstruction on the quality and ease of execution of vesico- urethral anastomosis during robot-assisted radical prostatectomy: results from a comparative non-randomized study","fulltext":[{"header":"Introduction","content":"\u003cp\u003e Radical prostatectomy (RP) has long been established as a primary surgical treatment for localized prostate cancer, with widespread adoption across open, laparoscopic, and robotic-assisted approaches. Despite its established oncological efficacy, radical prostatectomy may be associated with functional side effects, particularly regarding urinary continence and erectile function. While many patients recover well, urinary incontinence can persist in a subset of cases and may affect quality of life and postoperative satisfaction. One of the technical hurdles in radical prostatectomy is the vesico-urethral anastomosis (VUA), which demands precision and stability, particularly in the absence of supportive anatomical structures disrupted during prostate excision.\u003c/p\u003e \u003cp\u003eIn response to these functional challenges, particularly early urinary incontinence, a pivotal technique known as posterior reconstruction (PR) was introduced in the mid-2000s. Rocco and colleagues first described the restoration of the posterior rhabdosphincter during open radical retropubic prostatectomy as a means to anatomically support continence mechanisms. Their initial study demonstrated that restoring the posterior aspect of the rhabdosphincter significantly shortened the time to continence recovery after surgery [1]. This was followed by evidence of its benefit in minimally invasive surgery, where Rocco et al applied the same principles during transperitoneal videolaparoscopic RP and showed similarly improved functional outcomes [2]. The technique was subsequently adapted to robot-assisted radical prostatectomy (RARP), where enhanced visualization and instrument dexterity allowed for precise anatomical restoration. Gondo et al notably demonstrated that a double-layered posterior reconstruction during RARP led to a significantly faster recovery of continence in the early postoperative period [3], confirming the translatability and effectiveness of PR in robotic surgery.\u003c/p\u003e \u003cp\u003eBuilding upon these early results, several systematic reviews and meta-analyses have rigorously evaluated the impact of PR on continence outcomes. A landmark review by Rocco and colleagues in 2012 synthesized available evidence and concluded that PR is associated with improved early return of continence after RP [4]. This was later substantiated and updated in a meta-analysis by Grasso et al. in 2016, which confirmed the superiority of PR in both open and robotic cohorts [5]. Additional studies, including those by Vis et al. [6] and Cui et al. [7], have expanded upon these findings, incorporating comparisons of various pelvic floor reconstruction techniques and their respective impacts on postoperative function.\u003c/p\u003e \u003cp\u003eWhile the primary aim of PR has historically been to improve urinary continence outcomes, emerging evidence suggests it may also confer technical advantages beyond continence, particularly in facilitating the vesico-urethral anastomosis. By reapproximating the Denonvilliers\u0026rsquo; fascia and supporting posterior anatomical structures, PR appears to stabilize the anastomotic site, potentially simplifying the reconstruction and improving its integrity. The objective of this study is to investigate the potential impact of posterior reconstruction on the quality and ease of vesico-urethral anastomosis during radical prostatectomy.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eThis is a retrospective single-center comparative study conducted at a tertiary academic institution, the Fondazione Policlinico Gemelli Hospital IRCCS, Rome, Italy. Overall, 271 patients with localized prostate cancer who underwent robotic radical prostatectomy (RALP) were consecutively considered since November 2023. Patients signed a comprehensive informed consent for clinical and radiological data collection and analysis. All patients had a localized or locally advanced prostate cancer (PCa) diagnosis and were elected to surgery as the primary treatment. All RALP were carried out by five surgeons with Hugo RAS surgical system with a transperitoneal standard technique and a Van Velthoven vesico-urethral anastomosis (VUA). During surgery, a check for water-tightness of VUA was performed in all cases, accomplished with retrograde injection of saline and inspection of the pelvis. Afterwards, a retrograde cystogram prior to catheter removal was optional and suggested from the surgeon on an individual basis in difficult cases with challenging anastomotic suturing.