Robotic radical prostatectomy with preservation of the prostatic fascia: A feasibility study

Objectives. To describe a feasibility study of our ability to preserve the prostatic fascia in men undergoing robotic radical prostatectomy. The prostate is covered anterolaterally by prostatic fascia, also called lateral pelvic fascia or the parietal layer of endopelvic fascia. The prostatic fascia is rich in vessels, nerves, and smooth muscle. We hypothesized that preservation of this fascial layer may result in improved postoperative potency. Methods. The technique was first attempted in 15 men undergoing radical cystoprostatectomy, in which accidental entry to the prostatic tissue is not critical. Thereafter, it was performed in 6 impotent men undergoing robotic radical prostatectomy. The fascia was excised and stained for prostate-specific antigen and neural and muscle tissue. The technique was then performed in 35 potent men (Sexual Health Inventory for Men score greater than 21) undergoing robotic radical prostatectomy. Postoperative potency was evaluated with a self-administered questionnaire (Sexual Health Inventory for Men). Results. Under the magnification of the da Vinci robotic system, and also shown histologically, the prostatic fascia is a multifascial layer of fibrovascular tissue, covering the anterolateral aspect of the prostate. It stains positive for smooth muscle and nerves, but negative for prostate-specific antigen. The amount of neural tissue in the fascia is variable, but never exceeds that in the neurovascular bundle. At 12 months of follow-up, 34 (97%) of 35 men undergoing fascia-preserving robotic radical prostatectomy had erections strong enough for vaginal penetration, and 30 (86%) had normal erections (Sexual Health Inventory for Men greater than 21). Conclusions. Preservation of the prostatic fascia is safe and feasible, without compromising the surgical margins, and allows enhanced preservation of neural tissue during robotic prostatectomy with an apparent improvement in potency.