A comprehensive review of neuroanatomy of the prostate

Abstract

Although oncologic efficacy is the primary goal of radical prostatectomy, preserving potency and continence is also important, given the indolent clinical course of most prostate cancers. In order to preserve and recover postoperative potency and continence after radical prostatectomy, a detailed understanding of the pelvic anatomy is necessary to recognize the optimal nerve-sparing plane and to minimize injury to the neurovascular bundles. Therefore, we reviewed the most recent findings from neuroanatomic studies of the prostate and adjacent tissues, some of which are contrary to the established consensus on pelvic anatomy. We also described the functional outcomes of radical prostatectomies following improved anatomical understanding and development of surgical techniques for preserving the neurovascular bundles.

Keywords: Fascial anatomy; Neurovascular bundle; Penile erection; Prostatic neoplasms; Urinary incontinence.

Fig. 1.

Posterior view of the neurovascular bundle and prostate. The entire posterior surface of the prostate is covered by nerve fibers with fewer fibers at the 6-o’clock position. Reproduced from Costello et al. BJU Int 2004;94:1071-6, with permission of Wiley-Blackwell [9].

Fig. 2.

Fresh cadaver dissections to identify neurovascular bundle (NVB) (left lateral view). Caudal branches (arrows) of pelvic splanchnic nerve (PSN) appeared to join NVB at levels inferior to bladder-prostate junction (asterisks). BL, bladder; DPN, dorsal penile nerves; PP, pelvic plexus; PR, prostate; R, PSN rectal branches. Reproduced from Takenaka et al. J Urol 2004;172:1032–5, with permission of Elsevier B.V. [6].

Fig. 3.

(A) Neurovascular bundle (NVB) localized to the postero-lateral aspect of the prostate (S-100 stain). (B) NVB in the formation are relatively more spread to the anterior side of the prostate (S-100 stain). Reproduced from Lee et al. Urology 2008;72: 878–81, with permission of Elsevier B.V. [16].

Fig. 4.

Schematic of prostate and periprostatic fascias at mid-prostate with three different dissection planes demonstrated (intrafascial, interfascial, and extrafascial). VEF ant.-lat., visceral endopelvic fascia anterior-lateral; PEF, parietal endopelvic fascia; C, capsule of prostate; LAF post.-lat., levator ani fascia posterior-lateral; PF, prostatic fascia. Reproduced from Walz et al. Eur Urol 2010;57:179–92, with permission of Elsevier B.V. [43].