A review of surgical techniques for radical prostatectomy

Abstract

Since the early 20th century, radical prostatectomy has been used in the treatment of prostate cancer. However, before the widespread acceptance of prostate-specific antigen screening, the majority of cancers were clinically advanced and not amenable to cure, so relatively few men were candidates for this procedure. Modern advances have contributed dramatically to the reduction of complications and morbidity associated with radical prostatectomy. As a result, the procedure has become the most common treatment selected by men with localized prostate cancer. This article reviews several issues regarding radical prostatectomy, including surgical techniques, cancer control, intraoperative localization of the cavernous nerves, patient selection, and laparoscopic versus robotic approaches.

Figure 1

Cross-section of an adult prostate demonstrating the anatomic relationships between the lateral pelvic fascia, Denonvilliers’ fascia, and the neurovascular bundle. From Walsh PC et al. © 1983 Alan R. Liss, Inc. Reprinted with permission of Wiley-Liss, Inc., a subsidiary of John Wiley & Sons, Inc.

Figure 2

New York University nerve-sparing algorithm based on Gleason score, percent tumor volume, and evidence of perineural invasion (PNI) in biopsy specimens. The algorithm for decision regarding wide excision versus preservation of the neurovascular bundles (NVB) is presented. Reprinted with permission from Shah O et al.

Figure 3

Representative tissue section showing location of neurovascular bundle in relationship to midportion of prostate. Reprinted with permission from Lepor H et al.

Figure 4

Anatomic reconstruction of prostate, ejaculatory ducts, pelvic sidewall fascia, bladder, urethra, rectum, and neurovascular structures. Reprinted with permission from Lepor H et al.