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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

Jochen Walz a,*, Jonathan I. Epstein b, Roman Ganzer c, Markus Graefen d, Giorgio Guazzoni e,
Jihad Kaouk f, Mani Menon g, Alexandre Mottrie h, Robert P. Myers i, Vipul Patel j,
Ashutosh Tewari k, Arnauld Villers l, Walter Artibani m
a b
Department of Urology, Institut Paoli-Calmettes Cancer Centre, Marseille, France; Departments of Pathology, Urology, and Oncology, Johns Hopkins
Medical, Baltimore, MD, USA; University of Leipzig, Leipzig, Germany; Martini Clinic, Prostate Cancer Centre, Hamburg, Germany; e Department of Urology,
c d

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 Regional Universitaire de Lille, Lille, France;
m
Department Urology, University of Verona, Verona, Italy

Article info Abstract

Article history: Context: In 2010, we published a review summarising the available literature on
Accepted January 18, 2016 surgical anatomy of the prostate and adjacent structures involved in cancer control
and the functional outcome of prostatectomy.
Associate Editor: Objective: To provide an update based on new literature to help the surgeon improve
Stephen Boorjian 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,
Keywords: urinary continence, and erectile function. Relevant articles and textbook chapters
Prostate 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
Prostate cancer
update.
Anatomy Evidence synthesis: We found new evidence for several topics. Up to 40% of the cross-
Neurovascular bundle sectional surface area of the urethral sphincter tissue is laterally overlapped by the
Sphincter dorsal vascular complex and might be injured during en bloc ligation. Denonvilliers
Radical prostatectomy 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
Erectile dysfunction pelvic lymph node dissection, the erectile nerves are at risk in the presacral and internal
Urinary continence iliac area. Dissection planes for nerve sparing can be graded according to the amount of
Urethra 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
inuenced 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

* Corresponding author. Department of Urology, Institut Paoli-Calmettes Cancer Centre, 232, Bd Ste.
Marguerite, 13009 Marseille, France. Tel. +33 491223532; Fax: +33 491223613.
E-mail address: walzj@ipc.unicancer.fr (J. Walz).
http://dx.doi.org/10.1016/j.eururo.2016.01.026
0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Please cite this article in press as: Walz J, et al. 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. Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.01.026
EURURO-6626; No. of Pages 11

2 EUROPEAN UROLOGY XXX (2016) XXXXXX

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 ndings 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.
# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

1. Introduction 3. Evidence synthesis

In 2010, we published a review on the current knowledge of Regarding the pubovesical/puboprostatic ligaments, the
the anatomy of the prostate and surrounding tissue with the accessory pudendal arteries, the vesicoprostatic muscle,
aim of helping urologists better understanding the diverse and the periprostatic fascia, no new anatomic knowledge
structures encountered during radical prostatectomy (RP) was acquired (Figs. 14). Consequently, we refer to the
and applying the current nomenclature for these structures previous article for this information [1].
correctly [1]. We now present an update, taking the most
recent research results into consideration as well as the 3.1. Dorsal vascular complex
most recently published technical variations of RP and
adding topics that we left out of the previous article. The dorsal vascular complex (DVC) overlies the urethral
sphincter ventrally. During its ligation, injury to the
2. Evidence acquisition sphincter tissue is possible, resulting in potentially de-
creased postoperative continence. A recent study by Ganzer
We searched the PubMed database to identify original and et al demonstrated that 37% and 30% of the cross-sectional
review articles in English that addressed the anatomy of the urethral sphincter surface area are laterally overlapped by
prostate and relevant structures adjacent to the prostate, the DVC at the prostate apex and 5 mm distal to the apex,
with an emphasis on work published after the publication of respectively. The DVC covers the urethral sphincter tissue
our previous review (February 2010 to July 2015). The laterally and dorsally (Fig. 3) [2]. In the case of transverse en
keywords used were prostate, radical prostatectomy, anato- bloc ligation of the DVC dorsal to its lateral limits, a
my, neurovascular bundle, nerve, fascia, pelvis, sphincter, substantial portion of the sphincter tissue might be
urethra, urinary continence, and erectile function. Relevant included in the ligation and rendered nonfunctional. To
articles and textbook chapters were reviewed, analysed, avoid this problem, selective dissection and ligation of the
and summarised, with the consensus of all authors. DVC is strongly recommended [2,3].

Fig. 1 Axial section of prostatic and periprostatic fascia at midprostate.


