Wagaskar, et al. reported that “Hood technique” for robot-assisted radical prostatectomy (H-RARP) could accomplish the early return of urinary continence (UC) after RARP using anterior approach with preservation of the space of Retzius and its contents as much as possible, without worsen surgical margin rates (1). The original hood technique particularly focused on possible sparing of tissues (e.g., endopelvic fascia, puboperinealis muscle, arcus tendineus, puboprostatic ligament, detrusor apron, lateral ischioprostatic ligaments) around prostate and urethra under refined and delicate surgical procedure. The hood derived from those contents defense membranous urethra, external sphincter muscles and vesicourethral anastomosis. Some studies undergoing H-RARP also have described the higher rate of UC at early term after operation (2, 3), while in-depth analysis for bladder and urethral function between preoperative and postoperative phase has not been elucidated yet. In this study, we evaluated the differences between conventional anterior RARP (C-RARP) and H-RARP regarding continuous changes in UC status and urodynamic study (UDS) parameters following operation.

This study included a total of forty-three men with clinically localized prostate cancer who underwent RARP (C-RARP; n=17, and H-RARP; n=26) and pre- and postoperative examinations. Each group of C-RARP or H-RARP was performed from November 2019 to November 2020, from November 2020 to April 2023, respectively. All operations were performed by a single experienced surgeon. Some skills essential for the hood method, including bladder neck dissection, lateral pedicle control, prostatic apical dissection and urethral transection, were performed according to an initial report. Additionally, we attempted to preserve endopelvic fascia as much as possible and repaired the incised peritoneum. Postoperative UC was defined as being pad free or one safety pad usage per day, and continence status was assessed before RARP and 1, 3, and 6 months after the procedure. At 5–7 days prior to surgery and 3 months after surgery, a urodynamic study was carried out.

There is no significant difference between C-RARP and H-RARP group in the fundamental patients’ characteristics. There is also no significant difference between two groups in some perioperative data (e.g., console time, bleeding volume, rate of nerve sparing, rate of extended pelvic lymph node dissection, pathological stage, positive rate of surgical margin). Regarding the postoperative UC rates, each rate of H-RARP group tended to be higher than that of C-RARP (postoperative 1month: 53.8% vs 41.1%; 3months: 73% vs 64.3%; 6months: 84.6% vs 70.6%, respectively).
The postoperative values of maximum urethral closure pressure (MUCP) were significantly lower than the preoperative values of MUCP in C-RARP group. On the other hand, there is no significant difference between pre- and postoperative values of MUCP in H-RARP group. As for the postoperative functional profile length of urethra, there is no significant difference between C-RARP and H-RARP group. With respect to bladder contractility index (BCI) as a measurement derived from pressure flow study, postoperative vales of BCI were significantly lower than preoperative vales of BCI in C-RARP group. Conversely, there is no significant difference between pre- and postoperative BCI values in H-RARP group. 4 cases in C-RARP group showed postoperative detrusor overactivity (DO), but three of four cases included de novo DO. On the contrary, four cases in H-RARP group indicated preoperative DO and three of four have postoperative disappearance of DO.

H-RARP could suppress the postoperative decline of MUCP and BCI compared with C-RARP. There was no case with de novo DO in H-RARP group.

H-RARP has superiority in the postoperative maintenance of urethral and bladder function via the preservation of anatomical structure around prostate and membranous urethra, compared with C-RARP.

Wagaskar VG, Mittal A, Sobotka S et al. Hood Technique for Robotic Radical Prostatectomy-Preserving Periurethral Anatomical Structures in the Space of Retzius and Sparing the Pouch of Douglas, Enabling Early Return of Continence Without Compromising Surgical Margin Rates. Eur Urol. 2021; 80: 213-21.
Zhang H, Ning Z, Jia G et al. Modified hood technique for single-port robot-assisted radical prostatectomy contributes to early recovery of continence. Front Surg. 2023; 10: 1132303.
Vargo EH, Vetter JM, Figenshau RS, Kim EH. A Hybrid Approach to Hood-Sparing Robotic Prostatectomy to Maximize Functional Outcomes and Maintain Early Oncologic Efficacy. J Endourol. 2024; 38: 997-1003.