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

About Dr. Ye Dingwei

Dr. Ye Dingwei is Director of Urology at Fudan University Shanghai Cancer Center — China's foremost oncology institution and one of the highest-volume urological oncology centres in the country. He is a nationally recognised leader in prostate cancer, bladder cancer, and robotic-assisted urological surgery, with particular expertise in robotic-assisted radical prostatectomy (RARP) for high-risk and locally advanced disease, nerve-sparing techniques for functional preservation, and the integration of neoadjuvant intensified hormonal therapy into multimodal prostate cancer management. Dr. Ye's practice is defined by the philosophy that high-risk prostate cancer surgery must simultaneously achieve two goals that are often perceived as competing: oncological cure through complete tumour excision with negative margins, and functional preservation through meticulous nerve-sparing technique — because a patient who is cured of cancer but left incontinent or impotent has not been fully treated. His department at Fudan University Shanghai Cancer Center has established one of China's most comprehensive urological oncology programmes, integrating PSMA-PET/CT staging, multiparametric MRI-guided biopsy, neoadjuvant hormonal therapy, da Vinci Xi robotic surgery, and structured functional rehabilitation into a unified care pathway for patients with complex prostate cancer.

Case Overview

Mr. David Ashworth, a 68-year-old British retired engineer based in Shanghai, presented with a one-year history of progressive lower urinary tract symptoms and a PSA of 18.5 ng/mL on routine health screening. Multiparametric MRI demonstrated a PI-RADS 5 lesion in the right peripheral zone with extracapsular extension and right neurovascular bundle involvement. Systematic biopsy confirmed Gleason 4+5=9 (ISUP Grade Group 5) prostate adenocarcinoma in 6 of 12 cores. PSMA-PET/CT confirmed high intraprostatic tracer uptake (SUVmax 15.2) with no pelvic nodal involvement and no distant metastasis — clinical stage cT3aN0M0, high-risk locally advanced disease.

The multidisciplinary team led by Dr. Ye Dingwei recommended intensified neoadjuvant hormonal therapy with abiraterone acetate plus prednisone and goserelin (ADT) for six months before surgery — to downstage the tumour, convert the threatened surgical margin to a clear margin, and create the anatomical conditions for nerve-sparing surgery. After six months, PSA fell to 0.05 ng/mL (undetectable), prostate volume reduced by 30%, and MRI demonstrated clarification of the tumour-capsule interface. Dr. Ye performed transperitoneal robotic-assisted radical prostatectomy with bilateral intrafascial nerve-sparing using the da Vinci Xi system, extended pelvic lymph node dissection, and modified Rocco posterior urethrovesical reconstruction. Final pathology confirmed pathological downstaging to ypT2cN0, Gleason 4+4=8, all margins negative, 0/16 lymph nodes positive. The urinary catheter was removed on post-operative day three with immediate continence (0–1 pad per day). At three months, morning erections had returned (IIEF-5 score 18) and PSA remained below 0.01 ng/mL.

Patient Background

• Name / Nationality: Mr. David Ashworth (pseudonym) — British; retired engineer based in Shanghai; strong priorities for functional preservation (continence and erectile function) alongside oncological cure
• Age / Sex: 68-year-old male
• Chief Complaint: Progressive urinary difficulty and reduced stream for 1 year; nocturia 4–5 times per night; PSA 18.5 ng/mL on health screening 3 months prior
• Past medical history: Hypertension for 10 years — well controlled on medication; no prior surgery; no family history of prostate cancer
• Digital rectal examination: Firm nodule palpable in the right lobe of the prostate; ill-defined margins; no clinical seminal vesicle involvement
• Functional status: ECOG Performance Status 0; sexually active; strong preference for nerve-sparing approach if oncologically safe

Diagnostic Workup and Staging

Prostate Biopsy

• Technique: Systematic 12-core transrectal ultrasound-guided biopsy
• Positive cores: 6 of 12 cores positive for adenocarcinoma
• Gleason score: 4+5=9 — ISUP Grade Group 5; the highest-grade prostate cancer category; associated with the highest risk of biochemical recurrence, metastasis, and cancer-specific mortality
• Tumour distribution: Predominantly right-sided; bilateral involvement in 2 cores

Multiparametric MRI (mpMRI)