\u003c/p\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003cp\u003eStarting from September 2024, the PR was introduced as a standard technique for robotic radical prostatectomy. Posterior reconstruction is performed using a two layers technique, which involves first approximating the cut edge of Denonvilliers\u0026rsquo; fascia to the rhabdosphincter, followed by suturing the posterior bladder neck to the posterior urethral wall [8]. In all cases, a barbed suture was used.\u003c/p\u003e \u003cp\u003ePrimary endpoint\u003c/p\u003e \u003cp\u003eThe primary endpoint is to compare the quality of the VUA before (November 2023 to September 2024) and after the introduction of the PR technique (October 2024 to February 2025). Outcome measures representative of ease of execution and quality of the anastomosis are: 1) the rate of patients who required an optional cystogram due to a difficult suturing of anastomosis; 2) the rate of leakage at retrograde cystogram; 3) the rate of patients who required an emergency cystogram due to suspicion of urinary extravasation.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were conducted to compare baseline characteristics, intraoperative variables, histological findings, and postoperative outcomes between the Posterior and Non-posterior groups. Continuous variables were tested for normality using the Shapiro\u0026ndash;Wilk test and reported as means with standard deviations (SD) or medians with interquartile ranges (IQR), as appropriate. Group comparisons were performed using the independent t-test for normally distributed variables and the Mann\u0026ndash;Whitney U test for non-normally distributed variables. Categorical variables were summarized as frequencies and percentages, and comparisons were made using the Chi-square test or Fisher\u0026rsquo;s exact test, as appropriate. A p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e \u003cp\u003eA multivariable logistic regression model was used to assess the association between the type of reconstruction (posterior vs. non-posterior) and the occurrence of intraperitoneal leakage, which was the binary outcome variable. The primary predictor was the surgical technique (posterior reconstruction), while body mass index (BMI), age, final prostate volume at histological analysis, preoperative PSA levels, cancer stage \u0026gt;pTa2, and the Charlson Comorbidity Index were included as covariates to adjust for potential confounding factors. To select the most parsimonious and predictive model, the Least Absolute Shrinkage and Selection Operator (LASSO) method was applied. LASSO is a regularization technique that introduces a penalty proportional to the absolute values of the regression coefficients, effectively shrinking some coefficients to zero. This results in the exclusion of non-informative variables, thereby improving model interpretability and reducing the risk of overfitting\u0026mdash;particularly useful in datasets with multicollinearity or a limited number of outcome events [9]. All analyses were conducted using Stata\u0026reg; 18 for MacOS (StataCorp LLC, College Station, TX, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOverall, 184 patients received a RALP without posterior reconstruction and 87 with PR. Baseline age, BMI, PSA did not differ significantly between groups. Prostate volume at final pathology was slightly higher in the non-PR group (42 vs 36 gr, p\u0026thinsp;=\u0026thinsp;0.028); the PR group had a significantly higher proportion of patients with extracapsular disease (p\u0026thinsp;=\u0026thinsp;0.005).\u003c/p\u003e \u003cp\u003eA lower rate of cystogram usage (34.5% vs 52.7%, p\u0026thinsp;=\u0026thinsp;0.005) was recorded with the introduction of posterior reconstruction and, once performed, a lower rate of urinary leakages (6.7% vs 71.8%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) was evident with PR. No symptoms related to delayed detection of extravasation were described in both groups, nor the need of an emergency cystogram to rule out this side effect. Table\u0026nbsp;1 summarizes outcomes stratified by presence/absence of posterior reconstruction (non-PR versus PR). The surgical technique (posterior reconstruction) was the only relevant inverse predictor of urinary leakage, after LASSO regularization excluding all other covariates. The logistic regression confirmed that PR was significantly associated with a lower risk of urinary leakage, with an odds ratio (OR) of 0.18, 95% confidence interval (CI) 0.04\u0026ndash;0.80, and a p-value of 0.024. In this context, posterior reconstruction emerged as an independent predictor of leakage, supporting its primary influence regardless of patient- or disease-related factors (age, BMI, CCI, prostate volume).