A novel technique for approaching the endopelvic fascia in retropubic radical prostatectomy, based on an anatomical study of fixed and fresh cadavers
Article first published online: 24 MAR 2005
Volume 95, Issue 6, pages 766–771, April 2005
How to Cite
Takenaka, A., Hara, R., Soga, H., Murakami, G. and Fujisawa, M. (2005), A novel technique for approaching the endopelvic fascia in retropubic radical prostatectomy, based on an anatomical study of fixed and fresh cadavers. BJU International, 95: 766–771. doi: 10.1111/j.1464-410X.2005.05397.x
- Issue published online: 24 MAR 2005
- Article first published online: 24 MAR 2005
- Accepted for publication 29 November 2004
- endopelvic fascia;
- fresh cadaver;
- urinary incontinence
To present the anatomical basis and details of a technique for an approach to the endopelvic fascia devised to preserve urinary continence.
PATIENTS, MATERIALS AND METHODS
For cross-sectional macroscopic observation, seven formalin-fixed specimens of the male pelvic contents including the pelvic wall were serially sectioned at a 5-mm thickness. Semi-serial sections from eight other specimens were examined histologically. Eight fresh cadavers were dissected to mimic the various steps in a retropubic radical prostatectomy. After approaching the endopelvic fascia in an anatomically determined manner to reach the paraprostatic space, the pubic bone was removed and nerves near the rhabdosphincter dissected. To assess the clinical implication of this approach, we examined the time to achieve continence in 23 consecutive patients who had a radical retropubic prostatectomy using the new technique.
Sectional macroscopic observation depicted the fascia of the levator ani as a definite structure adherent to but not fused with the lateral pelvic fascia. The thin fascia overlying the levator ani fascia and lateral pelvic fascia represented the true endopelvic fascia. Microscopically, the lower part of the fascia of the levator ani was rich in smooth muscle, which interdigitated with the framework of the rhabdosphincter. In fresh cadavers, the levator ani muscle was removed laterally still covered by its fascia, without visualizing the muscle fibres. Small branches from the pudendal nerve entered the rhabdosphincter. The mean (sd, range) distance from the lowest point of the endopelvic fascia to the point where the sphincteric branch entered the rhabdosphincter was 5.5 (1.8, 3–8) mm. The continence rate at 1, 3, 6 and 9 months after surgery using the new technique was 44%, 83%, 96% and 100%, respectively.
Preserving the fascia of the levator ani helps to protect the levator ani muscle, rhabdosphincter and pudendal nerve branches to the rhabdosphincter. In retropubic radical prostatectomy, this anatomical approach to the endopelvic fascia should preserve or allow the earlier recovery of urinary continence.