This document summarizes the surgical anatomy of the prostate gland. It describes the prostate's location and relations to surrounding structures like the bladder, urethra, and rectum. It details the prostate's blood supply from branches of the internal iliac artery, innervation from pelvic splanchic and pudendal nerves, and lymphatic drainage routes. The document also outlines important surgical structures like the prostatic capsule, neurovascular bundle, and surrounding fascial planes important for nerve-sparing prostatectomy.

1. RADICAL PROSTATECTOMY
SURGICAL ANATOMY
- Dr. Abhishek Pandey

2. Prostatic relations
• Pyramidal shape –
– Base against bladder
– Apex joining membranous urethra
• Deep in pelvis – difficult surgical exposure
• Anterior – Pubic symphysis
• Lateral – Levator ani (wedged b/w levators)
• Posterior – Rectal ampulla separated by
denonvillier’s fascia

5. • Postero-superior
– Seminal vesicles
– Ampullae of the vasa
• Normal – 18-20g
• 70% glandular
• 30% Fibromuscular
stroma

6. Zonal Anatomy – McNeal (1988)

7. Prostatic Capsule
• Surgical capsule – relevant to TURP
– Compressed prostate gland remaining after procedure
• Anatomic Prostatic Capsule – relevant to RP
– Non-glandular fibromuscular stromal portion of prostatic
parenchyma distributed over surface
– Non-discrete with indistinct margin with strands mingling
in periprostatic fascia
– 2-3mm thick
– Microscopically integral part of prostate

10. Prostaic Sheath
• AKA Peri-Prostatic Fascia –
– Loose areolar tissue encasing prostate
– Derived from intermediate stratum of
retroperitoneal fascia
– Fuses anterolaterally with endopelvic fascia
(lateral pelvic fascia) continuous with obturator &
transversalis fasciae
– Lateral pelvic fascia – derived from outer stratum

11. Three parts of periprostatic fascia
• Anterior leaf – encloses dorsal venous complex
• Lateral leaf – most important surgically
– Extends from anterolateral to posterolateral area
– Encloses the Neurovascular bundle
• Posterior leaf – fuses with denonvillier’s fascia

13. Denonvillier’s Fascia
• Between posterior wall of prostate & rectum
• Loose areolar connective tissue – more condensed
than periprostatic fascia
Two Lamellae
• Anterior lamella – single layer fusion-fascia
– Arises by distal-to-proximal fusion of mesothelial layers of
two layers of pelvic peritoneum in rectovesical pouch
– Derived from inner stratum

14. A
– Adherent to posterior prostatic surface
– Limited laterally – merges with periprostatic fascia
– Shield shaped
• Posterior lamella – rectal fascia
– Overlies anterolateral wall of rectum over lamina propria
– Derived from inner stratum
• Both layers taken with specimen in RP
• No surgically separable plane between them

16. • Pearly Gates – Hugh Young
– Combined layers of denonvillier’s fascia appearing
glistening white on
perineal exposure
– Signify safe passage
past rectum
• Beware – Rectourethralis

17. Puboprostatic Ligaments
• AKA median puboprostatic ligaments
• Paired ligaments each 4.5mm wide
• Attached to perichondrium near inferior border of
symphysis pubis lateral to synchondrosis
• Each deviates slightly medially towards prostate
• Becomes continuous with prostatic sheath
• Branches of deep dorsal vein that run beneath & b/w
puboprostatic ligaments

20. Dorsal Venous Complex
• Deep Dorsal Vein of Penis
– Under Buck’s fascia between corpora cavernosa
– Penetrates Urogenital diaphragm to enter Retzius space
• Three major branches
– Superficial branch – Single median
• Travels between puboprostatic lig.
• Lies outside peri-prostatic fascia
– Lateral branches – Right & Left
• Travel posterolaterally peri-prostatic fascia

22. Prostatic Venous Plexus of Santorini
• Lies over anterior fibromuscular stroma & lateral
surface
• Embeded in peri-prostatic fascia
• Main input – Deep dorsal vein
• Empty in vesical venous plexus & Inferior Vesical Vein
• Thin-walled valve-less veins
• Intercommunication with all deep pelvic veins

25. Striated Sphincter
• Vertically oriented tubular sheath
• Horseshoe shaped fibers at apex
• Close to apex fibers fuse posteriorly in midline
• Innervation – Pudendal N.
• DVC travels through it
• Fuse with Ant. FMS
• Insert on perineal body

26. Prostatic Innervation
• Sympathetic – L1 & L2 → Sup. hypogastric plexus →
Inferior hypogastric plexus
• Parasympathetic - Pelvic Splanchnic nerves from S2,
3, 4 via Inferior hypogastric plexus
• Somatic – from sacral nerves S2, 3, 4 → supply EUS
via Pudendal N.

28. Inferior Hypogastric (Pelvic) Plexus
• Located retroperitoneally besides rectum
• 5-11cm from the anal verge
• Form a fenestrated rectangular plate in sagittal plane
• Midpoint at the level of tip of seminal vesicles
• Input from sacral centers & hypogastric nerves
• Gives rise to Neurovascular Bundle (NVB)

30. Neurovascular Bundle of Walsh
• Runs within periprostatic fascia at the postero-lateral
junction
• 1.5mm from prostate at base
• 3.0mm from prostate at apex
• Contains fibres of Prostatic nerves & Cavernous N.
• Prostatic nerve fibres closely associated with
prostatic capsular vessels
• Nerve-sparing – lateral displacement of NVB

34. Arterial Supply
• Anterior div. of Internal Iliac A. → Gluteo-pudendal
trunk → Prostatovesical A. → Inf. Vesicle & Prostatic A.
• Prostatic A.
– Urethral A. – Proximal branch – Transition zone (4 & 8 o’
clock position near bladder neck)
– Capsular branches – Posterolateral offshoots – Peripheral &
central zones
• Superior vesicle A. → Vesiculodeferential A. →
Seminal vesicles & vasa

36. Lymphatic Drainage
Three lymphatic routes of nodal spread
• Route 1 – along Prostatic pedicle – major lymphatic
vessels - obturator and internal iliac nodes
• Route 2 – along Vesiculodeferential A. – Central zone
– external iliac nodes
• Route 3 – along capsular vessels – capsular lymphatic
vessels – sacral nodes
• Primary drainage – Obturator & External Iliac nodes

39. Thank You

40. A
• A