Anatomy Of Pelvic Nerves Research Articles

Anatomical Pitfalls of Excision of Deep Endometriosis Nodules of the Sciatic Nerve: A three-dimensional Reconstruction and Surgical Educational Video

To highlight the anatomical keys to safely performing an excision of deep endometriosis nodules of the sciatic nerve DESIGN: We present a didactic video combining an anatomical three-dimensional reconstruction of the pelvis using the Anatomage table and a surgical dissection video of the removal of deep endometriosis nodules of the left sciatic nerve [1]. The patient's approval was obtained. The patient consented that this surgical video be used for publication. Tertiary referral center. To reach this specific area, we must localize precise anatomical pitfalls [2,3]. Taking the external iliac vessels as an anatomical plane of reference, we can divide anatomical structures into lateral and medial. During the first step of the procedure, we open the latero-pelvic peritoneum covering the external iliac artery. This step allows the identification of the lateral anatomic keys. Lateral anatomic keys are represented by: (1) the genito-femoral nerve, an element which is superficially situated between the psoas muscle and external iliac artery, and (2) the obturator nerve (Video Still 1), which is deep and is located within the ilio-lumbar fossa. To enter it, a dissection between the psoas muscle and external iliac artery and vein must be performed. At this point, particular attention must be paid to the obturator artery that runs below the obturator nerve. In this fossa, the lumbosacral trunk is easily identified just below the obturator nerve; it lies at this level on the iliac bone. Then the opening of the posterior leaf of the broad ligament is realized. Therefore, we access the medial anatomic keys: (1) the ureter, and (2) the umbilico-artery trunk with the umbilical and uterine artery. In the opening of the posterior leaf, we can find the obturator nerve and lumbosacral trunk again. Finally, following the umbilical artery (that is the first branch of the internal iliac artery), we discover the internal iliac artery and vein. A very careful dissection of these vessels must be done to avoid big hemorrhages, which can be life-threatening [4-6]. In the plane below the internal iliac artery and vein, we access the sacral roots S1, S2, and S3 (Video Still 2), which join the lumbosacral trunk (lying on the piriformis muscle) to form the ischiatic nerve [7]. At this level, the ischiatic nerve exits through the infra-piriform foramen behind the ischiatic spine and sacrospinous ligament toward the gluteal area in an oblique way [8]. Two other elements may be seen: the pudendal nerve exiting the pelvis behind the sacrospinous ligament in a craniocaudal way and the posterior femoral cutaneous nerve. During this dissection, the autonomous system must be spared as usual to avoid functional sequelae. Removal of deep endometriosis nodules of sciatic nerves is a challenging procedure. Because few surgeries are specifically dedicated to the sciatic area, the specific anatomy of the region is poorly taught and known. However, pelvic anatomical knowledge is indispensable to the safe removal of nodules of sciatic nerves. The main advantage of this anatomical 3D reconstruction is the possibility of visualizing the deep pelvic anatomy in a laparoscopic position. Surgeons must be aware of both somatic and autonomous pelvic nerve anatomy within the retroperitoneal spaces and the great vessels surrounding them.

Gynecologic Pathology Presenting As Urologic Symptoms: A Lesson on Pelvic Nerves

Study Objective Patients with underlying gynecologic pathology often present with a combination of seemingly unrelated and non-specific complaints such as pelvic pain, urinary frequency, urgency, and gastrointestinal symptoms. Thus, patients are often misdiagnosed and mismanaged. A thorough understanding of pelvic nerve anatomy is important in properly diagnosing and treating these patients. Design N/A Setting N/A Patients or Participants This video will highlight two patient cases which demonstrate how gynecologic pathology can present as urologic symptoms secondary to disease involvement of certain pelvic nerves. The first patient is a 32 year old female who struggled with urinary frequency, urgency, nocturia, and pelvic pain; all of which were secondary to endometriotic implants overlying the hypogastric nerve. The second patient is a 31 year old female who also presented with urinary urgency, nocturia, and pelvic pain which was secondary to a large broad ligament fibroid impinging the hypogastric nerve and causing mass effect on her bladder. Interventions The first patient underwent robotic assisted laparoscopic excision of endometriotic tissue. The second patient underwent robotic assisted laparoscopic myomectomy. Measurements and Main Results Each of these patients had pathology either directly compressing the pelvic nerves or causing chemical irritation to the nerves. Postoperatively, after removal of endometrial implants resulting in decreased nerve irritation, the first patient's pain and urinary symptoms improved. Likewise, in the second patient, when the fibroid was removed the compression of the surrounding pelvic nerves and bladder were relieved and the patients, symptoms subsequently resolved. Conclusion Understanding pelvic nerve anatomy is important in properly diagnosing and managing patients who do not present with conventional gynecologic symptoms. It is important to remember that with structural and biochemical irritation of these nerves, gynecologic pathology can present as urologic or even gastrointestinal symptoms. Proper diagnosis saves the patient from unnecessary testing and ineffective treatments.

