RADICAL PROSTATECTOMY
OO
PRACTICAL SURGICAL ANATOMY
FOR RADICAL PROSTATECTOMY
It is humbling to realize that even today basic
anatomy may not be known or understood.
PATRICK C. WALSH, 199856
Walsh’s quotation relative to radical prosta-
tectomy admonishes other surgeons who per-
form this surgery and take lightly the knowl-
edge of anatomy. The goals of radical
prostatectomy have been crystallized as (1)
cure of disease, (2) urinary control, and (3)
preservation of erectile function.55Unfortu-
nately, these key ingredients for health and
quality of life postoperatively will remain elu-
sive for significant numbers of patients until
understanding of the complex anatomy of the
pelvic floor is more widespread. As a nine-
teenth century plaque on the wall in the Anat-
omy Museum in Basel, Switzerland, warns
(translating the German), “Surgeons who ig-
nore anatomy are like moles. They work in
the dark and pile up dirt!”
At the heart of the complexity of the male
pelvis is significant individual variation.
Some pelves are wide, making the prostate
readily accessible, whereas other pelves are
deep and narrow, making access to the pros-
tate a test of patience, especially in the pres-
ence of morbid obesity. Because the width of
the pelvic arch prostate size must be
assessed before radical perineal prostatec-
tomy, the perineal operation. Variation also
applies to prostate architecture in terms of
size and shape, which are affected by the
From the Department of Urology, Mayo Clinic, Minnesota
UROLOGIC CLINICS OF NORTH AMERICA
VOLUME 28 * NUMBER 3 * AUGUST 2001
0094-0143/01 $15.00 + .
Robert P. Myers, MD
presence or absence of benign prostatic hy-
perplasia (BPH).Beyond the prostate, the sur-
geon must understand the pelvic fascia and
pelvic floor musculature, including the leva-
tor ani and associated musculature, which in-
cludes the anal sphincters and the bulbospon-
giosus. Disposition of the rectum, anal canal,
and anorectal flexure relative to the prostate
apex is key to successful radical retropubic
prostatectomy (the retropubic operation) and
the perineal operation. Relationships of the
prostate to the bladder, urethra, penis, and
pubis are also germane. The neurovascular
structures must be defined clearly in the sur-
geon’s mind before operating. Variation is a
part of every anatomic aspect of the pelvis.
Textbooks often present only one configura-
tion among many. Errors in illustration
abound and are perpetuated by copying with-
out substantiating validity.
The anatomic illustrations in this article are
drawn from fresh gross specimens taken at
autopsy, from radical prostatectomy speci-
mens, from MR images, and from histologic
material, as in previous related publications
on surgical anatomy of the p r ~ s t a t e . ~36 ~Be-
-~~,
cause the illustrations herein are based on
drawings of real material or photographs of
actual specimens, the reader should be able
to make a practical translation from textbook
to patient and avoid unnecessary surgical er-
ror based on mistaken notions of how things
ought to be.
473
474 MYERS
PROSTATE DEVELOPMENT AND
ARCHITECTURE
Based on wax casts,15 computer-assisted
three-dimensional reconstruction of serial em-
bryologic sections,"O and the architecture de-
scribed by M~Nea1,2~ it is clear that the pros-
tate is ejaculatory duct-centric and not
urethrocentric in origin. The prostate begins
as a plate of embryonic tissue central to the
ejaculatory ducts and posterior to the ure-
thra.2J
If no BPH develops, the urethra above the
veru maintains a position primarily anterior
to the prostate with the exception of a thin
and narrow band of tissue that constitutes the
anterior commissure (isthmus) of the pros-
tate. What McNeal termed anterior fibromus-
cular stromu included not only the commis-
sure but also the detrusor apron and the
anterior portion of the preprostatic sphinc-
ter.2t1, 22
Major histologic elements of the McNeal
prostate include peripheral, central, and tran-
sition zones, and the anterior fibromuscular
stroma and the preprostatic sphincter (Fig. 1,
see p 485). Grossly, the normal prostate (no
BPH) on section has a relatively uniform
brown color. The zonal glandular architecture
cannot be appreciated grossly except when the
transition zone has become hyperplastic and
BPH tissue is distinguishable from the com-
pressed peripheral zone (Fig. 2, see p 485).
The detrusor apron ends its attachment to
the prostate at approximately midcommis-
sure. In the midline from the distal end of the
apron to the prostatourethral junction, there
is an avascular plane that is short in the ab-
sence of BPH because the commissure is rela-
tively narrow. The more BPH enlarges the
commissure, the longer the avascular plane
to the apex in radical prostatectomy, and the
safer it is to pass a right angle to secure the
vascular plexus without damaging the
sphincter (Fig. 3, see p 485).
Because the detrusor apron is a loose con-
glomeration of predominantly veins and lon-
gitudinal smooth muscle bands (see Fig. l),it
can be compressed in the retropubic opera-
tion with bunching sutures over the commis-
sure to expose the anterolateral surfaces of the
From the point of view of anatomic
preservation of the striated sphincter and
neurovascular bundles at the apex, it is essen-
tial that these sutures never be placed distal
to the prostatourethral junction in the bunch-
ing process.
The preprostatic sphincter is simply an ex-
tension of the circular smooth muscle of the
vesical neck that ends beneath the anterior
commissure at the veru, whereas the detrusor
apron is an extension of the longitudinal
smooth muscle anterior to the commissure.
Under a-adrenergic control, the preprostatic
sphincter and the vesical neck or internal
sphincter are one and the same. The commis-
sure at its superior aspect lies between the
two detrusor-derived coats of smooth muscle
(Fig. 4, see p 485). The prostate literally grows
superiorly and anteriorly to impinge on the
bladder.
In neonates, the external striated sphincter
extends from the bulb of the penis to the
bladder neck more or less ~ircumferentially.~~
Growth of the prostate displaces striated fi-
bers of the sphincter in its upper half and
splays them out over its anterior surface. The
fibers are seen histologically in axial Masson
trichrome sections as a crescentic plate ante-
rior to the c o m m i s s ~ r e . ~ ~
Benign prostatic hyperplasia develops su-
perior to the veru in glands within the wall
of the urethra and in glands immediately ex-
ternal to the urethra, the transition zone.21
With BPH progression, the prostatic urethra
from veru to bladder neck increases in length,
and, in advanced cases, the mass of BPH tis-
sue comes to occupy the bulk of the prostate
anterolaterally. The original prostate becomes
no more than a compressed posterolateral
shell. The greatly elongated anterior commis-
sure is related solely to BPH. The commissure
also is increased in thickness as a result of
BPH growth anteriorly, but never greatly, as
can be appreciated during the finger fracture
of BPH tissue in the anterior midline that
begins a typical suprapubic adenectomy.
Surgeons need to be aware of how BPH is
disposed in individual cases because failure
to do so may lead to inadvertent dissection
between adenoma and the compressed pe-
ripheral zone. When the prostate in the retro-
pubic operation is palpably large, BPH should
be anticipated. The degree of development of
BPH affects the degree to which the periph-
eral zone is compressed posterolaterally (Fig.
5, see p 475).
PROSTATE VARIABILITY
Shape differences are important, especially
at the apex, where asymmetry and the pres-
ence or absence of various notch configura-
 PRACTICAL SURGICAL ANATOMY FOR RADICAL PROSTATECTOMY
Figure 5. Benign prostatic hyperplasia (BPH) in axial
section through the prostate (A-0). Expansion of transi-
tion zone progressively displaces peripheral zone. (A, 6,
and C are taken from whole-mount histologic section. D
is taken from MR image.)
tions abound (Fig. 6, see p 485). If the surgeon
expects symmetry at the apex but is con-
fronted with asymmetry, the dissection is
more troubling. Vagaries at the apex are ex-
posed adroitly by downward pressure at the
relatively mobile vesicoprostatic junction,
thereby rotating the apex upward. BPH sym-
metry or asymmetry then is appreciated
readily.
In the conduct of radical prostatectomy, the
surgeon confronts prostate variability with re-
spect to size, shape, and extent of dissection.
The extent refers to the amount of soft tissue
left adherent to the prostate, including in-
vesting fascia and neurovascular and adipose
tissue. There is a clear difference technically
in the challenge associated with delivering a
mere 15-g prostate compared with a massive
200-g gland filling the pelvic outlet (Fig. 7,
see p 485). Shape differences relate mostly to
the presence or absence of BPH superim-
posed on the basic shape of the prostate be-
fore BPH (Fig. 8, see p 485). Trilobar hypertro-
phy is the most familiar type of BPH, but
~ ~ described BPH
Randall and H i r ~ m a nhave
variations as types I through VIII.
With respect to texture, prostate adenoma
is more fibromuscular and dense than the
soft, acinar-rich composition of the peripheral
zone. After anterior urethral transection at the
apex during the retropubic operation, exces-
sive traction on the Foley catheter (once di-
vided) may produce inadvertent bilateral
splitting of the prostate in the plane between
peripheral zone and adenoma. The larger the
adenoma, the more likely it is that this phe-
nomenon will occur. Freeing the neurovascu-
lar bundles at the apex before urethral tran-
475
section will minimize traction tears in the
prostate.
Suprapubic adenectomy by a transvesical
approach involves anterior index finger frac-
ture of adenoma against what is known as
"capsule," which is attenuated prostate.
Whole-mount axial sections in cases of ad-
vanced BPH show the peripheral zone pos-
terolaterally to be so thinned out that it is
barely recognizable (see Fig. 50). When the
unwary surgeon proceeds to enucleate digi-
tally in retrograde fashion what is believed
to be adenoma, not only adenoma but also
seminal vesicles may be delivered.
PELVIC FASCIA
In looking down into the pelvis after re-
moval of the retropubic adipose tissue in the
retropubic operation, the surgeon appreciates
fascia (superior fascia of the pelvic dia-
phragm, parietal layer of the pelvic [endopel-
vic] fascia) that covers the levator ani sweep-
ing in laterally from the pelvic sidewall
toward the bladder. This lateral fascia de-
scends into recesses or sulci flanking the blad-
der. At the bottom of each sulcus, a white line
of condensed fascia, the fascial tendinous arch
of the pelvis, can be identified with variable
p r ~ m i n e n c e .When
~ ~ prominent, the line of
condensation can be seen to run from the
pubovesical (puboprostatic) ligaments to the
ischial spine. Fascia that sweeps up medially
from these curved white lines of condensed
fascia to cover the bladder is termed visceral
pelvicfascia because it covers an organ. A rich
profusion of large prostatovesical veins exists
beneath this visceral fascia medial to each
fascial tendinous arch. In the retropubic oper-
ation, when the lateral surfaces of the prostate
are exposed, it is important to stay lateral to
the white line when incising the pelvic fascia.
Incision medial to the white line risks entry
into the venous plexus, followed by unneces-
sary hemorrhage.
When the pelvic fascia is incised lateral to
the white line, the levator ani distal to that
incision appears denuded of fascia. When the
levator muscle is pushed laterally away from
the prostate in the retropubic operation, its
fascia remains attached to the lateral surface
of the prostate and the prostatourethral junc-
tion. It is appreciated readily that the fascia
continues to sweep posteriorly, covering the
lateral surfaces of the neurovascular bundles,
which are visible in the groove between the
476 MYERS
prostate and rectum. The fascia continues
from the bundles laterally over the rectum as
an uninterrupted sheet.6 The significance
from a surgical standpoint relates to the
placement of a fascia1 incision above and par-
allel to the bundle for nerve-sparing, bundle-
preserving radical prostatectomy. For wide
resection and bundle sacrifice, the parallel
incision is made below or posterior to the
bundle. When this parallel incision is made
carefully, the complication of rectal entry (rec-
totorny) is reduced. The rectal wall behind
the prostate is notably thin.
A distinct layer of fascia that continues
cephalad to cover the seminal vesicles covers
the posterior aspect of the prostate (Fig. 9,
see p 486). This prostatorectal (Denonvilliers‘)
fascia is generally more adherent to the pros-
tate than it is to the rectum, unless there
is some abnormal condition, such as from
preexistent, excessive transrectal prostate bi-
opsy that produces inflammatory adherence
to the anterior rectal wall. The fascia is de-
fined variably where it meets the bundles
laterally. Some of the most medial nerve fibers
associated with this fascia are prone to sacri-
fice during attempted bundle preservation.
Where the posterior cul-de-sac of peritoneum
meets this fascia varies from the prostatosem-
inal vesicular junction to a line roughly half-
way down the posterior surface of the pros-
tate. The manner in which the prostatorectal
and seminal vesicular fasciae are derived em-
bryologically is controversial. During radical
prostatectomy, the surgeon generally finds
the fascia over the prostate in one layer,
whereas the fascia over the seminal vesicles
often is found in multiple layers. The prosta-
torectal (Denonvilliers’) fascia is important as
a barrier in the spread of prostate cancer52
and should always be included as part of the
resected radical prostatectomy specimen.
In the perineal operation, a plane of dissec-
tion usually is achieved medial to or beneath
the fascia on the lateral surface of the pros-
tate. The surgical anatomic entry line is along
the lateral edge of the prostatorectal (Denon-
villiers’) fascia and medial to the bundle if
preservation of the bundle is a goal. In the
past, when erectile function continued after
operation,’” the operator unknowingly dis-
sected medial to the bundle or in a line paral-
lel through the bundle, leaving some of the
lateral cavernous nerves intact.
PUBOVESICAL (PUBOPROSTATIC)
LlGAMENTS
In reality, the puboprostatic ligaments are
pubovesical ligaments. As is true in the
woman, detrusor muscle in the man extends
to its pubic attachment within pubovesical
ligaments. The only difference between the
sexes is the prostate, which is underneath the
detrusor apron that covers its anterior sur-
face. The ligaments officially may be called
”puboprostatic,” but they are pubovesical
from the beginning of infancy. As the prostate
grows, and especially with the emergence of
BPH, the ligaments take on a progressive pu-
boprostatic appearance; however, this change
is just an illusion. The bladder does not end
where it forms a neck but continues anteriorly
and inferiorly over the anterior prostate (see
Figs. 3 and 10, see pp 485, 486).%Dorschner
and associates8 demonstrated histologically
the unequivocal smooth muscle extension of
the bladder to the pubis anterior to the pros-
tate.
An anatomic appreciation of this continuity
between bladder and pubis is possible grossly
at the time of opening the parietal pelvic (en-
dopelvic) fascia (Fig. 10). Correct medical il-
lustration should show the continuity of liga-
ments with the bladder, not prostate. Because
there is demonstrable anatomic continuity
with the bladder, there are no conceivable
means of preserving the pubovesical (pubo-
prostatic) ligaments in the course of radical
retropubic prostatectomy, and there must be
interruption at some point to expose the
prostatourethral junction. When surgeons de-
clare that they do not take down the pubo-
prostatic ligaments, they mean that they do
not interrupt the continuity of the ligaments
by disarticulation at their junction with the
pubis.19,41 In the perineal operation, the pros-
tate is shelled out from underneath the over-
lying detrusor apron and venous plexus,
thereby entirely avoiding these ligament^.^"
In the rebopubic operation, distal transec-
tion of the ligaments raises the risk for put-
ting the operator too far beyond the prosta-
tourethral junction. This positioning may lead
to sphincteric (membranous) urethral injury
with improper urethral transection and resul-
tant unnecessary urinary incontinence be-
cause the residual urethra is too short. A more
proximal transection of the detrusor apron
at a point superior to the prostatourethral
junction has the potential to protect the entire
continence mechanism. Anatomically, the
zone distal to the prostatourethral junction
should be considered a ”no-man’s land” be-
cause the critical association of the neurovas-
cular structures to the smooth muscle of the *
residual urethra and the enveloping striated
sphincter could be disrupted. The integrity of
this zone relates to preservation of urinary 1
B
 PRACTICAL SURGICAL ANATOMY FOR RADICAL PROSTATECTOMY 477

