Neuroanatomical Approach to Radical Cystoprostatectomy with Preservation of Sexual Function

Abstract

The technique for radical cystoprostatectomy has been modified to avoid injury to the branches of the pelvic plexus that innervate the corpora cavernosa. Although the course of the neurovascular bundles in the region of the prostate and urethra has been well charted, the exact relationship of the cavernous nerves to the seminal vesicles and bladder has remained unclear. In an effort to delineate this anatomy more clearly, detailed anatomical dissections were performed on 9 male human cadavers. This study demonstrated that the pelvic plexus is located retroperitoneally on the lateral wall of the rectum 5 to 11 cm. from the anal verge with its midpoint related to the tip of the seminal vesicle. The cavernous branches travel in a direct route from the pelvic plexus toward the posterolateral base of the prostate, gradually coalescing from a group of fibers approximately 12 mm. wide to a more organized bundle approximately 6 mm. wide at the level of the prostate. Because the bulk of the pelvic plexus and its important branches are located lateral and posterior to the seminal vesicles, the seminal vesicles can be used as a landmark intraoperatively to avoid injury to the pelvic plexus when ligating the posterior pedicle. During the last 5 years 25 men have undergone radical cystoprostatectomy. Pathological evaluation of all specimens demonstrated negative surgical margins and no patient has had locally recurrent tumor. Of the patients undergoing cystectomy alone 83 per cent are potent. Although all patients undergoing urethrectomy were able to have erections postoperatively, only 40 per cent have erections that are sufficient for intercourse. These data indicate that to date it is possible to perform radical cystoprostatectomy with preservation of sexual function in the majority of patients without compromise to the curative aspects of the radical operation.