A Critical Analysis of the Current Knowledge of Surgical Anatomy of the Prostate Related to Optimisation of Cancer Control and Preservation of Continence and Erection in Candidates for Radical Prostatectomy

An Update

Jochen Walz, Jonathan Ira Epstein, Roman Ganzer, Markus Graefen, Giorgio Guazzoni, Jihad Kaouk, Mani Menon, Alexandre Mottrie, Robert P. Myers, Vipul Patel, Ashutosh Tewari, Arnauld Villers, Walter Artibani

Research output: Contribution to journalArticle

Abstract

Context: In 2010, we published a review summarising the available literature on surgical anatomy of the prostate and adjacent structures involved in cancer control and the functional outcome of prostatectomy. Objective: To provide an update based on new literature to help the surgeon improve oncologic and surgical outcomes of radical prostatectomy (RP). Evidence acquisition: We searched the PubMed database using the keywords radical prostatectomy, anatomy, neurovascular bundle, nerve, fascia, pelvis, sphincter, urethra, urinary continence, and erectile function. Relevant articles and textbook chapters published since the last review were critically reviewed, analysed, and summarised. Moreover, we integrated aspects that were not addressed in the last review into this update. Evidence synthesis: We found new evidence for several topics. Up to 40% of the cross-sectional surface area of the urethral sphincter tissue is laterally overlapped by the dorsal vascular complex and might be injured during en bloc ligation. Denonvilliers fascia is fused with the base of the prostate in a horizontal fashion dorsally/caudally of the seminal vesicles, requiring sharp detachment when preserved. During extended pelvic lymph node dissection, the erectile nerves are at risk in the presacral and internal iliac area. Dissection planes for nerve sparing can be graded according to the amount of tissue left on the prostate as a safety margin against positive surgical margins. Vascular structures can serve as landmarks. The urethral sphincter and its length after RP are influenced by the shape of the apex. Taking this shape into account allows preservation of additional sphincter length with improved postoperative continence. Conclusions: This update provides additional, detailed information about the surgical anatomy of the prostate and adjacent tissues involved in RP. This anatomy remains complex and widely variable. These details facilitate surgical orientation and dissection during RP and ideally should translate into improved outcomes. Patient summary: Based on recent anatomic findings regarding the prostate and its surrounding tissue, the urologist can individualise the dissection during RP according to cancer and patient characteristics to improve oncologic and functional results at the same time. Based on detailed anatomy of the prostate and its surrounding tissue and variations, the surgeon should individualise the dissection in a patient according to cancer characteristics by altering the technique to improve both oncologic and functional results at the same time. Radical prostatectomy is no longer an all-in-one procedure but rather an individualised operation that should take many details into consideration.

Original languageEnglish (US)
JournalEuropean Urology
DOIs
StateAccepted/In press - 2016

Fingerprint

Prostatectomy
Prostate
Anatomy
Dissection
Neoplasms
Urethra
Fascia
Blood Vessels
Textbooks
Seminal Vesicles
Lymph Node Excision
Pelvis
PubMed
Ligation
Databases
Safety

Keywords

  • Anatomy
  • Erectile dysfunction
  • Neurovascular bundle
  • Prostate
  • Prostate cancer
  • Radical prostatectomy
  • Sphincter
  • Urethra
  • Urinary continence

ASJC Scopus subject areas

  • Urology

Cite this

A Critical Analysis of the Current Knowledge of Surgical Anatomy of the Prostate Related to Optimisation of Cancer Control and Preservation of Continence and Erection in Candidates for Radical Prostatectomy : An Update. / Walz, Jochen; Epstein, Jonathan Ira; Ganzer, Roman; Graefen, Markus; Guazzoni, Giorgio; Kaouk, Jihad; Menon, Mani; Mottrie, Alexandre; Myers, Robert P.; Patel, Vipul; Tewari, Ashutosh; Villers, Arnauld; Artibani, Walter.

In: European Urology, 2016.