control and erectile function. Within this area, Table 1. MALE URINARY CONTINENCE ZONE*
nerves come retrograde off the dorsal penile
nerves to innervate the striated ~phincter.3~ Inferior sphincter-sphincteric urethra
Furthermore, important pubourethral fascia
in t h s area supports the continence
CONTINENCE ZONE
In contrast to the situation in the woman,
characterizing an internal versus external
sphincter in the man is difficult because of
the imposition of the prostate. A neat dichot-
omy has been acheved by dividing the male
continence zone into a proximal or superior
sphincter versus a distal or inferior sphincter
separated by the veru. The primary tissues
comprising the urinary control mechanism in-
clude (1)an intact bladder neck with its pre-
prostatic sphincter (internal sphincter); (2)
above the bulb, the inframontanal urethral
wall with its smooth muscle and elastic tissue
and the external striated sphincter; and (3)
the levator ani (puboanalis-puboperinealis
complex34)forming the urogenital hiatus that
flanks the sphincteric (membranous) urethra
(Table 1).
During the course of radical prostatectomy,
the required vascular pedicle ligations dener-
vate the bladder neck or superior sphincter,
and, at endoscopy in the postoperative pe-
riod, the bladder neck remains fixed and
open. The vesical neck closure mechanism is
lost, and the patient is entirely dependent on
what Turner Wanvick and colleague^^^ call
the ”distal continence mechanism.’’
The distal continence zone begins at the
Superior sphincter-vesical neck (preprostatic) sphincter
External striated component
Internal smooth muscle and elastic tissue
component
Levator ani: puboanalis-puboperinealiscomplexM
‘Tissues associated with urinary control include functional
units above and below veru.
seminal colliculus or venunontanum (veru),
the sacrosanct distal limit of transurethral re-
section of the prostate. When apical prostate
overlaps urethra beyond the veru with ure-
thral transection in radical prostatectomy per-
formed at or beyond the apex, patients can
expect a period of incontinence that exceeds
what could be achieved if the transection had
been made just distal to the veru. The unwill-
ingness of surgeons to make transections at
the veru relates to the understandable fear
of leaving the patient with a positive apical
margin, or residual cancer. Sometimes, the
veru is at the apex, in which case transection
at the apex is gratifyingly safe with respect to
preserving the continence zone in its entirety.
These cases can be identified before surgery
by routine retrograde urethrography (Fig. 11).
M R imaging with T2-weighted images in the
midline sagittal plane also may be helpful
(Fig. 12).
OVERLAP OF CONTINENCE ZONE
BY PROSTATE
Preliminary study shows that MR imaging
in the sagittal plane through the sphincteric

