Fascial Layers in Nerve Sparing Robot-Assisted Radical Prostatectomy

The identification of prostatic fascial layers is of paramount importance for oncologic and functional outcomes in patients with localized prostate cancer treated with robot-assisted radical prostatectomy. We evaluated the relationship between the prostatic fascial layers and the nerve structures responsible for urinary continence and erection. Additionally, we examined how dissection of these structures might influence the degree of nerve sparing in the robotic era.

We performed a systematic literature review of the MEDLINE®, Embase™ and Web of Science™ databases. The search strategy included the terms radical prostatectomy, neurovascular bundles, nerve sparing, anatomy, robot-assisted prostatectomy and fascial layers.

The prostatic fasciae represent an important dissection plane. These anatomical structures are in close relationship with the neurovascular bundles and periprostatic nerve fibers, which spread widely from the posterolateral surface of the prostate to the anterolateral portion. During robot-assisted radical prostatectomy 2 main fascial layers might be identified, including the endopelvic fascia and the prostatic fascia. Identification and preservation of these structures allows for maximizing the sparing of nerve fibers related to continence and erection. Robotic surgeons have proposed 3 dissection planes associated with a different degree of nerve sparing, including intrafascial, interfascial and extrafascial dissection.

The visual magnification typical of robot-assisted radical prostatectomy facilitates the identification of prostatic fasciae, allowing the surgeon to tailor the extent of dissection to patient clinical and disease characteristics.