European European Urology 43 (2003) 444–454

Urology

An Operative and Anatomic Study to Help in Nerve Sparing

during Laparoscopic and Robotic Radical Prostatectomy
Ashutosh Tewaria,*, James O. Peabodya, Melissa Fischera, Richard Sarlea, Guy Vallancienb,
V. Delmasc, Mazen Hassana, Aditya Bansala, Ashok K. Hemala,
Bertrand Guillonneaub, Mani Menona
a
Vattikuti Urology Institute, Henry Ford Health System, 2F One Ford Place, Detroit, MI 48202, USA
b
L’Institut Mutualiste Montsouris, University Pierre & Marie Curie, Paris, France
c
UFR d’Anatomie, University Pierre & Marie Curie, Paris, France
Accepted 13 February 2003

Abstract
Objective: To provide a detailed description of the steps involved in a laparoscopic radical prostatectomy in relation
to the complex neurovascular anatomy of the male pelvis.
Aim and hypothesis: We aimed at delineating the neurovascular anatomy to assist in nerve preservation during
laparoscopic and robotic radical prostatectomies.
Methods: A team of urologists and an anatomist performed anatomic dissections of 12 male cadavers using a
combination of laparoscopic equipment, magnification, and open surgical dissection. Each step involved in laparo-
scopic prostatectomy was reviewed in relation to the possible impact the step could have on the neurovascular bundles.
Results: Dissections were performed systematically to mimic various steps of laparoscopic and robotic prosta-
tectomy. The neurovascular bundles were identified and correlated with video images of actual surgery. This enabled
us to construct computer simulations and show the actual nerves on the operative pictures. We specially unraveled
the relationship between neurovascular bundles and lateral pelvic and Denonvillier’s fascias, both of which enclose
and hide these important structures. The course of the bundles was traced from its origin at pelvic plexus to its distal
course along the urethra.
We also showed the important relationship between pelvic plexus ganglions and seminal vesicles to illustrate the
vulnerability of these nerves to thermal, electrical and/or crush injury during seminal vesicle and prostatic pedicle
dissections. The importance of additional fine neural plexus along the posterior and antero-lateral surface of the
prostate was shown by both gross anatomical and microscopic images. The distal precarious location of the bundles
was illustrated by dissections showing anteriorly lifted prostate.
These anatomico-operative correlations have not been published for laparoscopic and robotic prostatectomies,
which differ significantly in its visual angles, magnifications and sometimes three-dimensional (3D) visualization
from its open counter part.
Conclusion: Laparoscopic and robotic radical prostatectomy provides exposure and visualization of male pelvis not
previously appreciated. It is only through a careful reexamination of the anatomy of the male pelvis, in the context of
this new procedure, that the improvements in visualization and exposure benefit the surgeon. Our work provides a
detailed map relating to operative steps to aid the surgeon in the performance of a nerve sparing robotic and
laparoscopic radical prostatectomy.
# 2003 Elsevier Science B.V. All rights reserved.

Keywords: Prostate cancer; Robotics; Laparoscopic prostatectomy; Anatomic nerve sparing radical prostatect-
omy; Nerve sparing

*
Corresponding author. Tel. þ1-313-874-6722; Fax: þ1-313-874-6656.
E-mail address: atiwari@hfhs.org (A. Tewari).

