Denonvilliers' fascia as a potential nerve-course marker for the female urinary bladder.

OBJECTIVES: This study investigated the relationship between Denonvilliers' fascia (DF) and the pelvic plexus branches in women and explored the possibility of using the DF as a positional marker in nerve-sparing radical hysterectomy (RH). METHODS: This study included eight female cadavers. The DF, its lateral border, and the pelvic autonomic nerves running lateral to the DF were dissected and examined. The pelvis was cut into two along the mid-sagittal line. The uterine artery, deep uterine veins, vesical veins, and nerve branches to the pelvic organs were carefully dissected. RESULTS: The nerves ran sagitally, while the DF ran perpendicularly to them. The rectovaginal ligament was continuous with the DF, forming a single structure. The DF attached perpendicularly and seamlessly to the pelvic plexus. The pelvic plexus branches were classified into a ventral part branching to the bladder, uterus, and upper vagina and a dorsal part branching to the lower vagina and rectum as well as into four courses. Nerves were attached to the rectovaginal ligament and ran on its surface to the bladder ventral to the DF. The uterine branches split from the common trunk of these nerves. The most dorsal branch to the bladder primarily had a common trunk with the uterine branch, which is the most important and should be preserved in nerve-sparing Okabayashi RH. CONCLUSION: The DF can be used as a marker for nerve course, particularly in one of the bladder branches running directly superior to the DF, which can be preserved in nerve-sparing Okabayashi RH.

Beyond Total Mesorectal Excision: Compartment-based Anatomy of the Pelvis Revisited for Exenterative Pelvic Surgery.

OBJECTIVE: Magnetic resonance imaging-based subdivision of the pelvis into 7 compartments has been proposed for pelvic exenteration. The aim of the present anatomical study was to describe the topographic anatomy of these compartments and define relevant landmarks and surgical dissection planes. BACKGROUND: Pelvic anatomy as it relates to exenterative surgery is complex. Demonstration of the topographic peculiarities of the pelvis based on the operative situs is hindered by the inaccessibility of the small pelvis and the tumor bulk itself. MATERIALS AND METHODS: Thirteen formalin-fixed pelvic specimens were meticulously dissected according to predefined pelvic compartments. Pelvic exenteration was simulated and illustrated in a stepwise manner. Different access routes were used for optimal demonstration of the regions of interest. RESULTS: All the 7 compartments (peritoneal reflection, anterior above peritoneal reflection, anterior below peritoneal reflection, central, posterior, lateral, inferior) were investigated systematically. The topography of the pelvic fasciae and ligaments; vessels and nerves of the bladder, prostate, uterus, and vagina; the internal iliac artery and vein; the course of the ureter, somatic (obturator nerve, sacral plexus), and autonomic pelvic nerves (inferior hypogastric plexus); pelvic sidewall and floor, ischioanal fossa; and relevant structures for sacrectomy were demonstrated. CONCLUSIONS: A systematic approach to pelvic anatomy according to the 7 magnetic resonance imaging-defined compartments clearly revealed crucial anatomical landmarks and key structures facilitating pelvic exenterative surgery. Compartment-based pelvic anatomy proved to be a sound concept for beyond TME surgery and provides a basis for tailored resection procedures.

[Anatomical elucidation and histological study of pelvic autonomic nerve-plane based female fresh cadaver].

