Open Retropubic Nerve-Sparing Radical Prostatectomy Markus Graefen, Jochen Walz, Hartwig Huland  European Urology  Volume 49, Issue 1, Pages 38-48 (January 2006) DOI: 10.1016/j.eururo.2005.10.008 Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 1 (a+b) The right endopelvic fascia is incised and muscle fibers of the levator ani are removed blunt from the lateral prostate side using either a small sponge stick or blunt scissors. European Urology 2006 49, 38-48DOI: (10.1016/j.eururo.2005.10.008) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 2 The unsutured divided dorsal vein plexus is then distally selectively oversawn with the already placed thread from 10 to 2 o’clock without touching the fibers of the striated external sphincter. European Urology 2006 49, 38-48DOI: (10.1016/j.eururo.2005.10.008) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 3 Transverse section of the membranous urethra. European Urology 2006 49, 38-48DOI: (10.1016/j.eururo.2005.10.008) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 4 (a) The parapelvic fascia on the prostate is incised on the latero-ventral aspect of the prostate at 10 o’clock and 2 o’clock in safe distance to the neuro-vascular bundle. (b) After a small incision of the parapelvic fascia, the underlying areolar tissue and veins covering the prostate are undermined using a small overholt clamp for careful dissection. (c) The fascia and the vessels will then be clipped with the rectangular applicator (we prefer 5-mm titanium clips) and divided throughout the whole ventrolateral aspect of the prostate. European Urology 2006 49, 38-48DOI: (10.1016/j.eururo.2005.10.008) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 5 (a and b) An areolar space containing fat, connective tissue, veins, and small tethering vessels lies between the parapelvic fascia and the prostate capsule. In this space there are a mean of 30 nerve fibers on each side. (c) Whole mount section of the prostate demonstrating the areolar space between prostate capsule and parapelvic fascia. European Urology 2006 49, 38-48DOI: (10.1016/j.eururo.2005.10.008) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 6 The neurovascular bundles are separated from Müller's ligament (not seen on this graphic) which runs laterally from the striated external sphincter and represents a continuation off the ventral fascia of the striated sphincter (see also Fig. 3). The neurovascular bundles are gently pushed away from the apex and the proximal urethra. Following this maneuver the neurovascular bundles are lying beside the prostate and the proximal urethra and should not be touched during the rest of the procedure. European Urology 2006 49, 38-48DOI: (10.1016/j.eururo.2005.10.008) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 7 (a and b) The striated external sphincter runs circular and its fibers are attached at the outside of the apex (Fig. 7a). Once they are pushed away (Fig. 7b) the longitudinal smooth muscle is visible that runs into the prostate. After this maneuver the distal tip of the apex is precisely visible and the incision of the urethra can be done exactly at the end of the apex, preserving the whole length of the membranous urethra. European Urology 2006 49, 38-48DOI: (10.1016/j.eururo.2005.10.008) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 8 If extra-capsular extension is suspected a slice from the lateral surface of the prostate should be taken after the prostate is removed (a) and the area of the prostate capsule that was adjacent to the neuro-vascular bundle should be inked. In addition, the area from which the slice was taken should be inked in a different color for later differentiation of true surgical margin and margin of intraoperative frozen section (b). European Urology 2006 49, 38-48DOI: (10.1016/j.eururo.2005.10.008) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 9 The mucosa of the bladder is everted using a 4×0 Vicryl suture and the bladder outlet is narrowed using a tennis racket technique. The anastomotic sutures are placed and the anastomosis is tied after the transurethral catheter is inserted. European Urology 2006 49, 38-48DOI: (10.1016/j.eururo.2005.10.008) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 10 Number of radical prostatectomies (RRP), number of organ-confined cancers (pT2), and number of nerve-sparing procedures (NE) performed at the University Hospital Hamburg –Eppendorf between 1/1992 and 12/2004. European Urology 2006 49, 38-48DOI: (10.1016/j.eururo.2005.10.008) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 11 Kaplan-Meier analysis of recurrence free survival of 1755 patients operated at the University-Hospital Hamburg, Germany, stratified by pathologic stage and nerve sparing procedure. NS=nerve-sparing radical prostatectomy, non-NS=non-nerve-sparing radical prostatectomy. European Urology 2006 49, 38-48DOI: (10.1016/j.eururo.2005.10.008) Copyright © 2005 Elsevier B.V. Terms and Conditions