Volume 58, Issue 3, Pages 407-417 (September 2010) Complete Periprostatic Anatomy Preservation During Robot-Assisted Laparoscopic Radical Prostatectomy (RALP): The New Pubovesical Complex-Sparing Technique  Anastasios D. Asimakopoulos, Filippo Annino, Alejandro D'Orazio, Clovis Fraga T. Pereira, Camille Mugnier, Jean-Luc Hoepffner, Thierry Piechaud, Richard Gaston  European Urology  Volume 58, Issue 3, Pages 407-417 (September 2010) DOI: 10.1016/j.eururo.2010.04.032 Copyright © 2010 European Association of Urology Terms and Conditions

Fig. 1 Evidence of the triangular space formed by the base of the prostate, the bladder neck, and the right neurovascular bundle, closed inferiorly by the seminal vesicle. NVB=neurovascular bundle. European Urology 2010 58, 407-417DOI: (10.1016/j.eururo.2010.04.032) Copyright © 2010 European Association of Urology Terms and Conditions

Fig. 2 The asterisk represents a clipped distal artery that leaves the neurovascular bundle (NVB; between the dashed lines) to penetrate into the prostate. P=prostate; A=apex of the gland. European Urology 2010 58, 407-417DOI: (10.1016/j.eururo.2010.04.032) Copyright © 2010 European Association of Urology Terms and Conditions

Fig. 3 Focus on the anterior prostate. P=prostate; DA=detrusor apron, PVF=prostatic visceral fascia. European Urology 2010 58, 407-417DOI: (10.1016/j.eururo.2010.04.032) Copyright © 2010 European Association of Urology Terms and Conditions

Fig. 4 Detrusor apron (DA) grasped by the robotic atraumatic grasper. The asterisk represents the attachment of the DA to the pubis. The dashed line indicates the anterior commissure of the prostate and corresponds to the dissection plane that should be followed to separate the DA by the ventral surface of the gland. P=prostate; B=bladder. European Urology 2010 58, 407-417DOI: (10.1016/j.eururo.2010.04.032) Copyright © 2010 European Association of Urology Terms and Conditions

Fig. 5 The curved arrow indicates the avascular plane present between the point at which the detrusor apron (DA) leaves the prostate (to attach to the pubis) to the anterior prostate-urethral junction. From this level, it starts the anterior dissection of the pubovesical complex (ie, the DA and the dorsal vascular complex, sparing both the structures). P=prostate; A=apex; NVB=neurovascular bundle. * Dorsal vascular complex. European Urology 2010 58, 407-417DOI: (10.1016/j.eururo.2010.04.032) Copyright © 2010 European Association of Urology Terms and Conditions

Fig. 6 The fibromuscular tissue between the DVC and the prostate is dissected at the midline. A=prostate apex; DVC=dorsal vascular complex. * Membranous urethra. ** Fibromuscular tissue between the DVC and the prostate. European Urology 2010 58, 407-417DOI: (10.1016/j.eururo.2010.04.032) Copyright © 2010 European Association of Urology Terms and Conditions

Fig. 7 Dissection of the fibromuscular tissue (**) between the dorsal vascular complex (DVC) and the prostate in the midline. Combined movements of sharp and mainly bland dissection, with an upward direction, are necessary to detach the DVC from the anterior prostatic surface. A=apex. * Membranous urethra. European Urology 2010 58, 407-417DOI: (10.1016/j.eururo.2010.04.032) Copyright © 2010 European Association of Urology Terms and Conditions

Fig. 8 Development of the plane of dissection (curved arrow) between the detrusor apron and the anterior prostatic surface. The assistant pulls the gland to the right side. The preserved bladder neck is clearly evident (through a lateral view). European Urology 2010 58, 407-417DOI: (10.1016/j.eururo.2010.04.032) Copyright © 2010 European Association of Urology Terms and Conditions

Fig. 9 The anterior surface of the prostate has been totally freed from both the detrusor apron and the dorsal vascular complex. P=prostate; DA=detrusor apron; DVC=dorsal vascular complex; NVB=neurovascular bundle. * Bladder neck. ** Membranous urethra. European Urology 2010 58, 407-417DOI: (10.1016/j.eururo.2010.04.032) Copyright © 2010 European Association of Urology Terms and Conditions

Fig. 10 The final aspect of the surgical field. The prostate has already been shelled out from underneath the spared pubovesical complex; the urethrovesical anastomosis has been performed under the spared complex by a running suture with lateral approach. DA=detrusor apron. * Accessory pudendal artery. European Urology 2010 58, 407-417DOI: (10.1016/j.eururo.2010.04.032) Copyright © 2010 European Association of Urology Terms and Conditions

Fig. 11 Final pathology: (A) standard dissection and (B) pubovesical complex preservation. In the lower part of the figure, the microscopic view of the inserts is provided. In (A), the order of the tissues (from anterior to posterior) is ink, striated muscle (detrusor apron), fat tissue, striated muscle fibres mingled with some smooth muscle fibres, and prostatic parenchyma with glands. When the detrusor apron (DA) is preserved (B), the striated muscular layer (DA) and the majority of fat tissue (that represents our marker during the anterior dissection) are no longer visible. A mixed smooth and striated muscle layer covers the glandular parenchyma. Even if no prostatic capsule is present at this level, the limit of the prostate can be still well identified by the presence of these muscular fibres (which assume a more circular orientation at this level). In all cases, in the microscopic evaluation, this muscular layer was respected; thus, no benign prostatic glandular tissue was left in place during the anterior dissection. European Urology 2010 58, 407-417DOI: (10.1016/j.eururo.2010.04.032) Copyright © 2010 European Association of Urology Terms and Conditions

Fig. 12 Potency evaluation at 3 months. IIEF=International Index of Erectile Function. European Urology 2010 58, 407-417DOI: (10.1016/j.eururo.2010.04.032) Copyright © 2010 European Association of Urology Terms and Conditions

Fig. 13 Extent of utilisation of erectogenic medications. PDE5-Is=phosphodiesterase type 5 inhibitors. European Urology 2010 58, 407-417DOI: (10.1016/j.eururo.2010.04.032) Copyright © 2010 European Association of Urology Terms and Conditions

Fig. 14 Erection Hardness Score. European Urology 2010 58, 407-417DOI: (10.1016/j.eururo.2010.04.032) Copyright © 2010 European Association of Urology Terms and Conditions

Fig. 15 International Index of Erectile Function (IIEF-6) score. * Significance at p<0.05. European Urology 2010 58, 407-417DOI: (10.1016/j.eururo.2010.04.032) Copyright © 2010 European Association of Urology Terms and Conditions

Diagram 1 (a) Selective ligation and (b) standard ligation. European Urology 2010 58, 407-417DOI: (10.1016/j.eururo.2010.04.032) Copyright © 2010 European Association of Urology Terms and Conditions