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Collaborative Review – Prostate Cancer

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

By: Jochen Walza , Jonathan I. Epsteinb, Roman Ganzerc, Markus Graefend, Giorgio Guazzonie, Jihad Kaoukf, Mani Menong, Alexandre Mottrieh, Robert P. Myersi, Vipul Patelj, Ashutosh Tewarik, Arnauld Villersl and Walter Artibanim

European Urology, Volume 70 Issue 2, August 2016, Pages 301-311

Published online: 01 August 2016

Keywords: Prostate, Prostate cancer, Anatomy, Neurovascular bundle, Sphincter, Radical prostatectomy, Erectile dysfunction, Urinary continence, Urethra

Abstract Full Text Full Text PDF (2,2 MB) Patient Summary

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.

Take Home Message

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.

Keywords: Prostate, Prostate cancer, Anatomy, Neurovascular bundle, Sphincter, Radical prostatectomy, Erectile dysfunction, Urinary continence, Urethra.

Footnotes

a Department of Urology, Institut Paoli-Calmettes Cancer Centre, Marseille, France

b Departments of Pathology, Urology, and Oncology, Johns Hopkins Medical, Baltimore, MD, USA

c University of Leipzig, Leipzig, Germany

d Martini Clinic, Prostate Cancer Centre, Hamburg, Germany

e Department of Urology, Humanitas Research Hospital, Rozzano, Italy

f Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA

g Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA

h Onze Lieve Vrouw Robotic Surgery Institute, Aalst, Belgium

i Institute of Urology, Lahey Hospital and Medical Center, Burlington, MA, USA

j Global Robotics Institute, Florida Hospital Celebration Health, Celebration, FL, USA

k Prostate Cancer Institute, Department of Urology, Weill Cornell Medical College, New York, NY, USA

l Department of Urology, Centre Hospitalier Régional Universitaire de Lille, Lille, France

m Department Urology, University of Verona, Verona, Italy

Corresponding author. Department of Urology, Institut Paoli-Calmettes Cancer Centre, 232, Bd Ste. Marguerite, 13009 Marseille, France. Tel. +33 491223532; Fax: +33 491223613.

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