[Application status and progress of intraoperative nerve monitoring in pelvic autonomic nerve preserving radical resection of rectal cancer].

The current treatment strategy for rectal cancer is a comprehensive treatment centered on surgery. The application of total mesorectal excision (TME) has significantly reduced the local recurrence rate and improved the survival prognosis, but a series of pelvic organ dysfunction caused by pelvic autonomic nerve injury during the operation will reduce the postoperative quality of life of patients. Pelvic autonomic nerve preserving (PANP) radical proctectomy has emerged, but the biggest challenge in the implementation process of this technology is the accurate identification of nerves. A series of studies have shown that pelvic intraoperative autonomic monitoring (pIONM) can effectively assist surgeons to identify nerves, The purpose of this article is to introduce the function of pelvic autonomic nerve, the clinical manifestation of postoperative pelvic dysfunction and its relationship with nerve injury, the key points of implementing PANP, and the current situation and research progress of pIONM technology application.

Technical aspects of a new approach to intraoperative pelvic neuromonitoring during robotic rectal surgery.

It has been found that rectal surgery still leads to high rates of postoperative urinary, fecal, or sexual dysfunction, which is why nerve-sparing surgery has gained increasing importance. To improve functional outcomes, techniques to preserve pelvic autonomic nerves by identifying anatomic landmarks and implementing intraoperative neuromonitoring methods have been investigated. The objective of this study was to transfer a new approach to intraoperative pelvic neuromonitoring based on bioimpedance measurement to a clinical setting. Thirty patients (16 male, 14 female) involved in a prospective clinical investigation (German Clinical Trials Register DRKS00017437, date of first registration 31/03/2020) underwent nerve-sparing rectal surgery using a new approach to intraoperative pelvic neuromonitoring based on direct nerve stimulation and impedance measurement on target organs. Clinical feasibility of the method was outlined in 93.3% of the cases. Smooth muscle contraction of the urinary bladder and/ or the rectum in response to direct stimulation of innervating functional nerves correlated with a change in tissue impedance compared with the pre-contraction state. The mean amplitude (Amax) of positive signal responses was Amax = 3.8%, negative signal responses from a control tissue portion with no stimulation-induced impedance change had an amplitude variation of 0.4% on average. The amplitudes of positive and negative signal responses differed significantly (statistical analysis using two-sided t-test), allowing the nerves to be identified and preserved. The results indicate a reliable identification of pelvic autonomic nerves during rectal surgery.

The Role of Interventional Pain Management Strategies for Neuropathic Pelvic Pain in Endometriosis.

BACKGROUND: Endometriosis is a chronic common condition affecting 10% of reproductive-aged women globally. It is caused by the growth of endometrial-like tissue outside the uterine cavity and leads to chronic pelvic pain, affecting various aspects of a woman's physical, mental, emotional, and social well-being. This highlights the importance of an understanding of the potential involvement of the nervous system and involved nerves as well as an effective multidisciplinary pain management. OBJECTIVES: Our aim was to assess the current understanding of pain mechanisms in endometriosis and the effectiveness of different interventional pain management strategies. STUDY DESIGN: Literature review. METHODS: A search was conducted using multiple databases, including Google Scholar, MEDLINE (Ovid), PubMed, and Embase. We used keywords such as "endometriosis," "pain," pelvic pain, "management," and "anaesthesia" along with Boolean operators and MeSH terms. The search was limited to English language articles published in the last 15 years. RESULTS: Nerve involvement is a well-established mechanism for pain generation in patients with endometriosis, through direct invasion, irritation, neuroangiogenesis, peripheral and central sensitization, and scar tissue formation. Endometriosis may also affect nerve fibers in the pelvic region, causing chronic pelvic pain, including sciatic neuropathy and compression of other pelvic nerves. Endometriosis can cause sciatica, often misdiagnosed due to atypical symptoms. Interventional pain management techniques such as superior hypogastric plexus block, impar ganglion block, S3 pulsed radiofrequency, myofascial pain trigger point release, peripheral nerve hydrodissection, and neuromodulation have been used to manage persistent and intractable pain with positive patient outcomes and improved quality of life. LIMITATIONS: The complex and diverse clinical presentations of endometriosis make it challenging to compare the effectiveness of different pain management techniques. CONCLUSION: Endometriosis is a complex condition causing various forms of pain including nerve involvement, scar tissue formation, and bowel/bladder symptoms. Interventional pain management techniques are effective for managing endometriosis-related pain. KEY WORDS: Endometriosis, chronic pain, therapeutic interventions, interventional techniques, pain injections, visceral pain, peripheral pain.