• PI-RADS score: 5 — clinically significant cancer highly likely
• Tumour location: Right peripheral zone; dominant lesion measuring approximately 2.5 cm
• Extracapsular extension (ECE): Present — tumour breaching the prostatic capsule on the right side; cT3a staging confirmed
• Neurovascular bundle (NVB): Right NVB involved by tumour on MRI — direct nerve-sparing on the right side not safe without neoadjuvant tumour regression
• Seminal vesicles: No definite invasion — cT3b excluded
• Significance: Right NVB involvement on MRI in the context of Gleason 9 disease means that direct surgery carries a high probability of positive surgical margin at the right posterolateral aspect — the most common site of margin positivity in locally advanced prostate cancer

PSMA-PET/CT

• Intraprostatic uptake: SUVmax 15.2 — markedly elevated; consistent with high-grade primary tumour
• Pelvic lymph nodes: No pathologically enlarged or hypermetabolic nodes in the obturator, internal iliac, or external iliac regions — cN0 confirmed
• Distant metastasis: No bone lesions, no visceral metastasis — cM0 confirmed
• Clinical stage: cT3aN0M0 — high-risk locally advanced prostate cancer; curative-intent surgery appropriate

Dr. Ye's pre-operative assessment: The PSMA-PET is the most important staging tool we have for high-risk prostate cancer. It tells us with much greater sensitivity than conventional CT or bone scan whether there is nodal or distant disease that would change the treatment intent from curative to palliative. In this case, the PSMA is negative beyond the prostate — which means this patient has a curable cancer. The question is how to cure it. The MRI tells us the right NVB is involved. If we operate now, we will either sacrifice the nerve and accept impotence, or we will try to spare it and risk a positive margin. Neither is acceptable. Six months of abiraterone-based neoadjuvant therapy will shrink the tumour away from the nerve. Then we can spare the nerve safely. That is the strategy.

Multidisciplinary Team Discussion and Neoadjuvant Strategy

The MDT convened by Dr. Ye Dingwei included urological oncology, radiation oncology, medical oncology, and radiology. The consensus recommendation was intensified neoadjuvant hormonal therapy for six months followed by restaging MRI and RARP — with adjuvant radiotherapy planned post-operatively given the high-risk pathological features.

Neoadjuvant regimen: Abiraterone acetate 1000 mg daily plus prednisone 5 mg twice daily (CYP17 lyase inhibitor blocking extra-gonadal androgen synthesis) combined with goserelin 3.6 mg subcutaneous depot monthly (LHRH agonist for castration-level testosterone suppression). This intensified neoadjuvant hormonal therapy (iNHT) regimen achieves deeper androgen suppression than ADT alone, producing greater tumour volume reduction and higher rates of pathological downstaging in high-risk disease.

Rationale for neoadjuvant over direct surgery: For Gleason 9 cT3a disease, direct surgery carries a positive surgical margin rate of 30–40% at high-volume centres — and a positive margin is the strongest predictor of biochemical recurrence after radical prostatectomy. Neoadjuvant iNHT reduces the positive margin rate by shrinking the tumour away from the capsule and the neurovascular bundle, converting a threatened margin to a clear margin and creating the anatomical conditions for nerve-sparing surgery that would not be safe in the untreated state.

Restaging After Six Months of Neoadjuvant Therapy

• PSA: Reduced from 18.5 to 0.05 ng/mL — undetectable; profound biochemical response
• Prostate volume: Reduced by approximately 30% on MRI
• Tumour-capsule interface: MRI demonstrated clarification of the previously ill-defined right posterolateral margin — tumour no longer abutting the capsule at the NVB level
• NVB assessment: Right NVB no longer directly involved on restaging MRI — bilateral nerve-sparing now oncologically feasible
• Conclusion: Adequate neoadjuvant response; proceed to RARP with bilateral intrafascial nerve-sparing

Operative Procedure

Anaesthesia, Positioning, and Robotic Setup

Anaesthesia: General anaesthesia with endotracheal intubation; epidural catheter for post-operative analgesia. Steep Trendelenburg position (25–30 degrees head-down) to displace the bowel from the pelvis and optimise exposure of the retropubic space.

Da Vinci Xi robotic system: Five-port transperitoneal approach — camera port at the umbilicus, bilateral working ports along the lateral rectus borders, and a lower abdominal assistant port. The da Vinci Xi provides 10× three-dimensional magnification of the deep pelvic anatomy, 7 degrees of freedom in instrument articulation, and tremor filtration — enabling precision dissection in the confined retropubic space that exceeds the capability of conventional laparoscopy or open surgery.

