0022-5347/97/1571-0003$03.

00/0
T H E JOURNAL OF UROLOGY Val. 157,3-9, January 1997
Copyright 0 1997 by AMEFXAN UROLOGICAL INC.
AESOCIATION. Printed in U S A

Review Article

THE ANATOMY AND EMBRYOLOGICAL ORIGINS OF THE FASCIA OF

DENOWLLIERS: A MEDICO-HISTORICAL DEBATE
ARNDT VAN OPHOVEN* AND STEPHAN ROTH
From the Department of Urology, University of Miimter, Munster, Germany

ABSTRACT
Purpose: We reviewed the conflicting theories concerning the anatomy and embryological
derivation of Denonvilliers’ fascia since its first description in 1836.
Materials and Methods: An extensive review of the literature for the last 160 years was done.
Results: Various studies contributed to the debate on the anatomy and origins of Denonvilliers’
fascia. We chose to review these studies because of their sound methodology, large numbers of
cases and results, and the high quality of the macroscopic and/or microscopic evidence.
Conclusions: Denonvilliers’ fascia consists of a single layer arising from fusion of the 2 walls of
the embryological peritoneal cul-de-sac. Histologically, it has a double-layered quality. The fascia
of Denonvilliers extends from the deepest point of the interprostatorectal peritoneal pouch to the
pelvic floor. A so-called posterior layer is in reality the rectal fascia propria.
KEYWORDS:prostatectomy, fascia, pelvis, anatomy, urology
Since Young first performed radical perineal prostatec-
tomy in 1905,the fascia of Denonvilliers has been a surgical
landmark for urologists.1.2 On finding positive surgical mar-
gins in retropubic prostatectomies, Stamey et a1 described a
“super radical” prostatectomy involving all of the peripros-
tatic fascias, and also noted that “the surgeon must have a
precise understanding of the periprostatic fascias and their
fusion to form Denonvilliers’ fascia.”3 In a recent report on
the relationship between the progression of prostatic carci-
noma and invasion of Denonvilliers’ fascia, Villers e t al
stated “that a separate posterior layer of Denonvilliers’ fascia
was not seen during radical prostatectomy.”4 While in such
studies and the literature in general there exists little or no
disagreement regarding the clinical and oncological s i d -
cance of Denonvilliers’ fascia, this is nonetheless not the case
a s far as its origin and anatomical structure are concerned.
This lack of precise understanding regarding Denonvilliers’
fascia led us to review the literature, and describe the con-
flicting theories that have arisen concerning its anatomy and
embryological derivation since Denonvilliers first described
the structure in 1836.5

A BRIEF OUTLINE OF THE LIFE AND CAREER OF

DENONVILLIERS
Charles-Pierre Denonvilliers was born on February 4,1808
in Paris, where he was educated and worked as a scientific
researcher, teacher and physician until his death in 1872(fig.
1h6 After finishing his medical dissertation in 1837,he be-
came professeur agr6g6 in 1839,presenting his thesis enti-
tled “Determining in which cases trepanation is indicated.”
In 1840 he became a surgeon at the main hospital in Paris
and in 1841 he became head of the department of anatomical FIG. 1. Charles-Pierre Denonvilliers‘
studies. In 1843 he and several prominent colleagues (for
example NBlaton, Chassaignanc and so forth) founded the
SOciBte de Chirurgie de Paris, of which Denonvilliers was first for a ofyears and later an honorary
* Re uests for reprink: Department of of Be member. His extensive work in the field of descriptive and
chum, %arienhospitalII, Heme, Widumerstr. 8,44627Heme, Ger- anatomy led to Pubfiation O f n ~ e r articles
o ~ and
many. textboob as well as to the elaboration of innovative surgical
3
4 ANATOMY AND EMBRYOLOGICAL ORIGINS OF DENONVILLIERS’ FASCIA