[Classification system of radical surgery for rectal cancer based on membrane anatomy].

Because the classification system of radical surgery for rectal cancer has not been established, it is impossible to select the appropriate surgical method according to the clinical stage of the tumor. In this paper, we explained the theory of " four fasciae and three spaces " of pelvic membrane anatomy and then combined this theory with the membrane anatomical basis of Querleu-Morrow classification for radical cervical cancer resection. Based on this theory and the membrane anatomy of Querleu-Morrow classification of radical cervical cancer resection, we proposed a new classification system of radical rectal cancer surgery based on membrane anatomy according to the lateral lymph node dissection range of the rectum. This system classifies the surgery into four types (ABCD) and defines corresponding subtypes based on whether the autonomic nerve was preserved. Among them, type A surgery is total mesorectal excision (TME) with urogenital fascia preservation, type B surgery is classical TME, type C surgery is extended TME, and type D surgery is lateral extended resection. This classification system unifies the anatomical terminology of the pelvic membrane, validates the feasibility of using the " four fasciae and three fascial spaces " theory to classify rectal cancer surgery, and lays the theoretical foundation for the future development of a unified and standardized classification of radical pelvic tumor surgery.

Bloqueos Nerviosos. Bases Anatómicas del Dolor Somático Abdomino-Pélvico / Nerve Blocks. Anatomy of the Somatic Innervation of the Abdomino-Pelvic Cavity

El dolor abdominal es una de las sintomatologías que afectan con frecuencia la cavidad abdomino-pélvica. Dicha cavidad posee una inervación somática en la que intervienen del séptimo a doceavo nervios intercostales, ramos colaterales y terminales del plexo lumbar y el nervio pudendo; siendo objetivo de este trabajo la descripción anatómica del dolor abdominopélvico a través del plexo lumbar, nervios intercostales y nervio pudendo, sus diferentes patrones y variaciones de conformación, y las implicancias de éstas últimas en las distintas maniobras clínico-quirúrgicas. Se realizó un estudio descriptivo, observacional y morfométrico de la inervación somática de la cavidad abdomino-pélvica, en 50 preparaciones cadavéricas, fijadas en solución de formaldehído, de la Tercera Cátedra de Anatomía, Facultad de Medicina, Universidad de Buenos Aires, entre Agosto/2017-Diciembre/2019. La descripción clásica del plexo lumbar se encontró en 35 casos; la presencia del nervio femoral accesorio en ningún caso; así como también la ausencia del nervio iliohipogástrico en ningún caso; el nervio obturador accesorio se halló en 2 casos; el nervio genitofemoral dividiéndose dentro de la masa muscular del psoas mayor en 6 casos; el nervio cutáneo femoral lateral emergiendo únicamente de la segunda raíz lumbar en 6 casos y por último se encontró la presencia de un ramo del nervio obturador uniéndose al tronco lumbosacro en un caso. Los nervios intercostales y el nervio pudendo presentaron una disposición clásica en todos los casos analizados. Es esencial un adecuado conocimiento y descripción del plexo lumbar, nervios intercostales y nervio pudendo para un adecuado abordaje de la cavidad abdomino-pélvica en los bloqueos nerviosos.

SUMMARY: Abdominal pain is one of the symptoms that affect the abdominal-pelvic cavity. The abdominal-pelvic cavity has a somatic innervation involving the seventh to twelfth intercostal nerves, collateral and terminal branches of the lumbar plexus and the pudendal nerve. The objective of this work is the description of the lumbar plexus, intercostal nerves and pudendal nerve, its different patterns and structure variations, as well as its implications during pain management in patients. A descriptive, observational, and morphometric study of patterns and structure variations of the lumbar plexus, intercostal nerves and pudendal nerve was conducted in 50 formalin-fixed cadaveric dissections of the Third Chair of Anatomy at the School of Medicine in the Universidad de Buenos Aires from August 2017 to December/2019. The standard description of the lumbar plexus was found in 35 cases; accessory femoral nerve was not present in any of the cases; absence of the iliohipogastric nerve was also not found in any case, while the accessory obturating nerve was found in 2 cases; genitofemoral nerve dividing within the muscle mass of psoas in 6 cases; lateral femoral cutaneous nerve emerging only from the second lumbar root in 6 cases and finally, presence of a branch of the obturating nerve was found joining the lumbosacral trunk in one case. The pudendal and intercostal nerve patterns presented a typical pathway in all cases. Adequate knowledge and description of the lumbar plexus, intercostal nerves and pudendal nerve is essential for an adequate approach of the abdominal-pelvic cavity in nerve blocks.