What abdominal radiologists should know about extragenital endometriosis-associated neuropathy.

The aim of this study is to provide an overview of endometriosis-associated neuropathy and to review main anatomical concepts of intrapelvic peripheral nerves. In this pictorial essay, we review the anatomy of pelvic nerves and imaging features of endometriosis-associated neuropathy. We also evaluate clinical findings, imaging features, and outcome of seven patients with endometriosis-associated neuropathy. Nerve involvement by endometriosis is rare and may manifest with neurological symptoms, including pain, muscle weakness, bowel and bladder incontinence, and paraplegia. The neural involvement may be isolated or caused by a direct extension of a deep infiltrating endometriosis of the pelvic structure. Magnetic resonance imaging (MRI) is a reliable imaging modality for detecting neural involvement of endometriosis. On MRI, the main imaging features are retractile fibrous tissue and endometriomas. The signal intensity of the endometriotic tissue may vary depending on the age of the hemorrhage and the proportion of endometrial cells and stroma. Early diagnosis and treatment may avoid permanent neural damage. Considering that patients with endometriosis usually undergo pelvic MRI, which is generally reported by a non-musculoskeletal-trained radiologist, abdominal radiologists need to be familiar with the pelvic nerve anatomy and the possible patterns of presentation of neural endometriosis. Early diagnosis may obviate permanent nerve damage and MRI is a reliable tool for the diagnosis.

Vascular Entrapment of Both the Sciatic and Pudendal Nerves Causing Persistent Sciatica and Pudendal Neuralgia

Study ObjectiveTo demonstrate the laparoscopic approach to malformed branches of the vessels entrapping the nerves of the sacral plexus. DesignA step-by-step explanation of the surgery using video (educative video) (Canadian Task force classification II). The university's Ethics Committee ruled that approval was not required for this video. SettingKocaeli Derince Education and Research Hospital, Kocaeli, Turkey. PatientA 26-year-old patient who had failed medical therapy and presented with complaints of numbness and burning pain on the right side of her vagina and pain radiating to her lower limbs for a period of approximately 36 months. InterventionThe peritoneum was incised along the external iliac vessels, and these vessels were separated from the iliopsoas muscle on the right side of the pelvis. The laparoscopic decompression of intrapelvic vascular entrapment was performed at 3 sites: the lumbosacral trunk, sciatic nerve, and pudendal nerve. The aberrant dilated veins were gently dissected from nerves, and then coagulated and cut with the LigaSure sealing device (Medtronic, Minneapolis, Minn). Measurements and Main ResultsThe operation was completed successfully with no complications, and the patient was discharged from the hospital 24 hours after the operation. At a 6-month follow-up, she reported complete resolution of dyspareunia and sciatica (visual analog scale score 1 of 10). ConclusionA less well-known cause of chronic pelvic pain is compression of the sacral plexus by dilated or malformed branches of the internal iliac vessels. Laparoscopic management of vascular entrapment of the sacral plexus has been described by Possover et al [1,2] and Lemos et al [3]. This procedure appears to be feasible and effective, but requires significant experience and familiarity with laparoscopy techniques and pelvic nerve anatomy.

A step towards stereotactic navigation during pelvic surgery: 3D nerve topography

BackgroundLong-term morbidity after multimodal treatment for rectal cancer is suggested to be mainly made up by nerve-injury-related dysfunctions. Stereotactic navigation for rectal surgery was shown to be feasible and will be facilitated by highlighting structures at risk of iatrogenic damage. The aim of this study was to investigate the ability to make a 3D map of the pelvic nerves with magnetic resonance imaging (MRI).MethodsA systematic review was performed to identify a main positional reference for each pelvic nerve and plexus. The nerves were manually delineated in 20 volunteers who were scanned with a 3-T MRI. The nerve identifiability rate and the likelihood of nerve identification correctness were determined.ResultsThe analysis included 61 studies on pelvic nerve anatomy. A main positional reference was defined for each nerve. On MRI, the sacral nerves, the lumbosacral plexus, and the obturator nerve could be identified bilaterally in all volunteers. The sympathetic trunk could be identified in 19 of 20 volunteers bilaterally (95%). The superior hypogastric plexus, the hypogastric nerve, and the inferior hypogastric plexus could be identified bilaterally in 14 (70%), 16 (80%), and 14 (70%) of the 20 volunteers, respectively. The pudendal nerve could be identified in 17 (85%) volunteers on the right side and in 13 (65%) volunteers on the left side. The levator ani nerve could be identified in only a few volunteers. Except for the levator ani nerve, the radiologist and the anatomist agreed that the delineated nerve depicted the correct nerve in 100% of the cases.ConclusionPelvic nerves at risk of injury are usually visible on high-resolution MRI with dedicated scanning protocols. A specific knowledge of their course and its application in stereotactic navigation is suggested to improve quality of life by decreasing the likelihood of nerve injury.

