Hood technique in conventional laparoscopic radical prostatectomy

Anatomical preservation of the sphincteric complex and early recovery of urinary continence.

1. Introduction

Urinary incontinence after radical prostatectomy remains one of the functional complications with the greatest impact on patients' quality of life.

Recovery of continence depends on multiple factors, including preoperative sphincter function, age, functional urethral length, the integrity of the supporting structures, and the surgical technique used.

In this context, Ash Tewari and colleagues developed the so-called Hood Technique, a modification of robot-assisted radical prostatectomy aimed at preserving the anterior and periurethral musculofascial structures that contribute to the continence mechanism.

Its fundamental principle is to preserve a supporting anatomical covering around the membranous urethra and the external sphincter, avoiding unnecessary dissection of the anterior tissues during release of the prostatic apex.

Although it was developed for robotic surgery, its anatomical principles can be transferred to conventional laparoscopic radical prostatectomy, with the corresponding technical adaptations.

2. Anatomical basis of the Hood technique

The term Hood describes the configuration of the tissues preserved around the urethra after the prostate has been removed.

The structures of particular interest are:

• Puboprostatic ligaments and the pubovesical support complex.
• Endopelvic fascia and its attachments.
• Tendinous arch of the pelvic fascia.
• Anterior fibers of the detrusor muscle (detrusor apron).
• Periurethral musculofascial structures.
• Dorsal venous complex and its relationships with the prostatic apex.
• External urethral sphincter and functional length of the membranous urethra.

These structures contribute to the anterior support of the vesicourethral junction and to the anatomical stability of the sphincter mechanism.

The technique does not simply consist of preserving the puboprostatic ligaments; it involves an anatomical dissection that preserves the anterior and lateral supporting tissues as an integrated whole.

3. Patient selection and preoperative planning

The use of an anatomical preservation technique must be subordinate to oncological safety.

Preoperative assessment includes:

• PSA, clinical stage, and biopsy grade group.
• Multiparametric magnetic resonance imaging to locate the dominant lesions.
• Assessment of the relationship of the tumor with the apex, the anterior region, and the prostatic capsule.
• Assessment of baseline continence and erectile function.
• Planning of the dissection plane and of possible neurovascular preservation.

The presence of anterior or apical disease with suspected extraprostatic extension may limit the possibility of preserving certain tissues.

4. Adaptation to laparoscopic radical prostatectomy

Conventional laparoscopy makes it possible to reproduce the anatomical goals of the Hood technique, although it differs from robotic surgery, particularly because of the absence of articulated instruments and the limited maneuverability during apical dissection.

The strategy is to carry out a precise dissection, with controlled traction and countertraction, while keeping the planes between the prostatic capsule and the supporting structures permanently identified.

Step 1. Exposure and anatomical recognition

A transperitoneal or extraperitoneal laparoscopic approach is used according to the team's experience.

During exposure of the retropubic space, the bladder neck, the anterior surface of the prostate, the endopelvic fascia, and the puboprostatic ligaments are identified.

Unlike a wide anterior dissection, the aim is to limit mobilization of the supporting tissues that do not need to be divided in order to remove the prostate.

Step 2. Preservation of the anterior structures

The relationships between the anterior prostatic surface, the detrusor fibers, and the puboprostatic tissues are identified.

The dissection is kept close to the prostate when the oncological plane allows it, avoiding extensive release of the anterior attachments.

The goal is to preserve a bridge of musculofascial tissue that remains attached to the periurethral support structures.

This stage requires special attention to anatomical variations and to control of bleeding.

Step 3. Bladder neck dissection and posterior plane

The bladder neck is separated, preserving its anatomy whenever feasible.

The vasa deferentia and seminal vesicles are then identified and freed.

The posterior dissection is carried out in the appropriate plane, taking into account Denonvilliers' fascia and the individual oncological risk.

The neurovascular bundles are preserved according to tumor location and the defined safety plane.