Função sexual pós-histerectomia: quais os impactos e aspectos técnicos envolvidos? / Sexual function after hysterectomy: what are the impacts and technical aspects involved?

Objetivo: Identificar o impacto da histerectomia para patologias benignas sobre a sexualidade feminina. Métodos: Revisão de literatura com busca na plataforma PubMed, sendo selecionados 23 artigos em português e inglês publicados entre 2016 e 2021. Resultados: Foi descrita, majoritariamente, melhora na função sexual após histerectomia, semelhante às abordagens totais ou supracervicais e independentemente da via de acesso cirúrgico, apesar de impacto ligeiramente menor com a via laparoscópica. Na laparoscopia, houve melhor desfecho sexual no fechamento da cúpula vaginal, quando comparado ao fechamento via vaginal. Ademais, a ooforectomia concomitante apresentou resultados conflitantes e inconclusivos. Conclusão: A histerectomia afeta positivamente a saúde sexual feminina e aspectos técnicos podem interferir na função sexual, porém os dados são limitados. Devido à importância do tema, necessitam-se de mais estudos com metodologias padronizadas para possibilitar análises mais detalhadas.

Objective: To identify the impact of hysterectomy for benign pathologies on female sexuality. Methods: Literature review with search on PubMed platform, being selected 23 articles in Portuguese and English published between 2016 and 2021. Results: Improvement in sexual function after hysterectomy was mostly described, being similar in total or supracervical approaches and independent of the surgical access route, although it had slightly lower impact when laparoscopic. In the laparoscopic approach, there was better sexual outcome in the vaginal dome closure when compared to vaginal closure. In addition, concomitant oophorectomy showed conflicting and inconclusive results. Conclusion: Hysterectomy positively affects female sexual health and technical aspects may interfere with sexual function, but data are limited. Due to the importance of the theme, more studies with standardized methodologies are needed to enable more detailed analyses.

[Pelvic autonomic nerve preservation in rectal cancer: anatomical concept and clinical significance].

Colorectal cancer is one of the most common cancers in the world, and surgery is the mainstage treatment. Urogenital and sexual dysfunction after radical resection of rectal cancer has become an important problem for patients, which seriously affects the quality of life. Some patients give up radical surgery for rectal cancer because of the concerns about sexual and urinary dysfunction. The cause of this problem is intraoperative of injury pelvic autonomic nerve. The preservation of the hypogastric nerve during the surgery is important for the male ejaculation. Pelvic splanchnic nerves are mainly responsible for the male erection. The anatomical origin, distribution, and urogenital function of these two nerves are detailed described in this article. At the same time, this article introduces the classification, key points of the operation and the evaluation of autonomic nerve preservation surgery. With the rapid development of minimally invasive surgery, performing radical surgery for rectal cancer is important, we also need to fully understand the anatomical concept of pelvic autonomic nerves, and apply modern minimally invasive surgical techniques to preserve the patient's pelvic autonomic nerves as well. It is an compulsory course and an important manifestation for the standardization of rectal cancer surgery.

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.

Visualization of the pelvic nerves using magnetic resonance imaging for rectal cancer surgery.

