Robotic surgery after total neoadjuvant therapy for rectal cancer: pitfalls of beyond total mesorectal excision for patients with sidewall invasion.

AIM: Total neoadjuvant therapy (TNT) for locally advanced rectal cancer (LARC) is rapidly spreading. The robotic surgical techniques to approach lateral invasion, such as that of the pelvic plexus, have not yet been established. In this technical note, we present a video illustrating a surgical technique for lateral invasion using our novel technique and discuss its pitfalls. METHOD: We present the case of a 65-year-old man with LARC. Robotic surgery was performed after TNT using the da Vinci Xi Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). The surgical procedure was as follows: (1) D3 lymph node dissection around the inferior mesenteric artery using a medial-to-lateral approach; (2) rectal mobilization; (3) dissection of the ureterohypogastric fascia and ureter; and (4) combined resection of the hypogastric nerve and pelvic plexus. The key surgical point for sidewall invasion is the resection extent. Dividing the resection extent into three areas is important: zone A, which contains the pelvic plexus and is closest to the tumour; zone B, which contains the iliac vessels; and zone C, the most lateral zone, which contains the obturator nerves. This allows organ and function preservation by resecting only the smallest organ that truly requires R0 resection. RESULTS: The operating time was 333 min, console time was 232 min, and blood loss was 0 mL. The circumferential resection margin was 10 mm, and an R0 resection was achieved. CONCLUSION: We introduced a novel approach for robotic surgery after TNT for LARC with sidewall invasion. This technique can be performed safely and may help standardize 'beyond total mesorectal excision'.

A reappraisal of the deep uterine vein: a multimodal exploration with implications for pelvic surgery.

PURPOSE: Pelvic gynecological surgeries, whether for malignant or benign conditions, frequently result in functional complications due to injuries to the autonomic nervous system. Recognizing the deep uterine vein (DUV) as an essential anatomical reference can aid in preserving these structures. Despite its significance, the DUV is infrequently studied and lacks comprehensive documentation in Terminologia Anatomica. This research endeavors to elucidate a detailed characterization of the DUV. METHODS: We undertook a systematic literature review aligning with the "PRISMA" guidelines, sourcing from PUBMED and EMBASE. Our comprehensive anatomical examination encompassed cadaveric dissections and radio-anatomical evaluations utilizing the Anatomage® Table. RESULTS: The literary exploration revealed a consensus on the DUV's description based on both anatomical and surgical observations. It arises from the merger of cervical, vesical, and vaginal veins, coursing through the paracervix in a descending and rearward direction before culminating in the internal iliac vein. The hands-on anatomical study further delineated the DUV's associations throughout its course, highlighting its role in bifurcating the uterus's lateral aspect into two distinct zones: a superior vascular zone housing the uterine artery and ureter and an inferior nervous segment below the DUV representing the autonomic nerve pathway. CONCLUSION: A profound understanding of the subperitoneal space anatomy is paramount for pelvic surgeons to mitigate postoperative complications. The DUV's intricate neurovascular interplays underscore its significance as an indispensable surgical guide for safeguarding nerves and the ureter.

Anatomy of the lower hypogastric plexus applied to endometriosis: a narrative review.

OBJECTIVE: The objective of the present study is to evaluate the anatomy of the inferior hypogastric plexus, correlating it with urological pathologies, imaging exams and surgeries of the female pelvis, especially for treatment of endometriosis. MATERIAL AND METHODS: We carried out a review about the anatomy of the inferior hypogastric plexus in the female pelvis. We analyzed papers published in the past 20 years in the databases of Pubmed, Embase and Scielo, and we included only papers in English and excluded case reports, editorials, and opinions of specialists. We also studied two human fixed female corpses and microsurgical dissection material with a stereoscopic magnifying glass with 2.5x magnification. RESULTS: Classical anatomical studies provide few details of the morphology of the inferior hypogastric plexus (IHP) or the location and nature of the associated nerves. The fusion of pelvic splanchnic nerves, sacral splanchnic nerves, and superior hypogastric plexus together with visceral afferent fibers form the IHP. The surgeon's precise knowledge of the anatomical relationship between the hypogastric nerve and the uterosacral ligament is essential to reduce the risk of complications and postoperative morbidity of patients surgically treated for deep infiltrative endometriosis involving the uterosacral ligament. CONCLUSION: Accurate knowledge of the innervation of the female pelvis is of fundamental importance for prevention of possible injuries and voiding dysfunctions as well as the evacuation mechanism in the postoperative period. Imaging exams such as nuclear magnetic resonance are interesting tools for more accurate visualization of the distribution of the hypogastric plexus in the female pelvis.