A = apex; AFMS = anterior fibromuscular stroma; B = bladder; DA = detrusor apron; DF = Denonvilliers fascia; DVC = dorsal vascular complex;
FTAP = fascial tendinous arch of pelvis; LAF = levator ani fascia; M = midprostate; NVB = neurovascular bundle; PC = pseudocapsule; PPF = periprostatic
fascia; PPF/SVF = posterior prostatic fascia/seminal vesical fascia; PRS = perirectal space; PZ = peripheral zone; R = rectum; SV = seminal vesicle;
TZ = transition zone; U = urethra; VEF = visceral endopelvic fascia.

Please cite this article in press as: Walz J, et al. 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. Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.01.026
EURURO-6626; No. of Pages 11

EUROPEAN UROLOGY XXX (2016) XXXXXX 3

Fig. 2 Midline sagittal section of prostate, bladder, urethra, and striated sphincter.
B = bladder; CS = colliculus seminalis (verumontanum); DA = detrusor apron; DF = Denonvilliers fascia; DVC = dorsal vascular complex; MDR = medial
dorsal raphe; PC = pseudocapsule of prostate; PPF/SVF = posterior prostate fascia/seminal vesicle fascia; PS = pubic symphysis; R = rectum;
RU = rectourethralis muscle; SMS = smooth muscle sphincter; SS = striated sphincter; SV = seminal vesicles; U = urethra; VEF = visceral endopelvic fascia;
VS = vesical sphincter; VVPM = vesicoprostatic muscle.

3.2. Prostate arterial supply arteries. The most frequent origin of prostate arteries is from
the internal pudendal artery (3556%) [4,5]. The common
The internal pudendal artery is the prolongation of the glutealpudendal trunk is the next most frequent origin (15
internal iliac artery after branching off the obturator artery, 28%), and less frequently the prostate arteries branch off the
the vesical arteries, and the superior and inferior gluteal obturator artery (1012%) or the inferior gluteal artery. Per
side, there is only one common trunk in most cases (6076%),
and there are anastomoses with the termination of the
internal pudendal arteries (24%), contralateral prostate
arteries (12%), and superior vesical arteries (8%) [4,5]. After
branching off, the artery has a tortuous course obliquely
downward in trajectory towards the posterior and inferior
part of the bladder and provides several inferior vesical
arteries. It terminates with numerous prostate branches,
often after a bifurcation, resulting in two main pedicles. The
urologist can differentiate a posterior pedicle surrounding
seminal vesicles and deferential ducts reaching the prostate
base as well as an anterior pedicle surrounding the lateral
border of the prostate finally running to the prostate apex as
an anterior capsular prostate branch. These latter arteries,
when preserved during RP, may relate to postoperative
erectile function and penile integrity because they may be
responsible for ancillary penile blood flow [6,7]. After
reaching the prostate pseudocapsule, the prostate arteries
give rise to numerous perforating branches to the prostate,
with most penetrations found at the 2 oclock or 10 oclock
position for the anterolateral pedicle and at the 5 oclock or
7 oclock position for the posterolateral pedicle [4]. The
Fig. 3 Axial section of the sphincteric urethra.
A = apex; B = bladder; C SMS = circular smooth muscle sphincter;
anterolateral pedicle vascularises mainly the central gland
DVC = dorsal vascular complex; EPF = endoplevic fascia; LA = levator ani and the transition zone, whereas the posterior pedicle
muscle; LAF = levator ani fascia; L SMS = longitudinal smooth muscle vascularises most of the peripheral zone and apical area.
sphincter; M = midprostate; MDR = median dorsal raphe;
NVB = neurovascular bundle; PB = pubic bone; PV/PPL = pubovesical/
Note that there is considerable inter- and intraindividual
puboprostatic ligament; R = rectum; SS = striated sphincter; SV = seminal variability in the vascular anatomy.
vesicle; U = urethra.