techniques, particularly in the field of reconstructive plastic bryoneal peritoneum of the rectovesical cul-de-sac (fig. 2).10
surgery. Based on this work Denonvilliers became professor Zuckerkandl had already stated that this embryonic perito-
of anatomy at the University of Paris in 1849. In 1857, neal pouch was located between the bladder and rectum, and
shortly &r publication of his second textbook entitled Prac- that it extended down to the pelvic floor.’O Some years later,
tical and Theoretical Treatise on Diseases of the Eye, written Cuneo and Veau postulated that the sides of this cul-de-sac
in collaboration with Gosselin, Denonvilliers’ research came shaped pouch fuse at the caudal end during embryonic
to an abrupt end due, according to 1 author, to “an unpubli- growth, and that Denonvilliers’ prostatoperitoneal aponeuro-
cized acute physical ailment.”? sis was the end result of this process. They cited in support of
Nevertheless, as inspector general for public education in their theory the presence of perineal hernias and seminorec-
the medical sciences, a post he assumed in 1858,Denonvilliers tal cysts, both of which they believed to result from incom-
exercised a strong influence over the education and training plete fusion of the 2 peritoneal walls. However, they found no
of many medical students. It is generally agreed that his distinct layers of Denonvilliers’ fascia. In 1908,after compar-
professional activity ended in 1864 by the death of his pre- ing pelvic dissections in fetuses and adults, Smith was ”able
maturely born son, a blow from which he never fully recov- to confirm the work of Cuneo and Veau,” that is that the
ered. His death from a stroke on July 5,1872was thought by fascia of Denonvilliers derived from the pelvic portion of the
his contemporaries in the field of medical science to be a embryonic peritoneum.”. 12 Moreover, Smith first particu-
great loss of an eminent colleague.8 larly emphasized the presence of 2 layers of Denonvilliers’
fascia, that is a “thick posterior. . . and a much thinner an-
MEDICO-HISTORICAL REVIEW terior layer.”
In 1836 Denonvilliers reported to the Societk Anatomique
the discovery of a ”prostatoperitoneal” membranous layer THE CONTROVERSY GROWS
between the rectum and seminal vesicles.6 At no time did he In 1922 Wesson criticized the “hazy ideas of anatomical
use the term fascia. He described the texture as resembling relations” surrounding Denonvilliers’ fascial3.14 and began
that of the dartos. A year later he described this aponeurosis investigating whether “there was any scientific basis” for the
in greater detail: “Behind the prostate, between the seminal peritoneal fusion theory of Cuneo and Veau that had been
vesicles and the rectum, there is a distinct membranous generally accepted until that time.10 He also reported finding
layer, which I call prostatoperitoneal. This is its position: 2 layers of the fascia of Denonvilliers.13.14 However, Wesson
from the two sides it fuses with the compact cellular tissue concluded from histological studies of human embryos that
which surrounds the venous plexus at the base of the blad- during fetal development the rectovesical pouch “becomes
der; on the anterior side it runs to the far side of compressed and relatively shallow,” and that the resulting
the prostate; on the posterior side it adheres to the part of the
proximity and contact between the 2 walls lead to fusion of
peritoneum that descends between the bladder and the rec- the peritoneal layers. Thus, he theorized that the peritoneal
tum . . .The lower surface which touches the rectum barely mesothelium is absorbed, while the aforementioned fusion
adheres to it by a very loose cellular tissue; . . . .“9 Publication
initiates a “prompt reversion (of the peritoneum) to undiffer-
of the first description of this layer of tissue nearly 160 years
entiated embryonic tissue” in such a way that only mesen-
ago was to be the beginning of a lively, a t times acrimonious chyme remains once these 2 processes have been completed.
and still ongoing debate over its embryological derivation He added that inasmuch as fascia are actually condensations
and anatomical structure. of connective tissue, the fascia of Denonvilliers is, in effect,
the final condensation product of the aforementioned mesen-
THE BEGINNING OF THE DEBATE
chyma. These results led Wesson t o contradict the earlier
The aforementioned debate began in earnest in 1899,when findings of Cuneo and Veau,lo and state that “Denonvilliers’
Cur160 and Veau proposed the theory that the structure that fascia is formed by a condensation of mesenchyme tissue, and
Denonvilliers had discovered arose from fusion of the em- not by a fusion of layers of fetal peritoneum.”14