Fertility- and Nerve-sparing Laparoscopic Eradication of Deep Endometriosis with Total Posterior Compartment Peritonectomy: The Kurashiki Method.

OBJECTIVE: To show technical highlights of a nerve-sparing laparoscopic eradication of deep endometriosis (DE) with posterior compartment peritonectomy. DESIGN: Demonstration of the technique with narrated video footage. SETTING: An urban general hospital. A systematic review and meta-analysis has suggested significant advantages of the nerve-sparing technique when considering the relative risk of persistent urinary retention in the treatment of DE [1]. In addition, a recent article has suggested that complete excision of DE with posterior compartment peritonectomy could be the surgical treatment of choice to decrease postoperative pain, improve fertility rate, and prevent future recurrence [2]. However, in DE, nerve-sparing procedures are even more challenging than oncologic radical procedures because the pathology resembles both ovarian/rectal cancer in terms of visceral involvement and advanced cervical cancer in terms of wide parametrial infiltration through the pelvic wall. INTERVENTIONS: The video highlights the anatomic and technical aspects of a fertility- and nerve-sparing surgery in DE with posterior compartment peritonectomy. After adhesiolysis and ovarian surgery, we developed retroperitoneal space at the level of promontory. The hypogastric nerve consists of the upper edge of the pelvic plexus, therefore the autonomic nerves were separated in a "nerve plane" by sharp interfascial dissection of the loose connective tissue layers both above (between the fascia propria of the rectum and the prehypogastric nerve fascia) and below (between the prehypogastric nerve fascia and the presacral fascia) the hypogastric nerve [3,4]. As a result of these dissections, the autonomic nerves in the pelvis were separated like a sheet with surrounding fascia. We then completely resected all DE lesions including peritoneal endometriosis while avoiding injury to the nerve plane. In a small number of our experiences, none of the patients (n = 51) required clean intermittent self-catheterization after this procedure. CONCLUSION: Fertility- and nerve-sparing laparoscopic eradication of DE with total posterior compartment peritonectomy is a feasible technique and may provide both curability of DE and functional preservation. Our nerve-sparing technique can reproducibly simplify this complex procedure.

Nerve-sparing in Gynecology.

OBJECTIVE: To demonstrate identification and dissection of the pelvic autonomic nerves in gynecologic surgery. DESIGN: Identification on the right and left pelvic pelvises, dissection and preservation of the inferior hypogastric plexus in deep endometriosis, and dissection and preservation of the pelvic autonomic nerves in radical hysterectomy. SETTING: Academic center. INTERVENTIONS: Robotic excision of the pelvic peritoneum, excision of deep endometriosis in the uterosacral ligaments, and radical hysterectomy. CONCLUSION: Pelvic autonomic nerves are easy to identify with the magnification provided with an endoscopic camera. They should be dissected and preserved whenever possible because of their important function.

Efficacy of Superior Hypogastric Plexus Neurolysis for the Treatment of Cancer-Related Pelvic Pain.

