De-escalation surgery for localized prostate cancer: rationale and future direction of precision prostatectomy

The evolution of radical prostatectomy has resulted in excellent oncologic outcomes; however, postoperative erectile dysfunction remains a clinical constraint. While oncologic control in focal therapy remains its main limitation, Menon Precision Prostatectomy, also referred to as Millimeter Precision Prostatectomy (MPP) was developed to bridge this therapeutic gap. The purpose of this review is to summarize the rationale, development, and future direction of MPP.

Advances in anatomical understanding have demonstrated that periprostatic innervation extends beyond the classical neurovascular bundles, with a complex network of autonomic fibers distributed along the prostatic capsule, Denonvilliers' fascia, and the seminal vesicle complex. MPP was designed to enhance the preservation of these nerve-rich structures. In its initial iteration, a unilateral thin rim of prostatic tissue and the ipsilateral seminal vesicle were preserved, whereas dissection on the tumor-bearing side followed the principles of standard radical prostatectomy.

Prospective studies demonstrated favorable oncologic outcomes with superior functional recovery compared to contemporary radical prostatectomy. However, the technically demanding subcapsular dissection raised concerns regarding generalizability. MPP Version 2 was developed as a modification of this concept. In this technique, the prostate is removed en bloc, while both seminal vesicles are preserved, thereby maintaining the integrity of their surrounding neural structures. This approach extends beyond prior seminal vesicle-sparing techniques, which were limited to partial preservation. MPP V2 is currently under clinical investigation, aiming to improve functional outcomes for patients undergoing prostatectomy.