Objective: To investigate the rationality of nerve-plane sparing radical hysterectomy (NPSRH) for cervical cancer by observing the anatomical and histological characteristics of pelvic autonomic plane based on fresh cadaver. Methods: From October 2015 to September 2020, 14 fresh female cadavers were anatomically and histologically studied in the Laboratory of Anatomy and Embryology Department, Peking Union Medical College, Chinese Academy of Medical Sciences. The median age of the specimens was 79 years (range: 67 to 92 years). Twenty-eight hemi-pelvic specimens were obtained from 14 fresh female cadavers. NPSRH procedures were simulated in 8 hemi-pelvic cavities to prove its feasibility. Detailed dissection was conducted to recognize nerve plane and to observe the distribution of pelvic nerves in 10 hemipelvis. In the other 10 hemipelvis, whole parametrium tissue was taken from the crossing of ureter and the uterine artery to the ureterovesical entrance and be embedded, then continuous section was performed, and was stained by hematoxylin-eosin staining (HE) to observe the relationship of nerves and vessels. Immunohistochemical staining of S100, tyrosine dehydrogenase (TH), and vasoactive intestinal peptide (VIP) were performed to count and distinguish sympathetic and parasympathetic nerves, respectively. Results: (1) The pelvic autonomic nerve-plane was completely preserved in 7 of 8 hemipelvis by simulating NPSRH. (2) After detailed dissection in 10 hemipelvis, it was found that hypogastric nerve, pelvic splanchnic nerve, and their confluence of inferior hypogastric plexus were distributed in a planar statelocating in the ureteral mesentery and its caudal extension. This nerve plane showed a cross relationship with deep uterine vein and its branches. The bladder branches and vesical venous plexus were closely related to the inferior hypogastric plexus. The middle vesical vein and inferior vesical vein were intact in 7 of 10 hemipelvis, and either vesical vein was missing in 3 of them. It was observed that the vesical venous plexus communicated with the deep uterine vein trunk on the medial side of the nerve plane in 6 hemipelvis, while flowed into the deep uterine vein on the lateral side of the nerve plane in 2 hemipelvis, and in the other 2 hemipelvis it directly flowed into the internal iliac vein. (3) It was revealed that autonomic nerves were continuously distributed beneath the ureteral with sagittal plane by HE staining. The average nerve content below the ureteral width was 70.9% of the total in nerve plane by S100 staining. TH and VIP staining showed that the average number of sympathetic fibers was 13.5 and parasympathetic fibers was 8.2, reminding sympathetic predominated. Conclusion: Pelvic autonomic nerves are mainly distributed within the mesangial plane below the ureter, which provides an anatomic justification for NPSRH.

Morphological Peculiarities of the Pelvic Autonomic Nervous System and Their Impact on Clinical Interventions in the Lesser Pelvic Region.

Background: The aim of the work is to define the morphological peculiarities of the pelvic autonomic nervous system (ANS) and their importance in the clinical and surgical interventions in the lesser pelvis. Material and methods: Anatomical variations in the formation of the pelvic ANS were observed in 20 cadavers. The study included 17 men (85%), aged 18 to 84, and 3 women, aged 27 to 86. The average age was 53.8 years. The subjects most often died by violent death in car accidents, by asphyxia, or by sudden death. The study was approved by the Ethics Committee of the Health Care Surveillance Authority, Bratislava, Slovakia. We studied cadavers without congenital or detected anomalies, cancer, deformities of the body, or spinal or abdominal surgeries within 24 h of death. We observed a relationship between the dimensions and the number of ganglia, as well as the number and course of nerve branches and anastomoses. In the pelvic area, we observed the hypogastric plexus superior, hypogastric plexus inferior, and the truncus sympathicus. In all cadavers, we clarified the lumbosacral plexuses after evisceration. In the lumbosacral region, the roots were defined based on their participation in the formation of the plexuses. To show the intimate relationship between both systems, we also focused on the details of the structure (rami communicantes) related to the connections of the ANS with the spinal nervous system. Results: Anatomical variations in the formation of the pelvic ANS were observed in all cases. We included cases with more than two truncus sympathicus ganglia as the segmental type. The segmental form occurred in 14 (70%) cases, and was concentrated in 6 (30%) cases. Rami communicantes provided anastomoses to the spinal nerves. Small ganglia were observed on the rami communicantes. With the concentrated type, we observed the division of the sympathetic and parasympathetic systems. With the segmental and concentrated forms, symptoms of the "diffuse form" may occur, which we observed in all cases. We observed significant right-left asymmetry and differences in the formation of ganglia and anastomoses. Conclusions: This study allowed us to identify and describe the morphological peculiarities of the pelvic ANS and their possible influence on the clinical picture. Asymmetry and dependence of their occurrence on the type of ANS was observed. The variations were frequent. Their preoperative diagnosis is difficult to impossible. The absence or lack of intraoperative vigilance can lead to the damage of pelvic ANS during operations and blockades of the pelvic plexus. The acquired knowledge can be helpful in clarifying clinical signs and symptoms of these conditions.

Anatomy of the superior hypogastric plexus and its application in nerve-sparing paraaortic lymphadenectomy.