OBJECTIVE: Cancer-related abdominal and pelvic pain syndromes can be debilitating and difficult to treat. The objective of this study was to evaluate the efficacy of superior hypogastric plexus blockade or neurolysis (SHPN) for the treatment of cancer-related pelvic pain. DESIGN: Retrospective study. SETTING: MD Anderson Cancer Center, Houston, Texas. METHODS: We enrolled 46 patients with cancer-related pelvic pain who underwent SHPN. A numeric rating scale (NRS) was used for pain intensity, and symptom burden was evaluated using the Edmonton Symptom Assessment System at baseline, visit 1 (within one month), and visit 2 (within one to six months). RESULTS: Forty-six patients who received SHPN showed a significant reduction in pain score from 6.9 to 5.6 at visit 1 (P = 0.01). Thirty of the 46 patients continued to complete visit 2 follow-up, and the NRS score was consistently lower at 4.5 at visit 2 (P < 0.0001), with anxiety and appetite improved significantly. There was no significant change in the morphine equivalent dose at visits 1 and 2. The efficacy of the block was not influenced by patients' age, gender, type of cancer, cancer stage, regimen of chemotherapy and/or radiation therapy, diagnostic block, approach or laterality of procedure, or type or amount of neurolytic agent. Nonsmokers with high baseline pain scores were more likely to have improved treatment outcomes from SHPN at short-term follow-up. Adverse effects with SHPN were mild and well tolerated. CONCLUSIONS: SHPN was an effective and relatively safe procedure for pain associated with pelvic malignancies. There is a need for larger prospective trials.

Nerve-sparing Surgery for Deep Infiltrating Endometriosis: Laparoscopic Eradication of Deep Infiltrating Endometriosis with Rectal and Parametrial Resection According to the Negrar Method.

OBJECTIVE: To show technical highlights of a nerve-sparing laparoscopic eradication of deep infiltrating endometriosis with rectal and parametrial resection according to the Negrar method. DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: Tertiary care endometriosis unit. Bowel endometriosis accounts for about 12% of the total cases of endometriosis. Most frequently, rectal infiltration also means parametrial infiltration from the widespread infiltrating disease. Its removal with inadequate anatomical surgical knowledge may lead to severe damage to visceral pelvic innervation, causing bladder, rectal, and sexual function impairments and lasting lifelong. Nerve-sparing techniques, which are the heritage of onco-gynecologic surgery, have been described to have lower post-operative bladder, rectal, and sexual dysfunctions than classical approaches. INTERVENTIONS: Laparoscopic excision of deep infiltrating endometriosis was performed by following the nerve-sparing Negrar technique in 6 steps: step 0-adhesiolysis, ovarian surgery, and removal of the involved peritoneal tissues; step 1-opening of pre-sacral space, development of avascular spaces, and identification and preservation of pelvic sympathetic fibers of the inferior mesenteric plexus, superior hypogastric plexus, upper hypogastric nerves, and lumbosacral sympathetic trunk and ganglia; step 2-dissection of parametrial planes, isolation of ureteral course, lateral parametrectomy, and preservation of sympathetic fibers of postero-lateral parametrium and lower mesorectum (the lower hypogastric nerves and proximal part of the inferior hypogastric plexus or pelvic plexus); step 3-posterior parametrectomy, deep uterine vein identification, and preservation of the parasympathetic pelvic splanchnic nerves and the cranial and middle part of the mixed inferior hypogastric plexus in caudad posterior parametrium and lower mesorectal planes; step 4-preserving the caudad part of the inferior hypogastric plexus in postero-lateral parametrial ligaments; step 5-preserving the caudad part of the inferior hypogastric plexus in paravaginal planes; and step 6-rectal resection and colorectal anastomosis. CONCLUSION: As shown in this case, the laparoscopic nerve-sparing complete excision of endometriosis is a feasible and reproducible technique in expert hands and, as reported in the literature, offers good results in terms of bladder morbidity reduction with higher satisfaction than the classical technique.

Keep Your Landmarks Close and the Hypogastric Nerve Closer: An Approach to Nerve-sparing Endometriosis Surgery.