Please cite this article in press as: Walz J, et al. 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. Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.01.026
EURURO-6626; No. of Pages 11

4 EUROPEAN UROLOGY XXX (2016) XXXXXX

3.4. Posterior prostatic fascia and seminal vesicles fascia


(Denonvilliers fascia)

A recent work from Muraoka et al investigated the intra-


and interindividual variations of the posterior prostatic
fascia (PPF) and seminal vesical fascia (SVF) (Figs. 1 and 2).
They showed that although its configuration appeared to be
a firm membranous structure, it was actually recognised as
a fascicle of multiple leaves with interlacing branches, with
multiple leaves mainly ventrally, and a disorderly, loose
connective tissue mainly dorsally [11]. They observed a
fusion between the PPF/SVF and the pseudocapsule near the
base of the prostate at the insertion of the seminal vesicles
(Fig. 2). The PPF/SVF extended and dispersed laterally into
the neurovascular bundle (NVB), and periprostatic nerves
ran between multiple leaves and appeared embedded in the
fascial complex between PPF/SVF leaves and the pseudo-
capsule.[11] Another recent work by Kim et al suggests that
the tissue quality of PPF/SVF varies among patients as its
origin might be induced by tissue tension, created by organ
development in the pelvis and not by tissue fusion as
suggested previously. As this development can vary
substantially from patient to patient, the fascia can have
a multilayer configuration, a fragmentation into short
pieces, or be composed of a thick leaf [12]. This theory
Fig. 4 Coronal section of the prostate, sphincteric urethra, periprostatic
supports the observations from Muraoka et al as well as
fascia, and associated musculature. clinical experience, in which tissue quality varies [13].
CS = colliculus seminalis (verumontanum); CZ = central zone;
ED = ejaculatory duct; LA = levator ani muscle; LAF = levator ani fascia;
NVB = neurovascular bundle; OI = obturator internus muscle; 3.5. Neurovascular bundle
PC = pseudocapsule of prostate; PF = prostate fascia; PPF = periprostatic
fascia; PZ = peripheral zone; SMS = smooth muscle sphincter; 3.5.1. Neurovascular bundle and pelvic lymph node dissection
SS = striated sphincter; SV = seminal vesicle; U = urethra; VD = vas
deferens. In the male, the inferior hypogastric plexus, or pelvic plexus,
is responsible for the mechanisms of erection, ejaculation,
and urinary continence [14]. The pelvic plexus lies within a
fibrofatty, flat, rectangular, sagittally oriented plate be-
3.3. Exterior stromal edge of the prostate versus prostate tween the bladder and the rectum [1417]. Pelvic lymph
pseudocapsule node dissection (PLND) might be extended into this area.
Currently, a standard PLND is defined as a dissection of the
There is an ongoing controversy regarding the outer limits fibrofatty tissue between the landmarks of the external iliac
of the prostate. The structure often termed the capsule is the artery and the pelvic musculature laterally, the inner
exterior stromal edge of the prostate parenchyma, formed femoral canal distally, the common iliac artery or the
by transversely arranged fibromuscular layers of condensed bifurcation with the ureter proximally, and the bladder wall
smooth muscle, with a variable number of glands recog- medially, including a dissection around the internal iliac
nised at the outermost prostate surface [8]. Note that this artery [18,19]. In a recent lymph node mapping study, such
condensed fibromuscular layer may intermingle with the a dissection field allows the urologist to correctly stage
periprostatic tissue, rendering its appearance quite variable patients as N0 or N1 in 94% of all cases and removes 87% of
[1]. From a microscopic and pathologic point of view, the all positive nodes [20]. In the same study, a more limited
correct term for this layer would be condensed smooth dissection field (external iliac vessels and obturator fossa)
muscle or the outer edge of the prostate. Despite this correctly staged only 76% of all patients and removed only
microscopic evidence, from a macroscopic and surgical 52% of all positive nodes [20]. An extended PLND (ePLND)
point of view, the defined and distinct outer edge of the might extend the dissection up to the common iliac arteries
prostate, analogous to a capsule, is visibly and grossly as well as to the presacral areas [18,19]. Such a dissection
apparent during RP in many cases and is used as a landmark would correctly stage 97% of all patients, and 99% of all
for proper dissection [9]. Consequently, the coauthors positive nodes would be removed [20]. The pelvic plexus
agreed that the term pseudocapsule might represent an and the erectile nerves are at risk in standard dissection
acceptable compromise to respect its pathologic nature during the medial dissection in the area of the internal iliac
versus the clinical appearance of the prostate outer limits in artery and towards the bladder wall. During ePLND, the
daily practice. Note that the International Anatomical nerves are also at risk at their origin in the presacral area
Terminology refers to capsule (pseudocapsule) [10]. and medial to the common iliac vessels. In fact, decreased

Please cite this article in press as: Walz J, et al. 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. Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.01.026
EURURO-6626; No. of Pages 11