BACKGROUND: The purpose of this study was to clarify the anatomy of the superior hypogastric plexus, which would contribute to advancement of nerve-sparing paraaortic lymphadenectomy. MATERIALS AND METHODS: Eighteen cadavers were dissected and morphometrically analysed based on photographic images. Anatomical landmarks such as aortic bifurcation, transitional points of abdominal aorta to bilateral common iliac arteries, and cross point of the right ureter and pelvic brim, and cross point of sigmoid mesentery and pelvic brim were selected as reference points. RESULTS: The left lowest lumbar splanchnic nerve was located more laterally to transitional point of abdominal aorta to in 11/18 specimens, whereas the right lowest lumbar splanchnic nerve passed onto the right transitional point in only one specimen. The lowest lumbar splanchnic nerves or the superior hypogastric plexus covered the aortic bifurcation in 11/18 specimens. The superior hypogastric plexus was separate from the cross point of right ureter and pelvic brim as well as cross point of sigmoid mesentery and pelvic brim. CONCLUSIONS: The superior hypogastric plexus is at risk of injury during paraaortic lymphadenectomy because of its topography. Preservation of the superior hypogastric plexus regarding its anatomic basis during paraaortic lymphadenectomy is required.

[The key points to comprehend the pelvic fascia].

Pelvic fascia is considered to be one controversial human anatomic structure. According to the characteristics of specialized surgery, colorectal surgeons, gynecologic surgeons and urologic surgeons respectively marked the pelvic fascia, but the naming is not unified. For some specific anatomic structures (such as pelvic plexus), different scholars have different descriptions of their positions. The lack of standard anatomic terms makes it difficult to understand the corresponding anatomic structures, and also hinders the communication between disciplines. Combined with autopsy research, surgical observation and literature review, we discussed the common puzzles of pelvic clinical anatomy. The main points of this article are as follows. (1) Urogenital fascia and vesicohypogastric fascia are the components of visceral fascia. (2) The visceral fascia and fascia propria of rectum are two separate layers. (3) The pelvic plexus is located on the outside of the confluence of visceral fascia and Denonvilliers' fascia. (4) To understand the pelvic lateral ligament from the perspective of layers. (5) To understand pelvic fascia from a holistic perspective.

Anatomy of the female pelvic nerves: a macroscopic study of the hypogastric plexus and their relations and variations.

The autonomic nerves of the lesser pelvis are particularly prone to iatrogenic lesions due to their exposed position during manifold surgical interventions. Nevertheless, the cause of rectal and urinary incontinence or sexual dysfunctions, for example after rectal cancer resection or hysterectomy, remains largely understudied, particularly with regard to the female pelvic autonomic plexuses. This study focused on the macroscopic description of the superior hypogastric plexus, hypogastric nerves, inferior hypogastric plexus, the parasympathetic pelvic splanchnic nerves and the sympathetic fibres. Their arrangement is described in relation to commonly used surgical landmarks such as the sacral promontory, ureters, uterosacral ligaments, uterine and rectal blood vessels. Thirty-one embalmed female pelvises from 20 formalin-fixed and 11 Thiel-fixed cadavers were prepared. In all cases explored, the superior hypogastric plexus was situated anterior to the bifurcation of the abdominal aorta. In 60% of specimens, it reached the sacral promontory, whereas in 40% of specimens, it continued across the pelvic brim until S1. In about 25% of the subjects, we detected an accessory hypogastric nerve, which has not been systematically described so far. It originated medially from the inferior margin of the superior hypogastric plexus and continued medially into the presacral space. The existence of an accessory hypogastric nerve was confirmed during laparoscopy and by histological examination. The inferior hypogastric plexuses formed fan-shaped plexiform structures at the end of both hypogastric nerves, exactly at the junction of the ureter and the posterior wall of the uterine artery at the uterosacral ligament. In addition to the pelvic splanchnic nerves from S2-S4, which joined the inferior hypogastric plexus, 18% of the specimens in the present study revealed an additional pelvic splanchnic nerve originating from the S1 sacral root. In general, form, breadth and alignment of the autonomic nerves displayed large individual variations, which could also have a clinical impact on the postoperative function of the pelvic organs. The study serves as a basis for future investigations on the autonomic innervation of the female pelvic organs.

Anatomic Cartography of the Hypogastric Nerves and Surgical Insights for Autonomic Preservation during Radical Pelvic Procedures.

