The Value of Fascial Sparing in Radical Prostatectomy

Prostate removal via open, laparoscopic or robotic surgical techniques has been a treatment of choice for patients with prostate cancer. Historically, patients have been keen to inquire about "nerve-sparing" procedures for prostatectomy with a goal of reducing erectile dysfunction or urinary incontinence, two common unwanted side effects of prostate surgery. Research published in Prostate International journal proposes that exquisite knowledge of fascial anatomy is a key to minimizing negative impact from surgery caused by damage to the prostatic neurovascular bundles. The authors in this paper point out that anatomical controversy exists in the literature and that the anatomy is still being investigated, increasing the surgical challenge for those physicians who aim to identify the structures.

The pelvic organs are covered by pelvic, also called endopelvic, fascia, that is commonly divided into two layers: that which covers the viscera (wrapping around each organ structure and the parietal component which covers the medial levator ani, obturator internus, and piriformis. Access to the prostate gland is gained by an anterolateral incision through the endopelvic fascia at the fusion of the visceral and parietal fascia, according to the article. Layers of prostatic fascia and the endopelvic fascia attach laterally at the tendinous arch of the pelvic fascia, and these structures attach to the puboprostatic ligaments. The puboprostatic ligaments anchor the prostate to the pubic bone, creating an important aspect of continence through fascial tension and support.

While nerve-sparing techniques have focused on preserving pelvic plexus autonomic nerve fibers, the authors argue that there is not a definite anatomy of the periprostatic nerve fibers, possibly contributing to the variability in surgical outcomes reporting for nerve-sparing procedures. Various approaches have been detailed in the literature, and are described in this article, with emphasis on dissection plane and intra- and interfascial techniques utilized.

This is a full access article with images and details beyond what most pelvic rehabilitation providers need. What is of great interest across professions is the recognized need for acute anatomical knowledge with application of skilled techniques with such anatomy in mind. The authors conclude that "…the relation of the periprostatic fascial layers on the anterior, lateral, and posterior sides of the prostate should be of great interest. A better understanding of the relation between nerve fibers and pelvic fascial layers is crucial…" Most of us were never introduced to detailed pelvic anatomy, male or female, in school. To learn more about male pelvic anatomy, you can attend either the pelvic floor series course that introduces male pelvic health, called PF2A, offered in October in St. Louis- this is the only PF2A with open seats this year. You can also attend the Male Course, offered again this year in October in Tampa.