Skip to main content

Anatomy of autonomic nerve component in the male pelvis: the new concept from a perspective for robotic nerve sparing radical prostatectomy

World Journal of Urology volume 24, pages 136–143 (2006)Cite this article

Abstract

The DaVinci Robot (Intuitive Surgical, Sunnyvale California) with its magnified 3-D vision and multi-jointed wristed instruments enabled us to perform radical prostatectomy with consideration for the pelvic anatomy. In the present paper, we review the pelvic autonomic neuroanatomy with respect to robotic prostatectomy and demonstrate the procedures and critical points of nerve-sparing robotic radical prostatectomy based on novel anatomic concepts. Microscopic and macroscopic data were acquired from 30 fresh and 25 fixed male cadavers. A video study of 205 surgeries was performed for establishing the anatomy relevant to robotic prostatectomy. From a practical standpoint, we could group the relevant neural tissue into three broad zones: (1) proximal neurovascular plate (PNP), (2) predominant neurovascular bundles (PNB), (3) accessory distal neural pathways (ANP). Autonomic ganglion cells existed widely not only in nerve components but also along the viscera. The critical areas of nerve sparing surgery were the distal end of PNP, the entire PNB, and the circumference of the apex. Interindividual differences of cell counts were evident in all sites. Based on these concepts, we established the Athermal Robotic Technique (ART) for nerve sparing prostatectomy. Surgical and oncological outcomes were not mature but feasible. These tri-zonal and ganglion cell concepts may be of benefit to new surgeons undertaking nerve-sparing robotic radical prostatectomy.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8

References

  1. Ahlering TE, Eichel L, Chou D, Skarecky DW (2005) Feasibility study for robotic radical prostatectomy cautery-free neurovascular bundle preservation. Urology 65:994–997

    Article  PubMed  Google Scholar 

  2. Butler-Manuel SA, Buttery LDK, A’Hern RP, Polak JM, Barton DPJ (2002) Pelvic nerve plexus trauma at radical and simple hysterectomy: a quantative study of nerve types in the uterine supporting ligaments. J Soc Gynecol Investig 9:47–56

    Article  PubMed  Google Scholar 

  3. Costello AJ, Brooks M, Cole OJ (2004) Anatomical studies of the neurovascular bundle and cavernosal nerves. BJU Int 94:1071–1076

    Article  PubMed  Google Scholar 

  4. Elfvin LG, Lindh B, Hokfelt T (1993) The chemical neuroanatomy of sympathetic ganglia. Annu Rev Neurosci 16:471–507

    Article  PubMed  CAS  Google Scholar 

  5. El-Hakim A, Leung RA, Tewari A (2006) Robotic prostatectomy: pooled analysis of published literature. Expert Rev Anticancer Ther 6:11–20

    Article  PubMed  Google Scholar 

  6. Hemal AK, Bhandari A, Tewari A, Menon M (2005) The Window Sign: an aid in laparoscopic and robotic radical prostatectomy. Int Urol Nephrol 37:73–77

    Article  PubMed  Google Scholar 

  7. Kato R, Kiryu-Seo S, Sato Y, Hisasue S, Tsukamoto T, Kiyama H (2003) Cavernous nerve injury elicits GAP-43 mRNA expression but not regeneration of injured pelvic ganglion neurons. Brain Res 986:166–173

    Article  PubMed  CAS  Google Scholar 

  8. Kaul S, Bhandari A, Hemal A, Savera A, Shrivastava A, Menon M (2005) Robotic radical prostatectomy with preservation of the prostatic fascia: a feasibility study. Urology 66:1261–1265

    Article  PubMed  Google Scholar 

  9. Lepor H, Gregerman M, Crosby R, Mostofi FK, Walsh PC (1985) 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 133:207–212

    PubMed  CAS  Google Scholar 

  10. Lunacek A, Schwentner C, Fritsch H, Bartsch G, Strasser H (2005) Anatomical radical retropubic prostatectomy: ‘curtain dissection’ of the neurovascular bundle. BJU Int 95:1226–1231

    Article  PubMed  Google Scholar 

  11. Menon M, Tewari A, Peabody JO, Shrivastava A, Kaul S, Bhandari A, Hemal AK (2004) Vattikuti Institute prostatectomy, a technique of robotic radical prostatectomy for management of localized carcinoma of the prostate: experience of over 1100 cases. Urol Clin N Am 31:701–717