STUDY OBJECTIVE: To clarify the relationship of hypogastric nerves (HNs) with several pelvic anatomic landmarks and to assess any anatomic differences between the 2 sides of the pelvis, both in cadaveric and in vivo dissections. DESIGN: Prospective observational study. SETTING: An anatomic theater for cadaveric dissections and a university hospital for in vivo laparoscopy. PATIENTS: Five nulliparous female cadavers underwent laparotomic dissection; 10 nulliparous patients underwent laparoscopic surgery for rectosigmoid endometriosis without posterolateral parametrial infiltration. INTERVENTIONS: Measurements of the closest distance between HNs and ureters, the midsagittal plane, the midcervical plane, and uterosacral ligaments on both hemipelvises. A comparison of anatomic data of the 2 hemipelvises was conducted. MEASUREMENTS AND MAIN RESULTS: The right and left HNs were identified in all specimens, both on cadavers and in vivo dissections. A wide anatomic variability was reported. Regarding the differences between the 2 hemipelvises, we found that the right HN was significantly (p <.001) farther to the ureter (mean = 14.5 mm; range, 10-25 mm) than the left one (mean = 8.6 mm; range, 7-12 mm). The HN was closer to the midsagittal plane on the right side (mean = 14.6 mm; range, 12-17 mm) than on the left side (mean = 21.6 mm; range, 19-25 mm). The midcervical plane was found 2.7 mm (range, 2-4 mm) to the left of the midsagittal one. The right HN was found to be nonsignificantly closer to the midcervical plane and the uterosacral ligament on the right side than on the left side (p >.05). CONCLUSIONS: Despite a wide anatomic variability of position and appearance, the HNs are reproducibly identifiable using an "interfascial" technique and considering the ureters and uterosacral ligaments as anatomic landmarks.

Three-Dimensional Modelization of the Female Human Inferior Hypogastric Plexus: Implications for Nerve-Sparing Radical Hysterectomy.

BACKGROUND/AIMS: This study aims to describe the autonomic nervous network of the female pelvis with a 3D model and to provide a safe plane of dissection during radical hysterectomy for cervical cancer. METHODS: Pelvises of 3 human female fetuses were studied by using the computer-assisted anatomic dissection. RESULTS: The superior hypogastric plexus (SHP) was located at the level of the aortic bifurcation in front of the sacral promontory and divided inferiorly and laterally into 2 hypogastric nerves (HN). HN ran postero-medially to the ureter and in the lateral part of the uterosacral ligament until the superior angle of the inferior hypogastric plexus (IHP). IHP extended from the anterolateral face of the rectum, laterally to the cervix and attempted to the base of the bladder. Vesical efferences merged from the crossing point of the ureter and the uterine artery and ran through the posterior layer of the vesico-uterine ligament. CONCLUSIONS: The SHP could be injured during paraaortic lymphadenectomy. Following the ureter and resecting the medial fibrous part of the uterosacral ligament may spare the HN. No dissection should be performed under the crossing point of the ureter and the uterine artery.

The anatomy of the male inferior hypogastric plexus: What should we know for nerve sparing surgery.

The aim of this study was to investigate the nerve supply to the structures in the male lesser pelvis and review its clinical relevance, especially during nerve sparing surgery. Three formalin-embalmed and 16 Thiel-embalmed male hemipelves were used. They were microdissected after repeated treatments with nitric acid diluted 1:10 with milliQ-water. The inferior hypogastric plexus (IHP) is a fan-like structure lateral from the rectum on the fascia of the levator ani. Nerves emerging from the proximal, solid part of the plexus follow the internal iliacal vessels and reach the prostate from dorsolateral. The innervation of the urethra and the corpora cavernosa derives from two origins: one follows the ejaculatory duct and the seminal vesicle, reaching the proximal urethra and the prostate from dorsal; the other follows the inferior vesical artery to reach the prostate from lateral, and then forms the neurovascular bundle on both sides of the prostatic fascia, spreading to the pelvic floor muscles and the corpora cavernosa along with the distal urethra. A connection between the two parts was demonstrated in approximately one third of the samples investigated. The nerve supply to the urinary bladder, the urethra, and the corpora cavernosa emerges mainly from the IHP. The innervation of the proximal urethra and its autonomic muscular structures has a dorsal (ejaculatory duct) and lateral (inferior vesical artery) origin. To maintain good erectile and continence function it is important to save both the dorsal and lateral neurovascular roots. Clin. Anat. 31:788-796, 2018. © 2018 Wiley Periodicals, Inc.

Neural supply of the male urethral sphincter: comprehensive anatomical review and implications for continence recovery after radical prostatectomy.

