Nerve-sparing in radical perineal prostatectomy is performed with equal efficacy as in the retropubic approach. It does, however, require an intimate understanding of the course of the neurovascular bundles as viewed from the perineum to prevent unintended injury. The procedure differs in that initially a vertical instead of a transverse incision of the posterior layer of Denonvillier's fascia is made. Reflection of this layer over the apex of the prostate gland and laterally, allows establishing a plane between the prostate and the neurovascular bundles. Posterolateral dissection of the prostate is kept close to the prostatic substance and small clips rather than electro-cautery are used to achieve hemostasis. Finally, care is taken not to inadvertently injure the neurovascular bundles, which course in close proximity, when dissecting out the tips of the seminal vesicles.
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