    Article  Google Scholar 

  12. Menon M, Shrivastava A, Tewari A, Sarle R, Hemal A, Peabody JO, Vallancien G (2002) Laparoscopic and robot assisted radical prostatectomy: establishment of a structured program and preliminary analysis of outcomes. J Urol 168:945–949

    Article  PubMed  Google Scholar 

  13. Menon M, Kaul S, Bhandari A, Shrivastava A, Tewari A, Hemal A (2005) Potency following robotic radical prostatectomy: a questionnaire based analysis of outcomes after conventional nerve sparing and prostatic fascia sparing techniques. J Urol 174:2291–2296

    Article  PubMed  Google Scholar 

  14. Polak JM, Bloom SR (1984) Regulatory peptides-the distribution of two newly discovered peptides: PHI and NPY. Peptides 5:79–89

    Article  PubMed  CAS  Google Scholar 

  15. Takenaka A, Kawada M, Murakami G, Hisasue S, Tsukamoto T, Fujisawa M (2005) Interindividual variation in distribution of extramural ganglion cells in the male pelvis: a semi-quantitative and immunohistochemical study concerning nerve-sparing pelvic surgery. Eur Urol 48:46–52

    Article  PubMed  Google Scholar 

  16. Takenaka A, Murakami G, Soga H, Han SH, Arai Y, Fujisawa M (2004) Anatomical analysis of the neurovascular bundle supplying penile cavernous tissue to ensure a reliable nerve graft after radical prostatectomy. J Urol 172:1032–1035

    Article  PubMed  Google Scholar 

  17. Tewari A, Peabody JO, Fischer M, Sarle R, Vallancien G, Delmas V, Hassan M, Bansal A, Hemal AK, Guillonneau B, Menon M (2003) An operative and anatomic study to help in nerve sparing during laparoscopic snd robotic radical prostatectomy. Euro Urol 43:444–454

    Article  Google Scholar 

  18. Tewari A, Peabody JO, Sarle R, Balakrishnan G, Hemal A, Shrivastava A, Menon M (2002) Technique of da Vinci robot-assisted anatomic radical prostatectomy. Urology 60:569–572

    PubMed  Article  Google Scholar 

  19. Tewari A, Takenaka A, Mtui E, Horninger W, Peschel R, Bartsch G (2006) The proximal neurovascular plate (PNP) and the tri-zonal neural architecture around the prostate gland—importance in Athermal Robotic Technique (ART) of Nerve Sparing Prostatectomy. BJU Int (in press)

  20. Walsh PC, Donker PJ (1982) Inpotence following radical prostatectomy: insight into etiology and prevention. J Urol 128:492–497

    PubMed  CAS  Google Scholar 

  21. Wong DL, Hockenberry-Eaton M, Wilson D, Windelstein ML, Schwartz P (2001) Wong’s essentials of pediatric nursing, 6th edn. Mosby, St. Louis, p 1301

    Google Scholar 

Download references

Acknowledgments

The authors thank Professor Mani Menon for the intellectual interaction about the nerve preservation and for establishing the foundations for robotic prostatectomy by popularizing the VIP technique of prostatectomy. We are also grateful to Professor Gen Murakami in Department of Anatomy, Sapporo Medical University, Japan, for supplying the fresh and fixed cadavers and helpful technical comment in the anatomic study. Many thanks to Professor Georg Bartsch in Department of Urology, Medical University of Innsbruck, Austria, for his comments on clinical anatomy.

Author information

Affiliations

  1. Department of Urology, New York-Presbyterian Hospital, Weill Cornell Medical Center, 525 East 68th Street, Starr 900, New York, NY, 10021, USA

    Robert A. Leung & Ashutosh K. Tewari

  2. Division of Urology, Department of Organs Therapeutics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan

    Atsushi Takenaka & Masato Fujisawa

Authors
  1. Atsushi Takenaka
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Robert A. Leung
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Masato Fujisawa
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ashutosh K. Tewari
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Atsushi Takenaka.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Takenaka, A., Leung, R.A., Fujisawa, M. et al. Anatomy of autonomic nerve component in the male pelvis: the new concept from a perspective for robotic nerve sparing radical prostatectomy. World J Urol 24, 136–143 (2006). https://doi.org/10.1007/s00345-006-0102-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00345-006-0102-2

Keywords

  • Neural anatomy
  • Autonomic nerve
  • Robotic prostatectomy
  • Athermal technique
  • Nerve sparing