Patrick C. Walsh, M.D., Arthur L. Burnett, M.D., and Alan W. Partin, M.D., Ph.D.
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A.Cross section of the urethra just distal to the apex of the prostate demonstrating the inner circular layer of smooth muscle, the outer striated urethral sphincter,and the relationship of the neurovascular bundles.

B.Anatomical relationship of the prostate to the pelvic fascia, pelvic plexus, and neurovascular bundle. Note attachment of the striated urethral sphincter to the apex of the prostate.

 

A Historical Perspective
Over the past 15 years, an anatomical approach to radical prostatectomy has been developed. In 1978 we described a technique for control of bleeding from the dorsal vein complex. This enabled the surgeon to perform a more precise anatomical dissection in a relatively bloodless field, especially at the apex of the prostate. In 1982, the anatomy of the pelvic plexus and the branches that innervate the corpora cavernosa were identified and modifications in the surgical technique were made. With preservation of the cavernous nerves it was possible to preserve sexual function, and with a better understanding of the periprostatic anatomy, wider margins of excision were achieved. More recently, with improved understanding of the pelvic floor musculature, techniques for the apical dissection and the vesicourethral anastomosis were refined. This booklet describes the anatomical approach to radical prostatectomy that has evolved.

 

The Surgical Technique

Beginning the procedure
The patient is placed in the supine position with the table broken in the midline and tilted in the Trendelenburg position. A midline lower abdominal incision is made and a limited bilateral staging pelvic lymphadenectomy is performed. Bull-dog clamps are placed on the hypogastric arteries to reduce blood loss. Next, a Hoitgrewe malleable blade is used to displace the Foley balloon superiorly and posteriorly. Fibroadipose tissue is teased from the anterior surface of the prostate and the endopelvic fascia is opened against the pelvic sidewall. Using finger dissection, the pelvic sidewall musculature is separated from the lateral surface of the prostate.

Click on any step to get a detailed drawing of the procedure
Figure 1.

Division of the puboprostatic ligaments
With a sponge stick positioned on the prostate to place tension on the puboprostatic ligaments, the ligaments are incised laterally; residual fragments are fractured by finger dissection. The superficial branch of the dorsal vein is electrocoagulated and divided.

Figure 2.

Visualizing the field
A schematic illustration of the dorsal vein complex, pelvic fascia, striated urethral sphincter, smooth musculature of the urethra, and neurovascular bundles. When the right angle clamp is passed anterior to the urethra, it transverses the fascia, some small lateral venous branches, and the anterior one-half of the striated sphincter.

Figure 3.

Isolating the dorsal vein complex
A McDougal clamp is used. The lateral wall of the urethra is identified by palpating the indwelling catheter and the lateral pelvic fascia is gently perforated by the clamp, which is then passed through the avascular plane on the anterior surface of the urethra. Care must be taken to avoid entering the apex or anterior surface of the prostate.

Figure 4.

Dividing the dorsal vein complex
The McDougal clamp is positioned beneath the dorsal vein complex and surrounding striated urethral musculature. The dorsal vein can be ligated and divided or divided without ligation. We feel that dividing the dorsal vein without ligation avoids injury to the striated sphincter from the ligature and permits more tissue to be removed on the anterior surface of the prostate. If the clamp has been placed in the correct plane, the dorsal vein can be divided completely with little residual bleeding.

Figure 5.

Oversewing the dorsal vein/ urethral sphincter complex
The dorsal vein/striated urethral sphincter complex is oversewn horizontally using a running 2-0 Vicral suture on a 5-8 circle tapered needle. Large venous channels are often located at the posterolateral edges and should be oversewn. This maneuver forms an anterior hood of tissue that will be helpful in the final anastomosis. Venous backbleeders on the anterior surface of the prostate are oversewn with 2-0 chromic catgut suture.

Figure 6.

Transecting the urethra
The urethra is gently separated from the lateral and posterior portions of the striated sphincter without mobilization. The right angle clamp is positioned behind the urethra but anterior to the striated sphincter. The neurovascular bundles cannot be damaged by this maneuver because they are posterior to the striated sphincter. The anterior surface of the urethra is divided. The Foley catheter is brought through the incision, cross-clamped, and divided. The balloon on the Foley catheter is released from the malleable blade to provide proper traction on the prostate and the posterior wall of the urethra is divided.

Figure 7.

Visualizing the lateral and posterior components of the striated urethral sphincter
With traction on the catheter one can visualize a complex of skeletal muscle and fibrous tissue that tethers the apex of the prostate to the pelvic floor musculature. This is the residual lateral and posterior components of the striated urethral sphincter. A right angle clamp has been passed immediately beneath the left edge of the sphincter. The neurovascular bundle is posterior to the right angle clamp and should not be injured during this maneuver.

Figure 8.

