Anatomic Considerations During Radical Prostatectomy

In June 2009, Dr. Patrick Walsh was visiting professor to Guy’s Hospital. It was a pleasure to hear his insights into the development and refinement of anatomic radical prostatectomy over the years. Even more amazingly, he remarked that the last time he was passing through Guy’s, he met Dr. Peiter Donker, a urologist, in Leiden, Germany, during a conference. Donker, having retired as professor of urology, was studying anatomy and trying to find answers to vexing questions. Together, they worked on a cadaver of a stillborn infant, in which dissection was easier because there was less fibrofatty tissue. The rest is history. Walsh and Donker realised that the cavernous nerves were outside the capsule of the prostate [1]. This discovery led to a nerve-sparing radical cystectomy and, subsequently, in April 1982, to a nerve-sparing radical prostatectomy in a professor of psychology. Both men regained their potency. Since then, considerable progress has been made in the applied anatomy of the prostate and its importance in radical prostatectomy. There are two main reasons for this progress. First, patients and their surgeons are more aware of the so-called trifecta—cancer control, continence, and potency—following this difficult procedure. Because prostate cancer is being detected in younger patients, it is no longer acceptable to just cure them of their cancer by surgical excision. Maintaining their quality of life is as important, and our patients demand no less. Second, the improvements in technology with the advent of laparoscopic and robotic-assisted radical prostatectomy (RARP) have given surgeons a clearer, magnified view of the prostatic and pelvic anatomy and perhaps have increased their desire to understand it better. In the case of robotics, this anatomy is now magnified, with threedimensional (3D) high-definition vision providing exquisite detail. Consequently, a number of clinician-scientists have