Since the landmark 2016 review on surgical anatomy for radical prostatectomy (RP), new insights have emerged regarding the complex periprostatic fascial structures and neural networks crucial to optimizing cancer control while preserving continence and potency. This update distills key anatomical advances from the past decade, emphasizing their impact on surgical technique and functional outcomes.
Key Updates in Periprostatic Anatomy
Fascial Planes
The prostate is encased in multiple fascial layers, including the endopelvic fascia, prostatic fascia, and levator fascia. New evidence supports the role of the anterior fibromuscular stroma and detrusor apron in continence. Preservation of these anterior structures during radical prostatectomy (e.g., “hood” or Retzius-sparing approaches) correlates with earlier continence recovery.
Neurovascular Structures
Advancements in our understanding of the proximal neurovascular plate and its spray-like distribution of autonomic fibers have redefined nerve-sparing techniques. A more nuanced view of the neurovascular bundle reveals additional anterolateral fibers contributing to erectile function, supporting comprehensive nerve preservation strategies, including the 'veil of Aphrodite’ and graded nerve sparing.
Capsule and Seminal Vesicles
Improved dissection planes—particularly posteriorly through Denonvilliers' fascia—allow for tailored nerve-sparing while minimizing positive surgical margins. While seminal vesicle-sparing radical prostatectomy is debated, topographical studies confirm dense sympathetic innervation surrounding the vesicles, though evidence on erectile function preservation remains inconclusive.
Functional Outcomes and Technique Refinements
Continence Preservation
Data reinforce the value of preserving the bladder neck and distal membranous urethra. Studies highlight the importance of urethral length and pelvic diaphragm anatomy, along with individualized dissection near the puboprostatic ligaments and apex.
Hemostasis and Apical Dissection
The dorsal vascular complex is best managed with early or suture-free ligation to reduce blood loss and facilitate cleaner apical dissection. Techniques like the 'open collar' approach improve visualization and margin control.
Nerve-Sparing Grading Systems
Multiple grading schemas (e.g., periprostatic veins or capsular artery landmarks) have been proposed to standardize nerve-sparing. Research supports a risk-adapted approach based on imaging, anatomy, and real-time dissection cues.
Clinical Implications
- Functional Optimization: Techniques that preserve the anterior structures, neural hammock, and distal urethra consistently demonstrate improved continence and potency.
- Oncologic Control: Tailored approaches—incorporating new fascial landmarks and MRI-based nomograms—enable safe nerve-sparing even in intermediate- and selected high-risk disease.
- Surgical Education: High-resolution intraoperative images and 3D animation featured in this article offer powerful tools for teaching and refining anatomical understanding in surgical trainees.
Anatomic mastery remains central to successful radical prostatectomy. This updated review bridges surgical technique with anatomical precision—underscoring that improved oncologic and functional outcomes stem from a deep understanding of fascial planes, neurovascular anatomy, and individualized dissection strategies.
Written by: Asher Mandel,1 Sneha Parekh,1 Manish Choudhary,1 Suichi Morizane,2 Coskun Kacagan,1 Neeraja Tillu,1 Ryutaro Shimizu,2 Adriana Pedraza,1 Thomas Bessede,3 Jochen Walz,4 Ash Tewari1
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Division of Urology, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago, Japan.
- IRCM, Univ Montpellier, Inserm, ICM, Montpellier, France.
- Department of Urology, Institut Paoli-Calmettes Cancer Centre, Marseille, France.