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eVesicourethral anastomosis (VUA) is one of the most technically demanding steps during radical prostatectomy, a critical component whose quality directly influences the incidence of postoperative complications such as urinary leakage and long-term urinary incontinence [10]. Achieving a precisely aligned, watertight, tension-free, and stricture-free anastomosis is essential to preserve the integrity of the sphincter mechanism and to optimize functional recovery. Over the years, various techniques and tools have been proposed to refine this step, differing in suture type (e.g., barbed vs. non-barbed, monofilament vs. multifilament), suturing methods (e.g., interrupted vs. running sutures), and configuration (e.g., singleneedle vs. double-needle) [11\u0026ndash;13], along with alternative direct and indirect approaches to reduce technical complexity.\u003c/p\u003e \u003cp\u003eGiven the impact of anastomotic quality on postoperative outcomes, efforts have been made to objectively assess and standardize this phase. Notably, Porpiglia et al [10] introduced the Anastomosis Quality Score to guide intraoperative decision-making and improve outcomes during robot-assisted radical prostatectomy (RARP). Certain anatomical and technical variables are recognized as risk factors for a more complex anastomosis, including disparities in diameter between the bladder neck and urethral stump, degree of bladder neck preservation, and absence of urethral stump protrusion\u0026mdash;all of which can compromise approximation and increase suture tension [10].\u003c/p\u003e \u003cp\u003eAdditionally, the steep Trendelenburg position commonly used during RARP contributes to a gravitational shift that may further widen the anatomical distance between the bladder neck and the urethral stump. This increased tension can render the anastomosis more challenging and potentially jeopardize its integrity, especially in the absence of posterior support.\u003c/p\u003e \u003cp\u003ePosterior reconstruction (PR) was initially conceived to restore the anatomical structures contributing to continence, namely the rhabdosphincter and posterior support mechanisms. Since its introduction by Rocco et al [1,2], the technique has been widely adopted due to its positive impact on early continence recovery. Beyond its functional benefits, PR has now become an integral component of the standard technique in radical prostatectomy. It is cited as a key technical step in several authoritative resources, including the Hinman\u0026rsquo;s Atlas of Urologic Surgery [14], the ORSI (Orsi Academy) curriculum for robotic radical prostatectomy training [15], and Patel\u0026rsquo;s comprehensive textbook on robotic prostatectomy [8], where it is\u003c/p\u003e \u003cp\u003edescribed as a routine part of the procedure.\u003c/p\u003e \u003cp\u003eImportantly, PR may also provide technical advantages beyond continence. By reapproximating the Denonvilliers\u0026rsquo; fascia and stabilizing the posterior bladder neck, PR effectively reduces the tension across the anastomotic site, thereby facilitating easier and more secure suturing. This tension-relieving function of posterior support has also been described in the context of intracorporeal neobladder reconstruction, where approximating the ileal reservoir to the urethral stump can be particularly demanding. Sighinolfi and the ERUS Scientific Working Group described specific strategies for ileo-urethral approximation, emphasizing the utility of posterior support to reduce tension and simplify the anastomosis [16]. Similarly, Rocco et al. reported on the benefits of posterior reconstruction in the setting of radical cystectomy and neobladder formation, highlighting improved anastomotic ease and functional outcomes [17,18].\u003c/p\u003e \u003cp\u003eThe findings of the present study strengthen the hypothesis that posterior reconstruction serves not only a functional role in continence recovery but also a mechanical one in supporting the anastomosis.