BACKGROUND: This study evaluated the visualization of the pelvic nerves using magnetic resonance imaging (MRI) combined with computed tomography (CT) to synthesize three-dimensional (3D) reconstruction images of the pelvic organs. METHODS: The CT and MRI scans were performed for patients with rectal cancer who underwent surgery. The out-of-phase image of LAVA-Flex was used to identify the pelvic nerves. The images of the pelvic nerves were extracted from the MRI scans, and those of the arteries and rectum and pelvis were extracted from the CT scans. Each extracted organ image was used to synthesize 3D reconstruction images. RESULTS: The MRI scan allowed adequate visualization of the pelvic splanchnic nerves, inferior hypogastric plexus, and obturator nerves. The comparison of 3D reconstruction images and intraoperative findings showed matched images. CONCLUSION: We visualized the pelvic nerves using MRI and synthesized 3D reconstruction images of the pelvic organs. Preoperative confirmation of the location of the pelvic organs is important to prevent unanticipated injury during rectal cancer surgery.

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.

Classification system of radical surgery for rectal cancer based on membrane anatomy / 中华胃肠外科杂志

Because the classification system of radical surgery for rectal cancer has not been established, it is impossible to select the appropriate surgical method according to the clinical stage of the tumor. In this paper, we explained the theory of " four fasciae and three spaces " of pelvic membrane anatomy and then combined this theory with the membrane anatomical basis of Querleu-Morrow classification for radical cervical cancer resection. Based on this theory and the membrane anatomy of Querleu-Morrow classification of radical cervical cancer resection, we proposed a new classification system of radical rectal cancer surgery based on membrane anatomy according to the lateral lymph node dissection range of the rectum. This system classifies the surgery into four types (ABCD) and defines corresponding subtypes based on whether the autonomic nerve was preserved. Among them, type A surgery is total mesorectal excision (TME) with urogenital fascia preservation, type B surgery is classical TME, type C surgery is extended TME, and type D surgery is lateral extended resection. This classification system unifies the anatomical terminology of the pelvic membrane, validates the feasibility of using the " four fasciae and three fascial spaces " theory to classify rectal cancer surgery, and lays the theoretical foundation for the future development of a unified and standardized classification of radical pelvic tumor surgery.

Pelvic autonomic nerve preservation in rectal cancer: anatomical concept and clinical significance / 中华胃肠外科杂志

Colorectal cancer is one of the most common cancers in the world, and surgery is the mainstage treatment. Urogenital and sexual dysfunction after radical resection of rectal cancer has become an important problem for patients, which seriously affects the quality of life. Some patients give up radical surgery for rectal cancer because of the concerns about sexual and urinary dysfunction. The cause of this problem is intraoperative of injury pelvic autonomic nerve. The preservation of the hypogastric nerve during the surgery is important for the male ejaculation. Pelvic splanchnic nerves are mainly responsible for the male erection. The anatomical origin, distribution, and urogenital function of these two nerves are detailed described in this article. At the same time, this article introduces the classification, key points of the operation and the evaluation of autonomic nerve preservation surgery. With the rapid development of minimally invasive surgery, performing radical surgery for rectal cancer is important, we also need to fully understand the anatomical concept of pelvic autonomic nerves, and apply modern minimally invasive surgical techniques to preserve the patient's pelvic autonomic nerves as well. It is an compulsory course and an important manifestation for the standardization of rectal cancer surgery.

Exposure of the Middle Rectal Artery and Lateral Ligament of the Rectum Following the Gate Approach during Total Mesorectal Excision.

Controversial surgical anatomical landmarks in the deep pelvis can be visualized and identified using current technologies. Performing the gate approach technique during deep lateral dissection for total mesorectal excision facilitates visualization of the pelvic neurovascular structures following simple dissection steps to preserve the pelvic autonomic nerves and avoid accidental vascular injuries. Here, we discuss laparoscopic exposure of an infrequent disposition of the middle rectal artery anterior to the lateral ligament of the rectum while performing the gate approach.

Comprehensive anatomy of the superior hypogastric plexus and its relationship with pelvic surgery landmarks: defining the safe zone around the promontory.

