Fig. 53.1
Old Heilbronn technique. (a) Division of puboprostatic ligaments. (b) Distal stitch of dorsal vein complex. (c) Incision of endopelvic fascia and levator fasica (red arrows). (d) Dissection along the naked levator fascia
![A331567_2_En_53_Fig2_HTML.gif](https://i0.wp.com/abdominalkey.com/wp-content/uploads/2017/10/A331567_2_En_53_Fig2_HTML.gif?w=960)
Fig. 53.2
Posterior reconstruction. (a) Schematic drawing according to Rocco et al. [8]: Suture between posterior raphe (rectourethralis muscle = 3a) and vesico-prostatic muscle (3b). Laparoscopic technique does not include everting sutures of bladder mucosa (=4) or pre-placed stitches of urethral lissosphincter (=2). Posterior reconstruction reduces also tension on neurovascular bundles (NVB). (b) Endsocopic view of prosterior reconstruction
![A331567_2_En_53_Fig3_HTML.gif](https://i0.wp.com/abdominalkey.com/wp-content/uploads/2017/10/A331567_2_En_53_Fig3_HTML.gif?w=960)
Fig. 53.3
New Heilbronn technique. (a) Preservation of pubo-prostatic collar. (b) Proximal stitch of dorsal vein complex (i.e. mid-portion of prostate). (c) Incision of endopelvic fascia and preservation of levator fasica by blunt dissection (black arrows). (d) Endoscopic view of anatomic details during lateral and apical dissection with preservation of levator fascia
53.2.2 Anatomical and Physiological Considerations
As already pointed out by Walz et al. [29], the nomenclature and description of the pelvic anatomy differs in many articles. Basically anatomical and eponymical description can be distinguished, however, some authors also used different terminologies (Table 2). In the following we summarize the anatomical details described in the current literature.
53.2.2.1 Periprostatic Fascial Anatomy
Walsh described three layers covering the anterolateral surface of the prostate [22]: the prostatic fascia overlaying the prostatic capsule and levator fascia (fascia diaphragmatica pelvis superior). Both fascias fuse laterally to form the lateral pelvic fascia covered by the endopelvic fascia (fascia pelvis parietalis) reflecting off the transversalis fascia. This area also is described as tendinous arch of the pelvis. Posteriorly, there are two layers [23]: Denonvilliers’ fascia (Prostato-seminal-vesicular fascia; septum retrovesicale) and the prostatic capsule (Fig. 53.4). The neurovascular bundles (NVB) run along the posterolateral part of the prostate between levator and prostatic fascia and contain branches from the inferior vesical arteries running medial to cavernosal nerve branches originating from the pelvic plexus. These vessels enter the capsule through the prostatic fascia [38]. Some authors describe the levator fascia also as periprostatic or parapelvic fascia [24, 25].
![A331567_2_En_53_Fig4_HTML.gif](https://i0.wp.com/abdominalkey.com/wp-content/uploads/2017/10/A331567_2_En_53_Fig4_HTML.gif?w=960)
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Fig. 53.4
Fascial anatomy of the Prostate according to Walsh 1999. Definition of levator fascia, prostatic fascia, Denonvillers’fascia, and rectal serosa
53.2.2.2 Course and Branches of Pudendal Nerve
For preservation of continence, the course of intra-pelvic branches of the pudendal nerve is more relevant than the course of neurovascular bundles [5, 34]. The N. pudendus has three branches, (i) nervi rectales inferiors, (ii) nervi perinealis and (iii) nervus dorsalis penis. The perineal rami support the penile muscles (m. bulbospongiosus, m. ischiorectalis, m ischiocavernosus) and the striated urethral sphincter. Lesions of the perineal branches lead to incontinence. Thus, the anatomical course of pudendal vessels and nerve is important regarding postoperative continence after radical prostatectomy. A., V. and N. pudendus enter the small pelvis through the Foramen ischiadicus minus then following the canalis pudendalis (Alcock’s canal). Thereafter the nerve divides medially into its three branches. The perineal rami supporting the striated urethral sphincter run underneath the levator fascia (fascia diaphragmatica pelvis superior) as demonstrated by Hollabaugh et al. [34].
53.2.2.3 Anatomy of Urethral Sphincter Apparatus and the Bladder Neck
The urethral sphincter apparatus consists of the horse-shoe-shaped rhabdosphincter and the smooth-muscle longitudinal and circumferential lissosphincters [29]. Additionally, the prostate is connected laterally to the urethra by thickened fascial band components (Walsh’s pillars, Müller’s ischioprostatic ligaments). Anteriorly, puboprostatic (pubo-vesical) ligaments suspend the urethra. For preservation of the puboprostatic collar it is important to keep this part completely intact (Fig. 53.5). Posteriorly, the sphincter apparatus is supported by the median fibrous raphe respectively rectourethralis muscle [22, 23, 31]. Additionally, the striated sphincter is flanked by thickened anteriomedial edges of the anterior levator ani muscle (i.e. urogenital hiatus) forming an incomplete sling behind the urethra. On contraction they forcefully propel the prostate and prostatourethral junction upward and forward enabling quick stop of urination [23, 33, 34]. This movement is countered by the horse-shoe shaped striated sphincter contracting downwards and backwards.