0302-2838/03/$ – see front matter # 2003 Elsevier Science B.V. All rights reserved.
doi:10.1016/S0302-2838(03)00093-9
 A. Tewari et al. / European Urology 43 (2003) 444–454
1. Introduction
More than 170,000 men in the United States were
diagnosed with prostate cancer in 2002. The goal of
effective cancer screening is to identify patients with
more localized, and thus more potentially curable
disease. Radical retropubic prostatectomy offers an
effective cure [1–4], but can be associated with post-
operative morbidities, including erectile dysfunction
and incontinence [5–7]. Sexual function can often be
maintained by nerve sparing with the anatomic pros-
tatectomy developed by Walsh [8–10] and others [11–
15]. However, the results regarding potency preserva-
tion published in the literature by many centers are not
satisfactory [5–7].
Many factors influence postoperative potency,
including preoperative erectile function, patient age,
extent of disease, experience of the surgeon, and
anatomic variation. Identifying and sparing the neu-
rovascular bundle (NVB) on one or both sides is
crucial in maintaining erectile function. Several excel-
lent monographs, textbooks, and artist drawn figures
explaining the detailed course of the neurovascular
bundles are available based on the initial anatomical
dissections [8–10,16,17]. In recent years some centers
are attempting nerve sparing anatomic prostatectomy
using conventional and robotic-assisted laparoscopic
approaches [18–33]. The surgical steps for these
Fig. 1. Overview of neuroanatomy of pelvic, vesical and prostatic plexus.
445
minimally invasive approaches differ significantly
from the conventional radical prostatectomy for which
most existing anatomical descriptions have been done.
Both laparoscopic and robotic approaches differ from
open prostatectomy in terms of visualization, magni-
fication, and most importantly, procedure steps.
Laparoscopic and robotic prostatectomies are per-
formed in an antegrade manner, while conventional
radical retropubic prostatectomy is often performed in
a retrograde manner (i.e. transection of the urethra
prior to bladder neck disconnection from prostate).
A detailed anatomical map of the neurovascular
bundles from the laparoscopic perspective is currently
lacking. While artist drawn figures are adequate for the
open surgery which benefits from both vision and
tactile sense, they are not as useful during laparoscopic
and robotic procedures because (a) they were not
drawn with laparoscopic approach in mind and (b)
the magnification and three-dimensional (3D) stereo-
scopic vision of robotic cameras actually require see-
ing these important structures through the lenses rather
than surgical loupes or naked eye.
Therefore we undertook this anatomical study (with
the help of an anatomist) to unravel the course of
neurovascular bundles and superimposed the images
on the intra-operative captures. Our goal was to develop
a clear map to assist in the performance of nerve sparing
laparoscopic or robotic radical prostatectomy, with good
446 A. Tewari et al. / European Urology 43 (2003) 444–454