EUROPEAN UROLOGY XXX (2016) XXXXXX 5

erectile function in patients with a more extended yield is questionable [29]. Nevertheless, several studies proved
of lymph nodes relative to patients with a lower yield or that the high anterior release concept with preservation of
no lymph node dissection has been demonstrated the anterior nerve fibres improves both erectile function
[21,22]. Others could not find any influence from the extent and urinary continence relative to patients who did not
of PLND on erectile function [23]. Nevertheless, from an undergo a high anterior release [3638]. It remains unclear
anatomic point of view, ePLND occurs near or inside the whether this effect is a result of the nerve fibres that are
pelvic plexus and thus can lead to injury of proerectile nerves. preserved at the anterolateral aspect of the prostate or
This should be considered when performing PLND during whether it is a result of other aspects, such as less traumatic
pelvic surgery. handling of the NVB; better identification of dissection
planes; or other, hidden technical details [39].
3.5.2. Anterolateral nerves of the neurovascular bundle
Fibres of the pelvic plexus destined for erectile and urinary 3.5.4. Compartmentalisation of the neurovascular bundle
function surround the lateral aspect of the bladder neck, the Costello et al divided the NVB into the anterior fibres mainly
proximal prostate, and the seminal vesicles [15,16,24]. Dur- innervating the levator ani and the prostate and the more
ing their course lateral to the prostate, several studies posteromedial located fibres mainly innervating the corpo-
confirmed a spraylike distribution of the nerves on the ra cavernosa [16]. Tewari et al proposed a longitudinal
lateral and anterolateral surface of the prostate up to the trizonal compartmentalisation of the NVB by dividing it into
2 oclock and 10 oclock positions [2430]. Ganzer et al, the proximal neurovascular plate, which is synonymous
using computerised planimetry, identified the largest with the already-discussed pelvic plexus; the predominant
percentage of periprostatic nerve surface in the posterolat- NVB; and the accessory neural pathways [40]. Accessory
eral position. The periprostatic nerve distribution was neural pathways were noted within the layers of the
variable, with up to 19% of the overall nerve surface in the periprostatic fascia up to the anterolateral aspect of the
anterolateral position [30]. This finding was corroborated prostate. Two sets of neural tissue were identified: one
by Alsaid et al, who found that at the midpart the NVBs superficial that lays inside of the periprostatic fascia and a
became more dispersed, with less than two-thirds of the deeper group of nerves travelling within the pseudocapsule
periprostatic nerve fibres remaining in the posterolateral and probably responsible for direct innervation of the
regions and one-third in the anterior and anterolateral prostate [40]. In fact, a recent study by Ganzer et al
regions. At the apex, 60% of the nerves were located demonstrated that the total nerve surface decreases by 75%
posterolaterally, and 40% were located anterolaterally from the level of the seminal vesicles to the urethra, from
[31]. Clarebrough et al reproduced the methodology of 50.2 mm2 to 13.3 mm2, suggesting a role for these nerves
Ganzer et al and showed that the overall proportion of nerve other than innervation of the corpora cavernosa [41]. An-
surface on whole-mount sections increased at the ante- other study by Alsaid et al based on 3D reconstruction
rolateral side of the prostate, from 6.0% at the base to 7.6% at demonstrated that at the prostate apex and the urethra, the
the midpart to 11.2% at the apex, suggesting that especially NVB is separated into two distinct groups: the cavernous
at the apex nerve fibres are more predominant along the nerves and corpus spongiosum nerves [31]. They demon-
anterolateral aspect of the prostate [32]. All these differing strated that the cavernous nerve fibres running to the
results can be explained by the interindividual variability of corpora cavernosa were a continuation mainly of the fibres
the anatomy as well as by the difference in methodology running on the anterior and lateral aspect of the prostate.
(nerve surface vs number of nerve fibres). The corpus spongiosum nerve fibres running to the corpus
spongiosum were found to be a continuation of the fibres
3.5.3. Function of nerves lateral to the prostate running at the posterolateral aspect of the prostate
The role and function of the anterolateral nerves on the [42]. They concluded that the ideal dissection plane during
prostate are controversial, despite several studies that nerve sparing should include the preservation of the
included immunohistochemical staining of these nerve anterolateral tissue and fascia to avoid cavernous nerve
fibres. Alsaid et al showed in a foetus aged 17 wk using lesions [31].
three-dimensional (3-D) reconstruction that sympathetic, It is noteworthy that despite extensive research in the
parasympathetic, and sensory nerve fibres are found on the field of prostate anatomy, the exact anatomy of the fascia
anterolateral aspect of the prostate. Unfortunately, they did and the detailed function of the nerve fibres surrounding
not provide nerve counts [33]. Ganzer et al showed that up the prostate remain controversial and at times contradic-
to 14.6% of all parasympathetic nerve fibres are found tory.
anterolaterally, but in their study at the apex, only 1.5% of
all parasympathetic nerves were found anteriorly [34]. A 3.6. Anatomic landmarks for nerve sparing and grading of
similar study by Costello et al demonstrated that only 7% of nerve sparing extent
all parasympathetic nerve fibres are found on the ante-
rolateral aspect of the prostate [35]. As erectile function is In daily practice, the substantial interindividual and
assured by parasympathetic fibres, the physiologic nature intraindividual variations do not allow the urologist to
of these fibres makes participation in erectile function reproduce the same surgical dissection in every patient, but
possible, but because of the low percentage of anterolateral the multilayered character of the periprostatic fascia allows
parasympathetic fibres, their influence on overall function choice in the dissection between nerves and prostate

