High prostatic fascia release or standard nerve sparing? A viewpoint from the Royal Melbourne Hospital

Abstract

Radical prostatectomy with preservation of the neurovascular bundles (NVB) is a treatment option for localised prostate cancer in selected patients. An interesting debate has developed about the precise technique used to preserve these nerves. The standard technique releases the NVB from the postero-lateral groove between the prostate and rectum. A new technique, dubbed the "veil of Aphrodite" technique, proposes a higher release of the lateral prostatic fascia on the presumption that cavernosal nerves exist in this area. We have reviewed the evidence for the anatomical basis of nerve-sparing radical prostatectomy, particularly with respect to the standard versus the "veil" technique of radical prostatectomy. Microdissections of the NVB in cadaveric specimens have confirmed the course of the cavernosal nerves in the postero-lateral groove between the prostate and rectum. Though studies have also demonstrated nerves higher in the lateral prostatic fascia, these are likely to innervate the prostate rather than the cavernosal tissues. Though excellent potency results have been reported for the "veil" technique from one institution, there is not sufficient anatomical evidence to support this technique over the standard technique of nerve-sparing radical prostatectomy.