Fig. 2. (A) Anatomic dissection showing exact course of neurovascular bundles, pelvic plexus and its relation with seminal vesicles and prostate. The
neurovascular bundle is clearly visible once the periprostatic fascia is removed. (B) Anatomic dissection from the posterior view (looking through pouch of Douglas)
showing location of the seminal vesicles, pelvic plexus and rectum. (C) Intra-operative picture showing location of the ganglions in relation to the seminal vesicles.
 A. Tewari et al. / European Urology 43 (2003) 444–454
anatomical landmarks adapted for this new surgical
approach.
2. Materials and methods
The data for this analysis was acquired by anatomic study of 12
fresh male cadavers of more than 50 years of age. The dissections
were performed using laparoscopic camera, light source, video
monitor and hand equipments (CIRCON ACMITM Corporation).
Later the courses of the nerves were further traced by open
dissection using 2.5 surgical loops and an operating microscope.
The nerve tissue was finally confirmed by histopathological studies.
The dissection was planned to mimic actual surgical procedure.
The technique of antegrade laparoscopic and robotic nerve sparing
has been described in Section 3 [23,24,32,33]. This differs sig-
nificantly from classical open nerve sparing during which the
lateral pelvic fascia is incised and bundles are dropped before
actual urethral transection [34]. Some surgeons have also per-
formed antegrade nerve sparing much like laparoscopic and robotic
prostatectomies [35]. The detailed review of open nerve sparing is
beyond the scope of this article and reader is referred to several
excellent texts.
2.1. Pelvic neurovascular anatomy
An artist drawn schematic picture of the origin and course of the
neurovascular bundles is illustrated in Fig. 1. Additional anatomic,
microscopic and intra-operative pictures supplement these figures
(Figs. 2–8). Anatomically, the spinal nuclei involved in the control
of erectile function are located at the S2 to S4 level. These axons
travel ventrally to join the axons of the nuclei for the bladder and
rectum to form the sacral visceral efferent fibers. These fibers join
the sympathetic fibers to form the pelvic plexus, an extension of
inferior hypogastric plexus. The pelvic plexus lies on the antero-
lateral wall of the rectum. Each ganglion contains approximately 20
nerve cell bodies. The superior part of the aggregate of the nerve
cells is called the vesical plexus. The inferior part of the pelvic
plexus is the prostatic plexus. The NVB arises from the prostatic
Fig. 3. Oblique view: left side of apex showing delicate and veiled nature of the neurovascular bundles, nerve plexus and cross-communications (white arrows).
447
plexus, which is enclosed between the two layers of periprostatic
fascia. The prostatic plexus and the NVB is about 1.5 mm postero-
lateral to the prostate at the base and about 3 mm at the apex.
The anatomic relationships between the prostate, bladder, semi-
nal vesicles, rectum, pubo-prostatic ligaments, symphysis pubis,
venous plexus, prostatic apex, urethral sphincter, ureters, regional
vasculature and nerves were carefully dissected and recorded on
digital video (DV) for future evaluation. We also recorded the
actual surgical procedure using either Stryker Endoscopes three-
chip camera (Stryker Endoscopes1, Santa Clara, CA, USA) or da
Vinci stereoscopic camera attached to a Sony1 Digital camcorder
(Sony DCR-VX2000 Digital Video Handycam1 Camcorder, New
York, NY, USA). This equipment allowed for digital video record-
ing at a 530 lines horizontal resolution and 12 optical/48 digital
zoom video capture. The images were processed on a Pentium III1
700 MHz, Dell Computer Corporation computer with 500MB
RAM, 32MB video RAM and 200GB Hard Drive. Computer
simulations were done using anatomic images and volume render-
ing modeling algorithms to serve as intra-operative guide to assist
in nerve sparing.
3. Results
The relationship between various anatomic struc-
tures is described herein.
3.1. Pelvic and prostatic plexus
As seen in Figs. 1 and 2, the pelvic plexus is a
retroperitoneal structure located on the lateral wall of
the rectum. The mid-point of the plexus corresponds
approximately to the tip of the seminal vesicle. The
cavernous branches travel anteriorly on the surface of
the rectum. As seen in Fig. 3, lying on the surface of
rectum we noted cross-connections between branches
of pelvic plexus of two sides (Figs. 3 and 8). These
448 A. Tewari et al. / European Urology 43 (2003) 444–454

communications run within the fascial layer and their
physiologic significance has not been studied.
3.2. Relationship with the seminal vesicles
At the side of seminal vesicles the cavernous
branches coalesce to form a more compact (approxi-
mately 4–6 mm) bundle and travel anteriorly in a
groove between rectum and prostate (Figs. 2A–C
and 3). Fig. 2B and C delineates the relationship
between the pelvic plexus and seminal vesicles as
approached from the pouch of Douglas. The poster-
ior face of the seminal vesicle is never vascularized

Fig. 4. Anatomic dissections showing the lateral pelvic fascia from various angles: (A) lateral surface of the prostate showing small and large nerves (black
arrows); (B) undersurface of the prostate showing Denonvillier’s fascia and nerves.
 A. Tewari et al. / European Urology 43 (2003) 444–454 449

Fig. 5. Microscopic images of the nerves in the lateral pelvic fascia (brown structures) (note the small nerves posterior and antero-lateral to the prostate): (A)
low magnification; (B) medium magnification; (C) high magnification.

and the plane between the posterior layer of the
Denonvillier’s fascia and the seminal vesicle could
be easily developed. Vessels are approaching the
seminal vesicle laterally, and there is often one artery
that travels on the anterior surface of the seminal
vesicle between the superficial layers of the Denon-
villier’s fascia.
3.2.1. Technical points
These nerves and ganglions are likely to get injured
during dissection of seminal vesicles and control of
prostatic pedicles. The key is to get to the surface of
seminal vesicles and avoid dissecting outer layers.
Furthermore, sharp dissection rather than coagulation
should be used in this area.
450 A. Tewari et al. / European Urology 43 (2003) 444–454

Fig. 6. Computer enhanced intra-operative relationship between the lateral pelvic fascia, Denonvillier’s fascia, and prostate and neurovascular bundles:
(A) triangle of lateral pelvic fascia, prostate and Denonvillier’s sheet and their relationship with nerves; (B) relationship between pelvic plexus and
neurovascular bundles to the left prostatic pedicle.

