The Hood Technique for Robotic-Assisted Radical Prostatectomy: Preserving Vital Structures in the Space of Retzius and the Pouch of Douglas

This chapter describes the novel “Hood technique” for robotic-assisted radical prostatectomy (RARP) that is a simple, reproducible, adaptable approach of Anatomic Robotic Technique of removing prostate cancer. This technique preserves contents of space of Retzius and permits visualization of ureteric orifices and median lobes. The Hood technique also allows various grades of nerve sparing to occur in athermal manner and surgeon could focus on time tested anatomic principles to achieve trifecta. We have previously described our nerve sparing technique thus in this chapter we will focus on hood techniques impact on continence. First, we detail the structures that constitute the “Hood”. Then we will tie this to the anatomical foundations of urinary continence, including innervation to the urethra sphincter, the support structures of the sphincteric complex, and the components of urethral sphincter complex, that contribute to the pathophysiology of post-RARP urinary incontinence (PPI). We then describe our novel “Hood” concept and technique, an anterior approach designed to better preserve the anatomical structures surrounding the urethra—the space of Retzius and pouch of Douglas, to facilitate early return of continence. A step-by-step outline of the technique, as it was performed in patients using a four-arm da Vinci Xi System, is presented. We compared the results of patients of 272 patients who underwent the “Hood technique” for RARP and those of 58 patients who underwent an existing non-Hood RARP strategy using the same da Vinci System. Continence rates with the “Hood technique” at 1, 2, 4, 6, 12, and 24 weeks after catheter removal were 21%, 36%, 83%, 93%, and 94%; continence rates with the non-Hood technique at the same time points were 12%, 22%, 76%, 85%, 86%, and 88%. The Hood technique has shown to achieve early return of continence, better functional outcomes, and improve quality of life and survival without a negative impact on complications and cancer outcomes.