Anatomical Aspects of the Neurovascular Bundle in Prostate Surgery

  • Prasanna Sooriakumaran
  • Gerald Y. Tan
  • Sonal Grover
  • Atsushi Takenaka
  • Ashutosh K. TewariEmail author


Over recent years, widespread prostate-specific antigen screening has resulted in a downwards stage migration of prostate cancer in developed nations, with most patients being diagnosed nowadays at a younger age with early organ-confined disease (Schröder et al., N Engl J Med 360:1320–8, 2009; Jemal et al., CA Cancer J Clin 59:225–49, 2009; Quinn and Babb, BJU Int 90:162–73, 2002). Radical prostatectomy has a proven survival benefit over conservative treatment (Bill-Axelson et al., N Engl J Med 352:1977–84, 2005; Tewari et al., J Urol 171:1513–9, 2004), and thus is the gold standard for the management of clinically localized prostate cancer. Hence, with more patients undergoing surgery, minimizing functional loss is of utmost importance. However, despite recent advances in surgical technique and technologies, return of erectile function sufficient for sexual intercourse at 1 year after surgery varies from 15 to 87%, respectively, in contemporary series of radical prostatectomy (Zippe et al., Int J Impot Res 18:1–18, 2006; Berryhill et al., Urology 72:15–23, 2008; Ficarra et al., Eur Urol 55:1037–63, 2009). For younger men, postprostatectomy erectile dysfunction (PPED) significantly affects their sense of masculinity and their daily interactions with women (Penson et al., J Clin Oncol 21:1147–54, 2003; Kirschner-Hermanns and Jakse, Crit Rev Oncol Hematol 43:141–51, 2002). Patient age, clinical and pathological stage of cancer, preoperative potency status, and aggressiveness of nerve-sparing are the most significant factors for recovery of potency after surgery (Quinlan et al., J Urol 145:998–1002, 1991; Rabbani et al., J Urol 164:1929–34, 2000; Dubbelman et al., Eur Urol 50:711–20, 2006). Surgeon experience and surgical volume, penile ischemia and subsequent fibrosis, and veno-occlusive disease are also important for successful return of sexual function following surgery (McCullough, Asian J Androl 10:61–74, 2008; Bianco et al., J Sex Med 1:33, 2004).


  1. 1.
    Schröder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med. 2009;360:1320–8.CrossRefPubMedGoogle Scholar
  2. 2.
    Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2009. CA Cancer J Clin. 2009;59:225–49.CrossRefPubMedGoogle Scholar
  3. 3.
    Quinn M, Babb P. Patterns and trends in prostate cancer incidence, survival, prevalence and mortality. Part 1: international comparisons. BJU Int. 2002;90:162–73.CrossRefPubMedGoogle Scholar
  4. 4.
    Bill-Axelson A, Holmberg L, Ruutu M, et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med. 2005;352(19):1977–84.CrossRefPubMedGoogle Scholar
  5. 5.
    Tewari A, Johnsson CC, Devine G, Crawford ED, Gamito EJ, Demers R, Menon M. Long-term survival probability in men with clinically localized prostate cancer: a case–control, propensity modeling study stratified by race, age, treatment and co-morbidities. J Urol. 2004;171:1513–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Zippe C, Nandipati K, Agarwal A, Raina R. Sexual dysfunction after pelvic surgery. Int J Impot Res. 2006;18:1–18.CrossRefPubMedGoogle Scholar
  7. 7.
    Berryhill R Jr, Jhaveri J, Yadav R, et al. Robotic prostatectomy: a review of outcomes compared with laparoscopic and open approaches. Urology. 2008;72:15–23.CrossRefPubMedGoogle Scholar
  8. 8.
    Ficarra V, Novara G, Artibani W, et al. Retropubic, laparoscopic and robot-assisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies. Eur Urol. 2009;55:1037–63.CrossRefPubMedGoogle Scholar
  9. 9.
    Penson DF, Feng Z, Kuniyuki A, McClerran D, Albertsen PC, Deapen D, et al. General quality of life 2 years following treatment for prostate cancer: what influences outcomes? Results from the prostate cancer outcomes study. J Clin Oncol. 2003;21:1147–54.CrossRefPubMedGoogle Scholar
  10. 10.
    Kirschner-Hermanns R, Jakse G. Quality of life following radical prostatectomy. Crit Rev Oncol Hematol. 2002;43:141–51.CrossRefPubMedGoogle Scholar
  11. 11.