Please cite this article in press as: Walz J, et al. 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. Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.01.026
EURURO-6626; No. of Pages 11

6 EUROPEAN UROLOGY XXX (2016) XXXXXX

pseudocapsule with the aim of leaving a more or less thick nerve-sparing procedures despite the presence of EPE in
tissue layer on the prostate as a safety margin. In cases with well-selected patients.
a low risk of extraprostatic extension (EPE), a closer Depending on the dissection plane chosen during the
dissection and in cases with a higher risk of EPE a wider procedure, several technical variations are possible. Previ-
dissection plane can be chosen. This approach was termed ously, we described intrafascial, interfascial, and extra-
incremental nerve sparing [43,44]. It is known that EPE is in fascial dissection (Fig. 5a and 5b; Table 1) [1]. Intrafascial
most cases only a matter of millimetres, which could allow a dissection is considered a dissection that follows a plane on
nerve-sparing procedure in selected cases with focal EPE the pseudocapsule, remaining internal to the prostatic
[45]. Inoue et al evaluated the distance between cancer and fascia at the antero- and posterolateral aspect of the
the NVB at the classical 5 oclock and 7 oclock position in prostate and anterior to the PPF/SVF. The intrafascial
prostates without nerve sparing. In patients without EPE, approach allows a whole-thickness preservation of the
they found a mean distance of 3.3 mm (standard deviation NVB. Interfascial dissection of the NVB is considered a
[SD]: 2.6), 3.4 mm (SD: 2.7), and 3.7 mm (SD: 2.4) at the dissection within the thickness or between the leaves of the
apex, midgland, and base, respectively. In patients with EPE, periprostatic fascia and includes incremental nerve sparing.
the distance between cancer and the NVB was 2.0 mm (SD: Depending on anatomic variations, the NVB might be prone
1.9), 1.9 mm (SD: 1.9), and 1.8 mm (SD: 2.1) at the apex, to partial resection. This approach allows a greater safety
midgland, and base, respectively [46]. Note that in an margin around the prostate relative to the intrafascial
individual case, the nerves could be in direct contact with dissection, presumably resulting in an oncologically safer
the NVB. This observation corroborates the possibility of approach [47,48]. The extrafascial dissection is a dissection

Fig. 5 (a) Overview of an axial section of the prostatic and periprostatic fascia at midprostate (prostate rotated counterclockwise). (b) Enlarged axial
section with three dissection planes: intrafascial, interfascial, and extrafascial. (c) Enlarged axial section with three dissection planes according to the
Pasadena consensus [44]: full, partial, and minimal nerve sparing. (d) Enlarged axial section with four dissection planes according to Tewari et al [40]:
1 = dissection below veins, 2 = dissection on the veins, 3 = dissection distant from the veins, and 4 = extrafascial dissection. (e) Enlarged axial section
with five dissection planes according to Schatloff et al [50]: 1 = extrafascial dissection, 2 = sharp dissection distant from arteries, 3 = sharp dissection on
arteries, 4 = sharp dissection at the level of arteries, and 5 = blunt dissection below arteries.
LA = levator ani muscle; LAF = levator ani fascia; PC = pseudocapsule of prostate; PPF = periprostatic fascia; R = rectum.

