title: An operative and anatomic study to help in nerve sparing during laparoscopic and robotic radical prostatectomy.
abstract: 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.
authors.affiliation: Vattikuti Urology Institute, Henry Ford Health System, 2F One Ford Place, Detroit, MI 48202, USA. atiwari@hfhs.org
authors.forename: Ashutosh
authors.initials: A
authors.lastname: Tewari
authors.forename: James O
authors.initials: JO
authors.lastname: Peabody
authors.forename: Melissa
authors.initials: M
authors.lastname: Fischer
authors.forename: Richard
authors.initials: R
authors.lastname: Sarle
authors.forename: Guy
authors.initials: G
authors.lastname: Vallancien
authors.forename: V
authors.initials: V
authors.lastname: Delmas
authors.forename: Mazen
authors.initials: M
authors.lastname: Hassan
authors.forename: Aditya
authors.initials: A
authors.lastname: Bansal
authors.forename: Ashok K
authors.initials: AK
authors.lastname: Hemal
authors.forename: Bertrand
authors.initials: B
authors.lastname: Guillonneau
authors.forename: Mani
authors.initials: M
authors.lastname: Menon
mesh_terms: 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