Figure 11. Variable distance from veru to bulb (arrowheads) in retrograde urethrography after
transurethral resection of the prostate and before radical prostatectomy. Distance is approximately
1 cm in A and 2.5 cm in 5. (From Myers RP: Radical prostatectomy: Pertinent surgical anatomy.
Atlas Urol Clin North Am 22:1, 1994; with permission.)
478 MYERS
Figure 12. Variable distance from prostate (P)apex to bulb (Bu).Figures are of MR images
in midline sagittal plane. No sphincter overlap by prostate in A (no BPH) or B (BPH,90-g
gland). Significant sphincter overlap by prostate anteriorly in C and posteriorly in D. BI =
bladder; Pu = pubis; SY = seminal vesicle.
(membranous) urethra can identify situations
in which there is significant overlap of the
continence zone (Fig. 12C and D). The overlap
may be anterior, posterior, or anterior and
posterior. BPH does not necessarily signify
overlap (Fig. 12B). As stated previously, in
the presence of significant overlap, standard
technique, which involves transection of the
urethra at the apex or a few millimeters distal
to the apex, may result in unacceptable rates
of urinary incontinence, and the residual ure-
thra is rendered too short. Furthermore, anas-
tomotic technique eats up additional func-
tional urethral length by creating a ring of
fibrosis. The same criticism may apply to
laparoscopic radical prostatectomy if the ure-
thra is transected at the most distal aspect of
the apex of the prostate (Fig. 12C and D).
SPHINCTERIC URETHRA
The urethra from the vem to the bulb is
unique in its sphincteric capacity, and it is
useful to think of this zone as the "sphincteric
urethra" in contrast to the historical, illogical,
and functionally opaque but accepted com-
mon parlance term, "membranous" urethra.
The urethral smooth muscle wall of this par-
ticular segment with its elastic tissue30 is the
most important Component in the distal conti-
nence mechanism. It is an internal smooth
muscle sphincter as opposed to the external
striated sphincter. Recently, the smooth mus-
cle component was suggested to be conceptu-
ally part of an external sphincter.' In this case,
the use of external sphincter is opposed to
internal sphincter as applied to the prepros-
tatic (vesical neck) sphincter. The term sphinc-
teric urethra incorporates both muscle compo-
nents, smooth and striated.
Turner Warwick and colleague^^^ called the
smooth muscle component the "intrinsic
mechanism" and pointed out that it is the
critical element of urinary continence; pa-
tients who are totally incontinent after su-
prapubic enucleation of adenoma presumably
have an undisturbed striated component. Ear-
lier, Krahn and Morales17paralyzed the exter-
nal striated sphincter in postprostatectomy
patients and found continence undisturbed.
In one urethral pressure study, external stri-
ated sphincter and urethral wall integrity
were essential to urinary ~ontinence.~~
On MR imaging, the sphincteric (membra-
nous) urethra is of variable length (mean, 2.0
cm; range, 1.5-2.4 ~ r n )Anatomically,
.~~ the
sphincteric urethra is a cylindrical structure
from the apex of the prostate to the penile
bulb with a flair at its base (Fig. 13, see p
486).%,39 Its coat contains specialized, fine-
caliber, predominantly slow-twitch, striated
muscle that surrounds the urethra from the
apex of the prostate to the superior surface of
the bulb of the penis. The striated muscle is
especially thick anterolaterally and increas-
ingly sparse as it approaches the posterior
midline, where, in the adult, a fibrous raphe
can be identified that forms the most anterior
aspect of the perineal body. It has been
termed horseshoe- and omega-shaped; however,
the cross-sectional shape depends on where
the axial section is made.28Some anterior fi-
bers do not go circumferentially around the
urethra but are anchored in fibrous bands that
flank the sphincter and that provide critical
support (Fig. 14, see p 486). These bands have
been called "pillars" of the prostate.54If the
attachment of its posterior fibers to the raphe
is disrupted, the sphincter flails anteriorly on
either side of the urethra. The observation
that relaxation of the external striated sphinc-
 PRACTICAL SURGICAL ANATOMY FOR RADICAL PROSTATECTOMY 479