OBJECTIVE: Excisional techniques used to surgically treat deep infiltrating endometriosis (DIE) can result in inadvertent damage to the autonomic nervous system of the pelvis, leading to urinary, anorectal, and sexual dysfunction [1-4]. This educational video illustrates the autonomic neuroanatomy of the pelvis, identifying the predictable location of the hypogastric nerve in relation to other pelvic landmarks, and demonstrates a surgical technique for sparing the hypogastric nerve and inferior hypogastric plexus. DESIGN: Using didactic schematics and medical drawings, we discuss and illustrate the autonomic neuroanatomy of the pelvis. With annotated laparoscopic footage, we demonstrate a stepwise approach for identifying, dissecting, and preserving the hypogastric nerve during pelvic surgery. SETTING: Tertiary care academic hospitals: Mount Sinai Hospital in Toronto, Ontario, Canada, and S. Orsola Hospital in Bologna, Italy. INTERVENTIONS: Radical excision of DIE with adequate identification and sparing of the hypogastric nerve and inferior hypogastric plexus bilaterally was performed, following an overview of pelvic neuroanatomy. The superior hypogastric plexus was described and the hypogastric nerve, the most superficial and readily identifiable component of the inferior hypogastric plexus, was identified and used as a landmark to preserve autonomic bundles in the pelvis. The following steps, illustrated with laparoscopic footage, describe a surgical technique developed to identify and preserve the hypogastric nerve and the deeper inferior hypogastric plexus without the need for more extensive pelvic dissection to the level of the sacral nerve roots: (1) transperitoneal identification of the hypogastric nerve, with a pulling maneuver for confirmation; (2) opening of the retroperitoneum at the level of the pelvic brim and retroperitoneal identification of the ureter; (3) medial dissection and identification of the hypogastric nerve; and (4) lateralization of the hypogastric nerve, allowing for safe resection of DIE. CONCLUSION: The hypogastric nerve follows a predictable course and can be identified, dissected, and spared during pelvic surgery, making it an important landmark for the preservation of pelvic autonomic innervation.

The Urodynamics and Survival Outcomes of Different Methods of Dissecting the Inferior Hypogastric Plexus in Laparoscopic Nerve-Sparing Radical Hysterectomy of Type C: A Randomized Controlled Study.

BACKGROUND: Little data exist about the impact of dissection methods on bladder function during nerve-sparing radical hysterectomy (NSRH). This randomized controlled trial compared the urodynamic and survival outcomes of different methods dissecting the inferior hypogastric plexus (IHP) during laparoscopic NSRH. METHODS: Eligible patients presenting with stage IB cervical cancer from 9 May 2013 to 27 October 2015 were randomized at a ratio of 1:1 and subjected to waterjet (study group) or traditional blunt (control group) dissection of the IHP for laparoscopic type C radical hysterectomy. Participants were subjected to urodynamic evaluations before and after NSRH. The primary measurement was the proportion of patients with residual urine (RU) ≤ 100 ml, while secondary measurements included urodynamic parameters, disease-free survival (DFS), and overall survival (OS). RESULTS: In total, 191 women met the inclusion criteria, and 160 patients were included in the final analysis, with 80 randomized to each group. At 14 days after NSRH, the study group had more patients with RU ≤ 100 ml than the control group (82.5% vs. 62.5%, p = 0.005). The study group had similar urodynamic outcomes of preoperative and postoperative tests. Comparison with the study group and preoperative tests revealed the control group had significant bladder function impairment at 4 months after NSRH. After a median follow-up of 33 months, the dissection methods had no significant impact on DFS or OS. CONCLUSIONS: Waterjet dissection of the IHP in laparoscopic NSRH resulted in a more rapid return of normal urodynamics without compromising survival outcome. ClinicalTrials.gov Identifiers NCT03015376 (PUMCH-OBGYN-2013), NCT03291236 (SOCM-1).

Nerve-sparing radical hysterectomy: steps to standardize surgical technique.