Please cite this article in press as: Walz J, et al. 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. Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.01.026
EURURO-6626; No. of Pages 11

EUROPEAN UROLOGY XXX (2016) XXXXXX 7

Table 1 Overview of the different dissection planes for nerve sparing during radical prostatectomy and their influence on safety margin
and nerve-sparing quality

Author Dissection plane


Safety margin to avoid PSM
Low High

Nerve-sparing quality
Good Poor

Previous article Walz et al [1] Intrafascial Interfascial Extrafascial


Pasadena consensus, Full nerve sparing Partial Minimal nerve sparing NA
Montorsi et al [44] nerve sparing
Tewari et al [40] Grade 1 Grade 2 Grade 3 Grade 4
Schatloff et al [50] Grade 5 Grade 4 Grade 3 Grade 2 Grade 1

NA = not applicable; PSM = positive surgical margin.

carried out lateral to the levator ani fascia and posterior to Those arteries were identified in 73% of all prostate half-
the PPF/SVF. In this case, the NVB will be completely lobes [6]. Maximum nerve sparing was termed a grade
resected. This approach results in the largest amount of 5 dissection, and the dissection is performed without the
tissue surrounding the prostate and thus is the most need for sharp dissection between this artery and the
oncologically safe dissection, but it carries with it probable pseudocapsule outside the prostatic fascia. A grade
complete erectile dysfunction if done bilaterally [47]. Alter- 4 dissection is performed using sharp dissection in a plane
nate terminology for dissection planes has been suggested between the artery and the prostatic pseudocapsule across
by a consensus panel using the terms full, partial, and the NVB. Intraoperatively, the dissection is confirmed by the
minimal nerve sparing for the intrafascial, interfascial, and presence of a strip of adipose tissue over the prostate and an
sub extrafascial dissection, respectively (Fig. 5c; Table 1) absence of arterial vessels. For a grade 3 dissection, the
[44]. Note that the estimation of nerve-sparing extent is plane of nerve sparing is created at the arterys lateral
subjective, especially in the category of interfascial or aspect; therefore, the artery is clipped at the level of the
partial nerve sparing. prostate pedicle. Intraoperatively, the dissection is identi-
Recent studies pushed this concept even further and fied by the presence of a strip of adipose tissue over the
suggested subdividing the interfascial dissection into near prostate, with the artery on top. For a grade 2 dissection,
and far interfascial dissection planes relative to the nerve sparing is performed several millimetres lateral to the
pseudocapsule, proposing grading systems to define the artery, following the prostatic contour. Intraoperatively, the
extent of tissue margin on the prostate [6,43]. dissection is identified by the presence of a thick fat strip
Tewari et al proposed a grading system based on four over the prostate, with arteries embedded. Finally, for a
grades of dissection [43]. They used the veins on the lateral grade 1 dissection, an extrafascial dissection is performed
aspect of the prostate as vascular landmarks for the [50]. Using this grading system, Schatloff et al reported on
definition of the dissection planes as well as a scaling the amount of nerve tissue on the prostate according to the
system, with 1 being maximal nerve sparing and 4 being no degree of nerve sparing. They could confirm that with
nerve sparing (Fig. 5d; Table 1). A dissection between the increasing degrees of nerve sparing, the amount of nerve
periprostatic veins and the pseudocapsule of the prostate is tissue on the prostate decreased [50]. Further studies
considered a grade 1 dissection. Cases in which the evaluating the impact of different grades of nerve sparing on
dissection is performed just on the veins are considered functional outcomes are awaited.
grade 2 dissection. When leaving more tissue on the veins Bearing in mind that the anatomy of the nerves may vary
and the prostate, it is considered a grade 3 dissection, and an substantially, the concept of different dissection planes
extrafascial dissection is a grade 4 dissection [43]. Using the aims more for an incremental security margin on the
Tewari system, Srivastava et al demonstrated that the early prostate to avoid positive surgical margins (PSMs) than for
return of continence was associated with the grade of nerve true incremental nerves sparing. Incremental nerve sparing
sparing, in which 72% of patients with grade 1 nerve sparing would imply that the course and location of erectile nerve
had early continence versus 55%, 46%, and 44% for grades 2, fibres can reliably be identified, which is not the case
3, and 4, respectively [49]. Data on erectile function were because of their microscopic nature and the varying
not available. anatomy. The degree of nerve sparing with this approach
Patel and coworkers proposed an inverse five-grade scale is uncertain, and the true extent of nerve fibre preservation
of dissection, in which grade 5 represents optimal nerve in an individual patient cannot reliably be controlled or
sparing and grade 1 no nerve sparing (Fig. 5e; Table 1) predicted. In contrast, the amount of tissue remaining on
[50]. They used the arterial periprostatic vasculature as a the prostate to avoid a PSM can be well controlled during
landmark, with a landmark artery running on the lateral the procedure, with the aim of achieving an incremental
border of the prostate as either a prostate or capsular artery. safety margin to cover the pseudocapsule and cancer, if