PURPOSE: To review the anatomical facts of urethral sphincter (US) innervation discovered over the last three decades and to determine the implications for continence recovery after radical prostatectomy (RP). METHODS: Using the PubMed® database, we searched for peer-reviewed articles in English between January 1985 and September 2015, with the following terms: 'urethral sphincter,' 'urethral rhabdosphincter,' 'urinary continence and nerve supply' and 'neuroanatomy and nerve sparing.' The anatomical methodology, number of bodies examined, data, figures, relevant facts and text were analyzed. RESULTS: Seventeen articles on 254 anatomical subjects were reviewed. Coexisting pathways were described in every article. Dissection, histology, simulation or electron microscopy evidence supported arguments for somatic and autonomic pathways. From the most to the least substantiated, somatic sphincteric fibers were described extra- or intrapelvic as: direct from the distal pudendal nerve (PuN), recurrent from the dorsal nerve of the penis, from the proximal PuN with an intrapelvic course, extrapudendal somatic fibers dispersed among autonomic pelvic fibers. From the pelvic plexus, or from the neurovascular bundles, autonomic fibers to the US have been described in 13 of the reviewed articles, with at least each of the available anatomical methods. CONCLUSION: Because continence depends on a number of factors, it is challenging to delineate the specific impact of periprostatic nerve sparing on continence, but the anatomical data suggest that RP surgeons should steer toward the preservation and protection of these nerves whenever possible.

Anatomic relationships of the pelvic autonomic nervous system in female cadavers: clinical applications to pelvic surgery.

BACKGROUND: The integrity of the pelvic autonomic nervous system is essential for proper bowel, bladder, and sexual function. OBJECTIVE: The purpose of this study was to characterize the anatomic path of the pelvic autonomic system and to examine relationships to clinically useful landmarks. STUDY DESIGN: Detailed dissections were performed in 17 female cadavers. Relationships of the superior hypogastric plexus to aortic bifurcation and midpoint of sacral promontory were examined; the length and width of plexus was documented. Path and width of right and left hypogastric nerves were recorded. The origin and course of the pelvic splanchnic nerves were documented. Individual nerve tissue that contributed to the inferior hypogastric plexus was noted. Relative position of nerves to arteries, viscera, and ligaments was documented. In a subset of specimens, biopsy specimens were obtained to confirm gross findings by histologic analysis. Descriptive statistics were used for data analyses and reporting. RESULTS: In all specimens, the superior hypogastric plexus was embedded in a connective tissue sheet within the presacral space, just below the peritoneum. In 14 of 17 specimens (82.4%), the plexus formed a median distance of 21.3 mm (range, 9-40 mm) below aortic bifurcation; in the remaining specimens, it formed a median distance of 25.3 mm (range, 20.5-30 mm) above bifurcation. In 58.8% of specimens, the superior hypogastric plexus was positioned to the left of midline. The median length and width of the plexus was 39.5 (range, 11.5-68) mm and 9 (range, 2.5-15) mm, respectively. A right and left hypogastric nerve was identified in all specimens and formed a median distance of 23 mm (range, 5-32 mm) below the promontory. The median width of the hypogastric nerve was 3.5 mm (range, 3-4.5 mm) on the right and 3.5 mm (range, 2-6.5 mm) on the left. The median distance from midportion of uterosacral ligament to the closest nerve branch was 0.5 mm (range, 0-4.5 mm) on right and 0 mm (range, 0-27.5 mm) on left. In all specimens, the inferior hypogastric plexus was formed by contributions from the hypogastric nerves and branches from S3 and S4. In 47.1% of hemipelvises, S2 branches contributed to the plexus. The sacral sympathetic trunk contributed to the plexus in 16 of 34 hemipelvises where this structure was identified. The inferior hypogastric plexus formed 1-3 cm lateral to the rectum and upper third of the vagina. From this plexus, 1-3 discrete branches coursed deep to the ureter toward the bladder. A uterine branch that coursed superficial to the ureter followed the ascending branch of the uterine artery. An S4 branch was found directly attaching to lateral walls of the rectum in 53% of specimens. Pelvic splanchnic nerves merged into the inferior hypogastric plexus on the lower and medial surface of the coccygeus muscle. Histologic analysis confirmed neural tissue in all tissues that were sampled. CONCLUSION: Anatomic variability and inability to visualize the small caliber fibers that comprise the inferior hypogastric plexus grossly likely underlines the reasons that some postoperative visceral and sexual dysfunction occur in spite of careful dissection and adequate surgical technique. These findings highlight the importance of a discussion with patients about the risks that are associated with interrupting autonomic fibers during the preoperative consent.

