Prostate Cancer Diagnosis & Robotic Surgery | Dr. Ye Dingwei (Urology) | CMCS Shanghai

About Dr. Ye Dingwei

Dr. Ye Dingwei is Chief of Urology at Fudan University Shanghai Cancer Center, renowned for his expertise in prostate, bladder, and kidney cancer surgery. He is one of China's foremost urologic oncologists and a pioneer in robotic-assisted laparoscopic procedures. Dr. Ye has led numerous national clinical trials and is widely published in international urology journals. His team's outcomes in high-risk prostate cancer surgery are among the best documented in China.

Case Overview

A 58-year-old male corporate executive with a family history of prostate cancer presented with three months of voiding difficulty and elevated PSA (22.5 ng/mL). Multiparametric MRI demonstrated a PI-RADS 5 lesion with suspected left seminal vesicle invasion; systematic biopsy confirmed Gleason 4+4=8 adenocarcinoma in 6 of 12 cores. Clinical stage: cT3aN0M0 — high-risk locally advanced disease. Following MDT discussion chaired by Dr. Ye Dingwei, the patient received three months of neoadjuvant androgen deprivation therapy (ADT) combined with abiraterone for tumour downstaging, based on Dr. Ye's national clinical trial data. He then underwent transperitoneal da Vinci Xi robotic-assisted radical prostatectomy (RARP) with extended pelvic lymph node dissection (ePLND) and selective unilateral nerve-sparing. R0 resection was achieved; 2 of 22 lymph nodes showed micrometastasis. PSA fell to undetectable; social continence was restored at 2 weeks post-catheter removal; full continence at 3 months; IIEF-5 score recovered to 18 at 6 months. Adjuvant radiotherapy and hormonal therapy were commenced for pN1 disease. No biochemical recurrence at 2-year follow-up.

Patient Background

• Age / Sex: 58-year-old male
• Occupation: Corporate executive — socially active; high quality-of-life expectations
• Chief Complaint: Voiding difficulty with elevated PSA for 3 months
• Medical History: Hypertension (5 years, well-controlled); no prior surgery
• Family History: Father diagnosed with prostate cancer at age 70

Diagnosis & Risk Stratification

Laboratory Results

• PSA: 22.5 ng/mL (significantly elevated)
• Free/Total PSA ratio: 0.12 (<0.16 — high malignancy risk)

Multiparametric MRI (mpMRI)

• Peripheral zone low-signal nodule (PI-RADS 5); diameter approximately 1.8 cm
• Seminal vesicle invasion (SVI): Left seminal vesicle angle obliterated — tumour likely breaching the prostatic capsule into the seminal vesicle
• No pelvic lymph node enlargement on imaging; however, occult nodal metastasis risk elevated given PSA >20

Systematic Biopsy (12-core)

• 6/12 cores positive
• Gleason Score: 4+4=8 (high-grade)

Staging

• Clinical Stage: cT3aN0M0 — locally advanced, high-risk group
• Bone scan / PET-CT: No distant bone or lymph node metastasis

Clinical Decision Making & MDT Discussion

Clinical challenge: Locally advanced high-risk prostate cancer (Gleason 8, PSA >20, suspected seminal vesicle invasion) carries high rates of positive surgical margins, post-operative urinary incontinence, and erectile dysfunction under conventional surgical approaches. Traditional thinking classified T3 disease as a relative contraindication to surgery.

Dr. Ye Dingwei's MDT decision: "For a young, fit patient, radiotherapy alone may not achieve cure and forfeits the opportunity for surgical pathological staging. Although seminal vesicle invasion is suspected on imaging, there is no evidence of widespread metastasis — curative resection remains achievable. We will use robotic-assisted radical prostatectomy with extended pelvic lymph node dissection. Our core strategy has three pillars: oncological cure through en bloc resection of the prostate and seminal vesicles with negative margins; functional preservation through selective nerve-sparing using the robot's 10× magnified three-dimensional field; and pre-operative tumour downstaging through three months of neoadjuvant ADT plus abiraterone, based on our national clinical trial data, to reduce positive margin risk before surgery."