![A331567_2_En_53_Fig5_HTML.jpg](https://i0.wp.com/abdominalkey.com/wp-content/uploads/2017/10/A331567_2_En_53_Fig5_HTML.jpg?w=960)
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Fig. 53.5
Endoscopic view of pubo-prostatic collar
The precise anatomy of the bladder neck and its effect on continence has proven difficult to clarify [16–18, 23]. In the transverse plane, the bladder neck (BN) is composed of two different muscles, the ventrolateral and dorsal longitudinal muscles, which are positioned in an oblique direction. When the BN is examined in a truly transverse direction, there is a distinct circular muscle called the musculus sphincter vesicae [23] possibly representing the rationale for bladder neck preservation.
53.2.2.4 Neurologic Aspects of Urinary Continence Mechanism
Both, the somatic pudendal nerve and the autonomic branches of the pelvic plexus are involved in urinary continence mechanism. Somatic motor innervation passes from the anterior horn of S2-4 segments and travels to the external sphincter via an intra- and an extrapelvic branch of the pudendal nerve. Additional intrapelvic extrapudendal nerve fibres from S2-3 pass lateral to the pelvic plexus and then continue along the dorsolateral surface of the rectum until they disappear into the levator ani muscle and terminate in the urethral sphincter [34]. In addition to the efferent autonomic and somatic nerve fibres innervating the sphincteric musculature, intrapelvic afferents from the membranous urethra contribute to urinary continence. Intact afferents leads to a conscious sensation of urine entering the membranous urethra inducing either a spinal reflex or voluntary contraction of the rhabdosphincter. These afferent fibres run in branches of the pelvic plexus and the intrapelvic branch of the pudendal nerve.
53.2.3 Old Technique of Apical Dissection
Following lateral incision of endopelvic fascia including the levator fascia a dissection plane along the levator ani muscle was created (Fig. 53.2d). Subsequently, the levator fascia was incised secondarily to perform an interfascial nerve-sparing technique. This approach included complete division of puboprostatic ligaments and distal ligation of dorsal vein complex.
53.2.4 New Technique: Step by Step
53.2.4.1 Use of a Rectal Balloon
Prior to final positioning we place a balloon-catheter in the rectum and block it with 30 cc of air. After division of the DVC, the balloon is blocked with 50–60 cc (Fig. 53.6). This facilitates apical dissection by demonstrating the rectal fascia propria [23, 24] and is useful during identification of the apex of the prostate and the neurovascular bundle. Additionally, the risk of rectal injury can be minimized.
![A331567_2_En_53_Fig6_HTML.gif](https://i0.wp.com/abdominalkey.com/wp-content/uploads/2017/10/A331567_2_En_53_Fig6_HTML.gif?w=960)
![A331567_2_En_53_Fig6_HTML.gif](https://i0.wp.com/abdominalkey.com/wp-content/uploads/2017/10/A331567_2_En_53_Fig6_HTML.gif?w=960)
Fig. 53.6
Use of rectal balloon during retrograde dissection. (a) Rectal balloon mainly used for colonography. (b) Endoscopic view with inflated balloon. (c) Endoscopic view with deflated balloon and both preserved NVBs
53.2.4.2 Preservation of Puboprostatic Collar and Levator Fascia
The preservation of levator fascia requires a high medial incision of the endopelvic fascia just below the insertion of the puboprostatic ligaments. Subsequently the cleavage plane between the prostatic and levator fascia is developed bluntly using a right angle dissector (Video, Fig. 53.3d). Alternatively, this plane can be reached by careful incision of the endopelvic fascia lateral to the base of the prostate. During RALP, the same can be effectively carried out using the Metzenbaum scissors to bluntly sweep away the levator fascia. Thus, the perineal rami of the pudendal nerve running to the striated urethral sphincter remain untouched covered by levator fascia.
For preservation of puboprostatic collar DVC is sutured over the mid-part of the prostate. During division of DVC we place a 120° endodissector at prostato-vesical junction (Fig. 53.5) to provide counter-traction. The plane between DVC and anterior surface of prostate (McNeal’s anterior fibromuscular stroma; [27]) is dissected by cold scissors (Fig. 53.7a). In case of RALP, we use monopolar scissors for this step. This results in rotation of prostate towards the surgeon to reach urethra and the anterior striated sphincteric complex (Fig. 53.7b), thus straightening the prostato-urethral angulation varying from 35 to 90° [23, 27].
![A331567_2_En_53_Fig7_HTML.gif](https://i0.wp.com/abdominalkey.com/wp-content/uploads/2017/10/A331567_2_En_53_Fig7_HTML.gif?w=960)
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Fig. 53.7
![](https://freepngimg.com/download/social_media/63059-media-icons-telegram-twitter-blog-computer-social.png)
Retrograde extraperitoneal technique of LRP and RALP (Heilbronn-technique) – apical dissection. (a) Division of dorsal vein complex after suturing and bipolar coagulation. (b) Dissection between rectal serosa and Denonvillers’fascia using right angle dissector. (c) Incision of urethra and lifting the anterior wall by use of Foley catheter. (d) Division of posterior raphe (i.e. rectourethralis muscle)
![](https://freepngimg.com/download/social_media/63059-media-icons-telegram-twitter-blog-computer-social.png)
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