Dividing the superficial fascia
To prepare for preservation of the left neurovascular bundle, the superficial lateral pelvic fascia on the lateral surface of the prostate is released, first at the bladder neck and then towards the apex of the prostate. This maneuver releases the prostate, making it more mobile, and exposes the location of the neurovascular bundle in a groove at the posterolateral edge of the prostate.

Figure 9.

Releasing the lateral pelvic fascia
Beginning at the apex of the prostate, the lateral pelvic fascia is gently released posteriorly from the edge of the prostate, using a right angle clamp. This maneuver assures that Denonvilliers' fascia is not separated from the prostate. A small arterial branch is clipped and divided. Having released the bundle at the apex the dissection continues to the midprostate.

Figure 10.

Dividing the lateral pedicies
Once the neurovascular bundles have been released on both sides, the attachment of Denonvilliers'fascia to the rectum is divided in the midline, maintaining all layers of Denonvilliers'fascia on the prostate.

At this point, a prominent arterial branch running from the neurovascular bundle to the posterior surface of the prostate is identified. By dividing this posterior branch, the neurovascular bundle falls posteriorly, reducing the chance for injury during division of the lateral pedicies. The lateral pedicies are next divided on the lateral surface of the seminal vesicles without ligation. Obvious arterial bleeders are simply controlled with hemoclips once the lateral pedicle has been completely divided.

Figure 11.

Dividing the bladder neck
Once the bladder neck has been incised anteriorly, the Foley catheter is deflated and used for traction. The plane between the bladder neck and seminal vesicles is easily identified because the lateral pedicles have already been divided. This plane is developed and the bladder neck is divided on the anterior surface of the seminal vesicles. An Alice clamp is placed on the posterior bladder neck exposing the vasa deferens in the midline. The vasa deferens are clipped and divided. Next the seminal vesicles are mobilized, arterial branches are clipped and divided, and the specimen is removed.

Figure 12.

Closing the bladder neck
A tennis-racket closure of the bladder neck is preformed, using interrupted 2-0 chromic catgut suture; 4-0 chromic catgut sutures are used to evert the mucosa of the bladder over the raw edges of the detrusor musculature to avoid a bladder neck contracture.

Figure 13.

Catheter placement
A No. 16 French Foley catheter is placed through the urethra and a silk suture is used to pull the tip of the catheter through the urethral stump, exposing the urethral mucosa.

Figure 14.

Anastomosis with distal urethra
Using 2-0 Vicral sutures on 5-8 circle tapered needles, full thickness sutures are placed at 12, 3, 6, and 9 o'clock positions through the urethral mucosa, smooth muscle, striated urethral sphincter, and fascia. At the 6 o'clock position the suture is placed with care to avoid injuring the neurovascular bundles, which are located posterior to the striated sphincter. At the 12 o'clock position the suture incorporates the anterior dorsal vein/striated urethra sphincter hood.

Patient Follow-up and Summary

The patient had an uneventful postoperative recovery. Pathologically, there was established capsular penetration, but the surgical margins of excision, seminal vesicles, and pelvic lymph nodes were negative for tumor. One week after the Foley catheter was removed the patient was able to have intercourse. Although it is very unusual for a patient to have recovery of sexual function this early postoperatively, this illustrates that it is possible to perform a radical prostatectomy with ample soft tissue margins that preserves sexual function. Recovery of sexual function is related to the age of the patient, the pathologic extent of disease, and the surgical technique. Patients who are young and have organ-confined disease are the best candidates for cure and also have the best postoperative result. Using this anatomical approach, it is possible today to cure prostate cancer with fewer side effects than in the past.

Suggested Reading

  1. Partin AW, Pound CR, Clemens JQ, Epstein JI, and Walsh PC. Serum PSA following anatomical radical prostatectomy: The Johns Hopkins Experience after ten years. Urol Clin North Am. (in press).

  2. Quinlan DM, Epstein Ji, Carter B, Walsh PC. Sexual function following radical prostatectomy: influence of preservation of neurovascular bundles. J Urol. 1991; 145: 998-1002.

  3. Steiner MS. Morton RA, Walsh, PC. Impact of anatomical radical prostatectomy on urinary continence. J Urol. 1991; 145: 512-515.

  4. Walsh PC. Radical retropubic prostatectomy. In: Walsh PC, Retik AB, Stamey TA, Vaughan ED, eds. Campbefls Textbook of Urology. Philadelphia: W.B. Saunders; 1992; 3: 2865-2886.

  5. Steiner MS, Burnett, AR, Brooks JD, et al: Tubularized neourethra following radical prostatectomy. J Urol. (in press).

 

This educational brochure was made possible by a grant from Searle and Wyeth-Ayerst. Copyright 1993 Creative Medical Communications, Inc. 240 West 98th Street, Suite 6E New York, NY 10025 No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means without prior written permission of the publisher. Contents of the material contained in this publication are the sole responsibility of the author and not of Creative Medical Communications, Inc., Searle, or Wyeth-Ayerst. Printed in USA - 1993

 

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