\u003c/p\u003e \u003cp\u003eFrom the current analysis, this surgical strategy may reduce the occurrence of urinary extravasation. Furthermore, at multivariate analysis considering other variables likely to impact on tissue consistence and healing \u0026ndash; such as age, BMI, CCI score, prostate volume \u0026ndash; the posterior reconstruction remains the only inverse predictor of leakage. By acting as a scaffold between the bladder and urethra, PR may reduce anastomotic tension, improve suture handling, and facilitate a more efficient and secure reconstruction. These results support the notion that posterior reconstruction contributes to surgical quality by simplifying one of the most complex aspects of the procedure. A watertight anastomosis is at the very basis of an uneventful course [19]; to date, retrograde cystogram is the mostly used examination to rule out urinary leakage [20]. According to center\u0026rsquo;s practice, the exam could be performed on a regularly basis or it could be limited to cases with challenging anastomosis in which the surgeon deems it necessary, as in our clinical practice. Thus, we choose the need for a cystogram as part of the primary endpoint, hypothesizing a reduction of cystogram exams with implementing PR practice; however, recognizing the weakness of this variable, prone to surgeon\u0026rsquo;s subjective evaluation, we choose to rule out the presence of undiagnosed leakage by considering the rate of urgent VUA assessment for suspicious unrecognized leakage \u0026ndash; such as emergency cystogram or CT scan with cystography step.\u003c/p\u003e \u003cp\u003eThis study is not devoid of limitation. The relatively small sample size could be seen as the first one; the single center feature may raise concerns about the reproducibility of our outcomes. The different background of surgeons could be interpreted as another limitations, however, we should emphasize that all surgeons had already completed their learning curve for RALP (at least 50 robotic procedures). Opposite, the use of a new robotic system, the Hugo RAS, could be seen as a point of strength and novelty, and the current series confirms that routinary surgical steps are reproducible also on the Medtronic technology. To note, Hugo RAS was settled up by the end of 2022 at the Policlinico Gemelli and all surgeons have already achieved expertise \u0026ndash; in terms of both knowledge and practice - with this new system [21\u0026ndash;23].\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe Rocco Stitch - firstly described in 2006 for open radical prostatectomy - proved to be an effective and widespread technique contributing to improve post-prostatectomy continence recovery. From the current series, the PR may also improve the watertightness of the vesico-urethral anastomosis; by enhancing approximation and reducing tension, it provides support for sutures and therefore could be useful to reduce catheterization and to prevent urinary leakage.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization and study design: M.C.S., B.R. / Data curation: G.P., S.P., A.S., S.A. / Formal analysis: S.T. / Investigation: G.P., M.C.S., S.P., A.S., E.S., V.C., L.R., B.G., F.R., P.R., F.T., A.T., R.B., C.G., E.P. / Methodology: M.C.S., B.R., G.P. / Writing: G.P., M.C.S. / Supervision: B.R.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRocco F, Carmignani L, Acquati P, Gadda F, Dell'Orto P, Rocco B, Bozzini G, Gazzano G, Morabito A. Restoration of posterior aspect of rhabdosphincter shortens continence time after radical retropubic prostatectomy. J Urol. 2006 Jun;175(6):2201-6. doi: 10.1016/S0022-5347(06)00262-X. PMID:16697841.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRocco B, Gregori A, Stener S, Santoro L, Bozzola A, Galli S, Knez R, Scieri F, Scaburri A, Gaboardi F. Posterior reconstruction of the rhabdosphincter allows a rapid recovery of continence after transperitoneal videolaparoscopic radical prostatectomy. Eur Urol. 2007 Apr;51(4):996\u0026ndash;1003. doi: 10.1016/j.eururo.2006.10.014. Epub 2006 Oct 23. PMID: 17079070.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGondo T, Yoshioka K, Hashimoto T, Nakagami Y, Hamada R, Kashima T, Shimodaira K, Takeuchi H, Satake N, Tachibana M, Rocco B. The powerful impact of double-layered posterior rhabdosphincter reconstruction on early recovery of urinary continence after robot-assisted radical prostatectomy. J Endourol. 2012 Sep;26(9):1159-64. doi: 10.1089/end.2012.0067. Epub 2012 Jun 25. PMID: 22471623.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRocco B, Cozzi G, Spinelli MG, Coelho RF, Patel VR, Tewari A, Wiklund P, Graefen M, Mottrie A, Gaboardi F, Gill IS, Montorsi F, Artibani W, Rocco F. Posterior musculofascial reconstruction after radical prostatectomy: a systematic review of the literature. Eur Urol. 2012 Nov;62(5):779\u0026thinsp;\u0026minus;\u0026thinsp;90. doi: 10.1016/j.eururo.2012.05.041. Epub 2012 May 30. PMID: 22664219.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrasso AA, Mistretta FA, Sandri M, Cozzi G, De Lorenzis E, Rosso M, Albo G, Palmisano F, Mottrie A, Haese A, Graefen M, Coelho R, Patel VR, Rocco B. Posterior musculofascial reconstruction after radical prostatectomy: an updated systematic review and a meta-analysis. BJU Int. 2016 Jul;118(1):20\u0026ndash;34. doi: 10.1111/bju.13480. Epub 2016 Apr 7. PMID: 26991606.