FIG. 2. Embryological development of Denonvilliers’ fascia. l o Legend states that schematic sagittal sections show development of
prostatoperitoneal aponeurosis: first stage (left) and final stage (right,.
 ANATOMY AND EMBRYOLOGICAL ORIGINS OF DENONVILLIERS' FASCIA 5
Wesson further argued that the occurrence of this conden-
sation at 2 separate and distinct layers necessarily gives rise
to 2 different fascia1 layers, an anterior layer dorsal to the
bladder and a layer ventral to the rectal canal.13 According to
Wesson cysts arising between the bladder and rectum result
from incomplete mesothelial absorption and not, as Cuneo
and Veau had stated,10 from incomplete peritoneal fusion.
Although the theory of Wesson contributed significantly to
the debate over the peritoneal origins of Denonvilliers' fascia,
virtually no other investigators felt compelled to elaborate
this theory further or use it as a basis for further research
until, in an embryonic study in 1945, Tobin and Benjamin
showed that the assertion of Wesson that the bladder and
rectum are covered by mesenchyma was indeed correct.16
However, in contrast to Wesson, they found that these mes-
enchymal layers differentiate into connective tissue and
musculature. Between these 2 mesenchymal coverings of the
bladder and rectum Tobin and Benjamin also found a third
tissue layer, which they identified as mesothelium and which
was surrounded by a thin layer of subjacent mesenchyma.
Therefore, they classified this middle layer histologically as
peritoneum. Their analysis of embryonic dissections also con-
firmed that this middle tissue layer was, in fact, the pelvic
peritoneal continuation of the embryoneal cul-de-sac (figs. 3
and 4). In addition, Tobin and Benjamin found that in more
developed embryos this cul-de-sac regresses and approaches
the seminal vesicles as its caudal end fuses, and that in the
course of this fusion the peritoneal mesothelium recedes and
disappears. The aforementioned subjacent mesenchyma is
left behind in the form of a fibrous membrane, which later
develops into the fascia of Denonvilliers. These findings cor-
responded to an embryological process in the intestinal peri-
toneum that had been described previously by Toldt in
1893.16*17
Another aspect of the study of Tobin and Benjamin was
their assertion that the prerectal mesenchymal covering
eventually develops into the rectal fascia propia.16 They
noted that Denonvilliers had correctly identified this tissue
layer but that he did not classlfy it as part of the prostato-
peritoneal aponeurosis. Therefore, they said that it cannot FIG. 4. Anatomical conception of Tobin and Benjamin"
technically be defined as part of the fascia of Denonvilliers.

FIG. 3. AnatOmieal conception of Tobin and Benjamin''

6 ANATOMY AND EMBRYOLOGICAL ORIGINS OF DENONVILLIERS‘ FASCIA

However, they conceded that “. . . since this tissue is consid-
ered as part of Denonvilliers’ fascia in the clinical literature
and for the sake of simplicity, we suggest this fascia around
the rectum be designated the posterior layer of Denonvilliers’
fascia. The fibrous membrane derived from the cul-de-sac of
peritoneum could be designated, therefore, the anterior layer
of Denonvilliers’ fascia. This terminology would help to clar-
ify the descriptions of these fascial layers.” The positive iden-
tification of both cyst-like structures at the site of incomplete
fusion and regression of the mesothelium simultaneously
confirmed the theory of Tobin and Benjamin of the peritoneal
origin of the fascia of Denonvilliers,15 as well as the work of
CunCo and Veau.10
The importance of the study of Tobin and Benjamin is that
it was the first theory to provide a logical and convincing
explanation of the embryological derivation of Denonvilliers’
fascia.15 Moreover, their theory was free of the distracting
histological speculations that had marred the studies of
Wesson.13.14 Before their study the terms anterior and pos-
terior layers of Denonvilliers’ fascia had been used somewhat
loosely, and by correlating these terms with the histological
findings Tobin and Benjamin were able to demonstrate that,
histologically and medico-historically, the so-called posterior
layer is not a separate entity but is, in fact, the rectal fascia
propria.
OTHER STUDIES
Before and after the report of Tobin and Benjamin15 some
investigators used their own histological or gross anatomical
studies to cast serious doubt on the existence of a membrane
or fascia between the rectum and genital organs.18-24 For
instance, in 1931 Goff wrote that he had only found “a thin
layer of loosely arranged fascia of the areolar type” in the
pelvis.’* Some years later Ricci and Thom concurred, stating
even more categorically that “there is no substance which in
any way resembles a sheet-like structure of compact connec-
tive tissue, i.e., a fascia“ between the genital organs and
rectum.= However, they were also critical of Goff, whose
“clarity”they stated “was marred by his insistence on calling
meshed areolar fibers a fascia. . . a fascia is a covering or
enveloping membrane; areolar tissue is a packing or filling
material.” Curtis et al asserted that “the rectovaginal septum
of standard descriptions” actually consisted of the fascial
capsules of the rectum and vagina, plus the loose cellular
tissue between them.20
neum is particularly conspicuous, as everywhere else in the
pouch the peritoneum is perfectly smooth and devoid of ir-
regularities. . . . The location and direction of the line, both
corresponding to the line of attachment of the rectavesicai
septum, as well as the appearance of the peritoneum along
this line, leave no doubt that it represents the line along
which the dorsal and ventral walls of the pouch fused with
one another” (fig. 51.25 Despite the certainty with which
Uhlenhuth et a1 described their findings, they did not con-
clusively prove the existence of a “line of whitish color.”
Moreover, to date no other investigator has reported finding
any evidence of such a scar-like structure.
However, the large number of gross dissections performed
as well as t h e superb drawings derived from them led
Uhlenhuth et a1 to conclude correctly that “the rectovesical
septum is a structure additional to and independent of, the
fascial capsules of the adjacent viscera.”25 After measuring
the depth of the rectovesical pouch in fetuses at various
stages of development, they further concluded that “the ex-
tent to which the prostate and vagina are covered by perito-
neum diminishes distinctly during the last months of intra-
uterine life indicating that further retraction of the pouch is
in progress during this period.”
I n 1945 Tobin and Benjamin presented persuasive histo-
logical evidence concerning the embryological origin of
Denonvilliers’ fascia,’5 and from 1948 to 1957 Uhlenhuth et
a1 likewise presented macroscopic anatomical evidence
strongly supporting the theory of Cuneo and Veau’o that the
fascia of Denonvilliers arises from fusion of the regressing
peritoneal cul-de-sac.Zs28 Their results contradicted those of
aforementioned authors, who had either failed to find this
structure or who had provocatively called it a myth,”J as had