ter persists after retractile recovery of the ad-

jacent pelvic floor striated muscle supports
the concept that stream interruption is in-
duced primarily by voluntary contraction of
the fast-twitch pelvic floor. This mechanism
has been called the ”quick stop.”*2The mo-
ment the pelvic floor is relaxed, the stream
immediately resumes, suggesting that the
external striated sphincter stays relatively re-
laxed and reflexly resumes its passive slow-
twitch compression only at the end of urina-
tion.

ABSENCE OF A UROGENITAL
DIAPHRAGM

Neither Turner Warwick,5*the preeminent

practitioner of transsphincteric urethroplasty,
nor Oelri~h?~ the anatomist, found any sup-
port for the concept of a urogenital dia-
phragm as a plate of muscle situated trans-
versely between the ischiopubic rami.
Nevertheless, a muscle sandwich at the apex
of the prostate representing the external stri-
ated sphincter is illustrated widely. Courtney5
noted earlier than Oelrich that, ”the urogeni-
tal diaphragm as depicted in textbooks . . . is
the result of. . . the artist’s imagination rather
than anatomic fact. . . Recent reports have
.’I
Figure 15. Puboperinealis sling (arrowheads) in coronal
MR imaging as markedly thickened lower edges of the
levator ani that embraces the urethra from behind, forms
the urogenital hiatus, and has the anatomic position and
size to function as the primary muscle in the man respon-
sible for quick stop of urination. Bu = bulb; P = prostate;
R = ischiopubic ramus; 0.i. = obturator internus. Midline
sagittal MR imaging confirms that coronal image goes
through perineal body (Inset).