Selective visualization of pelvic splanchnic nerve and pelvic plexus using readout-segmented echo-planar diffusion-weighted magnetic resonance neurography: A preliminary study in healthy male volunteers.

PURPOSE: To evaluate the potential of readout-segmented echo-planar diffusion-weighted magnetic resonance neurography (RS-EPI DW-MRN) for the selective visualization of pelvic splanchnic nerve and pelvic plexus in healthy male volunteers. MATERIALS AND METHODS: Institutional review board approval and written informed consent were obtained. RS-EPI DW-MRN images were acquired from thirteen healthy male volunteers aged 25-48 years between September 2013 and December 2013. For RS-EPI DW-MRN, the following parameters were used: spatial resolution, 1.1×1.1×2.5mm; b-value, 250s/mm2; number of readout-segments, seven; and acquisition time, 7min 45s. For qualitative assessment, two abdominal radiologists independently evaluated the visibility of the pelvic splanchnic nerves and pelvic plexuses bilaterally in each subject on oblique coronal thin-slab 10-mm-thick maximum intensity projection images and scored it with a 4-point grading scale (excellent, good, fair, poor). Both readers scored twice at 6-month intervals. Inter-observer and intra-observer variability were evaluated using Cohen's quadratically weighted κ statistics. Image artifact level was scored on a 4-point grading scale by other two abdominal radiologists in order to evaluate the correlation between the nerve visibility and the severity of imaging artifacts using the Spearman's correlation coefficient. RESULTS: Qualitative grading showed the following success rate (number of nerves qualitatively scored as excellent or good divided by total number of nerves): reader 1 (first set), 73% (19/26); reader 2 (first set), 77% (20/26); reader 1 (second set), 81% (21/26); and reader 2 (second set), 77% (20/26). Inter-observer agreement between readers 1 and 2 was excellent: κ=0.947 (first set) and 0.845 (second set). Intra-observer agreement was also excellent: κ=0.810 (reader 1) and 0.946 (reader 2). The visibility of pelvic splanchnic nerve and pelvic plexus showed a moderate correlation with the image artifact level (ρ=0.54, p=0.004). CONCLUSION: This study demonstrated that RS-EPI DW-MRN is a promising approach for selectively visualizing the pelvic splanchnic nerve and pelvic plexus.

Careful Dissection of the Distal Ureter Is Highly Important in Nerve-sparing Radical Pelvic Surgery: A 3D Reconstruction and Immunohistochemical Characterization of the Vesical Plexus.

OBJECTIVE: Radical hysterectomy with pelvic lymphadenectomy (RHL) is the preferred treatment for early-stage cervical cancer. Although oncological outcome is good with regard to recurrence and survival rates, it is well known that RHL might result in postoperative bladder impairments due to autonomic nerve disruption. The pelvic autonomic network has been extensively studied, but the anatomy of nerve fibers branching off the inferior hypogastric plexus to innervate the bladder is less known. Besides, the pathogenesis of bladder dysfunction after RHL is multifactorial but remains unclear. We studied the 3-dimensional anatomy and neuroanatomical composition of the vesical plexus and describe implications for RHL. MATERIALS AND METHODS: Six female adult cadaveric pelvises were macroscopically dissected. Additionally, a series of 10 female fetal pelvises (embryonic age, 10-22 weeks) was studied. Paraffin-embedded blocks were transversely sliced in 8-µm sections. (Immuno) histological analysis was performed with hematoxylin and eosin, azan, and antibodies against S-100 (Schwann cells), tyrosine hydroxylase (postganglionic sympathetic fibers), and vasoactive intestinal peptide (postganglionic parasympathetic fibers). The results were 3-dimensionally visualized. RESULTS: The vesical plexus formed a group of nerve fibers branching off the ventral part of the inferior hypogastric plexus to innervate the bladder. In all adult and fetal specimens, the vesical plexus was closely related to the distal ureter and located in both the superficial and deep layers of the vesicouterine ligament. Efferent nerve fibers belonging to the vesical plexus predominantly expressed tyrosine hydroxylase and little vasoactive intestinal peptide. CONCLUSIONS: The vesical plexus is located in both layers of the vesicouterine ligament and has a very close relationship with the distal ureter. Complete mobilization of the ureter in RHL might cause bladder dysfunction due to sympathetic and parasympathetic denervation. Hence, the distal ureter should be regarded as a risk zone in which the vesical plexus can be damaged.

