Robotic Radical Prostatectomy. Anatomic Considerations

1. Robotic Radical Prostatectomy. Anatomic Considerations XIV Workshop of Oncologic Urology. J.Edson Pontes M.D. WSU/KCI

2. Background • With improved visualization in LRARP several papers have been published showing potential improvement in nerve sparing and urethral sphincter preservation. • This has led to revision of known established anatomical principles. • Do these “new” anatomical observations improve outcomes?

3. Neuroanatomy of penile erection. • Pelvic splanchic (parasympathetic) S2-S4 • Hypogastric nerves (sympathetic) T10-L2 • The nerves supplying the corpora cavernosa arise from the lower part of the prostatic plexus. • Lue, T. et al. J.Urol. 131:273 1984

4. “ After leaving the pelvic plexus, nerves travel along the lateral aspects of the rectum, posterolateral to the S.V. toward the apex of the prostate. At the proximal prostatic urethra, the nerves are quite distant from the capsule”Lue, T. et al. J. Urol.131:273, 1984

5. “ After leaving the pelvic plexus, nerves travel along the lateral aspects of the rectum, posterolateral to the S.V. toward the apex of the prostate. At the proximal prostatic urethra, the nerves are quite distant from the capsule”Lue, T. et al. J. Urol.131:273, 1984

6. Distally, the cavernous nerves begin to approach the prostate and at the apex they are only few mm from the capsule, at the 5 and 7 o’clock position.Lue, T. et al. J.Uro. 131:273 1984

13. Radical prostatectomy and cystectomy with preservation of potency • 64 patients underwent radical prostatectomy and 11 radical cystectomy. • Sexual function was preserved in 84% of prostatectomy and in 82% of cystectomy patients. • Walsh and Mostwin Brit.J.Urol. 56:694

16. Radical Prostatectomy.Implications of nerve preservation • Cholinergic innervation and muscarinic receptors in the human prostate. Lambertus et.al Eur.Urol. 54:326 • Nerve distribution along the prostatic capsule. Eichelberg et.al Eur. Urol.51:105 • The prostatic autonomic nerves- Bundle or layer? Sievert et.al Eur.Urol.54:1109

17. Role of extent of fascia preservation and erectile function after RLAP • A scoring system for the extent of circunferencial FP is a stronger predictor for erectile function than laterality or fascial depth. • More ventral FP significantly contributed to postop erectile recovery. • H.G Van der Poel and Blok Urol.73:816

18. Current Technique of open Intrafascial Nerve sparing retropubic prostatectomy • Erections sufficient for intercourse were reported in 84-92% and in 58-70% after bilateral and unilateral nerve sparing respectively. • Lars Budaus et.al Eur.Urol.56:317 2009

20. Implications of Nerve preservation • Nerves exist in the lateral and anterior areas of the prostate. • What is their function in relation to prostatic innervation vs.the corpora cavernosum? • Is the preservation of the layer “more efficient” in preserving potency because of less trauma to the NV bundle? • What are the implications on iatrogenic positive margins?

21. Conclusions • Improved visualization, with increase knowledge of anatomy, may lead to better outcomes. • Caution should be utilized, when attempts of preserving sexual function could compromise cancer control.