Volume 48, Issue 6, Pages 938-945 (December 2005) Improving the Preservation of the Urethral Sphincter and Neurovascular Bundles During Open Radical Retropubic Prostatectomy  Francesco Montorsi, Andrea Salonia, Nazareno Suardi, Andrea Gallina, Giuseppe Zanni, Alberto Briganti, Federico Deho’, Richard Naspro, Elena Farina, Patrizio Rigatti  European Urology  Volume 48, Issue 6, Pages 938-945 (December 2005) DOI: 10.1016/j.eururo.2005.09.004 Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 1 An Allis clamp is used to grasp the superficial veins of the Santorini's plexus. Care is taken not to place the clamp too deeply to avoid damaging the prostatic apex and the urethral sphincter. European Urology 2005 48, 938-945DOI: (10.1016/j.eururo.2005.09.004) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 2 A 3-0 monocryl suture is passed twice distal to the Allis clamp. Note that this suture is superficial and is only used to pull together the superficial vein branches to facilitate subsequent sharp division of the Santorini's plexus. European Urology 2005 48, 938-945DOI: (10.1016/j.eururo.2005.09.004) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 3 Following sharp division of the Santorini's plexus, a running suture with 3-0 monocryl on a UR-6 needle is used to control bleeders from the distal trunk. Note that neither the urethral sphincter nor the levator ani muscles are included in this suture. Subsequently, a suture of the same material and needle is placed proximally. European Urology 2005 48, 938-945DOI: (10.1016/j.eururo.2005.09.004) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 4 Two straight lines are marked from the lateral borders of the urethral sphincter to the bladder neck–prostate junction (at 11 and 1 o’clock positions). The levator and prostatic fascia are pierced and dissection is started. Small bleeders are controlled with 3-mm titanium clips. European Urology 2005 48, 938-945DOI: (10.1016/j.eururo.2005.09.004) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 5 On the right side, the levator and prostatic fasciae are reflected laterally. Note the triangular space between the lateral border of the urethral sphincter, the right side of the prostatic apex, and the displaced neurovascular bundle. The procedure is subsequently started on the left side as well. European Urology 2005 48, 938-945DOI: (10.1016/j.eururo.2005.09.004) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 6 The levator and prostatic fasciae have been dissected and displaced laterally. The urethral sphincter is completely dissected free from its attachments to the neurovascular bundles bilaterally. The line of division of the external urethral sphincter and membranous urethra at the prostatic apex is marked. European Urology 2005 48, 938-945DOI: (10.1016/j.eururo.2005.09.004) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 7 After sharp incision of the anterior wall of the urethra from 9 to 3 o’clock, the first three sutures of 3-0 monocryl with a UR-6 needle are placed at 12, 2, and 10 o’clock. When the urethral catheter is grasped, the posterior wall of the urethra is clearly visible to allow placement of the 4 and 8 o’clock sutures. Note the distance between the urethra and the right neurovascular bundle. European Urology 2005 48, 938-945DOI: (10.1016/j.eururo.2005.09.004) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 8 Mucosa-to-mucosa urethrovesical anastomosis with six sutures. European Urology 2005 48, 938-945DOI: (10.1016/j.eururo.2005.09.004) Copyright © 2005 Elsevier B.V. Terms and Conditions