3.3. Neurovascular bundle
3.3.1. Description
The classical description of the neurovascular
bundles states that there is one main nerve on either
side of the prostate, which is enclosed in fascial
sheaths and is accompanied with prostatic vessels.
We noted that in addition to these main bundles, there
are several smaller nerves, which ramify in the
prostatic and Denonvillier’s fascia (Fig. 5). The exact
physiologic role of these smaller nerves in the erec-
tion is not well defined but they do exist and may
contribute to the neural impulses to the cavernous
tissue.
3.3.2. Periprostatic fascia
As seen in Figs. 4–6, the neurovascular bundles are
enclosed within the layers of the periprostatic fascia.
This fascia has two flimsy layers, which splits poster-
iorly to enclose the neurovascular bundle. These layers
of periprostatic fascia fuses with the anterior layer of
 A. Tewari et al. / European Urology 43 (2003) 444–454
Fig. 7. Anatomic view of nerves and prostate at the apex. (Note how close
to the urethra bundles come at the apex.)
Denonvillier’s fascia lateral to the prostate in a man-
ner to enclose a potentially triangular space contain-
ing the neurovascular bundles. The inner layer of
periprostatic fascia (also called as the prostatic fas-
cia) forms the medial vertical wall of this triangle; the
outer layer of periprostatic fascia (also called as
lateral pelvic fascia) forms the lateral wall, and the
Fig. 8. Final view showing computer enhanced location of the neurovascular bundles following radical prostatectomy.
451
posterior wall of this triangle is formed by the ante-
rior layer of the Denonvillier’s fascia. The medial
wall of the triangle (prostatic fascia) is intimately
attached to the prostatic capsule (Fig. 6A). This
triangular space is wide near the base of the prostate
and becomes narrower near the apex. The neurovas-
cular bundle is located in this triangular space, cov-
ered by superficial layers of Denonvillier’s fascia,
that fuse with the posterior limits of levator fascia.
Along the course of the bundles, micropedicles (tiny
arteries, veins, and nerves) are found that supply, in
no consistent pattern, the adjacent prostate capsule
and tether the bundles to the postero-lateral surface of
the prostate (see Fig. 4).
3.3.3. Technical points
In order to perform nerve sparing, operator needs to
reflect the lateral pelvic fascia off the prostate. Meti-
culously controlling the prostatic pedicle proximally
and entering the triangular space between lateral pelvic
fascia, Denonvillier’s fascia and prostate best preserves
the nerves. Incising the lateral pelvic and Denonvil-
lier’s fascia the triangular space is entered. A fatty layer
is seen which is a hallmark of proper plane of dissec-
tion. In order to improve the nerve preservation,
attempt should be made to leave maximum amount
of surrounding fascial tissues.
3.4. Apical course
Near the apex of the prostate, the neurovascular
bundles are covered with fascial layers and are approxi-
mately 3 mm away and occupy 5 and 7 o’clock position
around the urethra (Figs. 7 and 8).
452 A. Tewari et al. / European Urology 43 (2003) 444–454
3.4.1. Technical points
The neurovascular bundles are at risk during urethral
trsansection and anastomosis. This risk can be mini-
mized by visual appreciation of the nerves in a blood-
less field and avoidance of electro-cautery in the
vicinity of the nerves. Inadvertent suture bites should
be avoided by exercising caution near the nerves and
placing the sutures under vision.
3.5. Relationship to the rectum
The course of the NVB is fairly consistent, despite
variations in prostate size. The NVBs form the sides of
an isosceles triangle (Figs. 7 and 8) with the bladder at
the base and the urethra at the apex. The triangle is
essentially the same size and configuration no matter
what size prostate is lifted away from the bundles. The
cross-communicating fibers are located underneath the
fascia, on the surface of rectum, and form a fine
meshwork of neural fibers communicating bilaterally.
3.5.1. Technical points
Dissection in the proper plane and keeping the
operative field dry will both help in avoiding inad-
vertent injury to rectum during posterior dissection.
