Synthesis

The past decade has seen the incorporation of radical prostatectomy into the therapeutic arsenal of most urologists. It is performed in a region of anatomic constraints, yet the careful delineation of anatomic relationships and morphologic variability allows surgeons the ability to optimize outcomes with regard to cancer control, maintenance of urinary continence and restoration of sexual function. Recent reviews emphasize certain anatomic observations that aid in the execution of this procedure:7,19,33

• Multiple micropedicles connect the neurovascular bundles along the lateral portion of the prostate. These can be significant near the urethra and must be dealt with carefully along the entire length of the prostate to avoid attrition of nerve fibers.

• The prostate is covered by a detrusor apron, which should not be bunched or divided beyond the prostate-urethral junction.

• The puboprostatic ligaments, in reality, are pubovesical ligaments that at some point need to be divided.

• The urethra is sphincteric from the verumontanum to the penile bulb. It is the principal source of continence post-prostatectomy, thus preservation of the urethra and associated structures is of paramount importance.

• In this regard, all attempts are made to preserve the circumferential musculature of the rhabdosphincter and the fascial support structures are left intact as much as possible (puboprostatic ligaments superiorly and median fibrous raphe posteriorly). This is accomplished by not passing clamps through or exerting traction on these structures during division.

• The dual innervation of the urethral sphincter is also best preserved by avoiding the intrapelvic branch of the pudendal nerve and awareness of the 5 and 7 o'clock entry of the somatic and autonomic innervation of the external sphincter. Awareness of anatomic variation and attention to detail can optimize this procedure for cancer control, and minimize potential long-term morbidity.

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