Editor’s Note: The 2025 Annual Meeting of the Chinese Urological Association (CUDA) was held from June 12–15 in the romantic city of Zhuhai. With the theme “Healthy China, Urology in Action,” the conference brought together experts from across the country to share the latest insights and practical experience in urologic surgery. At the conference, Professor Xuepei Zhang from the First Affiliated Hospital of Zhengzhou University delivered a compelling presentation titled “Clinical Application of Robotic Combined-Approach Radical Prostatectomy,” and further shared his institution’s experience in robotic-assisted urologic procedures with UroStream.Zhengzhou’s Experience with Combined Anterior-Posterior Approach in RLRP
UroStream: Your presentation on robotic prostate cancer surgery was one of the highlights of the conference. Could you share your clinical insights, such as your approach to surgical access and strategies for preserving urinary continence and sexual function?
Professor Xuepei Zhang: Prostate cancer is one of the most common malignant tumors of the male genitourinary system. In Western countries, its incidence ranks first among male malignancies, and the rate in China has been steadily increasing—now among the leading cancers affecting men. Radical prostatectomy remains a key treatment for localized and locally advanced disease. But beyond tumor removal, functional preservation is also crucial. Patients are not only concerned about whether the cancer is completely excised, but also whether they will experience postoperative urinary incontinence. Younger patients, in particular, hope to preserve their sexual nerves and function. In clinical practice, we refer to this as the “trifecta” goal: complete tumor removal, continence preservation, and sexual function preservation.
Robot-assisted laparoscopic radical prostatectomy (RLRP) is increasingly recognized as the optimal surgical treatment for localized prostate cancer. Historically, the anterior approach was most commonly used, where the prostate is accessed from the front, requiring dissection of the pelvic fascia, transection of the puboprostatic ligaments, and division of the dorsal venous complex (DVC). However, this approach often damages the supportive structures around the urethra, resulting in high rates of postoperative urinary incontinence. Consequently, its use has declined in recent years.
At our center, we have adopted a combined approach. We begin posteriorly, dissecting the space between the prostate and rectum. Then we move laterally to separate the bladder from the prostate, carefully preserving the bladder neck—an important step for maintaining urinary continence. In addition, we perform nerve-sparing dissection closely along the prostatic capsule, as we would with the anterior approach, preserving key neurovascular structures.
With meticulous dissection and surgical precision, this method enables both oncologic control and functional preservation. We have performed over 60 such procedures with encouraging outcomes. At three-month follow-up, about 70%–80% of patients had preserved sexual nerve function, and around 40% regained urinary continence immediately after catheter removal within two to three weeks. This technique deserves broader clinical adoption.
Innovative Robotic Surgery for Level III Tumor Thrombus at Zhengzhou University First Affiliated Hospital
UroStream : Recently, you and your team published a study in the leading journal European Urology detailing a novel robotic laparoscopic technique for managing level III inferior vena cava (IVC) tumor thrombus. Could you walk us through this innovative approach?
Professor Xuepei Zhang: Renal cell carcinoma (RCC) with tumor thrombus extension into the inferior vena cava (IVC) represents a complex and advanced disease stage, often referred to as the “Mount Everest” of urologic surgery due to its surgical challenges. The complexity increases significantly when the thrombus ascends toward the heart. In some cases, cancer cells may invade through the renal vein into the IVC and even extend into the right atrium, posing significant operative risks.
For Mayo level III thrombi—those that extend into the IVC below the diaphragm but have not reached the right atrium—traditional surgery typically involves two steps: initially placing the patient in the supine position to isolate and clamp the IVC below the heart, followed by a switch to the lateral position to open the IVC and remove the thrombus.
After extensive literature analysis, we developed a novel approach using a single left lateral decubitus position, with the right side elevated. This positioning allows us to directly dissect and control the distal IVC both above the liver and below the diaphragm (supradiaphragmatic and infradiaphragmatic segments). Once we have controlled the IVC, we clamp the left renal vein and the retrohepatic segment of the IVC, then incise the IVC to remove the thrombus.
For more extensive thrombi (Mayo IIIb–IIId), we also take special measures intraoperatively. After thrombectomy, we rapidly release the porta hepatis and proximal IVC clamps to prevent ischemia-reperfusion injury to the liver, which facilitates faster postoperative recovery.
This innovative technique, published in the latest issue of European Urology—one of the most prestigious journals in our field—marks an important recognition of our work by the international urologic community.
Domestic Innovation Accelerates the Popularization of Robotic Urologic Surgery
UroStream : In your view, what developments are needed in robotic surgical systems to enable their widespread adoption across all hospital tiers and eventually make them as routine as standard laparoscopy?
Professor Xuepei Zhang: The evolution of surgical techniques, particularly in urology, has gone through three major phases: from open surgery, to minimally invasive laparoscopy, and now to robotic-assisted surgery. Robotic systems offer magnified 3D visualization with a clear operative field and enhanced dexterity through mechanical arms with seven degrees of freedom, enabling highly precise maneuvers. As such, robotic surgery is poised to replace laparoscopy as the standard surgical approach in the future.
However, the current reliance on imported systems—most notably the Da Vinci robotic platform—presents challenges due to their high costs and resulting surgical expenses.
The solution lies in vigorously advancing domestically developed systems. In recent years, nearly ten Chinese-made robotic surgical systems have entered the market. Their quality has improved steadily and is approaching that of international counterparts like the Da Vinci system, but at a significantly reduced cost. As domestic robots continue to mature, they are expected to gradually replace imported platforms and become more affordable for widespread use.
I firmly believe that within the next decade, domestic robotic systems will not only replace conventional laparoscopy in many settings but also become widely accessible at primary and secondary hospitals, ultimately benefiting a much larger patient population.