Phase 1 — Extended Pelvic Lymph Node Dissection

Dissection template: Bilateral extended pelvic lymph node dissection including the obturator fossa, internal iliac, and external iliac nodal packets — the standard dissection template for high-risk prostate cancer per EAU guidelines. Extended dissection (versus limited obturator-only dissection) increases the nodal yield and the probability of detecting micrometastatic nodal disease that would alter adjuvant treatment planning.

Intraoperative frozen section: All nodal packets sent for intraoperative frozen section — all negative. Confirmed cN0 status; no change to surgical plan required.

Nodal yield: 16 lymph nodes harvested bilaterally; all negative on final pathology (0/16).

Dr. Ye's operative note: The lymph node dissection is not a staging procedure in high-risk prostate cancer — it is a therapeutic procedure. Removing micrometastatic nodal disease that is below the detection threshold of any imaging modality, including PSMA-PET, may contribute to long-term disease control. The extended template — obturator, internal iliac, external iliac — is the minimum acceptable dissection for Gleason 9 disease. Anything less is an incomplete operation.

Phase 2 — Prostatic Dissection and Dorsal Vascular Complex Control

Retzius space development: The retropubic space of Retzius was developed under robotic magnification — exposing the anterior surface of the prostate, the puboprostatic ligaments, and the endopelvic fascia bilaterally. The avascular nature of this plane, when correctly entered, allows bloodless exposure of the prostate apex and the dorsal vascular complex.

Dorsal vascular complex (DVC) control: The DVC — the venous plexus overlying the anterior urethra at the prostatic apex — was precisely suture-ligated and divided under robotic magnification. Controlled DVC division is the critical step that determines blood loss during prostatectomy: an uncontrolled DVC results in significant haemorrhage that obscures the apical dissection and increases the risk of positive apical margin. Total blood loss during this phase: less than 20 mL.

Phase 3 — Bilateral Intrafascial Nerve-Sparing (NVB Preservation)

Intrafascial dissection plane: The nerve-sparing dissection was performed in the intrafascial plane — between the prostatic capsule and the prostatic fascia — the most medial dissection plane available for nerve preservation. This plane keeps the neurovascular bundles, which run within and immediately lateral to the prostatic fascia, entirely outside the dissection field. The intrafascial technique provides the maximum possible nerve preservation but requires that the tumour does not extend to the capsular surface — a condition created in this case by the six months of neoadjuvant therapy that had regressed the tumour away from the capsule.

Intraoperative nerve monitoring: A real-time intraoperative nerve stimulator was used to identify the course of the cavernous nerves within the NVB during dissection — providing electrophysiological confirmation of nerve location and integrity at each step of the dissection. Nerve stimulation confirmed bilateral NVB preservation throughout.

Seminal vesicle dissection: Both seminal vesicles were dissected free and included in the specimen — standard practice for cT3a disease regardless of MRI seminal vesicle status, to ensure complete excision of any microscopic seminal vesicle involvement not detected on imaging.

Dr. Ye's technical note: The intrafascial technique is the most demanding nerve-sparing approach because the dissection plane is immediately on the prostatic capsule. There is no margin for error: too deep and you enter the tumour; too superficial and you damage the nerve. The robotic magnification makes this dissection possible in a way that open surgery cannot replicate — you can see individual nerve fibres, individual blood vessels, and the capsular surface simultaneously. The neoadjuvant therapy created the conditions for this dissection by regressing the tumour away from the capsule. Without the neoadjuvant therapy, the intrafascial plane on the right side would have been directly through the tumour. With it, the plane was clear.

Phase 4 — Urethral Division, Specimen Extraction, and Vesicourethral Anastomosis

Apical dissection and urethral division: The urethra was divided at the prostatic apex under direct robotic vision — maximising urethral length preservation, which is the primary determinant of post-operative continence. Intraoperative frozen section of the apical urethral margin: negative.

Specimen extraction: The prostate and seminal vesicles were placed in an endoscopic retrieval bag and extracted through a 4 cm lower abdominal incision — avoiding morcellation, which risks tumour cell dissemination in the peritoneal cavity.

Modified Rocco posterior reconstruction: Before the vesicourethral anastomosis, the posterior aspect of the rhabdosphincter and the posterior urethrovesical musculature were reconstructed using the modified Rocco technique — re-approximating the posterior urethral support structures that are disrupted during prostatectomy. This reconstruction restores the anatomical support of the external urethral sphincter, reducing the time to continence recovery after catheter removal.

Vesicourethral anastomosis: Running absorbable suture anastomosis between the bladder neck and the urethral stump — watertight closure confirmed by saline instillation. Single pelvic drain placed.