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVis AN, van der Poel HG, Ruiter AEC, Hu JC, Tewari AK, Rocco B, Patel VR, Razdan S, Nieuwenhuijzen JA. Posterior, Anterior, and Periurethral Surgical Reconstruction of Urinary Continence Mechanisms in Robot-assisted Radical Prostatectomy: A Description and Video Compilation of Commonly Performed Surgical Techniques. Eur Urol. 2019 Dec;76(6):814\u0026ndash;822. doi: 10.1016/j.eururo.2018.11.035. Epub 2018 Dec 2. PMID: 30514568.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCui J, Guo H, Li Y, Chen S, Zhu Y, Wang S, Wang Y, Liu X, Wang W, Han J, Chen P, Nie S, Yin G, Shi B. Pelvic Floor Reconstruction After Radical Prostatectomy: A Systematic Review and Meta-analysis of Different Surgical Techniques. Sci Rep. 2017 Jun 2;7(1):2737. doi: 10.1038/s41598-017-02991-8. PMID: 28578433.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWiklund P, Mottrie A, Gundeti MS, Patel V. Robotic Urologic surgery. Third Edition, Springer 2022\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTibshirani, R. (1996). Regression shrinkage and selection via the lasso. Journal of the Royal Statistical Society: Series B (Methodological), 58(1), 267\u0026ndash;288.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePorpiglia F, Checcucci E, De Cillis S, Amparore D, Pecoraro A, Piana A, Granato S, Verri P, Sica M, Piramide F, Manfredi M, Fiori C. Anastomosis quality score during robot-assisted radical prostatectomy: a new simple tool to maximize postoperative management. World J Urol. 2021 Aug;39(8):2921\u0026ndash;2928. doi: 10.1007/s00345-020-03549-6. Epub 2021 Jan 3. PMID: 33388913.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi H, Liu C, Zhang H et al (2015) The use of unidirectional barbed suture for urethrovesical anastomosis during robot- assisted radical prostatectomy: a systematic review and meta- analysis of efficacy and safety. PLoS ONE 10(7):e0131167. https://doi.org/10.1371/journal.pone.0131167 (Published 2015 Jul 2)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePorreca A, D\u0026rsquo;agostino D, Dandrea M et al (2018) Bidirectional barbed suture for posterior musculofascial reconstruction and knotless vesicourethral anastomosis during robot-assisted radical prostatectomy. Minerva UrolNefrol. 70(3):319\u0026ndash;325. https://doi.org/10.23736/S0393-2249.18.02969-7\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKowalewski KF, Tapking C, Hetjens S et al (2019) Interrupted versus continuous suturing for vesicourethral anastomosis dur- ing radical prostatectomy: a systematic review and meta-analysis. EurUrol Focus 5(6):980\u0026ndash;991. https://doi.org/10.1016/j. euf.2018.05.009\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith, Joseph A., Jr., MDHinman's Atlas of Urologic Surgery, Fourth Edition, 2019\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMottrie A, Mazzone E, Wiklund P, Graefen M, Collins JW, De Groote R, Dell'Oglio P, Puliatti S,Gallagher AG.Objective assessment of intraoperative skills for robot-assisted radical prostatectomy (RARP): results from the ERUS Scientific and Educational Working GroupsMetrics Initiative. BJU Int. 2021 Jul;128(1):103\u0026ndash;111. doi: 10.1111/bju.15311. Epub 2020 Dec 20.PMID: 33251703\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSighinolfi MC, Bertolo R, Rocco B, Checcucci E, Mistretta FA, Antonelli A, Soria F, Gallioli A, Campi R, Moretto S, Fiori C, Montorsi F, Mottrie A, Porpiglia F. Strategies and techniques for ileo-urethral approximation during intracorporeal orthotopic neobladder reconstruction: Results from the ERUS Scientific Working Group. Eur Urol Open Sci. 2025 May;52:29\u0026ndash;36. doi: 10.1016/j.euros.2023.03.003. PMID: 37225512.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRocco B, Sighinolfi MC, Sandri M, Bertoni F, Micali S, De Lorenzis E, et al. Posterior reconstruction of the rhabdosphincter in radical cystectomy with orthotopic ileal neobladder: a step toward better functional results. Int Braz J Urol. 2018;44(5):882\u0026ndash;889. doi:10.1590/S1677-5538.IBJU.2017.0572.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuciani LG, Rocco B, Sighinolfi MC, Cai T, Malossini G. Posterior fascial reconstruction during robotassisted radical cystectomy: technical description and impact on continence outcomes after intracorporeal neobladder. BJU Int. 2019;124(1):126\u0026ndash;133. doi:10.1111/bju.14651.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchatzl G, Madersbacher S, Hofbauer J, Pycha A, Reiter WJ, Svolba G, Marberger M. The impact of urinary extravasation after radical retropubic prostatectomy on urinary incontinence and anastomotic strictures. Eur Urol. 1999;36:187\u0026ndash;90. https://doi.org/10.1159/000067995.