Neoadjuvant Therapy

• Regimen: Androgen deprivation therapy (ADT) + abiraterone for 3 months pre-operatively
• Rationale: Based on Dr. Ye's national clinical trial data demonstrating that neoadjuvant intensified hormonal therapy reduces tumour volume, lowers positive margin rates, and may improve pathological downstaging in high-risk locally advanced prostate cancer
• Response: PSA reduction and MRI tumour volume decrease confirmed prior to surgical planning

Surgical Procedure

Approach: Transperitoneal da Vinci Xi robotic-assisted laparoscopic radical prostatectomy (RARP)
Operative time: 140 minutes
Estimated blood loss: 100 mL

Step 1 — Extended Pelvic Lymph Node Dissection (ePLND)

• Dissection boundaries: superiorly to the common iliac artery bifurcation; inferiorly to the Cloquet node; medially to the bladder wall; laterally to the genitofemoral nerve
• Total nodes retrieved: 22; intraoperative frozen section performed on suspicious nodes
• Final pathology: 2/22 nodes with micrometastasis — pN1 disease confirmed

Step 2 — Dorsal Vascular Complex (DVC) Control

• "Suture-first, divide-second" technique at the prostatic apex: DVC precisely ligated prior to division, maintaining a near-bloodless operative field and preserving clear visualization of the apical dissection plane — critical for urethral sphincter preservation and continence recovery

Step 3 — Seminal Vesicle & Vas Deferens Dissection

• Given pre-operative imaging suspicion of left seminal vesicle invasion, Dr. Ye performed sharp dissection immediately adjacent to the left seminal vesicle wall, achieving complete en bloc excision of the left seminal vesicle and distal vas deferens

Step 4 — Selective Nerve-Sparing (Critical Step)

• Using the da Vinci Xi's three-dimensional stereoscopic magnification, Dr. Ye identified the microscopic neurovascular bundles (NVB) at the posterolateral aspect of the prostate
• Technique: Layered "peeling" dissection — establishing a bloodless plane between Denonvilliers' fascia and the NVB, separating the nerve bundle from the prostatic surface with the precision of peeling an egg membrane, rather than en bloc excision
• Intraoperative decision: Left NVB found densely adherent to tumour — left nerve-sparing abandoned to ensure oncological clearance. Right NVB anatomy clearly defined and fully preserved — maintaining the neurological substrate for post-operative erectile function recovery

Dr. Ye's operative note: "For a Gleason 8 patient, bilateral nerve-sparing cannot be performed blindly. When we found the left tumour adherent to the nerve bundle, we made the immediate decision to sacrifice it. But the right side was anatomically clear — we preserved it completely. That preserved nerve is the seed of functional recovery. Without it, there is no possibility of return."

Step 5 — Urethrovesical Anastomosis

• Modified Rocco posterior reconstruction technique: posterior bladder neck and urethral posterior wall anastomosed first, providing urethral support and restoring the posterior musculofascial plate
• This reconstruction step is the primary determinant of early continence recovery — reducing the mechanical stress on the anastomosis during the immediate post-catheter period

Pathology & Post-operative Recovery

Final Pathology Report

• Histology: Prostatic adenocarcinoma, Gleason 4+4=8
• Pathological Stage: pT3b (left seminal vesicle invasion confirmed)
• Resection Margins: Bilateral and basal margins negative — R0 resection confirmed
• Lymph Nodes: 2/22 micrometastasis — pN1

Functional Recovery

• Urinary continence: Posterior wall reconstruction enabled social continence (1–2 pads per day) immediately after catheter removal at 2 weeks; complete continence (zero pads) achieved at 3 months
• Erectile function: IIEF-5 score recovered to 18 (mild-moderate ED; satisfactory sexual activity) at 6 months — patient reported high satisfaction with functional outcome
• Oncological: PSA <0.01 ng/mL post-operatively (undetectable)

Adjuvant Therapy & Long-term Follow-up

• Adjuvant treatment: Given pN1 disease (lymph node micrometastasis), Dr. Ye recommended adjuvant radiotherapy (ART) to the prostate bed and pelvic nodes, combined with continued androgen deprivation therapy
• 2-year follow-up: PSA persistently undetectable; no biochemical recurrence; no distant metastasis; quality-of-life scores approaching pre-operative baseline