    Quinlan DM, Epstein JI, Carter BS, Walsh PC. Sexual function following radical prostatectomy: influence of preservation of neurovascular bundles. J Urol. 1991;145:998–1002.CrossRefPubMedGoogle Scholar
  12. 12.
    Rabbani F, Stapleton AM, Kattan MW, Wheeler TM, Scardino PT. Factors predicting recovery of erections after radical prostatectomy. J Urol. 2000;164(6):1929–34.CrossRefPubMedGoogle Scholar
  13. 13.
    Dubbelman YD, Dohle GR, Schroder FH. Sexual function before and after radical retropubic prostatectomy: a systematic review of prognostic indicators for a successful outcome. Eur Urol. 2006;50:711–20.CrossRefPubMedGoogle Scholar
  14. 14.
    McCullough AR. Rehabilitation of erectile function following radical prostatectomy. Asian J Androl. 2008;10(1):61–74.CrossRefPubMedGoogle Scholar
  15. 15.
    Bianco F, Kattan M, Eastham J, Scardino P, Mulhall JP. Surgeon and surgical volume as predictors of erectile function outcomes following radical prostatectomy. J Sex Med. 2004;1:33.Google Scholar
  16. 16.
    Kim ED, Blackburn D, McVary KT. Post-radical prostatectomy penile blood flow: assessment with color Doppler ultrasound. J Urol. 1994;152:2276–9.CrossRefPubMedGoogle Scholar
  17. 17.
    Mulhall JP, Slovick R, Hotaling J, et al. Erectile dysfunction after radical prostatectomy: haemodynamic profiles and their correlation with the recovery of erectile function. J Urol. 2002;167:1371–5.CrossRefPubMedGoogle Scholar
  18. 18.
    Kawanishi Y, Lee KS, Kimura K, Kojima K, Yamamoto A, Numata A. Effect of radical retropubic prostatectomy on erectile function, evaluated before and after surgery using color Doppler ultrasonography and nocturnal penile tumescence monitoring. BJU Int. 2001;88:244–7.CrossRefPubMedGoogle Scholar
  19. 19.
    Walz J, Graefen M, Huland H. Basic principles of anatomy for optimal surgical management of prostate cancer. World J Urol. 2007;25:31–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Walsh PC, Donker PJ. Impotence following radical prostatectomy: insight into etiology and prevention. J Urol. 1982;128:492–7.CrossRefPubMedGoogle Scholar
  21. 21.
    Lepor H, Gregerman M, Crosby R, Mostofi FK, Walsh PC. Precise localization of the autonomic nerves from the pelvic plexus to the corpora cavernosa: a detailed anatomical study of the adult male pelvis. J Urol. 1985;133:207–12.CrossRefPubMedGoogle Scholar
  22. 22.
    Walsh PC. Anatomic radical prostatectomy: evolution of surgical technique. J Urol. 1998;160:2418–24.CrossRefPubMedGoogle Scholar
  23. 23.
    Costello AJ, Brooks M, Cole OJ. Anatomical studies of the neurovascular bundle and cavernosal nerves. BJU Int. 2004;94:1071–6.CrossRefPubMedGoogle Scholar
  24. 24.
    Takenaka A, Murakami G, Matsubara A, et al. Variation in course of cavernous nerve with special reference to details of topographic relationships near prostatic apex: histologic study using male cadavers. Urology. 2005;65:136–42.CrossRefPubMedGoogle Scholar
  25. 25.
    Kiyoshima K, Yokomizo A, Yoshida T, et al. Anatomic features of periprostatic tissue and its surroundings: a histological analysis of 79 radical retropubic prostatectomy specimens. Jpn J Clin Oncol. 2004;34:463–8.CrossRefPubMedGoogle Scholar
  26. 26.
    Eichelberg C, Erbersdobler A, Michl U, Schlomm T, Salomon G, Graefen M, et al. Nerve distribution along the prostatic capsule. Eur Urol. 2007;51(1):105–11.CrossRefPubMedGoogle Scholar
  27. 27.
    Tewari A, Takenaka A, Mtui E, Horninger W, Peschel R, Bartsch G, Vaughan ED. The proximal neurovascular plate and the tri-zonal neural architecture around the prostate gland: importance in the athermal robotic technique of nerve-sparing prostatectomy. BJU Int. 2006;98:318–23.Google Scholar
  28. 28.