4. Comments
Our study was undertaken to create a map of the
NVB, with the goal to improve urologists’ understand-
ing of pelvic anatomy from the new vantage point
provided by the laparoscopic approach. Based on our
dissection, the location of the pelvic plexus, course of
the NVB and its relationship with seminal vesicle,
lateral prostatic fascia and prostate were clearly identi-
fied. Keeping these relationships in mind, our discussion
will now focus on the specific steps of a laparoscopic
prostatectomy.
Most centers performing laparoscopic radical pros-
tatectomy begin the procedure by dissecting the semi-
nal vesicles through the cul-de-sac between the bladder
and rectum [21,24,28,36,37] or by mobilizing the
bladder [21,30–33,38,39]. The remaining steps are
more or less similar and include development of the
space of Rietzius, exposure of prostatic apex and
endopelvic fascia, control of dorsal venous plexus,
transection of the bladder neck, dissection of seminal
vesicles, lateral pedicle control, nerve sparing, apical
dissection, incision of dorsal venous complex and
urethra and finally urethro-vesical anastomosis.
The pelvic, vesical, and prostatic plexuses are at risk
of transection, clipping or coagulation injury during
posterior dissection through the recto-vesical cul-de-
sac. As seen in Figs. 1, 2 and 4, the bulk of the pelvic
plexus and its important branches are located lateral
and posterior to the seminal vesicles. Therefore the
seminal vesicles should be used as an intra-operative
landmark to avoid injury to the pelvic plexus when
ligating the posterior pedicle. The proponents of retro-
vesical dissection [21,24,28,36,37] suggest that since
the NVBs are very close to the tip of the seminal
vesicle, the initial dissection behind the bladder leaves
a bloodless field, which makes the neurovascular dis-
section easier and more accurate. However, even dur-
ing the extraperitoneal prostatectomy, neural injury can
be avoided by precise dissection and control of the
individual vessels close to the seminal vesicles [31,32].
Next several steps, such as bladder mobilization,
exposure of pubo-prostatic ligaments, control of dorsal
venous plexus and transection of anterior bladder neck
are relatively safe from the nerve sparing perspective. It
is important to note that the control of the Santorini
plexus indirectly helps in satisfactory nerve sparing by
ensuring bloodless field and good visualization of the
anatomical landmarks.
Caution is needed following incision of the posterior
bladder neck. The pelvic plexus is located laterally, and
too zealous a dissection in this direction may place few
pelvic, vesical or prostatic plexus fibers at risk. The vas
and seminal vesicles are next dissected and require
sharp incision of the superficial layer of Denonvillier’s
fascia. The tip of the seminal vesicles often is tethered
postero-laterally due to the vessels supplying the vesi-
cles and the vas. Traction on the seminal vesicles
during this dissection may tent the branches of pelvic
plexus medially. Therefore these vessels should be
controlled on the surface of seminal vesicles. As
mentioned before, the key to successful nerve sparing
requires meticulous dissection, clear visualization,
control of individual vessels on the surface of the
seminal vesicles and avoiding electro-cautery laterally.
The control of lateral pedicles also is a precarious step,
because the pelvic plexus lies postero-laterally. Staying
close to the prostatic surface avoids injury to these
nerves. At this stage some surgeons incise the levator
fascia above the neurovascular bundles and enter the
triangular space. Since the triangular space containing
the neurovascular bundles is more prominent at the
prostatic base rather than the apex, the antegrade
approach can easily develop plane of dissection within
the triangle leaving the medial fascia attached to the
prostate. This dissection may not be easy in retrograde
approaches of laparoscopic prostatectomy, as the trian-
gle is not so well developed at the apex [39,40]. The
neurovascular bundle is then reflected laterally and
incision is completed through the facial layers to leave
 A. Tewari et al. / European Urology 43 (2003) 444–454 453