NEW ARGUMENTS AND THEIR CONFIRMATION

In reaction to these studies Uhlenhuth et al, American
anatomists who favored the fusion hypothesis of Tobin and
Benjamin,15 decided to reinvestigate the problem and begin-
ning in 1948 they presented a series of studies concerning the
anatomy and embryological derivation of Denonvilliers’ fas-
cia.2s28 These articles contained persuasive macroscopic ev-
idence from 50 postmortem examinations supporting the
view that Denonvilliers’ fascia derives from the embryonic
rectogenital pouch: “If it is true that the rectovesical septum
is the result of the fusion of the peritoneal walls of the
rectovesical pouch, one might expect that in cases of an
exceptionally far caudal situs of the pouch the rectovesical
septum might be completely missing.” Their thesis was later
confirmed when they found that 1 subject was indeed lacking
a rectovesical septum.25
In addition, Uhlenhuth et al wrote that “[upon] inspecting
the peritoneum of the pouch on its inner [cranial] surface,
running transversely and corresponding to the line of attach-
ment of the rectovesical septum on the outside, [I observed] a
slightly grooved line of whitish color, which resembled a scar
such as remains after a surgical suture. Along this line and
on either side of it, the peritoneum was slightly wrinkled
perpendicularly to the line. This configuration of the perito- FIG.5. Pelvic fascial anatomy of Uhlenhuth et al”’
 ANATOMY AND EMBRYOLOGICAL ORIGINS OF DENONVILLIERS‘ FASCIA
Ricci and Thom in 1954.23 In a peritoneal anatomical study
published only 2 years later Silver reconfirmed the existence
of the rectovesical septum.29 In 1969 Milley and Nichols, in a
study of 143 specimens from patients ranging in age from 8
fetal weeks to 100 years, reignited the controversy.30 In their
investigation of the homology of “the rectogenital septum and
the male rectovesical septum (anterior layer) at both gross
and microscopic levels,” they supported the peritoneal fusion
theory, laying particular emphasis on the existence of the
rectogenital septum. Since the latter study, the existence of a
membrane between the rectum and genital organs, with only
1 exception,31 has not been seriously questioned.
DIFFERING ANATOMICAL CONCEPTS
However, the terminology for the fascia of Denonvilliers as
well as its embryological derivation remained matters of
debate. In 1975 a medical anatomy textbook by Waligora and
Perlemutter was published containing numerous drawings of
the male genital organs.32 Figure 87 in this book correctly
indicates the relationship of the membranous structure
known as the fascia of Denonvilliers to the peritoneum, while
on the other hand it erroneously labels the membrane lying
ventrally to the seminal vesicles as the anterior layer of
Denonvilliers’ fascia (fig. 6).This probably was the first time
that the fascia had ever been erroneously illustrated in an
anatomy textbook.33
Since 1983 Benoit et al reported several studies on the anat-
omy and surgical signiscance of the fascia of Denondiem in
radical prostate&my.”~8 They concluded that Denonvilliers’
fascia is attached not to the peritoneum of Douglas’ pouch
but, rather, to the prostate. Their findings classify the struc-
ture not as a true fascia but as “a layer of mesenchymal
tissue originating from the prostate and covering the poste-
rior surface of the genital ducts.” These results also led them
FIG. 87. - Ccmol dCfirrnt. Segment dfrpv&dcd.
Rapports par l’iitennCdiain de la 1- g6uit.k.
FIG. 6. Partial anatomy of male genital organs from anatomy
textbook of Waligora and Perlemutter.= Note location of anterior
layer (“Feuilletant.”)of Denonvilliers’fascia.
7
to assert that “Denonvilliers’ fascia is thus part of the vesi-
coprostatic unit. . . a n d . . . derived from the same wolffian
mesenchymal anlage as the vesical trigone, prostate and
genital ducts.” In contrast to the view of Benoit e t al that the
fascia of Denonvilliers is attached to the prostate and semi-
nal vesicles, in 1980 Goligher described Denonvilliers’ fascia
as more closely adhering to the rectum than to the genital
organs.39 This view is shared by few other surgeons and does
not correspond to conclusions reached by the majority of
studies.40
As mentioned at the beginning of our review, in 1993
Villers et al found no separate posterior layet‘ but did ques-
tion the fusion theory of Cur160 and Veau.10 ViUers et al
