Radical prostatectomy: the nerve-sparing pelvis

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. Drop the bladder: space of Retzius The retropubic fat is swept off the anterior abdominal wall until the endopelvic fascia is seen as a glistening line spanning from pubis to prostate. The puboprostatic ligaments, the dorsal venous complex and the balloon of the catheter are fixed as the landmarks every later step returns to. The bladder is peeled posteriorly off the pubis in an avascular plane, and fat that refuses to sweep usually marks accessory pudendal vessels, which are preserved rather than divided. Establishing these reference points early keeps the apex dissection oriented when the view tightens later in the case.
2. Bladder neck dissection The plane between bladder and prostate is entered anteriorly at 12 o'clock, where the fat line between smooth bladder wall and prostatic surface marks the junction. Scissors and bipolar develop the plane laterally until the catheter can be hooked through and used as traction. The neck is then transected exactly at the prostate, cutting close to the gland all the way round. The orifices are protected by that discipline and by looking for efflux as soon as the neck is open. A median lobe pushes the neck posteriorly, so the plane is re-found anterior to it rather than hunted for inside the bladder.
   where it bites: too wide catches the ureteric orifices; too narrow opens into the adenoma.
3. Seminal vesicles + vasa The vasa are clipped and divided within the pelvis and each seminal vesicle is freed toward its tip, where the small artery entering it is controlled before the gland is lifted. Working close to the vesicles keeps the dissection away from the pelvic sidewall and everything crossing it. Once both vesicles are delivered, their tips mark the entry to Denonvilliers’ fascia, and the posterior layer is incised there to expose the pearly plane below. Starting the posterior dissection anywhere other than this defined point is how the plane is lost before it is found.
4. Denonvilliers’ plane The posterior layer of Denonvilliers’ fascia is incised between the vesicle tips and the plane between the prostate-vesicle packet and the rectum is developed with blunt sweeping, keeping the fascia on the specimen. The rectum falls away as pale, avascular tissue opens, and fat that looks lobular or yellow means the plane has strayed, so the dissection stops and re-enters where the tissue is clean. Development continues to the apex so the rectum is safely off the specimen before the lateral work begins. Every posterior error in this operation is made one layer too deep, which is why the plane is entered under direct vision and widened, never forced.
   where it bites: the rectum is the next layer down; stay on the fascia.
5. Neurovascular bundles released Each lateral pedicle is clipped and divided athermally in short steps, cutting between clips rather than using energy, so heat never crosses to the bundle running on its posterolateral surface. The bundle is peeled off the prostatic fascia with gentle blunt dissection, kept under no traction and followed from the pedicle to the apex. Clips go on the prostatic side and the pedicle is released so the bundle drops back into the pelvis with its blood supply intact. Tissue that refuses to peel is read as disease at the capsule, and the plane on that side is converted to wide excision.
   where it bites: thermal or traction injury to a bundle that should have been spared; sacrifice is a cancer decision, not an accident.
6. DVC + urethra at the apex The dorsal venous complex is ligated or suture-controlled anterior to the urethra and divided close to the prostate, with the field kept dry rather than diathermised through the complex. The urethra is then divided flush with the prostatic apex with a cold blade, as far distally as the cancer allows, so maximal functional length and rhabdosphincter fibres stay with the patient. The remaining posterior attachments are released and the specimen is delivered. The stump left behind carries both the continence mechanism and the future anastomosis, which is why the cut is made once, deliberately, in a dry field.
   where it bites: the continence and the anastomosis both live on this stump.
7. Vesicourethral anastomosis The bladder neck is tailored to match the urethral stump and a running suture joins bladder mucosa to urethral mucosa circumferentially over a new catheter. Each pass takes a generous ring of bladder and a full thickness of urethra so the anastomosis is mucosa-to-mucosa and tension-free, and the suture ends are tied only once the running closure is complete. The bladder is filled through the catheter to test the closure watertight and a pelvic drain is left dependent in the pelvis. Leak and contracture are both born here: a leak from an imperfect closure and a contracture from an ischaemic or overlapping one, which is why the anastomosis is finished in a dry, unhurried field.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

Evidence and guidance