The periprostatic fascia has two layers: the outer layer, called levator fascia, and an inner layer, called prostatic fascia. The neurovascular bundles run between these two layers (Fig. 38.5). At this point they are in proximity with the Denonvillier's fascia. If nerve-sparing is to be undertaken, the two layers of
the periprostatic fascia should be separated and the obturator fascia detached until a subtle groove appears at the lateral aspect of the prostate, indicating the border of the bundles. The bundles can thus be detached from the prostate. The assistant grasps the left seminal vesicle and retracts towards the right, putting the left prostatic pedicle on stretch. Once the pedicle has been divided in contact with the prostate, the surgeon incises the periprostatic fascia and extends this incision to the apex. The neurovascular bundle is identified and allowed to fall laterally from the prostate by clipping and dividing the small branches leading to the prostate as they are encountered. The right side pedicle and proximal neurovascular bundle preservation are performed in a similar fashion.
During this maneuver, care should be taken not to overstretch the nerves; an elongation of 10% can lead to nerve damage. Again, we use hemoclips before sectioning the vascular branches running towards the prostate. The separation of the bundles is complete when the perirectal fatty tissue appears medially.
Then, the urethra is divided anteriorly and the catheter withdrawn until the posterior urethral mucosa is seen, which is then sharply divided. The assistant, grasping the proximal prostate stitch, retracts the prostate to each side in an exaggerated manner, allowing the suction tip to be positioned under the rectourethralis and above the rectum, which permits the surgeon to complete the prostatectomy (Figs 38.7 and 38.8). A watertight endocatch is introduced and the prostate placed within. The specimen sac is placed in the upper abdomen.
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