considered that Denonvilliers’ fascia actually lies anterior to
the peritoneal pouch and does not meet its lowest portion at
any point.* Instead “the adult cul-de-sac is continuous with
the areolar tissue plane, which separates the anterior rectal
wall from Denonvilliers’ fascia.” Unfortunately, their inter-
prostatorectal histological sections were obtained too cau-
dally, thereby making it difficult for the reader to understand
completely the anatomical conception.
However, at the end of 1993 Richardson argued in favor of
the peritoneal origin of the rectogenital septum.41 In a report
on the relationship between the rectovaginal septum and
rectocele, Richardson cited a study by Pawlina et al from
1991 who found =anabundant, subperitoneal layer of elastic
fibers throughout the pelvis of the female and in a lesser
degree the male.”42 This finding led Richardson to conclude
that “a doubly dense layer of elastin . . . would be expected if
it [the rectovaginal septum] represented a fusion of the peri-
toneal lining of the embryonic rectogenital pouch.”41 The
photomicrographic evidence of Richardson elegantly and
skillfully highlighted the double layered nature of the recto-
genital septum (fig. 7). In 1953 Uhlenhuth et alT7 and in
1969 Milley and Nichols30 had already detected macroscopic
evidence in cadavers of this double-layered quality. They
found that the rectovaginal septum could be easily divided
into 2 lamellae via blunt dissection. Because Milley and
Nichols found a single specimen “in which the two lamellae
had separate attachments to the recto-uterine pouch, the
interval between the two attachments Being] bridged over by
peritoneum” they concluded that this separation could not be
a dissection artifact.
Finally, in 1994 Benchekroun et al discovered a cystic
mesothelioma,a which according to Ross et al in 1989 is a
rare tumor.44 They believe that the unusual localization of
the mesothelioma below the pelvic peritoneum and behind
the prostate constitutes additional evidence for the perito-
neal origin of Denonvilliers’ fascia.
FIG. 7. Double-layered quality (result of pentoned fusion) Of--
togenital aeptum?1
8 ANATOMY AND EMBRYOLOGICAL ORIGINS O F DENONVILLIERS’ FASCIA
CONCLUSIONS
Because the debate on the anatomy and embryological
origins of Denonvilliers’ fascia is ongoing, the conclusions
presented are meant to contribute to that debate and not
definitively answer questions that have puzzled physicians
for 160 years. We based our conclusions primarily on a hand-
ful of the many articles we have read10.15.25-2s.41 plus our
own surgical experience. The persuasiveness of these studies
stems from their sound methodology, the large numbers of
cases and results reported, and the high quality of the mac-
roscopic andlor microscopic evidence. Regarding the anatomy
and embryological origins of the fascia of Denonvilliers we
conclude that Denonvilliers’ fascia consists of a single layer
arising from fusion of the 2 walls of the embryological peri-
toneal cul-de-sac. Histologically, it has a double-layered qual-
ity that nonetheless is not distinguishable intraoperatively.
The fascia of Denonvilliers extends from the deepest point of
the interprostatorectal peritoneal pouch to the pelvic floor
and, contrary to the theory of Villers et a12 does not lie
forward of the anterior wall of the pouch. Finally, there exists
no so-called posterior layer. Researchers who suggest such a
layer are in reality describing the rectal fascia propria.
The variability in anatomical characteristics and form that
has been observed in the fascia of Denonvilliers during the
last 160 years can be viewed as a natural result of slight
interindividual anatomical differences. However, this vari-
ability has led some authors to engage in unfounded specu-
lation concerning the existence of the fascia andlor to fail to
consider relevant scientific data sufficiently. In a recent ar-
ticle on radical prostatectomy Ruckle and Zincke demon-
strated how skillful application of medico-historical facts can
serve to modify surgical techniques. Their precise use of
anatomical terminology reflects their thorough knowledge of
the medico-historical context surrounding the controversy
over the anatomy and embryological origins of the fascia of
Denonvilliers.45
Robert Nussbaum provided writing assistance.
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