Research output: Contribution to journalArticle

Walz, Jochen ; Epstein, Jonathan Ira ; Ganzer, Roman ; Graefen, Markus ; Guazzoni, Giorgio ; Kaouk, Jihad ; Menon, Mani ; Mottrie, Alexandre ; Myers, Robert P. ; Patel, Vipul ; Tewari, Ashutosh ; Villers, Arnauld ; Artibani, Walter. / A Critical Analysis of the Current Knowledge of Surgical Anatomy of the Prostate Related to Optimisation of Cancer Control and Preservation of Continence and Erection in Candidates for Radical Prostatectomy : An Update. In: European Urology. 2016.
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abstract = "Context: In 2010, we published a review summarising the available literature on surgical anatomy of the prostate and adjacent structures involved in cancer control and the functional outcome of prostatectomy. Objective: To provide an update based on new literature to help the surgeon improve oncologic and surgical outcomes of radical prostatectomy (RP). Evidence acquisition: We searched the PubMed database using the keywords radical prostatectomy, anatomy, neurovascular bundle, nerve, fascia, pelvis, sphincter, urethra, urinary continence, and erectile function. Relevant articles and textbook chapters published since the last review were critically reviewed, analysed, and summarised. Moreover, we integrated aspects that were not addressed in the last review into this update. Evidence synthesis: We found new evidence for several topics. Up to 40{\%} of the cross-sectional surface area of the urethral sphincter tissue is laterally overlapped by the dorsal vascular complex and might be injured during en bloc ligation. Denonvilliers fascia is fused with the base of the prostate in a horizontal fashion dorsally/caudally of the seminal vesicles, requiring sharp detachment when preserved. During extended pelvic lymph node dissection, the erectile nerves are at risk in the presacral and internal iliac area. Dissection planes for nerve sparing can be graded according to the amount of tissue left on the prostate as a safety margin against positive surgical margins. Vascular structures can serve as landmarks. The urethral sphincter and its length after RP are influenced by the shape of the apex. Taking this shape into account allows preservation of additional sphincter length with improved postoperative continence. Conclusions: This update provides additional, detailed information about the surgical anatomy of the prostate and adjacent tissues involved in RP. This anatomy remains complex and widely variable. These details facilitate surgical orientation and dissection during RP and ideally should translate into improved outcomes. Patient summary: Based on recent anatomic findings regarding the prostate and its surrounding tissue, the urologist can individualise the dissection during RP according to cancer and patient characteristics to improve oncologic and functional results at the same time. Based on detailed anatomy of the prostate and its surrounding tissue and variations, the surgeon should individualise the dissection in a patient according to cancer characteristics by altering the technique to improve both oncologic and functional results at the same time. Radical prostatectomy is no longer an all-in-one procedure but rather an individualised operation that should take many details into consideration.",
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T1 - A Critical Analysis of the Current Knowledge of Surgical Anatomy of the Prostate Related to Optimisation of Cancer Control and Preservation of Continence and Erection in Candidates for Radical Prostatectomy

T2 - An Update

AU - Walz, Jochen

AU - Epstein, Jonathan Ira

AU - Ganzer, Roman

AU - Graefen, Markus

AU - Guazzoni, Giorgio

AU - Kaouk, Jihad

AU - Menon, Mani

AU - Mottrie, Alexandre

AU - Myers, Robert P.