the most of Denonvillier’s fascia on the posterior surface
of the prostate while leaving the minimal, lateral most
fibers of the Denonvillier’s fascia around the neurovas-
cular bundles. Others make initial cut in the Denonvil-
lier’s fascia parallel to the neurovascular bundles and
thus enter the triangular space medial to the bundles. The
incision of the levator fascia is next performed to reflect
the neurovascular bundles laterally. In the patients in
whom pedicle is long and mobile, the posterior incision
first is a good option, but sometime, when the postero-
lateral pedicle is tight, we have no access to Denonvil-
lier’s fascia, and thus the incision of the periprostatic
fascia is more reasonable.
Once the correct plane is entered, the majority of the
dissection occurs in a relatively avascular plane. Some-
times there are two to three micropedicles entering the
capsule of the prostate medially [8,41–43]. They
require sharp transection and hence bleed minimally.
We avoid any clipping or use of electro-cautery
because the bleeding is often self-limiting.
Sometimes, one could find a small lateral pedicle
coming from the NVB and penetrating the prostate close
to its apex. This pedicle should be controlled, with clip or
accurate coagulation, far from the bundle [41–43].
The next stage of the procedure involves the apical
dissection, where the NVB lies more laterally and are
at risk for damage during both the urethral transection
and anastomosis. Keeping the NVBs in view at all
times and keeping the field dry can avoid these pitfalls.
The use of a magnified view through the laparoscopic
camera or enhanced 3D visualization dramatically
improves the identification of various anatomic struc-
tures. When performed properly, the laparscopic pro-
cedure allows the surgeon to appreciate the pulsation of
the arterial components of the bundle. Again, the
improvements in visualization provided by both the
magnification and a bloodless field, cannot be under-
emphasized. At the end of a successful nerve sparing
prostatectomy, if the field is dry, we can often see
pulsations of the vessels in the NVB and may use this
finding as a surrogate for the integrity of the nerves.
It is our hope that the anatomic details provided here
will assist surgeons in recognizing and thus sparing the
neurovascular bundles.
5. Conclusion
Laparoscopic and robotic prostatectomies provide a
view of the male pelvis not previously appreciated in
open surgery. Vantage point, magnification, three-
dimensional imaging, and improved hemostasis are
all factors responsible for the better visualization
encountered in laparoscopic and robotic prostatec-
tomies. While logic dictates that a superior view should
translate into the ability to perform a more meticulous
dissection, unless surgeons are familiar with the new
perspective provided by laparoscopic and robotic optics,
outcome improvements will fail to occur. By providing a
step-by-step, anatomic outline of pelvic anatomy from
the laparoscopic perspective, we hope to shorten the
learning curve, and assist surgeons undertaking the