AIM: The primary objective of this review was to study and analyze techniques of nerve-sparing radical hysterectomy so as to be able to characterize and elucidate intricate steps for the dissection of each component of the pelvic autonomic nerve plexuses during nerve-sparing radical hysterectomy. METHODS: This review was based on a five-step study design that included searching for relevant publications, selecting publications by applying inclusion and exclusion criteria, quality assessment of the identified studies, data extraction, and data synthesis. RESULTS: There are numerous differences in the published literature concerning nerve-sparing radical hysterectomy including variations in techniques and surgical approaches. Techniques that claim to be nerve-sparing by staying above the dissection level of the hypogastric nerves do not highlight the pelvic splanchnic nerve, do not take into account the intra-operative patient position, nor the fact that the bladder branches leave the inferior hypogastric plexus in a ventrocranial direction, and the fact that inferior hypogastric plexus will be drawn cranially with the vaginal walls (if this is not recognized and isolated earlier) above the level of hypogastric nerves by drawing the uterus cranially during the operation. CONCLUSIONS: The optimal nerve-sparing radical hysterectomy technique has to be radical (type C1) and must describe surgical steps to highlight all three components of the pelvic autonomic nervous system (hypogastric nerves, pelvic splanchnic nerves, and the bladder branches of the inferior hypogastric plexus). Recognizing the pelvic splanchnic nerves in the caudal parametrium and the isolation of the bladder branches of the inferior hypogastic plexus requires meticulous preparation of the caudal part of the ventral parametrium.

Nerve-Sparing Technique during Laparoscopic Radical Hysterectomy: Critical Steps.

STUDY OBJECTIVE: To show the feasibility and safety of nerve-preserving laparoscopic radical hysterectomy (type C1 Querleu-Morrow Classification [1]) for the treatment of early cervical cancer. DESIGN: A surgical video article (Canadian Task Force classification III). SETTING: A university hospital (University Hospital of Barcelona, Barcelona, Spain). PATIENTS: Nerve-preserving radical hysterectomy is performed in a patient with Fédération Internationale de Gynécologie et d'Obstétrique stage 1B1 cervical cancer with deep stromal invasion. INTERVENTIONS: Three steps are fundamental for the removal of the cérvix with a safe oncologic margin and preservation of the pelvic autonomic nerves [2]. 1. Step 1: for the correct preservation of the pelvic splanchnic nerves (ventral roots from spinal nerves S2-S4) and the inferior hypogastric plexus during the section of the paracervix, it is essential to identify the deep uterine vein. This vein will correspond with the inferior limit of the dissection. 2. Step 2: during the dissection of the uterosacral ligament and after dissecting the Okabayashi space, the inferior hypogastric nerve is isolated. This nerve runs 2 cm parallel below the uterosacral ligament in the peritoneal leaf of the broad ligament. 3. Step 3: during the section of the vesicouterine ligament, the lateral side must be preserved because it includes the medial and inferior vesical veins that drain to the deep uterine vein. CONCLUSION: Nerve-sparing laparoscopic radical hysterectomy is an attractive surgical approach for early-stage cervical cancer. Direct visualization of the pelvic autonomic nervous system (sympathetic and parasympathetic branches) innervating the bladder and rectum makes the nerve-sparing approach a safe and feasible procedure.

The Optimal Approach for a Superior Hypogastric Plexus Block.

INTRODUCTION: Superior hypogastric plexus block (SHGPB) is technically difficult, and an accurate procedure is required to avoid potential complications. We attempted to determine the reference angles for fluoroscopy-assisted SHGPB and to establish a predictor as a guide to select the optimal approach between the classic posterior approach and transdiscal approach. METHODS: Abdominopelvic computed tomography (CT) scans from 268 patients diagnosed with pelvic malignancies were examined. The oblique and axial angles needed for the fluoroscope were measured both for posterior and transdiscal approaches by simulating the needle trajectory on CT imaging. We developed an SHGPB index defined by the ratio (%) of the interposterior iliac border distance to the L5 body transverse diameter, which represents the relative transverse diameter of the bony pelvis. We evaluated whether it can help select the optimal approach for the SHGPB between the posterior and transdiscal approaches. RESULTS: Males had a significantly smaller angle than females (right oblique angle for posterior approach, males 14 [range 12 to 17] degrees vs. females 19 [range 16 to 23] degrees; P < 0.001). An SHGPB index of < 150 was an independent predictor for failure of the classic posterior approach (odds ratio 31.3, 95% confidence interval 5.1 to 104.7). CONCLUSIONS: The optimal right oblique angle of fluoroscopy for the posterior approach is 13° to 15° in males and 19° to 20° in females. The transdiscal approach may be favored over the posterior approach when the bony pelvis is narrow relative to the target vertebral body, which can be measured by the SHGPB index being < 150.