Laparoscopic anatomy of the autonomic nerves of the pelvis and the concept of nerve-sparing surgery by direct visualization of autonomic nerve bundles.

OBJECTIVE: To demonstrate the laparoscopic neuroanatomy of the autonomic nerves of the pelvis using the laparoscopic neuronavigation technique, as well as the technique for a nerve-sparing radical endometriosis surgery. DESIGN: Step-by-step explanation of the technique using videos and pictures (educational video) to demonstrate the anatomy of the intrapelvic bundles of the autonomic nerve system innervating the bladder, rectum, and pelvic floor. SETTING: Tertiary referral center. PATIENT(S): One 37-year-old woman with an infiltrative endometriotic nodule on the anterior third of the left uterosacral ligament and one 34-year-old woman with rectovaginal endometriosis. INTERVENTION(S): Exposure and preservation by direct visualization of the hypogastric nerve and the inferior hypogastric plexus. MAIN OUTCOME MEASURE(S): Visual control and identification of the autonomic nerve branches of the posterior pelvis. RESULT(S): Exposure and preservation of the hypogastric nerve and the superficial part of the left hypogastric nerve were achieved on the first patient. Nerve roots S2, S3, and S4 were identified on the second patient, allowing for the exposure and preservation of the pelvic splanchnic nerves and the deep portion inferior hypogastric plexus. DISCUSSION(S): Radical surgery for endometriosis can induce urinary dysfunction in 2.4%-17.5% of patients owing to lesion of the autonomic nerves. The surgeon's knowledge of the anatomy of these nerves is the main factor for preserving postoperative urinary function. The following nerves are the intrapelvic part of the autonomic nervous system: the hypogastric nerves, which derive from the superior hypogastric plexus and carry the sympathetic signals to the internal urethral and anal sphincters as well as to the pelvic visceral proprioception; and the pelvic splanchnic nerves, which arise from S2 to S4 and carry nociceptive and parasympathetic signals to the bladder, rectum, and the sigmoid and left colons. The hypogastric and pelvic splanchnic nerves merge into the pararectal fossae to form the inferior hypogastric plexus. Most of the nerve-sparing techniques involve the dissection and exposure of the pelvic splanchnic nerves and the inferior hypogastric plexus. However, knowledge of the topographic anatomy and awareness of the landmarks for avoiding intraoperative nerve injuries seem to be the most important factors in avoiding postoperative bladder and bowel dysfunction, although this latter nerve-sparing technique seems to be associated with reduced radicality and symptom persistence. CONCLUSION(S): This video demonstrates a technique to expose the sympathetic and parasympathetic nerves of the pelvis to preserve them in radical pelvic surgery, by means of direct visualization, in a similar fashion to the technique used to preserve the ureters. An alternative to this technique is to use landmarks for limiting dissection and avoiding intraoperative nerve injury. Despite being safe and more easily reproducible, this latter technique is associated with a higher rate of symptom persistence.

Total laparoscopic nerve-sparing radical parametrectomy for occult early-stage cervical cancer: surgical technique and postoperative bladder function.

Surgery and radiotherapy are both regarded as standard treatments for occult cervical cancers. Surgery has several theoretical advantages over radiotherapy; therefore, such cancers, especially in their early stages, are commonly treated with radical parametrectomy. However, postoperative bladder dysfunction is an important potential complication of this type of surgery. This is a case report of total laparoscopic nerve-sparing radical parametrectomy for an occult cervical cancer using our original surgical concept based on detailed anatomical investigation of pelvic nerve networks in a fresh cadaver. We evaluated the validity of our nerve-sparing technique by assessing postoperative bladder function using urodynamic studies.

New insights in the neuroanatomy of the human adult superior hypogastric plexus and hypogastric nerves.

