Abstract
An understanding of the anatomy of the Denonvilliers’ fascia is essential for successful surgical outcomes for patients with rectal cancer in the mid- to lower regions, especially near the seminal vesicles and prostate in males. Whether the correct surgical plane during a total mesorectal excision should be anterior or posterior to the Denonvilliers’ fascia is currently under debate. This study aimed to investigate the Denonvilliers’ fascia using micro-computed tomography (micro-CT) to acquire three-dimensional images nondestructively for assessments of the relationship between the Denonvilliers’ fascia, the mesorectal fascia, and neurovascular bundles to elucidate the correct anterior total mesorectal excision plane. Eight specimens were obtained bilaterally from four fresh human cadavers. Four specimens were stained with phosphotungstic acid to visualize the soft tissue, and micro-CT images were obtained; the other four specimens were stained with Masson’s trichrome to visualize connective tissue. Micro-CT images corroborate that the Denonvilliers’ fascia consists of a multilayered structure that separates the rectum from the seminal vesicles and the prostate. Specimens stained with Masson’s trichrome showed that the urogenital neurovascular bundle located at the posterolateral corner of the prostate is separated from the mesorectum by the Denonvilliers’ fascia. For the preservation of autonomic nerves necessary for urogenital function and optimal oncologic outcomes in patients with rectal cancer, a successful mesorectal excision requires a dissection plane posterior to the Denonvilliers’ fascia.
Highlights
An understanding of the anatomy of the Denonvilliers’ fascia is essential for successful surgical outcomes for patients with rectal cancer in the mid- to lower regions, especially near the seminal vesicles and prostate in males
Multiple laminae of the medial Denonvilliers’ fascia (DVF) appeared fused to the mesorectal fascia (MRF), with only the inferolateral region of the DVF able to be distinguished from the MRF (Fig. 1, Supplemental Video 1)
Starting from the posterolateral corner of the seminal vesicles and prostate, the DVF appeared as a homogenous monolayer that was adherent to the medial prostate in both the coronal and sagittal sections
Summary
An understanding of the anatomy of the Denonvilliers’ fascia is essential for successful surgical outcomes for patients with rectal cancer in the mid- to lower regions, especially near the seminal vesicles and prostate in males. Heald et al described that a dissection performed anterior to the DVF is an oncologically safe TME plane because it constitutes the anterior surface of the m esorectum[8,9] These authors stressed that to prevent injury to the NVBs, it is necessary to identify and preserve both edges of the DVF using a U-shaped incision[9]. This interpretation of the DVF is consistent with those of previous studies in which the origin of the DVF is described as a fused, single layer of two primitive fetal peritoneal layers that pass between the rectum posteriorly and the prostate or seminal vesicles a nteriorly[2,10,11]. The aim of this study was to clarify the three-dimensional structures of the DVF and their association with the MRF using micro-CT and to verify the anatomic relationship between the DVF and NVBs using histological analyses
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