Please cite this article in press as: Walz J, et al. 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. Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.01.026
EURURO-6626; No. of Pages 11

8 EUROPEAN UROLOGY XXX (2016) XXXXXX

present. For this reason, the term incremental safety margin this paper as the urethral sphincter (musculus sphincter
instead of incremental nerve sparing may better reflect this urethrae) [55]. This terminology seems more appropriate as
technical variation [39]. most of the vesical sphincter tissue is found at the level of the
So far, there is no consensus on which grading system (caudal) urinary bladder, and its function is to close the
should be used, and a standard system would need clear and storage organ bladder at the bladder level and not at the
reproducible landmarks to provide comparability and urethral level. Moreover, the vesical sphincter helps separate
reproducibility [44]. Moreover, selection of patients for the storage organ bladder form the genital part of the
such an incremental safety margin approach depends on genitourinary tract that then serves for its genital function
patient and cancer characteristics and is the fundamental (ejaculation). At the same time, the urethral sphincter has its
concern with this technique. Address this issue is beyond function at the level of the urethra as it closes the urethra at a
the scope of this review but needs to be taken into distance to the bladder when activated [55]. Consequently,
consideration when these variations in surgical techniques the terms vesical sphincter and urethral sphincter will be used
are applied in daily practice. in the following text to replace the terms internal and external
urethral sphincter, respectively.
3.7. Pelvic floor musculature
3.8.1. Bladder neck and vesical sphincter
The innermost muscle of the anterior pelvis is the levator ani The bladder neck is the anatomic area of the urinary bladder
muscle. Close to the urethral sphincter, it has been termed the outlet and the entrance to the prostatic urethra. It is formed
puboperinealis muscle and represents the anteromedial by several structures, including detrusor muscle, the vesical
component of the levator ani [3,51,52]. Voluntary contrac- sphincter, and adjacent proximal prostatic tissue. The
tion of the puboperinealis muscle pulls the urethra and detrusor muscle consists of a densely interwoven network
prostate forward and upward, resulting in closure of the of three recognised smooth muscle layers: an inner
urethra [51,53]. Innervating this muscle are fibres of the long longitudinal layer, a middle circular layer, and an outer
pelvic nerve, or levator ani nerve, which runs on the levator longitudinal layer [55,56]. The detrusor is anteriorly and
ani surface just lateral to the fascial tendinous arch (Fig. 6) laterally in close contact with the bladder neck, but there is
[54]. For full functional integrity of the puboperinealis and no participation of any of the three layers in the formation of
the quick-stop mechanism, this nerve needs to be identified the vesical sphincter. Some anterior fibres of the outer
and preserved. It might be injured by incision of the longitudinal muscle layer reach out over the prostate to
endopelvic fascia and by mobilisation of the levator ani reach the os pubis in puboprostatic/pubovesical ligaments.
laterally away from the prostate [54]. This sheath of smooth muscle is also termed the anterior
detrusor apron (Fig. 2) [1,57]. Posterior fibres of the outer
3.8. Bladder neck and urinary sphincter longitudinal muscle layer cover the trigone posteriorly and
reach out over the bladder neck to penetrate the posterior
There are two well-recognised urinary sphincter systems: (1) aspect of the prostate. This structure is also termed the
a proximal internal urethral sphincter, referred to in this vesicoprostatic muscle or posterior detrusor apron (Fig. 2)
paper as the vesical sphincter (musculus sphincter vesicae), [1,58,59]. These muscle bundles attach the urinary bladder
and (2) the distal external urethral sphincter, referred to in in the pelvis but do not participate in the sphincter system.
The trigone is a creaseless, triangular area extending
anteriorly from the two ureteral orifices to the urethral
opening, with superficial submucosal longitudinal smooth
muscle fibres [55]. This smooth muscle extension is the site
of formation of middle-lobe benign prostatic hyperplasia
(BPH). At its cranial border, the trigone consists of a
transverse, submucosal band formed by the prolongation of
ureteral muscle, extending from one ureteral orifice to the
contralateral orifice [55]. The main part of the trigone is
formed by fibres of the vesical sphincter, which is an elliptic
structure formed by circular smooth muscle fibres sur-
rounding the urethral opening circumferentially. The
urethral opening is eccentrically positioned and located
in the anterior third of the ellipsis. Posteriorly, the circular
muscle fibres reach almost to the ureteral orifices (Fig. 2)
[55]. This muscular structure is part of the vesical sphincter
that assures continuous urinary continence as well as
bladder neck closure during ejaculation to avoid retrograde
Fig. 6 Intraoperative picture of the long pelvic nerve or the levator ani ejaculation. Inferiorly, circular fibres of this muscle
nerve (arrow) on the left side of the prostate. Picture taken at the surround the proximal prostatic urethra down to the
moment of the endopelvic fascia opening (pelvic wall on the left side,
prostate on the right side). Reproduced with permission from V. Patel,
colliculus seminalis. This part of the sphincter is modified
Ohio State University (Columbus, OH, USA). by and interspersed with the development of BPH, and the