noted that T2-weighted MR images of pros-

tate, external striated sphincter, and bulb do
not show any evidence of a urogenital dia-
~ h r a g m 34
. ~Histologic
, findings in axial, sagit-
tal, or coronal planes also fail to show evi-
dence of a urogenital diaphragm. In some
coronal sections of some individuals, the thin
perineal membrane can be seen in whole or
in part at the most posterior aspect of the
bulb, but not where the urethra perforates the
bulb. In most coronal MR images of the pelvis
in living patients, it is difficult to visualize
the perineal membrane (Fig. 15).At the point
where the urethra perforates the bulb, the
corpus spongiosum is convex upward in the
living state. The fibrofatty anterior recess of
each ischioanal fossa and the puboperinealis
portion of the levator ani flank the external
striated sphincter. There is not even a hint
of what might be called Henle’s artifact, his
“diaphragma ~rogenitale.”’~ Medical illustra-
tions that show a transverse plate of muscle
indicated as “urogenital diaphragm” or ”ex-
ternal sphincter” immediately distal to the
prostate apex constitute egregious error; those
plates of muscle represent a portion of the
levator ani.
LEVATOR AN1
Historically, the levator ani adjacent to the
apex of the prostate has been illustrated as
thin and tapering to the point where a hiatus
(urogenital hiatus39)allows passage of the
sphincteric (membranous) portion of the ure-
thra.’, 38 MR images (Fig. 15) and whole-pelvic
cadaveric coronal sections through the prosta-
tourethral junction show the levator ani (pel-
vic diaphragm) adjacent to the prosta-
tourethral junction to be notably thicker than
the relatively thin sheet of levator (also pelvic
diaphragm) applied directly to the lateral sur-
faces of the prostate. Other investigators have
confirmed this bulbous thickening?, 7,25,39 This
observation can be made with forceps after
the endopelvic fascia has been opened and
the levator muscle has been pushed to one
side away from the lateral surface of the pros-
tate and prostatourethral junction. In the man,
this thickened levator is disposed as a distinct
puboperinealis component of the otherwise
broad expanse of levator ani that forms the
pelvic diaphragm.34The thick bands of mus-
cle that comprise the puboperinealis portion
480 MYERS
of the levator ani form the urogenital hiatus.
The urogenital hiatus, in turn, flanks the
sphincteric (membranous) portion of the ure-
thra. The puboperineales, as part of the adja-
cent levator muscle shown to have predomi-
nantly fast-twitch capability,’* are anchored to
the pubes anteriorly and to the perineal body
directly behind the urethra, forming a poten-
tial sling mechanism. The puboperineales, as
part of the puboanalis-puboperinealis com-
~ l e x , ”are
~ situated anatomically and ideally
to have specialized function and are suited
ideally for the quick stop phenomenon of uri-
nation3s (Fig. 15). As shown elegantly in T2-
weighted MR images by Mikuma and col-
leagues? contraction of this portion of the
levator ani produces upward and forward
movement of the prostate and bladder and
forward movement of the rectum. Three-di-
mensional reconstruction of the Visible Hu-
man data set also confirms the slinglike dis-
position of this greatly thickened levator in
the man, which is anchored to the perineal
body behind the urethra? This portion of the
Ievator, like the external striated sphincter, is
innervated by the pelvic nerve.14 Because of
its assumed ancillary role in urinary conti-
nence, the puboperinealis portion of the leva-
tor ani should not be sutured into the vesi-
courethral anastomosis to function properly
after radical prostatectomy.
ARTERIES
Although control of the venous plexus is
the major impediment to obtaining a dry
field, attention to securing the arterial supply
of the prostate is also important in radical
prostatectomy.
Derived from a branch of the internal iliac
(hypogastric) artery, arteries of the main vas-
cular pedicle to the prostate are found at the
right and left base of the gland at the prosta-
tovesical junction. The major pedicle supplies
the prostate and base of bladder, including
the vesical neck, but small arterial branches
accompany the neurovascular bundles run-
ning along the posterolateral aspect of the
prostate. The bundle, in turn, provides ran-
domly situated, tiny, arterial branches as com-
ponents of the capsular micropedicles, which
are readily identifiable with loupe magnifica-
tion during surgery (see Fig. 3). At the apex
of the prostate, arterial branches continue to-
ward the penis. Suture ligation and oversew-
ing of the venous plexus anterior to the ure-
thra beyond the apex result in interruption of
some tiny secondary arteries to the penis that
run with the veins.
In addition to the capsular branches, inter-
nal prostate arterial branches exist, predomi-
nantly at the 5-, 7-, 11-,and 1-o’clock positions
of the bladder neck as viewed endoscopically
at the time of planned transurethral resection
of the prostate, or from above during the
conduct of suprapubic adenectomy.ll
Occasionally, in the radical retropubic oper-
ation, a pudendal artery with or without an
accompanying vein can be identified coursing
unilaterally or bilaterally in the sulcus on ei-
ther side of the prostatovesical junction.
These arteries arise from the internal iliac ar-
tery and dive into the fascia between, or close
to, the pubovesical (puboprostatic) ligaments.
They may be free or partially bound laterally
into the pelvic fascia (superior fascia of the
pelvic diaphragm). Because the prostate is an-
atomically beneath these arteries, it is often
possible to save them with meticulous dissec-
tion, thereby improving postoperative penile
arterial perfusion. When particularly large,
they may constitute the only arterial supply
to the penis (Ajay X. Nehra, MD, personal
communication, April 7, 2000).
For the most part, blood supply to the sem-
inal vesicles and ampullae of the vasa defer-
entia is located variably on their respective
surfaces. An almost constant supply comes in
at the tips of the seminal vesicles and laterally
in association with the major pedicles to the
prostate. Almost uniformly a prominent ar-
tery exists between the ampulla of the vas
deferens and the seminal vesicle.
In the perineal operation, the pudendal ar-
tery branches that need to be protected serve
the anal canal and anal sphincters posteriorly
and the external striated sphincter and penis
anteriorly. The arteries to the bulb and base
of the external striated sphincter come in lat-
erally toward the midline under cover of the
superficial transverse perinei muscles. Too
vigorous retraction (at the 10- and 2-o’clock
positions that are the common retraction
points of the inverted U-shaped perineal inci-
sion) could injure the blood supply to the
sphincter and the nerve supply.
VEINS
One of the most vexing parts of radical
prostatectomy entails control of the venous
plexus associated with the prostate but pri-
 PRACTICAL SURGICAL ANATOMY FOR RADICAL PROSTATECTOMY
marily present to drain the penis. This situa-
tion renders the common parlance name,
”dorsal vein complex of the penis.” Other
names include ”Santorini’s” or “pudendal”
plexus. Once it comes under the pubic arch,
the dorsal vein complex divides into anterior
and posterior divisions relative to the prostate
and prostatourethral junction. Because it con-
tains arteries and veins, the anterior division
becomes a ventral vascular plexus with re-
spect to the prostate and urethra in the con-
duct of radical prostatectomy. Some veins of
variable size also accompany the neurovascu-
lar bundles. MR T2-weighted images often
show veins posterolateral to the prostate.
Asymmetry of the veins with respect to the
prostate is common, and the number of veins
branching from the neurovascular bundles to
course over the lateral surface of the prostate
to enter the ventral plexus is variable.
As mentioned previously, if there is sig-
nificant anterolateral BPH expansion of the
prostate at the apex and a broad commissure,
the venous plexus rides up, leaving an acces-
sible, relatively avascular space for the inser-
tion of a right angle for the purpose of venous
ligation.A?If there is no BPH, there will be
relatively little space; the venous plexus will
come off the urethra and enter the vesicoven-
ous plexus after passing a narrow prostate
commissure. In this situation, passage of a
right angle could lead to tremendous bleed-
ing from disruption of the venous complex at
the prostatourethral junction. Also, the exter-
nal striated sphincter is subject to damage
(see Fig. 3).
In the initial exposure of the vesical visceral
fascia in the retropubic operation, the retropu-
bic adipose tissue (fat) must be removed gin-
gerly to avoid disruption of a preprostatic
vein with potential serious blood loss if the
vein is large. The vein arises from the dorsal
vein plexus of the penis and usually is found
coming out into the fat from between the
pubovesical (puboprostatic)ligaments. It then
promptly reenters the vesicovenous plexus in
most men. In approximately 10% of patients,
no preprostatic vein is found. The vein is in
the midline in 80% of men and associated
with a left or right pelvic sidewall branch in
another
NEUROVASCULAR BUNDLES
As defined by Walsh and c0lleagues,5~pres-
ervation of the neurovascular bundles by
481
leaving them in situ and intact during pros-
tate removal leads to resumption of erectile
function and satisfactory intercourse for a sig-
nificant number of patient^.^, 58
In the axial (transverse) plane through the
midprostate, the bundles have a crescentic
disposition with respect to the posterolateral
capsule of the prostate (Fig. 16, see p 486).
Veins exist in variable profusion from the top
to the bottom of the bundle. Arteries are visi-