Autonomic nerve preserving in laparoscopic total mesorectal excision

Since the introduction of total mesorectum excision and combined modality therapy has dramatically improved the oncologic outcome for the patients with rectal cancer, the quality of functional outcome has been increasingly important. Urogenital dysfunctions due to intraoperative inadvertent pelvic autonomic nerve damage are well-recognized. Pelvic autonomic nerve preservation may be limited and challenged by the anatomical constrains of the curved narrow pelvis. Laparoscopic technology with the advantages of direct illumination and magnification may enable better visualization and facilitate pelvic autonomic nerve preservation. There are a few key zones at risk of nerve injury and a proper surgical technique with step-by-step checklist at the critical points should be carried on. The increased experience with laparoscopic and understanding of the pelvic nerve anatomy may relate to the improving functional outcomes. Here, we discuss the current understanding of anatomy, key zones at risk and tips and tricks of our experience of nerve preservation during the laparoscopic total mesenteric excision (TME).

Nerve Sparing and Surgery for Deep Infiltrating Endometriosis: Pessimism of the Intellect or Optimism of the Will

Nerve-sparing surgery is an emerging technique for surgery-related dysfunction. Within the past 15 years, an essential progress in recognition and understanding of the anatomy of the pelvic autonomous nervous system has been made. Surgical preservation of vegetative nerves has become well known in many cancer centers. The technique has led to improvement of the quality of life following oncologic radical procedures. Positive results have led to the adoption of such techniques in the surgical treatment of deep infiltrating endometriosis in an aim to prevent urinary, rectal, and sexual dysfunction. Even though nerve-sparing excision of endometriosis is feasible and offers good outcomes in terms of bladder morbidity; digestive and sexual functions seem to be more complex to assess. Moreover, functional impairment in deep infiltrating endometriosis may preexist prior to surgery and function may not be restored despite nerve preservation. In cases where endometriosis lesions are deeply embedded in the parametrium, nerve-sparing techniques may only be feasible in those with a unilateral involvement. The nerve-sparing surgical approach is therefore a safer radical surgery in the hands of experienced surgeons that has to be tailored to the unique nature of deep infiltrating endometriosis and balanced between the natural aggressiveness of such a debilitating disease and postoperative morbidity. Good knowledge of pelvic nerve anatomy and function allows understanding of related symptoms to reduce morbidity, whenever this goal is still achievable.

Pelvic autonomic nerve preservation in radical rectal cancer surgery: changes in the past 3 decades.

The advent of total mesorectal excision (TME) together with minimally invasive techniques such as laparoscopic colorectal surgery and robotic surgery has improved surgical results. However, the incidence of bladder and sexual dysfunction remains high. This may be particularly distressing for the patient and troublesome to manage for the surgeon when it does occur. The increased use of neoadjuvant and adjuvant radiotherapy is also associated with poorer functional outcomes. In this review, we evaluate current understanding of the anatomy of pelvic nerves which are divided into the areas of the inferior mesenteric artery pedicle, the lateral pelvic wall and dissection around the urogenital organs. Surgical techniques in these areas are discussed. We also discuss the results in functional outcomes of the various techniques including open, laparoscopic and robotic over the last 30 years.

Where does pelvic nerve injury occur during rectal surgery for cancer?

Optimal treatment of rectal adenocarcinoma involves total mesorectal excision with nerve-preserving dissection. Urinary and sexual dysfunction is still frequent following these procedures. Improved knowledge of pelvic nerve anatomy may help reduce this and define the key anatomical zones at risk. The MEDLINE database was searched for available literature on pelvic nerve anatomy and damage after rectal surgery using the key words 'autonomic nerve', 'pelvic nerve', 'colorectal surgery', and 'genitourinary dysfunction'. All relevant French and English publications up to May 2010 were reviewed. Reviewed data were illustrated using 3D reconstruction of the foetal pelvis. The ligation of the inferior mesenteric artery and dissection of the retrorectal space can cause damage to the superior hypogastric plexus and/or hypogastric nerve. Anterolateral dissection in the 'lateral ligament' area and division of Denonvilliers' fascia can damage the inferior hypogastric plexus and efferent pathways. Perineal dissection can indirectly damage the pudendal nerve. In most cases, the pelvic nerves can be preserved during rectal surgery. Complete oncological resection may require dissection close to the nerves where the tumour is located anterolaterally where it is fixed and when the pelvis is narrow.