Expert Commentary — Dr. Ye Dingwei

1. Surgical Timing in Locally Advanced Disease

The historical view that T3 prostate cancer is a contraindication to surgery is outdated. With neoadjuvant intensified hormonal therapy for downstaging and robotic surgical precision for margin control, T3 and even selected oligometastatic patients can achieve durable cure through radical prostatectomy. The key is rigorous patient selection and disciplined pre-operative staging. Surgery provides something that radiotherapy cannot: a definitive pathological specimen that reveals the true extent of disease, confirms margin status, and guides adjuvant treatment decisions. In this case, the discovery of pN1 micrometastasis at ePLND directly determined the adjuvant therapy plan — information that would have been unavailable with a non-surgical approach.

2. The Robotic Advantage in the Male Pelvis

The male pelvis is anatomically unforgiving. The neurovascular bundles, the urethral sphincter, and the prostatic apex are separated by millimetres in a confined space that conventional laparoscopy struggles to navigate safely. The da Vinci Xi system's multi-articulated wrist instruments, tremor filtration, and 10× three-dimensional magnification provide a level of anatomical discrimination that is simply not achievable with open or standard laparoscopic surgery. An estimated blood loss of 100 mL in a radical prostatectomy for pT3b Gleason 8 disease — following neoadjuvant therapy that increases tissue fibrosis — is a direct consequence of robotic precision. The technology does not replace surgical judgment. It amplifies it.

3. Negative Margins Are Non-Negotiable

Regardless of how elegantly the nerve-sparing is performed, a positive surgical margin (R1) negates the oncological value of the entire procedure. In this case, R0 resection was achieved through extended lymph node dissection, precise fascial plane identification, and the intraoperative decision to sacrifice the left NVB when tumour adherence was identified. Functional preservation and oncological clearance are not competing priorities — but when they conflict, oncological clearance wins. Every time. The patient's long-term survival depends on it.

4. Whole-Journey Management

Prostate cancer is not a single-event disease. Neoadjuvant therapy, robotic surgery, adjuvant radiotherapy, hormonal therapy, continence rehabilitation, and erectile function recovery — these are not sequential episodes. They are an integrated management continuum. Our centre's data show that high-risk patients who receive standardised whole-journey management achieve five-year survival rates exceeding 90%. The surgery is the centrepiece. But it is the programme around the surgery that determines the outcome.

How CMCS Shanghai Coordinated This Case

China Medical Concierge Shanghai (CMCS) supported this patient's care pathway from initial overseas inquiry through two-year oncological follow-up. Our coordination included:

• Pre-arrival PSA panel, biopsy pathology, and mpMRI review; specialist referral to Dr. Ye Dingwei's urologic oncology team at Fudan University Shanghai Cancer Center
• Arrangement of multiparametric MRI, systematic biopsy, bone scan, and PSMA PET-CT for complete staging workup
• Bilingual interpretation during MDT discussion, including detailed explanation of neoadjuvant therapy rationale, robotic versus open surgical options, nerve-sparing decision framework, and realistic functional outcome expectations
• Coordination of three-month neoadjuvant ADT plus abiraterone monitoring: PSA trending, interim MRI scheduling, and endocrine side-effect management liaison
• Surgical admission logistics: hospital registration, da Vinci Xi operative suite scheduling, and accommodation support for accompanying family
• On-site medical interpretation throughout the hospitalization and post-operative recovery period, including catheter management and early continence rehabilitation guidance
• Post-discharge coordination of pelvic floor physiotherapy referral, erectile function rehabilitation programme (PDE5 inhibitor protocol), and PSA surveillance at 3, 6, and 12 months
• Adjuvant therapy coordination: radiotherapy planning appointment scheduling, hormonal therapy monitoring, and communication with the patient's home urologist for ongoing management

For international patients facing a high-risk prostate cancer diagnosis — particularly those who have been told their disease is "too advanced" for surgery — the combination of neoadjuvant downstaging expertise and robotic surgical precision at Shanghai's leading cancer centres represents a genuine pathway to cure that may not be available in their home country. CMCS exists to connect patients with that pathway: ensuring every staging option is explored, every treatment decision is explained in their language, and every step from diagnosis to long-term follow-up is coordinated with precision and care.

This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.