BACKGROUND: Pelvic surgery carries an inherent risk of autonomic nerve injury leading to genitourinary and bowel dysfunction due to the close proximity of the superior hypogastric plexus (SHP). The aim of this study was to define the detailed anatomy of SHP and identify its relationship with the vascular landmarks and ureters for pelvic autonomic nerve-preserving surgery. METHODS: A cadaveric study on the detailed anatomy of the SHP was conducted in our surgical anatomy research unit. Between 02/2019 and 10/2019, macroscopic anatomical dissections were performed on 45 fresh adult cadavers (39 male, 6 female). Distances between the SHP, major vascular structures, and other anatomical landmarks were measured. RESULTS: Three types of SHP morphology were observed: mesh (64.8%), single nerve (24.4%), and fiber (10.8%). SHP bifurcation was located inferior to the aortic bifurcation in all cases; however, it was observed cranial to the promontory in 80% of the cases, whereas 18% were caudally and 2% were over the promontory. The closest vessels to the left and right of the SHP bifurcation were the left common iliac vein (LCIV) (86.2%, the mean distance was 8.49 ± 7.97 mm) and the right internal iliac artery (RIIA) (48.2%, mean distance was 13.4 ± 9.79 mm), respectively. At SHP bifurcation level, the lateral edge of the SHP was detected on the LCIV in 22 cases and on the RIIA in 10 cases for the left and right side of the plexus, respectively. The distance between the SHP bifurcation and the ureter was 27.9 mm on the right and 24.2 mm on the left. The width of the left (LHN) and right hypogastric nerves (RHN) were 4.35 mm and 4.62 mm at 2 cm below the SHP bifurcation, respectively. LHN was on the vascular structures in 13 cases, whereas RHN in only 1 case, 2 cm below the SHP bifurcation. CONCLUSIONS: Understanding the location of the SHP, including its relationship with important anatomical landmarks, might prevent iatrogenic injury and reduce postoperative morbidity in the pelvic surgery setting.

Fascial space priority approach for laparoscopic total pelvic exenteration in patients with locally advanced rectal cancer.

BACKGROUND: Total pelvic exenteration (TPE) with intent to achieve a pathological R0 resection is now considered as the only chance of a long-term survival for locally advanced rectal cancer (LARC) invading into adjacent organs. Lately, laparoscopic total pelvic exenteration (LTPE) is performed and achieved in several specialized centers and showed a promising application prospect. Although this is universally realized by surgeons, there are only few specialized centers to perform this complex surgery, due to concerns about the high morbidity and mortality. The techniques associated need to be disclosed and facilitated. OBJECTIVE: The aim of this article is to introduce a fascial space priority approach for laparoscopic TPE step by step (with video). METHODS: We describe here a fascial space priority approach for LTPE in highly selected patients with locally advanced rectal cancer. The main principle of this approach is that all of the pelvic organs are considered as a whole, the non-vascular spaces surrounding it are separated in the first place, the vascular pedicle and nerve pedicle of pelvic organs can be isolated and then transected precisely. Meanwhile, the associated key landmarks of this approach are disclosed (see the video). RESULTS: The ureterohypogastric nerve fascia (UHGNF) and the vesicohypogastric fascia (VHGF) are two vital embryological planes on the lateral compartment of pelvis. The spaces on either side of them together with the retrorectal space, the space of Retzius, are all non-vascular spaces, and dissection of these spaces in LTPE surgery can be achieved simply and practicably. The ureter, the umbilical artery, the arcus tendinous fasciae pelvis (ATFP), piriformis and the puboprostatic ligament (PPL) are all important landmarks during surgery. Step-by-step illustration with precise anatomical landmarks in the present video may lead to less intraoperative blood loss and complications. CONCLUSIONS: LTPE with fascial space priority approach might be a standard surgical procedure for total pelvic exenteration with clear anatomy and reduced blood loss.

Anatomy of the vesicovaginal fascia and its relation to branches of the inferior hypogastric plexus.

The inferior hypogastric plexus (IHP) lies in the extraperitoneal pelvis, and supplies branches to pelvic and perineal viscera. In men, the rectoprostatic fascia (Denonvillier's fascia) forms a distinct double fascial layer between the seminal glands and the rectum. The hypogastric nerve projections to the prostate and seminal glands run anterior to this. An analagous fascial layer in women between the vagina and cervix posteriorly and the urinary bladder anteriorly has recently been described. The purpose of this study was to examine the anatomy of the vesicovaginal fascia (VVF) and to determine its relationship to the anterior branches of the IHP. This dissection study examined the fascial layers between the posterior urinary bladder and anterior vagina/cervix (VVF) in 15 female embalmed cadavers and three fresh specimens. Anterior branches of the IHP were identified and followed distally. The relationship between these nerve projections and the VVF was examined. In 16 dissection, the VVF was identified as a complete fascial plane extending beneath the vesicouterine pouch to the neck of the bladder inferiorly and to the endopelvic fascia laterally. Anterior projections from the hypogastric nerves and IHP maintained an extraperitoneal course passing anteriorly to the VVF towards the urinary bladder The VVF is a distinct fascial structure and projections of the hypogastric nerves pass anterior to this. This may have implications for nerve sparing hysterectomy.