ble. Major nerves are seen in the midbundle
but may be applied closely to the capsular
surface. It is clear from the crescentic distribu-
tion that the nerves at the tips of the crescent
and those closely juxtaposed to the capsular
surface are most vulnerable to injury during
attempts to “save the nerves.” Imprudent ve-
nous hemostasis along the top of the bundle
may snare underlying cavernous nerves.
Nerves running in the crescentic tip along the
prostatorectal (Denonvilliers’) fascia may be
sacrificed easily when the fascia is divided
laterally. The surgeon’s goal should be to min-
imize nerve attrition at vulnerable points.
Wide resection may leave some of the most
peripheral nerves intact because the operator
simply has bisected the length of the bundle.
The relationship of the bundles to the pros-
tate is variable depending on the girth or size
of the prostate in the midaxial plane. This
element, in turn, is related directly to the
presence or absence of BPH. If the prostate is
large, such as in massive BPH, the bundles
may be obscured because they are tucked
more posteriorly. If the prostate is relatively
small, such as in the absence of BPH, the
bundles will take up a more lateral position
with respect to the prostate.
The bundles have a fixed relationship to the
underlying rectum. From the vesicoprostatic
pedicles that have been ligated and divided
at the base of the prostate, the bundles form
the sides of an isosceles triangle with the
bladder as its base and the urethra as its apex.
The triangle is essentially the same size no
matter what size prostate is lifted away from
the bundles. In the perineal operation, the
prostate must be brought through the trian-
gle, leaving alone the delicate junction points
of the bundle at the external striated sphincter
and prostate pedicle.
All along the course of the bundles, micro-
pedicles (tiny arteries, veins, and nerves) are
found that supply in no consistent pattern
the adjacent prostate capsule and tether the
bundles to the posterolateral surface of the
482 MYERS
prostate (see Fig. 3). Considering perineural
space invasion as a phenomenon in the local
extraprostatic spread of prostate adenocarci-
noma, Villers and found discrete
major superior and minor inferior capsular
nerve groups and nerves in between (middle
region) in one third of cases. Lepor and asso-
ciatesI8 also clearly showed that nerves
(which can be seen with surgical loupes) ac-
company capsular vessels. Each micropedicle
must be divided to release the bundle and
thereby preserve the cavernous nerve supply
to the penis. As emphasized by Walsh and
c0lleagues,5~a particularly prominent micro-
pedicle needs identification and division at
the apex adjacent to the prostatourethral junc-
tion.
At the junction of the prostate and bladder
at the base of the vascular pedicle, there are
many ganglia in what constitutes the prostatic
plexus. Proper pedicle transection preserves
the ganglia, the important switches in a sys-
tem of “wires” that make up the bundles. The
bundles are applied closely to the posterolat-
era1 surfaces of the seminal vesicles, and the
tips of the seminal vesicles are embedded in
the pelvic plexus.
The bundles should be thought of as car-
rying not only the cavernous nerves for erec-
tile function but also autonomic innervation
to the sphincteric (membranous) urethra.
LYMPHATICS
The lymphatics of the prostate gland
proper are microscopic and rarely are seen
grossly during surgery. In contrast, the lym-
phatics that leave the prostate to drain into
the pelvic lymph nodes are often apparent.
The major immediate nodal groups that re-
ceive lymphatic drainage from the prostate
are the obturator, internal iliac, external iliac,
presacral, and para-aortic nodes. Rarely, a
small node is found in association with the
main vascular pedicle. Cancer cells do not
always travel to the closest nodal groups, the
obturator and internal iliac nodes, which are
the most common groups removed in the
course of limited routine pelvic lymphadenec-
tomy. Metastasis may occur first in the exter-
nal iliac and presacral node groups.
SUSPENSORY LIGAMENT OF THE
PENIS
The midline penile fundiform ligament sus-
pends the penis and is continuous above with
the membranous layer of the superficial ab-
dominal (Scarpa’s) fa~cia.4~Below, it is contin-
uous with the superficial penile fascia. In the
retropubic operation, if the lower midline in-
cision is carried too close to the penis, the
suspensory ligament can be drawn upward
into the inflammatory process of the healing
wound, leading to apparent postoperative
foreshortening of the penis.
PERINEUM
The perineal skin has a prominent raphe
that continues in the subcutaneous tissue as
a fibrous midline raphe of variable thickness.
The superficial or subcutaneous anal sphinc-
ter is disposed on either side of this raphe.
On the way to the prostate in the perineal
operation, a distinct layer of subcutaneous
fascia is encountered and must be incised
with care to avoid damage to the nerve sup-
ply of perianal structures, including the anal
sphincters.
ANAL SPHINCTERS
From a practical standpoint, the anal
sphincters can be thought of as the subcutane-
ous superficial external (superficialsphincter)
and deep external (deep sphincter), with the
deep external continuous with the puboanalis
(puborectalis) portion of the pelvic dia-
phragm of levator ani directly above it. The
external anal sphincter is apposed to an inter-
nal smooth muscle sphincter surrounding the
anal canal. The superficial sphincter consists
of opposing bow-shaped extensions on either
side of the anus.34The anterior extension is
associated intimately with the central, or me-
dian, perineal raphe anterior to the anus and
its tendinous insertion in the midline to the
inferior surface of the bulb. It does not attach
to the perineal body at the level of the super-
ficial transverse perinei as shown so often
in textbook illustrations. Bow-shaped fibers
extend backward toward the tip of the coccyx.
Some superficial sphincter fibers insert subcu-
taneously in front of and behind the anus. In
the perineal operation, its attachment to the
bulb allows the creation of a retrobulbar space
by insertion of the tip of an index finger be-
neath it (Fig. 17, see p 486; and Fig. 18, see
p 483).
The ”central tendon” in descriptions of the
perineal operation is a combination of super-
ficial sphincter and midline fibrous tissue ra-
 PRACTICAL SURGICAL ANATOMY FOR RADICAL PROSTATECTOMY
Figure 18. Young versus Belt routes past the superficial external anal
sphincter with results A. 6.and C. Each route provides entry to the
retrobulbar space.
phe. “Taking down” the central tendon
means one of three possibilities: (1) sphincter-
preserving transection of the fibrous attach-
ment of the superficial sphincter at its junc-
tion with the bulb (Young technique, Fig.
18A); (2) transection of the sphincter on both
sides of the midline together with fibrous ra-
phe tissue (also, Young technique, Fig. ZSB);
or (3) going just above the anus and through
or beneath the sphincter and retracting it as
a circumferential band (Belt technique) (Fig.
18C). From an anatomic standpoint, any mid-
line reconstruction, as is customary in wound
closure, should be functionally equivalent for
A, €3, and C.
Much hoopla is made of the Young versus
Belt technique.*,6o Both techniques involve the
superficial sphincter, which can be sacrificed
in fistulotomy without affecting anal conti-
nence. Neither technique involves the deep
sphincter that is bound closely and circumfer-
entially to the wall of the anal canal. In either
technique, the subcutaneous midline tissues
that include subcutaneous sphincter fibers an-
terior to the anus should be reconstructed
carefully on wound closure during the peri-
neal operation.
The deep anal sphincter is key to anal con-
tinence and should not and does not need to
be disturbed. A plane should not be devel-
oped beneath it. It is only necessary to dis-
place the superficial sphincter to reach the
“rectourethraliscomplex,” whose point of at-
tachment is appreciated by digital palpation
of the anterior dimple at the anorectal junc-
tion (Fig. 19, see p 486). The deep sphincter,
which is closely applied circumferentially
about the anal canal from the superficial
483
sphincter to the anorectal junction, is in-
termeshed and continuous posteriorly with
the puboanalis (puborectalis) portion of the
pelvic diaphragm (see Fig. 17). Some of its
fibers may interdigitate with the bulbospongi-
osus and the puboperinealis portion of the
levator ani. Once the retrobulbar space is en-
tered after division of the central tendon, the
dissection should proceed anatomically and
directly to the rectourethralis attachment,
exposing only the white external surface of
the anorectal junction.
ANAL CANAL
The anal canal is 3 to 4 cm in length and
angles forward toward the anorectal junction.
The anal canal is much thicker than the rec-
tum above because of the presence of the
internal anal sphincter. At the anorectal junc-
tion, there is an abrupt change in tluckness,
and, at this point, the injurious midline rec-
totomy may occur in the perineal operation.
The area called rectum in descriptions of
radical perineal prostatectomy by perineal
prostatectomists is really anal canal until the
”rectourethralis” attachment is reached. No-
menclature changed in 1950 as a result of a n
agreement by anatomists of the International
Anatomical Nomenclature Committee in
Paris. Before that consensus, the anal canal
was a part of the rectum, and referring to the
anal canal as rectum was not incorrect. Since
1950, the anal canal has been considered a
separate entity by anatomists and colorectal
surgeons. Nevertheless, the nomenclature still
is muddIed because terms such as inferior
484 MYERS

