Development, Applied, and Surgical Anatomy of the Prostate
Contemporary anatomical insights beginning in the 1970s have driven the dramatic improvements in outcomes for men treated by surgical removal of the prostate. Before the 1980s, only the very hardy patient was able to tolerate the morbidity of attempted su
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Development, Applied, and Surgical Anatomy of the Prostate Anthony J. Costello and Niall M. Corcoran
Applied Prostatic Anatomy History of Prostatic Anatomy and Radical Prostatectomy Contemporary anatomical insights beginning in the 1970s have driven the dramatic improvements in outcomes for men treated by surgical removal of the prostate. Before the 1980s, only the very hardy patient was able to tolerate the morbidity of attempted surgical cure of prostate cancer. The operation was attended often by massive blood loss, certain impotence, and a high likelihood of permanent urinary incontinence. It was preferable therefore to opt for radiation therapy as primary treatment to avoid the morbidity of radical prostatectomy.
Introduction Two factors have changed urologists’ attitudes to surgery for prostate cancer since 1980. The first was the work of Dr. Patrick Walsh who “discovered” the neurovascular bundle so key in potency preservation at prostatectomy [1, 2]. Walsh also recognized that bleeding occurred due to failure to control Santorini’s plexus of dorsal penile veins. These two anatomical insights ushered in three improvements in prostatectomy outcomes [3]. Because the operative field was no longer immersed in blood, greater care in the precise dissection of the striated sphincter was possible. This meant that with care being taken
A.J. Costello, M.D., FRACS (*) Department of Urology, Royal Melbourne Hospital, 32 Erin Street, Richmond VIC 3121, Australia e-mail: [email protected] N.M. Corcoran, Ph.D., FRACS (Urol) Departments of Urology and Surgery, Royal Melbourne Hospital and University of Melbourne, Grattan Street, Parkville, VIC 3050, Australia e-mail: [email protected] A. Tewari (ed.), Prostate Cancer: A Comprehensive Perspective, DOI 10.1007/978-1-4471-2864-9_1, © Springer-Verlag London 2013
in this step of the operation, most men would maintain urinary continence. The anatomic description of a discrete autonomic neural bundle running in a groove posterolateral to the prostate between rectum and prostate meant potency preservation was a surgical reality. The surgeon’s ability to perform the operation now in a mainly bloodless field allowed a better oncological procedure with clean dissection in and around the fascial compartments of the prostate. This led to steady and steep decline in the positive pathological margin rate. Dr. Whitmore quoted saying that surgery (before 1975) was unlikely to lead to cure and is also less quoted stating “There is no better way to cure prostate cancer that is confined to the prostate than its total removal” [4, 5]. Before the mid1970s, most men presented with locally very advanced cancer or regularly with metastatic disease. Surgery was most unlikely to cure those men. The advent in the 1980s of PSA allowed a lead time of around 9 years from localized to metastatic prostate cancer. In 2000, the arrival of telerobotic surgery [6] provided the prostatectomist with an unprecedented ×10 magnified 3-dimensional surgical field. These incremental advances in surgery
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