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prostatic fascia, which travels around the prostate (some people call it the prostatic capsule or the prostatic fascia, it is the same structure) and the levator fascia. Figure 4
T.S.: Since the first description of a nerve-sparing technique, many technical modifications have been described, like the introduction of the fascial planes and the high release of the levator fascia and intussusception of the bladder neck. Do you believe that all these modifications
really have an impact on optimizing post- prostatectomy continence and potency rates?
P.W.: Beginning with the first patient, I developed a database that included cancer control, modifications in surgical technique, and quality of life information. I ended up operating on 4,569 men, using this database, and I made 28 major changes over 29 years, which I documented. (6) One of my major concerns was delay in recovery of continence. At three months, only half of my patients were dry. I attempted a number of different procedures to try to improve it. And finally, when I developed the technique for intussusception of the bladder neck, instantly 80% of patients at three months were not wearing a pad versus 50%. (7) Figure 6
Figure 6
Moreover, when I asked patients if they had encountered any significant problems, 94% of them answered that they had not. So, it was a dramatic improvement in urinary control. Considering all the things that people are now doing down at the apex of the prostate, trying to preserve fascia, where margins are so critical, I worry about cancer control. Dr. Mohamad Allaf, the current chairman at the Brady and a brilliant surgeon, is doing intussusception with his robotic cases with wonderful results. The second thing was high anterior release of the levator fascia. (8) Normally, the levator fascia was released posteriorly near the neurovascular bundles. But using that approach, neurovascular bundles had to be stretched by pushing them away from the prostate in
Walsh PC, Lepor H, Eggleston JC. Radical prostatectomy with preservation of sexual function: anatomical and pathological considerations. Prostate. 1983;4(5):473-85.
Lateral Pelvic Fascia
Figure 4
The neurovascular bundle is in between the two. In performing a nerve-sparing operation you are outside the levator fascia, until you get close to the prostate, where you preserve the bundles. In an operation where there is extensive disease, you are outside the levator fascia and you excise the neurovascular bundle. So, the operation involves preservation of the nerves where possible, wide excision where necessary. Figure 5
Perfecting the Technique: Sequential Modifications of Radical Prostatectomy 1982 -
• October 2000 #2801: Bladder neck intussusception:
Wide excision of the neurovascular bundle Lowe J Urol. 1987;138:823-7.
Figure 5
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The levator fascia was never excised before. Previously, the prostate was pulled back and the neurovascular bundles were torn from the prostate and left in place (they were never excised), and later cut when the pedicle was ligated. So, not only was this operation a better quality of life operation, but it was also a better cancer operation! (5)
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