Uterine-Sparing Laparoscopic Pelvic Plexus Ablation, Uterine Artery Occlusion, and Partial Adenomyomectomy for Adenomyosis.

STUDY OBJECTIVE: To evaluate safety, feasibility, and long-term clinical effects of adding laparoscopic pelvic plexus ablation to uterine-sparing procedures (uterine artery occlusion and partial adenomyomectomy) for adenomyosis. DESIGN: A prospective controlled study (Canadian Task Force classification II-1). SETTING: A teaching hospital. PATIENTS: A total of 112 patients with symptomatic adenomyosis were eligible for uterine-sparing laparoscopy. INTERVENTIONS: Laparoscopic pelvic plexus ablation, uterine artery occlusion, and partial adenomyomectomy. MEASUREMENTS AND MAIN RESULTS: After the exclusion of patients with malignant tumors or those lost to follow-up, 102 women underwent laparoscopic uterine artery occlusion and partial adenomyomectomy; 50 of these patients also had laparoscopic uterine pelvic plexus ablation (group A) with the remaining 52 patients serving as the control group (group B). Other than operative time (107.0 ± 15.4 vs 98.9 ± 20.2 minutes, p = .02), there were no statistical differences regarding other operative parameters between groups A and B. Relief of severe dysmenorrhea (Visual Analogue Scale score ≥ 7) at 36 months was higher in group A than in group B (100% vs 76.9%, p < .01). No patient suffered constipation or uroschesis in either group. CONCLUSION: Adding laparoscopic uterine pelvic plexus ablation to laparoscopic uterine artery occlusion and partial adenomyomectomy was more effective in relieving dysmenorrhea.

A comparison of maternal outcomes in complicated vaginal and cesarean deliveries.

OBJECTIVE: The purpose of this study was to compare general characteristics, laboratory data, and maternal outcomes of patients who experienced complications in the first 24 hours after a normal vaginal delivery or cesarean section (C-section). This way, the authors intended to determine the results of complications in these patients. MATERIALS AND METHODS: Data of patients referred from the peripheral care centers to the present tertiary care center in the first 24 hours after a vaginal delivery or C-section due to the presence of various complications were screened retrospectively from 2009 to 2013. Clinical and demographic characteristics, laboratory parameters, indications for C-section, mortality rates, maternal morbidities, surgical and medical treatments administered in the clinic, as well as operations performed in other care centers were noted. RESULTS: A total of 330 patients were included in this study. Of these patients, 285 constituted the postoperative group (C-sections) whereas 45 constituted the postpartum (vaginal deliveries) group. There was no statistically significant difference between the two groups in demographic characteristics, results of laboratory parameters, maternal morbidity, and mortality rates. Requirement of hysterectomy and relaparotomy was significantly higher in the postoperative group. CONCLUSIONS: In the early follow-up, it was found that complicated C-sections and vaginal deliveries had similar results. However, it should also be mentioned that higher requirement of hysterectomy and relaparotomy emerged as an undesirable condition among the postoperative patients in this study. With this in mind, mode of delivery should be selected according to the overall health status of the patient and indications for C-section.

Laparoscopically implanted system for stimulation of the hypogastric plexus induces colonic motility, defecation, and micturition: experimental study.