Table 1
Critical maneuvers in nerve sparing

Step of operation Neurovascular structure at risk Critical maneuvers

Retrovesical dissection
Anterior dissection
Control of dorsal venous complex
Anterior bladder neck transection
Posterior bladder neck transection
Seminal vesicle dissection
Control of pedicles
Lateral dissection
Urethral transection
Anastomosis
Pelvic, vesical and prostatic plexus
(Figs. 1 and 2)
If the dissection is carried too far laterally,
the nerves may be injured
None
None
Laterally pelvic, vesical and prostatic
plexus are located deep to the bladder neck
Pelvic, vesical and prostatic plexus
(Fig. 2B and C)
Vesical and prostatic plexus and proximal
part of neurovascular bundles (Fig. 6B)
Neurovascular bundles (Figs. 4–8)
Neurovascular bundles (Fig. 8)
Neurovascular bundles (Fig. 8)
No dissection lateral to the seminal vesicles, and no excessive
use of cautery or clips.
Avoid dissecting too deep in the groove between prostate and rectum.
This is an important step due to its effect on hemostasis and
visualization. Poor visualization is detrimental for nerve sparing.
None.
Dissection under vision and with meticulous hemostasis.
Avoid excessive incision lateral to the bladder neck.
No dissection lateral to the seminal vesicles, and no excessive use of
monopolar cautery. Use accurate control (clips or bipolar cautery).
Meticulous dissection to expose the blood supply and individually
control them using clips applied or bipolar current close to the
prostate. Avoid monopolar cautery.
Approach through the triangle and leave a thick sheath of lateral
pelvic fascia (see Comments).
Transection under vision.
Anastomosis should be performed under vision without any pool of
blood. Be careful for the posterior stitches, particularly at 5 and
7 o’clock.
454 A. Tewari et al. / European Urology 43 (2003) 444–454
laparoscopic or robotic prostatectomy procedure, in
sparing the neurovascular bundles. Using the images
and data from our study, we have constructed a table
References
[1] Walsh PC. Radical prostatectomy for localized prostate cancer
provides durable cancer control with excellent quality of life: a
structured debate. J Urol 2000;163:1802–7.
[2] Han M, Partin AW, Pound CR, Epstein JI, Walsh PC. Long-term
biochemical disease-free and cancer-specific survival following
anatomic radical retropubic prostatectomy. The 15-year Johns
Hopkins experience. Urol Clin North Am 2001;28:555–65.
[3] Han M, Partin AW, Piantadosi S, Epstein JI, Walsh PC. Era specific
biochemical recurrence-free survival following radical prostatectomy
for clinically localized prostate cancer. J Urol 2001;166:416–9.
[4] Walsh PC, Partin AW. Treatment of early stage prostate cancer:
radical prostatectomy. Important Adv Oncol 1994:211–23.
[5] Fischetti G, Cuzari S, De Martino P, Musy M, Valentini MA, Leone
P, et al. Postprostatectomy erectile dysfunction. Personal experience.
Minerva Urol Nefrol 2001;53:185–8.
[6] Chang SS, Peterson M, Smith Jr JA. Intraoperative nerve stimulation
predicts postoperative potency. Urology 2001;58:594–7.
[7] Miyao N, Adachi H, Sato Y, Horita H, Takahashi A, Masumori N,
et al. Recovery of sexual function after nerve-sparing radical
prostatectomy or cystectomy. Int J Urol 2001;8:158–64.
[8] Walsh PC, Lepor H, Eggleston JC. Radical prostatectomy with
preservation of sexual function: anatomical and pathological
considerations. Prostate 1983;4:473–85.
[9] Walsh PC, Mostwin JL. Radical prostatectomy and cystoprostatect-
omy with preservation of potency. Results using a new nerve-sparing
technique. Br J Urol 1984;56:694–7.
[10] Walsh PC. Radical prostatectomy, preservation of sexual function,
cancer control. The controversy. Urol Clin North Am 1987;14:
663–73.
[11] Stenzl A, Colleselli K, Poisel S, Feichtinger H, Pontasch H, Bartsch
G. Rationale and technique of nerve sparing radical cystectomy
before an orthotopic neobladder procedure in women. J Urol
1995;154:2044–9.
[12] Steiner M. Continence preserving anatomic radical prostatectomy.
Urology 2000;55:427–35.
[13] Myers RP. Practical surgical anatomy for radical prostatectomy. Urol
Clin North Am 2001;28:473–90.
[14] Huland H. Morphologic principles for radical prostatectomy.
Urologe A 1991;30:361–8.
[15] Huland H, Noldus J. An easy and safe approach to separating
