In 1836, the membranous structure between the rectum and the seminal vesicles was named Denonvilliers’ fascia after Charles-Pierre Denonvilliers (1). Denonvilliers’ fascia has been a surgical landmark that urologists must consider during intrapelvic surgery (2,3). Denonvilliers’ fascia consists of a single layer arising from the fusion of the two walls of the embryological peritoneal cul-de-sac, under embryological and anatomical review (4). In our institution, a urologic intrapelvic surgery was performed, utilizing Denonvilliers’ fascia. However, experienced urologists should not disregard cases where Denonvilliers’ fascia is identified in surgery, and cases where Denonvilliers’ fascia is not noted in radical prostatectomy. The incidence of such differences is frequent. To assess these differences, we reviewed the intraoperative findings and the excised specimens obtained during a radical prostatectomy, as well as fixed specimens obtained during total pelvic exenteration.

Between April 2008 and March 2009, at our institution, the clinical anatomy of perioperative regions and excised specimens were reviewed macroscopically for 62 cases of antegrade radical prostatectomy. Not all cases had a treatment history for prostate cancer preoperatively. We observed the relationship between the deferent duct and the surrounding tissue after bladder neck transection, macroscopically. We also observed the detachment between the prostate and rectum, following deferential ligation and ablation, as well as the seminal vesicle detachment, macroscopically. In addition, we observed the dorsal surface of the excised specimen macroscopically. Finally, we histologically examined the region between the prostate and rectum using fixed specimens from three cases that underwent total pelvic exenteration performed during the same time period.

Although Denonvilliers’ fascia is present between the prostate and rectum anatomically, Denonvilliers’ fascia cannot be identified in all surgical cases. Urologic surgeons may accomplish surgery more securely and safely when they can identify Denonvilliers’ fascia without becoming perplexed by the differences present in each sugical case.

We firstly observed Denonvilliers’ fascia during a an antegrade radical prostatectomy, macroscopically. To solve such contradictions, five findings were focused on. It was noted that i) a connective tissue clung to the deferent duct following bladder neck transection and that the connective tissues were separated from the deferent duct; ii) the connective tissues that clung to the deferent duct continued to Denonvilliers’ fascia; iii) Denonvilliers’ fascia was identified as a membranous structure surgically; iv) the webbed connective tissue was observed more distally when the membranous structure was sharply cut open and v) the webbed connective tissue was identified as a membranous structure again as tension was applied to this webbed connective tissue.

As a result of these findings, we believe that Denonvilliers’ fascia may be perceived surgically only as an intricate connective tissue. In other words, the intricate connective tissue present in three dimensions gave the appearance of a membranous structure in two dimensions since tension was applied to this connective tissue in a definite direction, and this new membranous structure was recognized merely as a membrane surgically.

We represented this structure schematically to fully explain the misleading two-dimensional appearance of this connective tissue. As a result of these findings, we conclude that the connective tissue between the prostate and rectum is complex. Moreover, this connective tissue continues with the connective tissue around the deferent duct and seminal vesicles (Fig. 8). As the seminal vesicles, deferent duct and prostate are pulled ventrally to develop an operative field, tension can be applied to this connective tissue. This connective tissue changes to a membranous structure and may be identified as Denonvilliers’ fascia (Fig. 9). While tension was applied to the tissue, an incision was made to Denonvilliers’ fascia, and this membranous structure mitigated the tension (arrowheads). In addition, the prostate was pulled more ventrally and tension was applied to the connective tissue which was noted more distally. Consequently, the connective tissue was identified as a new membranous structure. Thus, the above-mentioned series of operations may lead to the identification of the membranous structure, Denonvilliers’ fascia. This identification occurred while tension was applied to the connective tissue when it was in a state of no tension due to previous perioperative operations (Fig. 10).

When we observed macroscopically the dorsum of a specimen from a radical prostatectomy, the dorsal surface of the prostate appeared to be covered with a thin membrane that we considered to be Denonvilliers’ fascia. It was noted in several parts of the area which continued with Denonvilliers’ fascia, but which were judged macroscopically to be a stump (Fig. 6). This stump which continued along Denonvilliers’ fascia was different in number. The stump also varied with respect to the region and the thickness in each prostatectomy specimen. Denonvilliers’ fascia, which changed shape from a connective tissue to a membranous structure upon the application of tension, released tension upon perioperative operation. Therefore, the issue that arises is whether the stumps of Denonvilliers’ fascia, which represent a congregation of connective tissue, is present in various forms in different specimens.

Finally, we examined three cases of fixed specimens between the prostate and rectum in the pelvic exenteration. We noted that the fat and connective tissue were present intricately at several levels between the prostate and rectum in the 62 cases. These fixed specimens of the pelvic exenteration cases are thought to be in an approximate state to the living body (Fig. 7). It was thought that these results also supported our observations of Denonvilliers’ fascia.

Therefore, the reason for the surgical understanding of the Denonvilliers’ fascia differing in each case may be that the quantity of connective tissue identified as Denonvilliers’ fascia is dissimilar and that its tension varies. It is beneficial that a surgeon performing urological intrapelvic surgery understand that Denonvilliers’ fascia is identified surgically as a structure consisting of connective tissue by a detachment operation. In addition, the fascia itself consists of a complex dense connective tissue. Moreover, it can be speculated that retroperitoneal fascia is similar to Denonvilliers’ fascia in its constitution. We consistently discussed the membranous structure in the surgical procedure, but we did not discuss the structure either embryologically or anatomically.

In conclusion, intricate connective tissue was anatomically present between the prostate and the rectum. A surgeon separated and applied tension to this connective tissue and in the process created a membranous structure. This structure was surgically identified as Denonvilliers’ fascia.