Protecting Sexual Function Via The Hood Technique in Prostate Cancer

Ash Tewari, MD, MBBS, MCh, FRCS, professor and chair of the Milton and Carroll Petrie Department of Urology at the Icahn School of Medicine at Mount Sinai, is currently developing the “hood technique,” a new prostate cancer surgery technique.¹

During a conversation with CancerNetwork®, he discussed the intricacies of preserving sexual function during prostate cancer surgery. The erectile nerves surrounding the prostate are arranged in a complex meshwork pattern, which complicates the process, and there are also phenomena like extracapsular extension through perineural invasion that make assessing the situation even more difficult.

Detailing the entire process of prostate cancer surgery, Tewari lists the priorities as getting all the cancer out of the body, restoring continence, and then restoring sexual function. All 3 of these goals are complex, and even after completing a great deal of surgeries with the hood technique, the process continues to be optimized.

Transcript:

The hood technique is not just about the continence. [The second component of] the hood technique is how we save the erectile nerves that are traveling around the prostate. These nerves make a meshwork—like a hammock—and they travel around the prostate, sometimes supplying to the prostate, sometimes to the blood and legs, and sometimes to the seminal vesicle. Most of the time, [they] travel in a very narrow zone, encased within the fascial layers, around the prostate to ultimately exit the pelvis to get into the penile tissue. These erectile nerves are what we call an autonomic nerve or the cavernous nerve, and there is not a simple one bundle on the left and one bundle on the right [design]. It’s an interconnected meshwork of structures [and a] meshwork of nerves that is ultimately supporting the erections, the orgasm, and the continence mechanism.

To save these nerves, you have to make the right decision because prostate cancer is a cancer in which where there is a very delicate love-hate relationship between the nerves and the cancer cells. Certain cancer cells, up to 30% [to] 40% of the time, interconnect with the nerves within the prostate to the point where they sometimes excite the nerves to start sprouting towards the cancer cell, [and then] the cancer cells wrap around the perineural sheet, and they find an exit strategy to get out of the organ.

[Approximately] 30% to 40% of the time, the cancer is trying to come out using the same nerves [that] we are trying to save, [and that] can make the operation a little bit more challenging because you have to recognize if that phenomenon—[extracapsular extension through perineural invasion]—is happening. Using preoperative nomograms, preoperative imaging, preoperative prostate-specific antigen [PSA], preoperative biopsy data, and the rectal exam, you have to make an assessment [on] if that phenomenon is happening to a patient or not. If it is happening, is it happening on the left side or the right side? Is it happening near the apex or the base? Is it happening on the posterior side or the anterior side? The nerves around the prostate are traveling in different zones—different layer compartments—so if there is a risk of this cancer coming close to the base on the right side, you can tailor the surgery to stay a little bit wider on the exact area where you expect that the cancer is trying to escape. You get a negative margin yet save as much of a nerve as you can and remaining human anti-mouse antibodies [HAMA].

This entire packaging of the decision-making, finding the right plane, executing it delicately, controlling the bleeding, and then reconnecting everything back—yet saving the anterior hood—is what we call an athermal technique or the “RARP [robot-assisted radical prostatectomy]” technique along with the “hood” technique. The combination of this preserved urethra, preserved muscle, preserved anterior-supporting structures, and the neurovascular hammock…balanced our surgery to match the risk of extracapsular extension. That is what gets us a trifecta outcome, in which goal number 1 is to get all the cancer out, goal number 2 is to get the continence back, and goal number 3 is to get the sexual function back, all in a [proper] sequential manner. That’s the complexity of this operation, and that’s the reason we are talking about it. Even after doing 10,000 of these operations, we are tweaking it a little bit to make things better.

Reference

Hood technique enables early return to continence following RARP. Mount Sinai. Accessed February 10, 2025. https://tinyurl.com/2v23h8bm