OPEN RETROPUBIC

PROSTATECTOMY
Dr Shankar HS
Ram Dept of
Urology TDMCH
 Goals
• Radical prostatectomy is the only form of
treatment for localized prostate cancer
to reduce progression

• Cancer control, preservation of urinary

control, and preservation of sexual function
Surgical
Anatomy
 Venous Plexus

• The superficial branch, between the

puboprostatic ligaments, lies outside the
anterior prostatic fascia
• communicating branches over the bladder
itself and into the endopelvic fascia.
 Lateral Venous Plexus – Santorini
• Common trunk (above urethra) and lateral
venous plexuses are covered and concealed by
the prostatic and endopelvic fascia

• Communication with pudendal, obturator, and

vesical plexuses – inferior vesical vein - IIV

• Near Puboprostatic ligament small

branches communicate with pelvic side wall
muscle and communicate with internal
 Blood supply

• Inferior vesical artery

• Enter and Division at P/ L V- P Junction -2
• Urethral Branches that supply Bladder neck,
periurethral prostate
• Capsular branches on lateral pelvic fascial P/L
to prostate supply its outer portion .
• Capsular braches –identification landmark for
microscopic pelvic plexus nerves
 Pelvic pexus nerves

• Visecral sympathetic - Hypogastric

• Visceral parasympathetic – S234
• Somatic Motor
 Nerves
• The nerves innervating the prostate travel
outside the capsule of the prostate and
Denonvilliers fascia until they perforate the
capsule where they enter the prostate.

• The branches to the membranous urethra and

corpora cavernosa also travel outside the
prostatic capsule in the lateral pelvic fascia
dorsolaterally between the prostate and
rectum.
 NVB of Walsh

• Cavernous branches join Capsular arteries

• 20 – 30 mm Distal to PV junction
• Spray like distribution
• In Lateral pelvic fascia between prostatic fascia
and levator fascia
• At apex supplies branches of prostate
and striated sphincter –spray
dist wide variation.
• pierce urogenital diaphragm ,pass behind Dorsal
penile artery and nerve and enter cavernosa
 Blood supply –Cavernosa

• Blood supply of Penis Int Pudendal Artery

• Pedendal vessels can arise from
Obturator and inferior Vesical – Aberrant
vessels
• Divided during Radical Prostatectomy
• Compromise Blood supply
• The nerves innervating the prostate travel outside
the capsule of the prostate and
• Denonvilliers fascia until they perforate the
capsule where they enter the prostate.
• The branches to the membranous urethra and
corpora cavernosa also travel outside the
prostatic
• capsule in the lateral pelvic fascia dorsolaterally
between the prostate and rectum
Cavernosal
nerve
 Striated spinchter
• Tubular
• Horse shoe shaped
• Surround membranous urethra and smooth
muscle
• At apex the edges fused in midline
• Slow twich – passive control
• Active control – LA (Levator urethrae ,
Pubourethralis)- Pudendal and somatic motor
nerves in plexus
• Kiegel –Pudendal Nerve - LA + striated
sphincter
 3 prostate fascial covering
• 1.Denonvilliers-
• Cover post surface of prostate & Seminal Vesicle
• dense at base thin at apex .
• Must be excised (A &P in seperable).
• 2.Prostatic fascia (capsule)-
• anterior and lateral in contuinity with prostate
parenchyma.
• Anteriorly lies DVP and
• Santorinis plexus
• 3 .Levator facsia - Laterally fuses with
prostatic fascia forms lateral pelvic
fascia

• NVB lies between Levator fascia and

Prostatic fascia .
• In performing a Nerve sparing surgery
the prostatic fascia (capsule) must remain
on the Prostate
Anterior
Pelvic
Fascia

Latera
l
Pelvic
Fascia
 Superficial branch DVC

Ant Pelvic Fascia Extn

Common trunk /
deep branch DVC
Sphincter Ant layer
Smooth muscle Ant Layer
Urethral mucosa Ant
layer
Lumen with Foley
Urethral mucosa post layer
Smooth muscle Post Layer
Sphincter Post layer
Lateral Pelvic Facsia
NVB

Denonvilliers fascia

Ram S Layers of Apical Dissection in RRP

• Surgery is deferred for 6 to 8 weeks after PNB
and 12 weeks after TURP.
• Helps to preserve NVB and
• Prevents Rectal Injury
 Extraperitoneal
midline
• PLND (Iliac + Obturator) done
before prostatectomy.
• Preserve soft tissue over EIA .
• Inferiorly up to Femoral canal
• Cloquet node not removed
• obturator nerve preserved
• Obturator and Hypogastric
vessels skeletonised
 Frozen section
• If the patient has a well differentiated
to moderately well-differentiated
tumor (Gleason grade < 8) and The
lymph nodes are normal to
palpation, frozen-section analysis is
not performed
Superficial branch
ligated
• Incision in the endopelvic fascia and division
of the puboprostatic ligaments.

• Expose the juncture between the apex of the

prostate and the anterior surface of DVC

• Pubourethral component of the complex is

intact to preserve anterior fixation of the
striated sphincter to the pubis.
• Small arterial and venous branches from the
pudendal vessels are encountered that
perforate the pelvic musculature to supply the
prostate.
• pudendal artery and nerve, which are located
just deep to pelvic muscle as they travel
along the pubic ramus.
• These vessels should be ligated with clips to
avoid coagulation injury to the pudendal
• Large visible accessory pudendal arteries are
present in 4% of men – preserved to prevent
ED.

• Careful dissection avoids bleeding

• Division of the endopelvic fascia lateral to

the vessels and division of the puboprostatic
ligament
• (the vessels are beneath the
LIGATION OF DVC
• The goal is to divide the complex with minimal
blood loss while avoiding damage to the
striated sphincter and inadvertent entry into
the anterior apex of the prostate.
• sponge stick
• figure-of-eight horizontal mattress suture ON
DVC , which is then tied
• Another on anterior surface of the prostate
to reduce bleeding from the proximal dorsal
venous complex.
DIVISION OF URETHRA
s
 DIVISION OF BLADDER NECK
SEPERATION OF SEMINAL VESICLES
 References
• https://www.youtube.com/watch?v=sasFpB
lv xLg
• RRP as performed by Patrick Walsh
• Campbell 11 edition