BACKGROUND: Modulation of the enteric nervous system seems to be promising in several functional colorectal disorders for which targeted, causal treatment methods do not exist. However, sacral nerve stimulation can induce undesirable muscle contraction or paresthesia. Therefore, we have developed a laparoscopic technique for implanting a neural electrode, placed directly over the pelvic autonomic nerve plexus. The aim of this experimental study was to evaluate the effect of stimulating the hypogastric plexus and pelvic nerves on inducing distal colon contraction, defecation, and micturition. METHOD: A total of 10 white, male healthy pigs (25-30 kg) were subjected to the laparoscopic implantation of the electrode and the stimulator. In the third and fourth weeks postimplantation, the efficacy of the acute and chronic stimulation to induce defecation was evaluated. RESULTS: The average operative time was 105 minutes (85-150 minutes). In all pigs, acute stimulation activated induced defecation, every second day, every time on demand, with an average delay of 139.7 s. Micturition was induced incidentally. Acute or chronic stimulation did not cause any harm, pain, or suffering to the animals. No adverse effects of the stimulation were observed, and no septic complications or macroscopic fibrosis around the electrodes were found on autopsy. CONCLUSION: Hypogastric plexus stimulation can be a useful and safe option of distal colon contraction, defecation, and micturition. However, the efficacy of the stimulation was observed for a relatively short period of time, and it is not known if it will be sustained for a longer duration.

[Nerve-preserving low anterior rectum resection]. / Nervenschonende offene tiefe anteriore Rektumresektion beim Rektumkarzinom.

AIM: The Performance of an oncological low anterior rectum resection with preservation of the sympathic and parasympathic nerves is illustrated. INDICATION: The total mesorectal excision (TME) by Robert Heald et al. is the gold standard for rectal cancer operations which has lowered drastically the local recurrence rate. As the survival data improve, the new focus is the postoperative quality of life with preserving of the bladder and sexual function. METHOD: We demonstrate an anterior rectal cancer operation with preserving of the sympathetic and parasympathetic nerves step by step. CONCLUSION: The critical parts of preserving the nerves with the N. hypogastricus superior and inferior as well as the neurovascular bundle "erigent pillar" are demonstrated.

Localisation and preservation of the autonomic nerves in rectal cancer surgery - technical details.

Iatrogenic surgical injury to pelvic autonomic nerves followed by genitourinary dysfunctions are well known problems after total partial mesorectal excision for rectal cancer. The purpose of our paper is to present the useful anatomical landmarks for a safe nerve-sparing surgery in rectal oncology. Over the course of a total mesorectal excision we describe and illustrate the key risk zones of autonomic nerve injury based on our experience in rectal surgery and on the revised literature.

Robot versus laparoscopic nerve-sparing radical hysterectomy for cervical cancer: a comparison of the intraoperative and perioperative results of a single surgeon's initial experience.

OBJECTIVE: The aim of the study was to compare the initial surgical outcomes and learning curve of nerve-sparing robotic radical hysterectomy (RRH) with nerve-sparing total laparoscopic radical hysterectomy (TLRH) for the treatment of early-stage cervical cancer in the first 50 cases. METHODS: Between January 2008 and March 2012, 50 consecutive patients underwent nerve-sparing RRH. These patients were compared with a historic cohort of the first 50 consecutive patients who underwent nerve-sparing TLRH. RESULTS: Both groups were similar with respect to patients and tumor characteristics. The mean operating time in the RRH group was significantly longer than that in the TLRH group (230.1 ± 35.8 vs 211.2 ± 46.7 minutes; P = 0.025). The mean blood loss for the robotic group was significantly lower compared with the laparoscopic group (54.9 ± 31.5 vs 201.9 ± 148.4 mL; P < 0.001). There was no significant difference in the mean pelvic lymph nodes between the 2 groups (25.0 ± 9.9 vs 23.1 ± 10.4; P = 0.361). The mean days to normal residual urine were 9.6 ± 6.4 in RRH and 11.0 ± 6.2 in TLRH (P = 0.291). The incidence of intraoperative complication was profoundly lower in RRH compared with that of TLRH (0% vs 8%; P = 0.041). Moreover, no intraoperative transfusion was required in RRH, whereas 4 (8%) were required in TLRH (P = 0.041). In both groups, we found no evidence of a learning effect during the first 50 cases. CONCLUSIONS: During the first 50 cases, surgical outcomes and complication rates of nerve-sparing RRH were found to be comparable to those of nerve-sparing TLRH. Moreover, the mean blood loss and intraoperative complication rate in the robotic group were significantly lower than those in the laparoscopic group. Surgical skills for nerve-sparing TLRH easily and safely translated to nerve-sparing RRH in case of experienced laparoscopic surgeon.