Denonvilliers’ fascia from rectum during radical retropubic prosta-
tectomy. J Urol 1999;161:1533–4.
[16] Walsh PC. Nerve sparing radical prostatectomy for early stage
prostate cancer. Semin Oncol 1988;15:351–8.
[17] Walsh PC. Radical retropubic prostatectomy with reduced morbidity:
an anatomic approach. NCI Monogr 1988;7:133–7.
[18] Abbou CC, Salomon L, Hoznek A, Antiphon P, Cicco A, Saint F,
et al. Laparoscopic radical prostatectomy: preliminary results.
Urology 2000;55:630–4.
[19] Abbou CC, Hoznek A, Salomon L, Olsson LE, Lobontiu A, Saint F,
et al. Laparoscopic radical prostatectomy with a remote controlled
robot. J Urol 2001;165:1964–6.
[20] Binder J, Kramer W. Robotically-assisted laparoscopic radical
prostatectomy. BJU Int 2001;87:408–10.
[21] Gill IS, Zippe CD. Laparoscopic radical prostatectomy: technique.
Urol Clin North Am 2001;28:423–36.
[22] Gill IS, Kerbl K, Clayman RV. Laparoscopic surgery in urology:
current applications. Am J Roentgenol 1993;160:1167–70.
summarizing various critical points in nerve sparing
during laparoscopic and robotic radical prostatectomy
(Table 1).
[23] Guillonneau B, Rozet F, Barret E, Cathelineau X, Vallancien G.
Laparoscopic radical prostatectomy: assessment after 240 proce-
dures. Urol Clin North Am 2001;28:189–202.
[24] Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy:
the Montsouris technique. J Urol 2000;163:1643–9.
[25] Rassweiler J, Sentker L, Seemann O, Hatzinger M, Rumpelt HJ.
Laparoscopic radical prostatectomy with the Heilbronn technique: an
analysis of the first 180 cases. J Urol 2001;166:2101–8.
[26] Schuessler WW, Schulam PG, Clayman RV, Kavoussi LR. Laparo-
scopic radical prostatectomy: initial short-term experience. Urology
1997;50:854–7.
[27] Schulam PG, Link RE. Laparoscopic radical prostatectomy. World J
Urol 2000;18:278–82.
[28] Turk I, Deger IS, Winkelmann B, Roigas J, Schonberger B, Loening
SA. Laparoscopic radical prostatectomy. Experiences with 145
interventions. Urologe A 2001;40:199–206.
[29] Guillonneau B, Jayet C, Tewari A, Vallancien G. Robot assisted
laparoscopic nephrectomy. J Urol 2001;166:200–1.
[30] Menon M, Tewari A, Baize B, Guillonneau B, Vallancien G.
Prospective comparison of radical retropubic prostatectomy and
robot-assisted anatomic prostatectomy: the Vattikuti Urology In-
stitute experience. Urology 2002;60:864–8.
[31] Menon M, Tewari A, Peabody JO. Technique of Vattikuti Institute
Prostatectomy. J Urol, in press.
[32] Tewari A, Peabody JO, Sarle R, Balakrishnan G, Hemal AK,
Shrivastava A, et al. Technique of da Vinci robot-assisted anatomic
radical prostatectomy. Urology 2002;60:569–72.
[33] Menon M, Shrivastava A, Tewari A, Sarle R, Hemal A, Peabody JO,
et al. Laparoscopic and robot assisted radical prostatectomy:
establishment of a structured program and preliminary analysis of
outcomes. J Urol 2002;168:945–9.
[34] Walsh PC. Re: Potency-sparing radical retropubic prostatectomy: a
simplified anatomical approach. J Urol 1996;155:294.
[35] Menon M, Vaidyanathan S. The University of Massachusetts
technique of radical retropubic prostatectomy. Eur J Surg Oncol
1995;21:66–8.
[36] Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy:
the Montsouris experience. J Urol 2000;163:418–22.
[37] Guillonneau B, Cathelineau X, Doublet JD, Vallancien G. Laparo-
scopic radical prostatectomy: the lessons learned. J Endourol
2001;15:441–5.
[38] Bollens R, Vanden Bossche M, Roumeguere T, Damoun A, Ekane S,
Hoffmann P, et al. Extraperitoneal laparoscopic radical prostatect-
omy. Results after 50 cases. Eur Urol 2001;40:65–9.
[39] Rassweiler J, Sentker L, Seemann O, Hatzinger M, Stock C, Frede T.
Heilbronn laparoscopic radical prostatectomy. Technique and results
after 100 cases. Eur Urol 2001;40:54–64.
[40] Rassweiler J, Frede T, Seemann O, Stock C, Sentker L. Telesurgical
laparoscopic radical prostatectomy. Initial experience. Eur Urol
2001;40:75–83.
[41] Villers A. Anatomy of the prostate: insight into benign prostatic
hyperplasia anatomy and pathogenesis. Prog Clin Biol Res 1994;
386:21–30.
[42] Villers A, McNeal JE, Freiha FS, Boccon-Gibod L, Stamey TA.
Invasion of Denonvillier’s fascia in radical prostatectomy specimens.
J Urol 1993;149:793–8.
[43] Villers A, Steg A, Boccon-Gibod L. Anatomy of the prostate: review
of the different models. Eur Urol 1991;20:261–8.