The ‘multilayer’ theory of Denonvilliers’ fascia: anatomical dissection of cadavers with the aim to improve neurovascular bundle preservation during rectal mobilization

Abstract

Aim Denonvilliers' fascia is thought to be a multilayered fascial structure, based on its embryological development with the neurovascular bundle embedded within it. Recently, this theory had been proven histologically and by confocal microscopy in many published articles. However, the literature does not report on how surgeons can identify these structures. We aimed to determine the optimal surgical approach for preserving these critical structures.Method Eighteen cadavers (13 male/five female) were included and treated according to the ethical considerations stated in the donation consent of our institution. Dissection was performed with the assistance of binocular loupes for better anatomical detail. The compositions of the prerectal fascia and the neurovascular bundle were observed and recorded at different levels of dissection using a high-definition camera. ResultsThe theoretical multilayered fascia was found in male specimens as three fascial layers originating from the perineal body, seminal vesicles and posterior bladder neck. The first layer merged posterolaterally and fused with the rectosacral fascia (Waldeyer's fascia). The neurovascular bundle in male specimens was observed piercing the second and third layers, while the first layer acted as a protective cover. Dissection of female specimens demonstrated only one layer in the prerectal space.Conclusion Intiating anterior rectal mobilization by incising the peritoneum posterior to its reflection seems to be anatomically correct to preserve DVF. However, its applicability may be difficult in a narrow chanllenging pelvis. The lateral rectal ligaments and Waldeyer's fascia should be dissected from their attachments to the proper fascia of the rectum.What does this paper add to the literature? Applicability of preserving Denonvilliers' fascia (DVF), taking into consideration the multilayered theory, has not previously been reported. Magnified dissections of male and female cadaveric specimens will help surgeons map a safe and easily accessible plane when performing anterior rectal mobilization to preserve urosexual function.

Identification of the surgical indication line for the Denonvilliers’ fascia and its anatomy in patients with rectal cancer

“…Additionally, it is easy to damage the parasympathetic corpus cavernosum from the pelvic plexus in front of the Denonvilliers' fascia, which plays an important compensatory role in the damage of the pelvic wall and cause urogenital dysfunction [25]. We believe that the preservation of the Denonvilliers' fascia is of great significance in reducing the rate of postoperative urogenital dysfunction in rectal cancer patients [26][27][28], which is supported by the results from other studies [29][30][31].…”

The Female Pelvic Floor Fascia Anatomy: A Systematic Search and Review

“…All studies were consistent in characterizing the PB as a mass of fibromuscular tissue lying between the anal canal and the vaginal wall. Several authors described the pyramidal shape of the PB, which had a large base located inferiorly underneath the perineal skin and a tip extending superiorly between the vagina and the anorectum [ 70 , 75 , 77 ]. The PB was also shown to connect the two halves of the membrane together [ 55 ].…”

“…The PB was also observed to be in continuity with the RVF [ 62 ]. The PB was commonly described as having a superior and inferior portion [ 58 , 65 , 75 , 77 ]. Some authors also characterized the lateral expansions of the PB more specifically in relation to muscle insertions [ 58 , 65 , 77 ].…”

Seminal Vesicle Adherent to Rectal Wall Following Neoadjuvant Chemoradiotherapy: A Potential False-Positive Diagnostic Pitfall

“…7 CRT can cause fibrous adhesion of anteriorly placed urogenital structures to the rectum, increasing the difficulty of separating the rectum from adjacent urogenital structures. 8,9 In addition to the fascial planes, CRT introduces changes in the neoplastic and non-neoplastic epithelium. Grossly, these changes manifest as flattened mucosa, loss of mucosal folds, ulceration, atrophic patches, and puckering.…”