Anatomy and preservation of accessory pudendal arteries in laparoscopic radical prostatectomy.
Academic Article
Overview
abstract
OBJECTIVE: The incidence of laparoscopically diagnosed accessory pudendal arteries (APAs) varies depending on how proactive the surgeon is to find them. Their preservation depends on their calibre and location. Our objective was to provide a detailed description of how to identify, dissect, and preserve APAs during laparoscopic radical prostatectomy (LRP). METHODS: Between January 2003 and January 2005, we treated 377 men with LRP; 325 met inclusion criteria for this study. We defined an APA as any artery located within the periprostatic region running parallel to the dorsal vascular complex and extending caudally towards the anterior perineum, other than cavernous arteries, corona mortis, and satellite arteries to the superficial and deep vascular complex. Two distinct varieties of APAs were identified: (1) lateral APAs course along the lateral aspect of the prostate and branch off any of the terminal branches of the hypogastric artery; and (2) apical APAs emerge through the levator ani fibres near the apical region of the prostate and most likely branch off the pudendal artery or corresponds to an aberrant course of the pudendal artery itself. We present a video depicting the laparoscopic anatomy of APAs and the technique to preserve them. RESULTS: Ninety-six of 325 men (30%) were found to have 125 separate APAs. Using the depicted surgical technique, we were able to preserve 83% of all APAs. Forty-nine of 55 lateral APAs (89%) and 55 of 70 apical APAs (79%) were preserved. Thirty-five of 38 large-calibre APAs (92%) and 70 of 87 small-calibre APAs (80%) were spared. The side-specific incidence of PSMs were 3% and 6% when APAs were preserved and not preserved, respectively (p=0.5). CONCLUSIONS: APAs are frequently identified during laparoscopic prostatectomy. Their preservation is feasible in LRP without increasing the risk of causing a PSM. It is reasonable to integrate APA preservation as part of the modern radical prostatectomy, although their role in functional outcomes still needs to be prospectively established.