Operative data: Total operative time 135 minutes (including lymph node dissection); total blood loss approximately 50 mL; no allogeneic blood transfusion; no conversion to open surgery.

Post-operative Course and ERAS Outcomes

ERAS Milestones

• 6 hours post-operatively: Mobilised to chair; liquid diet commenced
• Post-operative day 1: Pelvic drain removed (output less than 50 mL, no chyle leak); patient ambulating independently; normal diet commenced
• Post-operative day 3: Urinary catheter removed; voiding trial successful — immediate continence with 0–1 pad per day; no significant urinary leakage
• Post-operative day 5: Discharged home; pelvic floor physiotherapy commenced

Functional Outcomes at Three Months

• Urinary continence: Complete continence (0 pads per day) at 6 weeks; maintained at 3 months
• Erectile function: Spontaneous morning erections returned at 3 months; IIEF-5 score 18 (mild erectile dysfunction — responsive to PDE5 inhibitor support); patient satisfied with functional recovery trajectory
• PSA: Below 0.01 ng/mL at 3 months — undetectable; no biochemical evidence of residual or recurrent disease

Final Pathology

• Pathological stage: ypT2cN0 — significant downstaging from clinical cT3aN0; tumour confined within the prostate after neoadjuvant therapy
• Tumour size: 1.5 cm × 1.2 cm residual viable tumour — marked reduction from the pre-treatment 2.5 cm lesion
• Gleason score (post-treatment): 4+4=8 — treatment-related grade reduction from the pre-treatment Gleason 9; reflects partial tumour response to neoadjuvant hormonal therapy
• Surgical margins: Basal margin negative; apical margin negative; circumferential (posterolateral) margin negative — R0 resection confirmed; no positive surgical margin
• Lymph nodes: 0/16 positive — complete nodal clearance; pN0 confirmed
• Seminal vesicles: No tumour involvement — ypT2c (bilateral intraprostatic disease) rather than ypT3b

Adjuvant Treatment and Long-term Management

Given the pre-treatment Gleason 9 score and the pathological findings, the MDT recommended adjuvant radiotherapy commencing four weeks post-operatively — intensity-modulated radiotherapy (IMRT) to the prostate bed at 66 Gy in 33 fractions — to eliminate any microscopic residual disease at the surgical site. Concurrent ADT was continued for two years post-operatively per EAU high-risk guidelines. The combination of radical surgery, adjuvant radiotherapy, and prolonged ADT represents the most aggressive curative-intent treatment available for high-risk locally advanced prostate cancer and is associated with the highest rates of long-term disease-free survival in this risk category.

Expert Commentary — Dr. Ye Dingwei

1. Intensified Neoadjuvant Hormonal Therapy: Redefining the Operable Boundary

For a decade, the standard neoadjuvant approach for high-risk prostate cancer was conventional ADT — LHRH agonist alone — for three to six months before surgery. The evidence for this approach showed modest tumour volume reduction but no consistent improvement in positive margin rates or long-term outcomes. The introduction of intensified neoadjuvant hormonal therapy — combining LHRH agonist with abiraterone, enzalutamide, or apalutamide to achieve deeper androgen suppression — has changed this picture. The PROTEUS and ACIS trials demonstrated that iNHT with abiraterone produces pathological complete response rates of 10–15% and significant downstaging in 40–60% of high-risk patients — rates that conventional ADT cannot approach. In this case, the iNHT converted a cT3a tumour with NVB involvement into a ypT2c tumour with clear margins and preserved nerves. That conversion is not cosmetic — it is the difference between a positive margin with biochemical recurrence and a negative margin with a realistic chance of cure. For Gleason 9 cT3 disease, iNHT before surgery is now our standard approach at Fudan University Shanghai Cancer Center.

2. Robotic-Assisted Radical Prostatectomy: Precision in the Confined Pelvis

The deep male pelvis is the most anatomically confined operative field in abdominal surgery. The prostate sits behind the pubic symphysis, surrounded by the bladder, rectum, and pelvic floor musculature, with the neurovascular bundles running in immediate contact with its posterolateral surface and the external urethral sphincter at its apex. Open radical prostatectomy in this space requires a large incision, significant retraction, and limited visibility — conditions that make precise nerve-sparing and apical dissection technically demanding even for experienced surgeons. The da Vinci Xi robotic system transforms this operative environment: 10× three-dimensional magnification reveals anatomical planes that are invisible to the naked eye; 7 degrees of instrument articulation allows dissection angles that are impossible with straight laparoscopic instruments; tremor filtration eliminates the physiological hand tremor that limits precision at the millimetre scale. The result is not just a smaller incision — it is a fundamentally more precise operation. In our programme, RARP produces positive margin rates below 10% for pT2 disease and below 20% for pT3 disease — outcomes that reflect the combination of robotic precision and neoadjuvant tumour regression, not either factor alone.