Relationship between uterine veins, ureter, and hypogastric nerve for uterine transplantation: An anatomic study.

Uterine transplantation is on the rise worldwide. In contrast to its arterial anatomy, venous drainage of the uterus is poorly defined in the literature. Our aim was to provide a standardized description of uterine veins through a multimodal approach to establish anatomical landmarks for the uterine transplantation surgeon. Data were obtained from: (1) an anatomical study of eight fresh female cadavers (16 hemipelves) studied separately by an extra fascial dissection from the iliac bifurcation to the uterine pedicle, with analysis of the urinary tract and nerve structures and (2) a virtual anatomical study from the Anatomage® Table comprising a high-fidelity virtual reconstruction of two deceased female subjects by imaging and anatomical methods. An inconstant duality of uterine veins was identified: a deep uterine vein of larger caliber and a superficial uterine vein observed in 25% of cases. A close relationship of the ureter passing posterior to the superficial uterine vein and anterior to the deep uterine vein was evident in the parametrium. The inferior hypogastric plexus was identified in all cases immediately behind the deep uterine vein. The data obtained from the fresh female cadavers were validated by the Anatomage® Table. We describe the close relationship of the uterine veins with the ureter and the inferior hypogastric plexus. This knowledge represents a surgical landmark to support the success of uterine transplantation by respecting both the graft and the safety of the living donor by limiting the risk of injuries during uterus procurement.

A new method of intraoperative pelvic neuromonitoring: a preclinical feasibility study in a porcine model.

Low anterior resections (LAR) are frequently associated with complications such as urinary and fecal incontinence as well as sexual disorders. Typical risk factors are rectal cancer with low tumor location, preoperative radiotherapy, and surgery-related damage of pelvic autonomic nerves. As preserving the pelvic autonomic nerves without any technical assistance is challenging, the objective of this preclinical study was to investigate the technical feasibility of a new method for intraoperative pelvic neuromonitoring. Twelve female pigs undergoing low anterior resections were involved in a prospective preclinical study. Intraoperative pelvic neuromonitoring included direct pelvic nerve stimulation and tissue impedance measurement on the urinary bladder and the rectum for the identification of efferent pelvic nerves in the surgical area. Immunohistochemistry was used to verify the results. Smooth muscle contraction of the urinary bladder and/or the rectum in response to direct stimulation of the innervating nerves was detectable with impedance measurement. The macroscopic contraction of both the urinary bladder and the rectum correlated with a change in tissue impedance compared to the status before contraction. Thus, it was possible to identify pelvic nerves in the surgical area, which allows the nerves to be preserved. The results indicate a reliable identification of pelvic autonomic nerves, which allows nerve damage to be prevented in the future.

Vulvodynia: a neuroinflammatory pain syndrome originating in pelvic visceral nerve plexuses due to mechanical factors.

This short opinion aimed to present the evidence to support our hypothesis that vulvodynia is a neuroinflammatory pain syndrome originating in the pelvic visceral nerve plexuses caused by the failure of weakened uterosacral ligaments (USLs) to support the pelvic visceral nerve plexuses, i.e., T11-L2 sympathetic and S2-4 parasympathetic plexuses. These are supported by the USLs, 2 cm from their insertion to the cervix. They innervate the pelvic organs, glands, and muscles. If the USLs are weak or lax, gravitational force or even the muscles may distort and stimulate the unsupported plexuses. Inappropriate afferent signals could then be interpreted as originating from an end-organ site. Activation of sensory visceral nerves causes a neuro-inflammatory response in the affected tissues, leading to neuroproliferation of small peripheral sensory nerve fibers, which may cause hyperalgesia and allodynia in the territory of the damaged innervation. Repair of the primary abnormality of USL laxity, responsible for mechanical stimulation of the pelvic sensory plexus, may lead to resolution of the pain syndrome.