BACKGROUND: The superior hypogastric plexus (SHP) is an autonomic plexus, located ventrally to the abdominal aorta and its bifurcation, innervating pelvic viscera. It is classically described as being composed of merely sympathetic fibres. However, post-operative complications after surgery damaging the peri-aortic retroperitoneal compartment suggest the existence of parasympathetic fibres. This immunohistochemical study describes the neuroanatomical composition of the human mature SHP. MATERIAL AND METHODS: Eight pre-determined retroperitoneal localizations including the lumbar splanchnic nerves, the SHP and the HN were studied in four human cadavers. Control tissues (white rami, grey rami, vagus nerve, splanchnic nerves, sympathetic ganglia, sympathetic chain and spinal nerve) were collected to verify the results. All tissues were stained with haematoxylin and eosin and antibodies S100, tyrosine hydroxylase (TH), vasoactive intestinal peptide (VIP) and myelin basic protein (MBP) to identify pre- and postganglionic parasympathetic and sympathetic nerve fibres. RESULTS: All tissues comprising the SHP and hypogastric nerves (HN) showed isolated expression of TH, VIP and MBP, revealing the presence of three types of fibres: postganglionic adrenergic sympathetic fibres marked by TH, unmyelinated VIP-positive fibres and myelinated preganglionic fibres marked by MBP. Analysis of control tissues confirmed that TH, VIP and MBP were well usable to interpret the neurochemical composition of the SHP and HN. CONCLUSION: The human SHP and HN contain sympathetic and most likely postganglionic parasympathetic fibres. The origin of these fibres is still to be elucidated, however surgical damage in the peri-aortic retroperitoneal compartment may cause pelvic organ dysfunction related to both parasympathetic and sympathetic denervation.

Lower urinary tract dysfunction after nerve-sparing radical hysterectomy.

INTRODUCTION AND HYPOTHESIS: The aim of this review is to provide a comprehensive overview of the current role of nerve-sparing radical hysterectomy (NSRH) in reducing the incidence of postoperative lower urinary tract dysfunction (LUTD) and in improving quality of life. METHODS: A detailed online search was performed using the following keywords: nerve sparing, radical hysterectomy, cervical cancer, and all these terms in combination with urinary dysfunction or bladder dysfunction in order to analyze the effect of NSRH on urinary functional outcomes. Articles retrieved were analyzed and assigned a level of evidence (LE) according to the criteria of the Centre for Evidence-Based Medicine in Oxford, UK. RESULTS: Our review highlights the heterogeneity of conducting and reporting studies in the literature. Autonomic pelvic nerve injuries during the procedure are thought to be the major cause of LUTD. The amount of LUTD depends upon the extent and type of nerve injury. Anatomically based surgical techniques are developed to avoid nerve injury without compromising oncological control. All studies comparing NSRH to standard RH yielded promising results with respect to postoperative LUTD. A recent meta-analysis showed similar cancer control rates between the two techniques. However, controversies remain about the ideal surgical approach for nerve sparing and there is no consensus as to the level and landmarks of dissection to preserve the maximal amount of nerves without compromising oncological outcomes. CONCLUSIONS: Available evidence suggests that NSRH is safe and associated with lower incidence of LUTD. However, there is no standardized technique for NSRH and controversies remain about its oncological safety. Long-term oncological data from multicenter surgical trials are needed as well as a universally accepted standard to report studies on NSRH.

Recurrent rectal cancer causing lumbosacral plexopathy with perineural spread to the spinal nerves and the sciatic nerve: an anatomic explanation.

Several groups have reported cases of rectal cancer with carcinomatous involvement of the lumbosacral plexus and sciatic, obturator, pudendal, or spinal nerves. To our best knowledge, clear examples of perineural tumor spread in rectal carcinoma have not yet been described. We retrospectively reviewed clinical data and imaging studies of three patients with primary or recurrent rectal cancer involving the lumbosacral plexus. Imaging studies included MRI and (18)FDG PET/CT scans in all (n = 3) patients, histological samples were available in two (n = 2). Imaging studies demonstrated distinct features of tumor spread from the organ to the plexus and beyond in all cases (n = 3), histological specimens demonstrated perineural involvement thus supporting our theory (n = 2). We present these three cases of perineural tumor spread in rectal cancer as a proof of concept. We hypothesize that not only our cases, but other similar reported cases can be explained anatomically by extension of the rectal cancer to the inferior hypogastric plexus with perineural tumor spread to the lumbosacral plexus using the pelvic and sacral splanchnic nerves as conduits. Once the tumor reaches the lumbosacral plexus, it can continue to spread proximally or distally. We believe that perineural spread of colon cancer represents an important, under-recognized mechanism of recurrence to neighboring major nerves in the pelvis.