A novel technique for approaching the endopelvic fascia in retropubic radical prostatectomy, based on an anatomical study of fixed and fresh cadavers.
OBJECTIVE
To present the anatomical basis and details of a technique for an approach to the endopelvic fascia devised to preserve urinary continence.


METHODS
For cross-sectional macroscopic observation, seven formalin-fixed specimens of the male pelvic contents including the pelvic wall were serially sectioned at a 5-mm thickness. Semi-serial sections from eight other specimens were examined histologically. Eight fresh cadavers were dissected to mimic the various steps in a retropubic radical prostatectomy. After approaching the endopelvic fascia in an anatomically determined manner to reach the paraprostatic space, the pubic bone was removed and nerves near the rhabdosphincter dissected. To assess the clinical implication of this approach, we examined the time to achieve continence in 23 consecutive patients who had a radical retropubic prostatectomy using the new technique.


RESULTS
Sectional macroscopic observation depicted the fascia of the levator ani as a definite structure adherent to but not fused with the lateral pelvic fascia. The thin fascia overlying the levator ani fascia and lateral pelvic fascia represented the true endopelvic fascia. Microscopically, the lower part of the fascia of the levator ani was rich in smooth muscle, which interdigitated with the framework of the rhabdosphincter. In fresh cadavers, the levator ani muscle was removed laterally still covered by its fascia, without visualizing the muscle fibres. Small branches from the pudendal nerve entered the rhabdosphincter. The mean (sd, range) distance from the lowest point of the endopelvic fascia to the point where the sphincteric branch entered the rhabdosphincter was 5.5 (1.8, 3-8) mm. The continence rate at 1, 3, 6 and 9 months after surgery using the new technique was 44%, 83%, 96% and 100%, respectively.


CONCLUSIONS
Preserving the fascia of the levator ani helps to protect the levator ani muscle, rhabdosphincter and pudendal nerve branches to the rhabdosphincter. In retropubic radical prostatectomy, this anatomical approach to the endopelvic fascia should preserve or allow the earlier recovery of urinary continence.
Takenaka
Atsushi
A
Department of Urology, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192, Japan. atake@med.kawasaki-m.ac.jp
Hara
Ryoei
R
Soga
Hideo
H
Murakami
Gen
G
Fujisawa
Masato
M
D000368:Aged; D000369:Aged, 80 and over; D002102:Cadaver; D004210:Dissection / Q000379:methods; D006801:Humans; D008297:Male; D008875:Middle Aged; D010388:Pelvis / Q000473:pathology*; D011183:Postoperative Complications / Q000517:prevention & control*; D011468:Prostatectomy / Q000379:methods*; D011471:Prostatic Neoplasms / Q000473:pathology / Q000601:surgery*; D014549:Urinary Incontinence / Q000473:pathology / Q000517:prevention & control*