Highlights from the 15th Shanghai Urologic Oncology Academic Conference
Editor’s Note: The 15th Shanghai Urologic Oncology Academic Conference was grandly held in Pudong, Shanghai, bringing together leading experts in urology from China and abroad. In-depth discussions focused on innovative surgical techniques for prostate cancer, preoperative imaging assessment, and individualized treatment strategies. During the dedicated session on Innovative Techniques and Advances in Prostate Cancer Surgery, Professor Ming Liu delivered an insightful presentation entitled “A Preoperative Imaging Evaluation for Radical Prostatectomy”, in which he systematically proposed a preoperative prediction model for the difficulty of intrafascial excision using the Hood technique. This article summarizes the rationale, methodology, and preliminary findings of this prospective study, with the aim of informing clinical practice.
The Hood Technique and the Clinical Challenges of Intrafascial Excision
In recent years, radical prostatectomy using the Hood technique has been increasingly adopted by experts worldwide. Compared with earlier approaches such as the VIP technique or the “super veil” technique, the key advantage of the Hood technique lies in its emphasis on preserving periprostatic supporting structures and fascial layers. This approach particularly advocates bilateral intrafascial excision, aiming to maximize preservation of the neurovascular bundles (NVBs) and surrounding tissues, thereby optimizing postoperative erectile function and urinary continence.
Professor Liu pointed out that although intrafascial excision is widely recognized as a critical method for functional preservation, the technical difficulty varies substantially among patients. In some cases, once the correct plane is identified, tissues can be easily separated, revealing the white prostatic capsule. In other patients, however, dense adhesions exist between the surrounding fascia and the capsule; dissection may inadvertently enter the vascular layer of the fascia, increasing the risk of vascular injury or capsular tearing.
Current research on postoperative erectile function has largely focused on postoperative parameters, such as the relationship between periprostatic fascial thickness and erectile recovery (thicker fascia correlating with better outcomes), or the size of the NVB at the 5- and 7-o’clock positions (larger areas associated with improved recovery). However, there remains a significant gap in preoperative assessment tools capable of systematically predicting the difficulty of intrafascial excision before surgery.
Innovation: An MRI-Based Preoperative Prediction Model
Addressing this unmet clinical need, Professor Liu’s team initiated a prospective study to investigate whether preoperative magnetic resonance imaging (MRI) features could predict the technical difficulty of intrafascial excision using the Hood technique, the degree of nerve preservation, and ultimate postoperative pathological and functional outcomes (urinary continence, erectile function, and voiding function).
The study enrolled patients with clinical stage T2 or lower prostate cancer who were scheduled for bilateral intrafascial excision using the Hood technique. Patients who had received neoadjuvant therapy were excluded. In close collaboration with radiologists, the team identified several key MRI-based evaluation parameters:
- Thickness of the periprostatic fascia: Precise measurements were obtained at multiple positions (3, 9, 5, 7, and 12 o’clock) to assess their impact on surgical difficulty.
- Clarity of the capsular boundary: On T2-weighted images, the low-signal-intensity plane between the prostatic capsule and surrounding fascia was carefully examined. The team categorized this feature as either “clear” or “unclear,” reflecting the likelihood of adhesion.
- Distance between tumor and capsule: The minimum distance from the tumor lesion to the prostatic capsule was measured.
- Post-biopsy secondary changes: T1-weighted images were used to assess post-biopsy hemorrhage (extensive hyperintense signals), while T2-weighted images were evaluated for inflammatory changes (multiple low-signal areas), both of which may interfere with accurate identification of surgical planes.
Establishing Intraoperative Adhesion and Postoperative Pathological Assessment Systems
To enable quantitative analysis, the research team developed multidimensional scoring systems to evaluate both intraoperative findings and postoperative outcomes:
- Intraoperative assessment: Surgeons used a five-grade scoring system to quantify the degree of adhesion encountered during intrafascial excision, as well as their subjective assessment of nerve preservation.
- Postoperative pathological assessment: This represents a major strength of the study. Using routine large-section pathological techniques, the team objectively quantified nerve preservation at the histological level. Professor Liu explained:
“With large-section pathology, we can clearly visualize whether nerves, adipose tissue, and vessels are present outside the prostatic capsule.”
A five-grade pathological classification was established, ranging from clearly identifiable nerve structures to complete capsular-adjacent excision with no visible neuromuscular fibers. This approach transformed nerve preservation assessment from subjective intraoperative perception to objective histopathological evidence.
Early Data: Emerging Associations and High-Risk Features
At the time of reporting, 17 patients had been enrolled in this prospective study, most with clinical stage T2c disease. The median interval between biopsy and surgery was 36 days. Although the sample size remains limited, preliminary multivariate analyses revealed meaningful trends.
Among the various imaging features analyzed, periprostatic fascial thickness at the 3- and 9-o’clock positions showed a correlation with the degree of intraoperative adhesion. This suggests that specific regional fascial characteristics may serve as potential imaging biomarkers for predicting surgical difficulty. Professor Liu noted that a sample size of at least 100 cases will be required to generate statistically robust conclusions.
Notably, despite all patients being classified as having organ-confined disease (≤T2) on preoperative imaging, postoperative pathology revealed upstaging to T3a in approximately 20% of cases (4 patients).
Perspectives and Future Clinical Application
Professor Liu concluded that the core concept of this study is to establish a comprehensive MRI-based preoperative prediction system. Rather than focusing solely on tumor-related factors (such as T3 staging), the model integrates multiple imaging dimensions—including periprostatic fascial thickness, capsular boundary clarity, and benign inflammatory signals—to predict surgical difficulty and the potential impact on nerve preservation.
He emphasized that the innovation of this work lies not in prognostic tumor evaluation, but in providing a quantitative tool for precision and individualized surgical planning in radical prostatectomy. In the future, this model may help surgeons determine preoperatively whether a patient is suitable for technically demanding intrafascial excision, thereby optimizing functional preservation during the perioperative period and offering a new evidence-based framework for decision-making in function-preserving radical prostatectomy.
Professor Ming Liu