Please cite this article in press as: Walz J, et al. 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. Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.01.026
EURURO-6626; No. of Pages 11

EUROPEAN UROLOGY XXX (2016) XXXXXX 9

intravesical part may be displaced upward, in this case into results at the same time. Today, RP is no longer an all-in-one
the bladder lumen. The so-called bladder necksparing procedure but rather an individualised operation that
technique is performed in this anatomic area to improve should take many details into consideration.
postoperative continence. To date, there is a controversy
regarding the effect of bladder neck sparing on urinary
continence, and no clear conclusion for or against bladder Author contributions: Jochen Walz had full access to all the data in the
study and takes responsibility for the integrity of the data and the
neck sparing can be drawn [44,6062].
accuracy of the data analysis.

3.8.2. Urethral sphincter Study concept and design: Walz, Artibani.


The urethral sphincter complex is found primarily distal to the Acquisition of data: Walz, Ganzer.
prostate apex. It is in close relationship with but independent Analysis and interpretation of data: Walz, Epstein, Ganzer, Graefen,
from the levator ani muscle (pars puboperinealis) and thus Guazzoni, Kaouk, Menon, Mottrie, Myers, Patel, Tewari, Villers, Artibani.
independent of the pelvic floor musculature [47,63,64]. Drafting of the manuscript: Walz.
Critical revision of the manuscript for important intellectual content: Walz,
The urethral sphincter itself consists of two muscle types
Epstein, Ganzer, Graefen, Guazzoni, Kaouk, Menon, Mottrie, Myers, Patel,
(Fig. 2 and 3). First, the outer striated muscle fibres, described
Tewari, Villers, Artibani.
to be omega shaped and extending to the apex and the
Statistical analysis: Walz.
anterior surface of the prostate [6568]. Recently, an Obtaining funding: None.
extension of the striated muscle not only on the outside of Administrative, technical, or material support: Walz, Villers, Tewari, Myers,
the apex but also inside the apex was suggested [69]. Second, Patel.
an inner muscle layer of the urethral sphincter surrounds the Supervision: Artibani.
urethra completely and consists of smooth muscle fibres Other (specify): None.
(outer circumferential and an inner, longitudinally oriented
Financial disclosures: Jochen Walz certies that all conicts of interest,
layer) and elastic tissue [64]. The smooth muscle layer has its
including specic nancial interests and relationships and afliations
proximal limits at the level of the colliculus seminalis or relevant to the subject matter or materials discussed in the manuscript
verumontanum (Fig. 2) [30,65]. The shape of the prostate at (eg, employment/afliation, grants or funding, consultancies, honoraria,
the apex may vary substantially, directly influencing the stock ownership or options, expert testimony, royalties, or patents led,
form and length of the urethral sphincter after emerging from received, or pending), are the following: None.
the apex because parts of the urethral sphincter can be found
Funding/Support and role of the sponsor: None.
inside the prostate apex as a distinct structure surrounded by
prostatic tissue [47,69]. The apex may overlap the urethral
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Related to Optimisation of Cancer Control and Preservation of Continence and Erection in Candidates for Radical Prostatectomy:
An Update. Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.01.026
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Related to Optimisation of Cancer Control and Preservation of Continence and Erection in Candidates for Radical Prostatectomy:
An Update. Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.01.026
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Please cite this article in press as: Walz J, et al. 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. Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.01.026