A critical analysis of the current knowledge of surgical anatomy related to optimization of cancer control and preservation of continence and erection in candidates for radical prostatectomy.
BACKGROUND
Detailed knowledge of the anatomy of the prostate and adjacent tissues is mandatory during radical prostatectomy to ensure reliable oncologic and functional outcomes.


OBJECTIVE
To review critically and to summarize the available literature on surgical anatomy of the prostate and adjacent structures involved in cancer control, erectile function, and urinary continence.


METHODS
A search of the PubMed database was performed using the keywords radical prostatectomy, anatomy, neurovascular bundle, fascia, pelvis, and sphincter. Relevant articles and textbook chapters were reviewed, analyzed, and summarized.


RESULTS
Anatomy of the prostate and the adjacent tissues varies substantially. The fascia surrounding the prostate is multilayered, sometimes either fused with the prostate capsule or clearly separated from the capsule as a reflection of interindividual variations. The neurovascular bundle (NVB) is situated between the fascial layers covering the prostate. The NVB is composed of numerous nerve fibers superimposed on a scaffold of veins, arteries, and variable amounts of adipose tissue surrounding almost the entire lateral and posterior surfaces of the prostate. The NVB is also in close, cage-like contact to the seminal vesicles. The external urethral sphincter is a complex structure in close anatomic and functional relationship to the pelvic floor, and its fragile innervation is in close association to the prostate apex. Finally, the shape and size of the prostate can significantly modify the anatomy of the NVB, the urethral sphincter, the dorsal vascular complex, and the pubovesical/puboprostatic ligaments.


CONCLUSIONS
The surgical anatomy of the prostate and adjacent tissues involved in radical prostatectomy is complex. Precise knowledge of all relevant anatomic structures facilitates surgical orientation and dissection during radical prostatectomy and ideally translates into both superior rates of cancer control and improved functional outcomes postoperatively.
Walz
Jochen
J
Department of Urology, Institut Paoli-Calmettes Cancer Center, 232, Bd Ste. Marguerite, 13009 Marseille, France. walzj@marseille.fnclcc.fr
Burnett
Arthur L
AL
Costello
Anthony J
AJ
Eastham
James A
JA
Graefen
Markus
M
Guillonneau
Bertrand
B
Menon
Mani
M
Montorsi
Francesco
F
Myers
Robert P
RP
Rocco
Bernardo
B
Villers
Arnauld
A
D007172:Erectile Dysfunction / Q000517:prevention & control*; D006801:Humans; D008297:Male; D011467:Prostate / Q000033:anatomy & histology* / Q000601:surgery; D011468:Prostatectomy / Q000009:adverse effects / Q000379:methods*; D011471:Prostatic Neoplasms / Q000601:surgery*; D014549:Urinary Incontinence / Q000517:prevention & control*