3. Intrafascial Nerve-Sparing: The Anatomy of Functional Preservation

Erectile function after radical prostatectomy depends on the preservation of the cavernous nerves — the autonomic nerve fibres that run within and immediately lateral to the prostatic fascia on the posterolateral surface of the prostate. These nerves are invisible to the naked eye; they cannot be identified by colour, texture, or any visual characteristic. They are identified by their anatomical location — within the neurovascular bundle — and by intraoperative nerve stimulation, which produces a measurable cavernous pressure response when the correct tissue is stimulated. The intrafascial dissection plane — between the prostatic capsule and the prostatic fascia — keeps the NVB entirely outside the dissection field, providing the maximum possible nerve preservation. This plane is only safe when the tumour does not extend to the capsular surface — which is why neoadjuvant therapy is not just an oncological strategy but a functional strategy. By regressing the tumour away from the capsule, it creates the anatomical conditions for intrafascial dissection that would otherwise be oncologically unsafe. In our high-risk patient population, the combination of iNHT and intrafascial RARP achieves functional nerve preservation rates above 60% — a result that was not achievable with conventional ADT and standard nerve-sparing technique.

4. Multimodal Comprehensive Management: Surgery as One Component of Cure

Radical prostatectomy for high-risk prostate cancer is not a standalone treatment — it is the surgical component of a multimodal curative strategy. The surgery removes the primary tumour and provides definitive pathological staging. The adjuvant radiotherapy eliminates microscopic residual disease at the surgical site that is below the detection threshold of any imaging modality. The prolonged ADT suppresses micrometastatic disease that may be present in distant sites despite a negative PSMA-PET. Each component addresses a different failure mode: local recurrence, surgical bed recurrence, and systemic micrometastasis. Omitting any component increases the risk of treatment failure in a patient who has undergone a major operation and deserves the best possible chance of cure. At Fudan University Shanghai Cancer Center, every high-risk prostate cancer patient is managed by a multidisciplinary team from the first consultation through the last follow-up visit — because the surgeon who performs the operation is not the only physician responsible for the outcome. The outcome belongs to the team.

How CMCS Shanghai Coordinated This Case

CMCS Shanghai supported Mr. Ashworth from initial PSA alert through adjuvant treatment completion, including: urgent coordination of multiparametric MRI, PSMA-PET/CT, and systematic prostate biopsy with same-week scheduling and bilingual radiology and pathology report translation; specialist referral to Dr. Ye Dingwei at Fudan University Shanghai Cancer Center's Department of Urology with priority MDT scheduling; bilingual interpretation throughout all MDT discussions, neoadjuvant therapy consent, and surgical planning sessions; coordination of abiraterone acetate and goserelin neoadjuvant therapy initiation with pharmacy access, tolerability monitoring, and monthly PSA tracking; restaging MRI coordination at six months with results communicated to the patient and his urologist in the United Kingdom; real-time surgical updates to the patient's wife and his GP in London during the 135-minute RARP procedure; post-operative daily bilingual updates covering drain output, catheter management, continence assessment, and discharge planning; pelvic floor physiotherapy scheduling and erectile rehabilitation programme coordination including PDE5 inhibitor counselling; three-month functional outcome assessment (IIEF-5, pad usage, PSA) with results communicated to the patient's urologist in the UK; adjuvant IMRT scheduling and radiotherapy planning coordination with the radiation oncology department; ADT continuation monitoring with testosterone suppression confirmation and metabolic side effect management; and establishment of a long-term PSA surveillance protocol with direct liaison between Dr. Ye's team and the patient's urologist in London.

For international patients with prostate cancer, bladder cancer, or complex urological malignancy requiring expert surgical evaluation in Shanghai, Dr. Ye Dingwei's team at Fudan University Shanghai Cancer Center represents urological oncological expertise at the international frontier — combining PSMA-PET staging precision, intensified neoadjuvant hormonal therapy, da Vinci Xi robotic surgery, and multimodal adjuvant treatment to achieve oncological cure and functional preservation in patients with high-risk locally advanced disease. CMCS ensures that expertise is accessible: in the patient's language, with overseas physicians informed at every step, from the first PSA result through long-term oncological surveillance.

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.