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eW\u0026uuml;rnschimmel C, Panagl V, Mattei A, Fankhauser CD.Assessment of the Anastomosis after Radical Prostatectomy: A Review of Available Diagnostic Methods. Urol Int. 2022;106(11):1091\u0026ndash;1094. doi: 10.1159/000526762. Epub 2022 Oct 11.PMID: 36220005\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSighinolfi MC, Messina LA, Stocco M, Moscovas MC, Pelliccia P, Palma A, Rossini M, Gallo A, Ramondo A, Pozzi E, Assumma S, Terzoni S, Sandri M, Patel V, Rocco B. Cost analysis of new robotic competitors: a comparison of direct costs for initial hospital stay between Da Vinci and Hugo RAS for radical prostatectomy. J Robot Surg. 2024 Jun 13;18(1):251. doi: 10.1007/s11701-024-01930-w. PMID: 38869636.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarino F, Moretto S, Rossi F, Pio Bizzarri F, Gandi C, Filomena GB, Gavi F, Russo P, Campetella M, Totaro A, Pierconti F, Lentini N, Pastorino R, Sacco E.Robot-assisted Radical Prostatectomy with the Hugo RAS and da Vinci Surgical Robotic Systems: A Systematic Review and Meta-analysis of Comparative Studies. Eur Urol Focus. 2024 Oct 24:S2405-4569(24)00192-5. doi: 10.1016/j.euf.2024.10.005. Online ahead of print.PMID: 39455408\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRocco B, Sighinolfi MC, Sarchi L, Assumma S, Turri F, Sangalli M, Gaia G, Grasso A, Dell'Orto P, Calcagnile T, Piacentini I, Coelho RF, Terzoni S, Panio E, Moscovas MC, Patel V. First case of robotassisted radical cystectomy and intracorporeal neobladder reconstruction with the Hugo RAS system: step-by-step surgical setup and technique. J Robot Surg. 2023 Oct;17(5):2247\u0026ndash;2251. doi: 10.1007/s11701-023-01629-4. Epub 2023 Jun 9.PMID: 37294418\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Robotic radical prostatectomy, urinary leakage, posterior reconstruction","lastPublishedDoi":"10.21203/rs.3.rs-8918811/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8918811/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground and Objective\u003c/p\u003e\n\u003cp\u003ePosterior reconstruction (PR) during radical prostatectomy was originally introduced to improve early urinary continence. Emerging evidence suggests PR may also facilitate vesico-urethral anastomosis (VUA) by reducing tension and enhancing anatomical alignment. This study aimed to assess the impact of PR on the quality and ease of VUA during robot-assisted laparoscopic prostatectomy (RALP).\u003c/p\u003e\n\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003eRetrospective, single-center comparative study at Fondazione Policlinico Gemelli IRCCS, Rome, Italy. Included 271 patients with localized prostate cancer undergoing RALP between November 2023 and February 2025. PR introduced in October 2024 using a standardized two-layer technique. Primary outcomes: rate of cystogram use, urinary leakage, and emergency imaging due to suspect extravasation. Multivariable logistic regression was performed to identify independent predictors of leakage.\u003c/p\u003e\n\u003cp\u003eKey Findings and Limitations\u003c/p\u003e\n\u003cp\u003eOverall, 87 patients received PR, 184 did not; PR group had significantly lower cystogram use (34.5% vs. 52.7%, p=0.005) and leakage rates (6.7% vs. 71.8%, p\u0026lt;0.001). PR was independently associated with lower leakage risk (OR 0.18; 95% CI 0.04–0.80; p=0.024). No emergency cystograms required in either group. Limitations are the retrospective design, single-center setting, non-randomized allocation, relatively small sample size.\u003c/p\u003e\n\u003cp\u003eConclusions and Clinical Implications\u003c/p\u003e\n\u003cp\u003ePosterior reconstruction improves anastomotic quality by reducing leakage and potentially simplifying VUA. Incorporating PR into standard RALP protocols may enhance perioperative outcomes and reduce the need for postoperative imaging. Further prospective, multi-center studies are warranted to confirm\u003c/p\u003e\n\u003cp\u003ereproducibility.\u003c/p\u003e","manuscriptTitle":"The impact of posterior reconstruction on the quality and ease of execution of vesico- urethral anastomosis during robot-assisted radical prostatectomy: results from a comparative non-randomized study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-03 20:42:00","doi":"10.21203/rs.3.rs-8918811/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9a7f24f7-ece4-470b-b71b-0f96be926c55","owner":[],"postedDate":"March 3rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T10:56:43+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-03 20:42:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8918811","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8918811","identity":"rs-8918811","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}