Anatomic Considerations of the Neurovascular Bundle

Robotic-assisted laparoscopic prostatectomy (RALP) has become the standard of care in the treatment of localized prostate cancer. Over the years, several studies have been published in the literature which delineate the course of the autonomic nerves from the pelvic plexus to the pelvic organs. This research was important as autonomic nerves have been shown to mediate erectile function and urinary continence, both of which are intimately related to quality-of-life (QOL) for patients. Thus, an understanding of the nervous anatomy intra-operatively is of relevance to urologists to improve functional outcomes while achieving negative surgical margins. In this chapter, we detail the pelvic plexus and fascial anatomy as it relates to the prostate, we define the concept of a neurovascular bundle, we describe the concept of a neural hammock, and we discuss current surgical techniques targeted at minimizing damage to the neural structures in the peri-prostatic region. In doing so, the authors hope to provide a summary of our current understanding of the anatomic considerations one must be aware of during a RALP.