Figure 1. Normal adult prostate of 44-year-old man in midaxial S-100 section. Smooth muscle
bundles (arrowheads) of the detrusor apron mix with veins, arteries, and nerves across anterior
surface of prostate in a ventral neurovascular plexus. AFMS = anterior fibrornuscular strorna; CZ =
central zone; PZ = peripheral zone; U = urethra. Neurovascular bundles at posterolateral periphery
are outfined. Nerves by 5-100immunostaining are prominent orange bodies. Prostatorectal(Denonvil-
liers’) fascia is not well defined in this specimen. (The stain does not allow clear demarcation of the
periurethral transition zone and smooth muscle of the preprostatic sphincter.)

Figure 2. Benign prostatic hyperplasia. Radical prostatectorny specimen cut in the sagittal plane
through adenoma (1) and urethra (2) with apex to the lefl and seminal vesicles to the right. Marked
compression of peripheral zone (3). Veru and ejaculatory duct are seen posteriorly. Note marked
anterior angulation of the urethra at the veru.

Figure 3. Capsular micropedicles tether neurovascular bundle to nonhyperplastic prostate (A) and
hyperplastic prostate (6). Blue = veins; red = arteries; green = nerves. BI = bladder; Bu = bulb;
P = prostate; Pu = pubis; S = sphincter; sv = seminal vesicle. Distance from end of detrusor
apron (arrowheads) to prostatourethraljunction is short for A and long for 6.(Prostate outlines are
taken from MR images obtained before radical prostatectorny.)

Figure 4. Prostatourethraljunction in whole-mount, midline, sagittal, Masson trichrome section shows

anterior cornrnissure (1) of prostate (P) and striated sphincter (2) about urethra (U).Lower urethro-
bulbar section is slightly paramidline sagittal and shows rectum (R), puboperinealis(3),bulbourethral
gland (4), and corpus spongiosum (5).Rectoperinealisabove (upper arrow) and anoperinealis (lower
arrow) below anorectal flexure.
Figure 6. Contrasting prostate apices. A, Apical notch of cadaveric “croissant” prostate. Note veru.
Same prostate with urethra intact to show its insertion into the notch (Insef). B, “Doughnut,” or
toroidal, apex of radical prostatectomy specimen with no notch configuration.

Figure 7. Variation in prostate size in radical prostatectorny specimens. A, 15-g prostate. 6,200-9
prostate with benign prostatic hyperplasia.

Figure 8. Variation in adult prostate apex in radical prostatectorny specimens. Insets, Juvenile
phenotypes (both from 16-year-oldcadavers). A, Simultaneous anterior and posterior apical notches
in the adult prostate. B,“Cliff-type’’ apex that is broad, flat, and vertical (perpendicularto the urethra),
with pronounced, anterolateral benign prostatic hyperplasia expansion.
Figure 1. Flgure 2.

Figure 3.

Figure 4.

Figure 6.

Figure 8. Figure 7.
485
 Figure 9. Figure 10.

Figure 13. Figure 14.

Figure 16.

Figure 17. Figure 19.

486
 PRACTICAL SURGICAL ANATOMY FOR RADICAL PROSTATECTOMY 487

Figure 9. Prominent prostatorectal (Denonvilliers’) fascia of cadaveric gross specimen with “terminal
plate” (arrowhead) at prostate apex. Prostate (P) has been dissected off rectum (R). Photograph
proves that final cut to release the apex in the retropubic operation is not “rectourethralis,” which is
distal to ordinary point of transection.