AU - Patel, Vipul

AU - Tewari, Ashutosh

AU - Villers, Arnauld

AU - Artibani, Walter

PY - 2016

Y1 - 2016

N2 - Context: In 2010, we published a review summarising the available literature on surgical anatomy of the prostate and adjacent structures involved in cancer control and the functional outcome of prostatectomy. Objective: To provide an update based on new literature to help the surgeon improve oncologic and surgical outcomes of radical prostatectomy (RP). Evidence acquisition: We searched the PubMed database using the keywords radical prostatectomy, anatomy, neurovascular bundle, nerve, fascia, pelvis, sphincter, urethra, urinary continence, and erectile function. Relevant articles and textbook chapters published since the last review were critically reviewed, analysed, and summarised. Moreover, we integrated aspects that were not addressed in the last review into this update. Evidence synthesis: We found new evidence for several topics. Up to 40% of the cross-sectional surface area of the urethral sphincter tissue is laterally overlapped by the dorsal vascular complex and might be injured during en bloc ligation. Denonvilliers fascia is fused with the base of the prostate in a horizontal fashion dorsally/caudally of the seminal vesicles, requiring sharp detachment when preserved. During extended pelvic lymph node dissection, the erectile nerves are at risk in the presacral and internal iliac area. Dissection planes for nerve sparing can be graded according to the amount of tissue left on the prostate as a safety margin against positive surgical margins. Vascular structures can serve as landmarks. The urethral sphincter and its length after RP are influenced by the shape of the apex. Taking this shape into account allows preservation of additional sphincter length with improved postoperative continence. Conclusions: This update provides additional, detailed information about the surgical anatomy of the prostate and adjacent tissues involved in RP. This anatomy remains complex and widely variable. These details facilitate surgical orientation and dissection during RP and ideally should translate into improved outcomes. Patient summary: Based on recent anatomic findings regarding the prostate and its surrounding tissue, the urologist can individualise the dissection during RP according to cancer and patient characteristics to improve oncologic and functional results at the same time. Based on detailed anatomy of the prostate and its surrounding tissue and variations, the surgeon should individualise the dissection in a patient according to cancer characteristics by altering the technique to improve both oncologic and functional results at the same time. Radical prostatectomy is no longer an all-in-one procedure but rather an individualised operation that should take many details into consideration.

AB - Context: In 2010, we published a review summarising the available literature on surgical anatomy of the prostate and adjacent structures involved in cancer control and the functional outcome of prostatectomy. Objective: To provide an update based on new literature to help the surgeon improve oncologic and surgical outcomes of radical prostatectomy (RP). Evidence acquisition: We searched the PubMed database using the keywords radical prostatectomy, anatomy, neurovascular bundle, nerve, fascia, pelvis, sphincter, urethra, urinary continence, and erectile function. Relevant articles and textbook chapters published since the last review were critically reviewed, analysed, and summarised. Moreover, we integrated aspects that were not addressed in the last review into this update. Evidence synthesis: We found new evidence for several topics. Up to 40% of the cross-sectional surface area of the urethral sphincter tissue is laterally overlapped by the dorsal vascular complex and might be injured during en bloc ligation. Denonvilliers fascia is fused with the base of the prostate in a horizontal fashion dorsally/caudally of the seminal vesicles, requiring sharp detachment when preserved. During extended pelvic lymph node dissection, the erectile nerves are at risk in the presacral and internal iliac area. Dissection planes for nerve sparing can be graded according to the amount of tissue left on the prostate as a safety margin against positive surgical margins. Vascular structures can serve as landmarks. The urethral sphincter and its length after RP are influenced by the shape of the apex. Taking this shape into account allows preservation of additional sphincter length with improved postoperative continence. Conclusions: This update provides additional, detailed information about the surgical anatomy of the prostate and adjacent tissues involved in RP. This anatomy remains complex and widely variable. These details facilitate surgical orientation and dissection during RP and ideally should translate into improved outcomes. Patient summary: Based on recent anatomic findings regarding the prostate and its surrounding tissue, the urologist can individualise the dissection during RP according to cancer and patient characteristics to improve oncologic and functional results at the same time. Based on detailed anatomy of the prostate and its surrounding tissue and variations, the surgeon should individualise the dissection in a patient according to cancer characteristics by altering the technique to improve both oncologic and functional results at the same time. Radical prostatectomy is no longer an all-in-one procedure but rather an individualised operation that should take many details into consideration.

KW - Anatomy

KW - Erectile dysfunction

KW - Neurovascular bundle

KW - Prostate

KW - Prostate cancer

KW - Radical prostatectomy

KW - Sphincter

KW - Urethra

KW - Urinary continence

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