    Tewari A, Tan GY, Dorsey PJ Jr, Yadav R, Ramanathan R, Patel N, Takenaka A. Optimizing erectogenic outcomes during athermal robotic prostatectomy: a risk-stratified tri-zonal approach. Urol Times Clin Ed. 2008;3:s4–s12.Google Scholar
  29. 29.
    Tewari A, Peabody JO, Fischer M, et al. An operative and anatomic study to help in nerve-sparing during laparoscopic and robotic radical prostatectomy. Eur Urol. 2003;43:444–54.CrossRefPubMedGoogle Scholar
  30. 30.
    Chuang MS, O’Connor RC, Laven BA, Orvieto MA, Brendler CB. Early release of the neurovascular bundles and optical loupe magnification lead to improved and earlier return of potency following radical retropubic prostatectomy. J Urol. 2005;173:537–9.CrossRefPubMedGoogle Scholar
  31. 31.
    Magera JS, Inman BA, Slezak JM, Bagniewski SM, Sebo TJ, Myers RP. Increased optical magnification from 2.5× to 4.3× with technical modification lowers the positive margin rate in open radical retropubic prostatectomy. J Urol. 2008;179:130–5.CrossRefPubMedGoogle Scholar
  32. 32.
    Klotz L, Herschorn S. Early experience with intraoperative cavernous nerve stimulation with penile tumescence monitoring to improve nerve sparing during radical prostatectomy. Urology. 1998;52:537–42.CrossRefPubMedGoogle Scholar
  33. 33.
    Walsh PC, Marschke P, Catalona WJ, Lepor H, Martin S, Myers RP, et al. Efficacy of first-generation CaverMap to verify location and function of cavernous nerves during radical prostatectomy: a multi-institutional evaluation by experienced surgeons. Urology. 2001;57:491–4.CrossRefPubMedGoogle Scholar
  34. 34.
    Holzbeierlein J, Peterson M, Smith JA Jr. Variability of results of cavernous nerve stimulation during radical prostatectomy. J Urol. 2001;165:108–10.CrossRefPubMedGoogle Scholar
  35. 35.
    Ukimura O, Gill IS, Desai MM, et al. Real-time transrectal ultrasonography during laparoscopic radical prostatectomy. J Urol. 2004;172:112–8.CrossRefPubMedGoogle Scholar
  36. 36.
    Huang D, Swanson EA, Lin CP, et al. Optical coherence tomography. Science. 1991;254:1178–81.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Mourant JR, Bigio IJ, Boyer J, et al. Spectroscopic diagnosis of bladder cancer with elastic light scattering. Lasers Surg Med. 1995;17:350–7.CrossRefPubMedGoogle Scholar
  38. 38.
    Crow P, Molckovsky A, Stone J, et al. Assessment of fibreoptic near-infrared Raman spectroscopy for diagnosis of bladder and prostate cancer. Urology. 2005;65:1126–30.CrossRefPubMedGoogle Scholar
  39. 39.
    Davila HH, Mamcarz M, Nadelhaft I, et al. Visualization of the neurovascular bundles and major pelvic ganglion with fluorescent tracers after penile injection in the rat. BJU Int. 2007;101:1048–51.CrossRefPubMedGoogle Scholar
  40. 40.
    Yadav R, Mukherjee S, Hermen M, et al. Multiphoton microscopy of prostate and periprostatic neural tissue: a promising imaging technique for improving nerve-sparing prostatectomy. J Endourol. 2009;23:861–7.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Prasanna Sooriakumaran
    • 1
  • Gerald Y. Tan
    • 2
  • Sonal Grover
    • 3
  • Atsushi Takenaka
    • 4
  • Ashutosh K. Tewari
    • 5
    • 6
    Email author
  1. 1.Department of UrologyKarolinska University HospitalStockholmSweden
  2. 2.Department of UrologyTan Tock Seng HospitalSingaporeSingapore
  3. 3.James Buchanan Brady Foundation Department of UrologyLefrak Institute of Robotic Surgery, Weill Medical College of Cornell UniversityNew YorkUSA
  4. 4.Division of UrologyKobe University Graduate School of MedicineKobeJapan
  5. 5.James Buchanan Brady Foundation Department of UrologyCentre for Prostate Cancer Research and Clinical Care, LeFrak Institute of Robotic Surgery, Weill Medical College of Cornell UniversityNew YorkUSA
  6. 6.Prostate Cancer InstituteNew YorkUSA

Personalised recommendations