Step 4. Lateral prostatic release

Dissection of the lateral pedicles is performed using a combination of controlled traction, sharp dissection, and selective hemostasis.

When neurovascular preservation is intended, it is preferable to minimize thermal energy near the bundles.

Progressive release of the prostate facilitates exposure of the apex without the need to extensively disrupt the anterior tissues.

Step 5. Apical dissection and preservation of the Hood complex

The transition between the prostatic apex and the membranous urethra is carefully identified.

The dissection must allow the prostatic tissue to be separated from the anterior musculofascial elements that form the supporting covering.

The objectives are:

1. To maintain the greatest possible functional urethral length without compromising the apical margin.
2. To avoid injury to the external urethral sphincter.
3. To preserve the anterior and lateral support structures that can be safely maintained.
4. To control the dorsal venous complex without causing extensive injury to the periurethral tissues.
5. To perform a precise urethral division under direct vision.

The strategy for managing the dorsal venous complex may vary according to anatomy, bleeding, and the surgeon's experience.

There is no single laparoscopic maneuver that has been universally validated to reproduce all the details of the original robotic technique.

Step 6. Vesicourethral anastomosis

Once the prostate has been removed, the length and quality of the urethral stump, the integrity of the bladder neck, and the preserved tissues are assessed.

A watertight, tension-free vesicourethral anastomosis with adequate mucosal coaptation is performed.

When the anatomy allows it, posterior or anterior reconstruction maneuvers can be added to restore support of the vesicourethral junction.

These reconstructions are complementary and should be conceptually distinguished from Hood anatomical preservation.

5. Fundamental technical aspects

• Selective anatomical preservation: it should not be interpreted as an obligatory intrafascial dissection in all patients.
• Apical dissection: this is the moment of greatest functional importance and one of the main risk points for positive margins.
• Energy control: thermal damage close to the sphincter and the neurovascular structures should be minimized.
• Urethral length: it should be preserved as much as possible, always respecting oncological limits.
• Reconstruction: the quality of the anastomosis and the restoration of anatomical support may contribute to functional recovery.

6. Functional outcomes and scientific evidence

In the original series published by Tewari and colleagues, which included 300 patients undergoing robotic radical prostatectomy using the Hood technique, continence rates were 83% at four weeks and 95% at 48 weeks after catheter removal. The positive surgical margin rate was 6%.

However, this was a series without a randomized comparator group, so these results should not be interpreted as definitive proof of superiority.

In September 2026, a retrospective experience was published comparing a modified Hood technique using an extraperitoneal approach in 36 conventional laparoscopic and 30 robotic prostatectomies.

The study found that the laparoscopic adaptation was technically feasible, with encouraging early functional results. However, the limited number of patients and the short oncological follow-up preclude establishing equivalence between the two platforms.

Therefore, the specific evidence for Hood in conventional laparoscopy remains preliminary.

7. Technical errors to avoid

• Performing an overly extensive anterior dissection that unnecessarily removes the supporting tissues.
• Mistaking the preservation plane for a safe plane in patients with anterior or apical disease.
• Applying excessive energy near the urethral sphincter.
• Applying traumatic traction to the prostatic apex.
• Dividing the urethra without clearly defining the prostatourethral transition.
• Prioritizing functional preservation when a compromised surgical margin is suspected.
• Attributing to the Hood technique continence results obtained with other surgical modifications without distinguishing between them.

8. Conclusions

The Hood technique represents an evolution of the concept of anatomical preservation during radical prostatectomy.

Its main contribution is to highlight the importance of preserving not only urethral length and the neurovascular bundles, but also the anterior musculofascial complex that supports the continence mechanism.

Adaptation to conventional laparoscopy is technically possible, but it requires experience in prostate surgery, detailed knowledge of apical anatomy, and appropriate oncological selection.

The ultimate goal is not to mechanically reproduce a robotic technique, but to apply its anatomical principles to a laparoscopic operation that is safe, functional, and oncologically rigorous.