Figure 10. Detrusor apron. With pelvic fascia open, prostate (P)sits beneath thick overlying vesico-
venous plexus and extension of detrusor to pubis (Pu). Pubovesical (puboprostatic)ligaments (arrow-
heads) clearly go to bladder, not prostate.

Figure 13. External (striated) sphincter (S) extends distally from prostate (P) and fans out to join
bulb (Bu)of penis below. Portion of transverse ligament of the perineum (arrowheads). (From Myers
RP: Radical prostatectomy: Pertinent surgical anatomy. Atlas Urol Clin North Am 22:1, 1994; with
permission.)

Figure 14. Lateral fascia1 bands (prostato-ischialligaments,Walsh’s pillars, arrowhead)flank vascular

plexus (removed) anterior to prostate (P) and anchor the vertically oriented external striated sphincter
(S). BU = bulb.

Figure 16. Neurovascular bundles magnified from Figure 1. Not discounting possible artifact, note
proximity to prostate capsule of major nerves on right compared with left. Many tiny nerves are
associated with prostate visceral fascia on both sides. Veins (v) and arteries (a) are distributed
differently within the bundle on the two sides. PZ = peripheral zone.

Figure 17. Anal sphincters in simplified outline. a.c. = anal canal; ACL = anococcygeal ligament;
Bu = bulb: C = coccyx; 0 = deep external anal sphincter; P = prostate; Pa = puboanalis
(puborectalis); R = rectum; S = urethral sphincter; Se = superficial external anal sphincter. Black
spikes at anorectal junction: upper, rectoperinealis; lower, anoperinealis. = retrobulbar space.

Figure 19. Dimple that marks anorectal junction distal to prostate (P) apex where rectum (R) and
anal canal (ax.) meet in a fresh (4-hour) cadaveric specimen. Sv = seminal vesicle.
488 MYERS
rectal arteries, veins, and nerves currently ex-
ist. These designations should be renamed
anal arteries, veins, and nerves as recom-
mended by the Jena Nomina Anatomica in
1935.16The clinician should use the term ischi-
ound fossa and not ischiorecfal fossa. If Roux
were alive today, he might have arrived at
“ano-urethralis” as opposed to his “recto-ure-
thralis.”15
RECTOURETHRALIS COMPLEX
Although the name is figurative and widely
used, ”rectourethralid’ is among the misno-
mers that grace a frequently imprecise and
misleading pelvic floor nomenclature. Actu-
ally, inferior to the anorectal junction, there is
longitudinal muscle that comes off the outer
longitudinal smooth muscle of the anal canal
and that anchors into the midline fibrous tis-
sue at the top of the bulb, the male perineal
body. This muscle is the anoperinealis, TA.9
Similarly, above or superior to the anorectal
junction, outer longitudinal muscle of the
midline rectal wall descends to anchor in the
perineal body distal to the prostate. This mus-
cle is termed recfoperineulis, TA. Neither the
anoperinealis, which is more luxuriant than
the rectoperinealis, nor the rectoperinealis has
any direct connection to the urethra. The an-
operinealis and rectoperinealis contribute to
the “rectourethralis” complex, the common
figurative expression. In the perineal opera-
tion, the apex of the prostate cannot be ex-
posed without division of this fibromuscular
complex. In the retropubic operation, the
complex can be avoided entirely (see Figs. 4,
9, and 17),and descriptions of posterior apical
transection of the prostate that instruct divi-
sion of the rectourethralis are anatomically
incorrect. The area that is divided is the fi-
brous continuity (Stamey’s “terminal plate”47)
of the prostatorectal fascia with the perineal
body (see Fig. 9). Some striated sphincter fi-
bers often appear at the lateral aspects of
the posterior division, but the transection is
primarily fascial. MR imaging shows that
midline adherence of the rectourethralis com-
plex of the anorectal junction begins inferiorly
with attachment of the anoperinealis to the
upper aspect of the bulb (the lower aspect of
the perineal body).%It ends superiorly with
attachment of the rectoperinealis to the peri-
neal body. On h4R imaging, the anoperinealis
and rectoperinealis appear as hypointense
black bands34that correspond to smooth mus-
cle bands in the same region (see Fig. 4).
PERINEAL NERVES
The pudendal nerves stream in on either
side of, and deep to, the anus and course
anteriorly toward the ischiopubic arch.
Branches are given off to the anal sphincters,
the scrotum, the striated urethral sphincter,
the bulbospongiosus and ischiocavernosus
muscles, and the penis. The pudendal nerve
supply is somatic and autonomic, the former,
motor and sensory, and the latter, sympa-
thetic and parasympathetic. The best way to
avoid these nerves during radical prostatec-
tomy is to stay as close to the midline as
possible at all times during dissection.
The effect of fixed retractor systems on the
delicate neurovascular anatomy deserves con-
sideration. Fixed retractor systems have be-
come popular, but the constant force of retrac-
tor blades against perineal muscle and
pudendal neurovascular structures risks pres-
sure injury. Adhering as much to the midline
as possible with intermittent retraction by
hand-held retractors in the hands of an assis-
tant should be potentially more protective of
nerve fibers subserving sphincteric function,
urinary and fecal. Gentle retraction should
reduce any period of incontinence to a mini-
mum. In the course of the perineal operation,
major retraction is necessary at the 10 and 2
o’clock positions precisely at the points where
the pudendal nerve supply approaches the
external striated sphincter under cover of the
superficial transverse perinei.
SUMMARY
Practical guidelines in surgical anatomy for
radical prostatectomy can be summarized as
follows:
1. There is significant individual variation
in the anatomy of the male pelvis.
2. The prostate is covered anteriorly by a
prominent detrusor apron.
3. Prostates vary with respect to size and
shape.
4. BPH compresses and flattens the periph-
eral zone.
5. In reality, the puboprostatic ligaments
are pubovesical ligaments.
6 . The dorsal vein complex of the penis is
 PRACTICAL SURGICAL ANATOMY FOR RADICAL PROSTATECTOMY
a neurovascular plexus of veins, arteries,
and nerves situated primarily ventral to
the prostate and urethra.
7. The urethra from the verumontanum to
the penile bulb is sphincteric, with its
smooth muscle and elastic tissue compo-
nents primarily responsible for postpros-
tatectomy urinary continence.
8. Multiple micropedicles tether the neuro-
vascular bundles along the entire pos-
terolateral aspect of the prostate.
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Address reprint requests to
Robert P. Myers, MD
Mayo Clinic
200 First Street SW
Rochester, MN 55905