Using 10, male, fresh cadavers, we traced the endopelvic fascia, the fascia of levator ani, puboprostatic ligaments, rhabdosphincter, and puboperinealis muscle to devise strategies in preserving this complex. The modifications were then attempted by a single surgeon (A.K.T.) in 19 patients undergoing robotic prostatectomy during September 2005.

After incision of the endopelvic fascia within the fascial tendinous arch of the pelvis, the puboprostatic collar and the levator ani could be separated laterally. The puboperinealis muscle attached to part of the pubic symphysis behind the puboprostatic ligament and terminated at the perineal body. We were able to preserve the puboprostatic collar in all attempted cases. Furthermore, puboperineoplasty took 5min to complete. The total continence rate was 63.2% at median follow-up of 38.1 d. Immediate continence rate just after catheter removal was 42.1%. The rate at 1 and 4 wk was 52.6% and 71.4%, respectively. The margins of the examined specimens were all negative for malignancy.

This modification should preserve or allow for early recovery of urinary continence from an anatomic perspective. Further studies are necessary to elucidate the clinical impact on a patient's early continence.

Atsushi Takenaka, Ashutosh K. Tewari, Robert A. Leung, Kevin Bigelow, Nasr El-Tabey, Gen Murakami, Masato Fujisawa

Department of Urology, Weill Medical College of Cornell University, New York City, New York, USA
Department of Anatomy, Sapporo Medical University School of Medicine, Sapporo, Japan
Division of Urology, Department of Organ Therapeutics, Kobe University Graduate School of Medicine, Kobe, Japan