An operative and anatomic study to help in nerve sparing during laparoscopic and robotic radical prostatectomy.
OBJECTIVE
To provide a detailed description of the steps involved in a laparoscopic radical prostatectomy in relation to the complex neurovascular anatomy of the male pelvis. AIM AND HYPOTHESIS: We aimed at delineating the neurovascular anatomy to assist in nerve preservation during laparoscopic and robotic radical prostatectomies.


METHODS
A team of urologists and an anatomist performed anatomic dissections of 12 male cadavers using a combination of laparoscopic equipment, magnification, and open surgical dissection. Each step involved in laparoscopic prostatectomy was reviewed in relation to the possible impact the step could have on the neurovascular bundles.


RESULTS
Dissections were performed systematically to mimic various steps of laparoscopic and robotic prostatectomy. The neurovascular bundles were identified and correlated with video images of actual surgery. This enabled us to construct computer simulations and show the actual nerves on the operative pictures. We specially unraveled the relationship between neurovascular bundles and lateral pelvic and Denonvillier's fascias, both of which enclose and hide these important structures. The course of the bundles was traced from its origin at pelvic plexus to its distal course along the urethra. We also showed the important relationship between pelvic plexus ganglions and seminal vesicles to illustrate the vulnerability of these nerves to thermal, electrical and/or crush injury during seminal vesicle and prostatic pedicle dissections. The importance of additional fine neural plexus along the posterior and antero-lateral surface of the prostate was shown by both gross anatomical and microscopic images. The distal precarious location of the bundles was illustrated by dissections showing anteriorly lifted prostate.These anatomico-operative correlations have not been published for laparoscopic and robotic prostatectomies, which differ significantly in its visual angles, magnifications and sometimes three-dimensional (3D) visualization from its open counter part.


CONCLUSIONS
Laparoscopic and robotic radical prostatectomy provides exposure and visualization of male pelvis not previously appreciated. It is only through a careful reexamination of the anatomy of the male pelvis, in the context of this new procedure, that the improvements in visualization and exposure benefit the surgeon. Our work provides a detailed map relating to operative steps to aid the surgeon in the performance of a nerve sparing robotic and laparoscopic radical prostatectomy.
Tewari
Ashutosh
A
Vattikuti Urology Institute, Henry Ford Health System, 2F One Ford Place, Detroit, MI 48202, USA. atiwari@hfhs.org
Peabody
James O
JO
Fischer
Melissa
M
Sarle
Richard
R
Vallancien
Guy
G
Delmas
V
V
Hassan
Mazen
M
Bansal
Aditya
A
Hemal
Ashok K
AK
Guillonneau
Bertrand
B
Menon
Mani
M
D005205:Fascia / Q000033:anatomy & histology; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D010388:Pelvis / Q000294:innervation*; D011467:Prostate / Q000098:blood supply / Q000294:innervation; D011468:Prostatectomy; D011471:Prostatic Neoplasms / Q000473:pathology / Q000601:surgery; D012371:Robotics; D012669:Seminal Vesicles / Q000294:innervation; D001743:Urinary Bladder / Q000294:innervation