Prospective single-arm IDEAL stage 2a feasibility study of urethra-preserving RARP in localized prostate cancer.

Our study introduces a urethra-preserving prostatectomy concept that maintains the entire intraprostatic urethra, thereby avoiding both urethral transection and vesicourethral anastomosis. We embed the technique in a transparent IDEAL-based framework with predefined intra-operative decision rules, including prespecified conversion to standard robot-assisted radical prostatectomy. This positions the technique as a distinct step beyond existing bladder neck- or urethra-sparing modifications, and provides the first prospective multicentre data supporting its feasibility in selected patients.

Inclusion criteria:

• Life expectancy >=10 years (biological age)
• No prior prostate therapy (laser enucleation, TURP, focal therapy)
• No pelvic/prostate radiotherapy;
• No prior abdominal/rectal surgery;
• No prior (neoadjuvant) androgen-deprivation therapy
• No prior stroke/cerebral ischemia with neurological sequelae;
• No neurological disease (e.g., Parkinson's)
• Transrectal or transperineal bilateral biopsy >=12 cores (MRI-ultrasound fusion, targeted + systematic)
• PSA <=15 ng/mL; prostate volume <=80 mL
• Biopsy ISUP grade 1-3 (= Gleason 3+3 / 3+4 / 4+3)
• No Gleason pattern 5; no intraductal, cribriform or neuroendocrine carcinoma
• mp/bpMRI (mandatory if biopsy Gleason >=3+4)
• No suspected metastases at staging

Exclusion Criteria:

- Failure to meet any inclusion criterion, or patient declining ToP-RAP (offered standard RARP per EAU guidelines)

De-identified patient-level data may be made available from the corresponding author upon reasonable request, subject to institutional approval and privacy/ethical restrictions.