Genitofemoral Research Articles

Variations of the extrapsoas course of the lumbar plexus with implications for the lateral transpsoas approach to the lumbar spine: a cadaveric study

BackgroundTogether with an increased interest in minimally invasive lateral transpsoas approach to the lumbar spine goes a demand for detailed anatomical descriptions of the lumbar plexus. Although definitions of safe zones and essential descriptions of topographical anatomy have been presented in several studies, the existing literature expects standard appearance of the neural structures. Therefore, the aim of this study was to investigate the variability of the extrapsoas portion of the lumbar plexus in regard to the lateral transpsoas approach.MethodsA total of 260 lumbar regions from embalmed cadavers were utilized in this study. The specimens were dissected as per protocol and all nerves from the lumbar plexus were morphologically evaluated.ResultsThe most common variation of the iliohypogastric and ilioinguinal nerves was fusion of these two nerves (9.6%). Nearly in the half of the cases (48.1%) the genitofemoral nerve left the psoas major muscle already divided into the femoral and genital branches. The lateral femoral cutaneous nerve was the least variable one as it resembled its normal morphology in 95.0% of cases. Regarding the variant origins of the femoral nerve, there was a low formation outside the psoas major muscle in 3.8% of cases. The obturator nerve was not variable at its emergence point but frequently branched (40.4%) before entering the obturator canal. In addition to the proper femoral and obturator nerves, accessory nerves were present in 12.3% and 9.2% of cases, respectively.ConclusionNerves of the lumbar plexus frequently show atypical anatomy outside the psoas major muscle. The presented study provides a compendious information source of the possibly encountered neural variations during retroperitoneal access to different segments of the lumbar spine.

The Genitofemoral Nerve Is the Structure Closest to the Tendon Footprint and Is Most at Risk for Iatrogenic Injury During Proximal Adductor Longus Repair: A Cadaveric Anatomy Study

To identify structures at risk during proximal adductor longus repair and to report observed distances between these structures and the adductor longus (AL) footprint. Eight hemipelves from fresh cadaver whole-body specimens were dissected using a previously established surgical approach. The tendinous attachment of the AL was scored into the underlying bone and the footprint size was measured in millimeters. A guidewire was placed at the footprint center along the longitudinal axis of the resected AL muscle. Utilizing a digital caliper, the proximity of key anatomic structures was measured as the radial distance from the guidewire and distance distal to the footprint along the guidewire axis. The AL footprint was on average 16.95 ± 3.02 mm wide by 9.36 ± 1.66 mm high. The ilioinguinal nerve was 27.10 ± 7.25 mm distal to the AL footprint and 31.75 ± 7.51 mm medial, with a resulting mean surface area of 158.12 ± 39.90 (110.9-230.2). mm2 The genital branch of the genitofemoral nerve was found 7.79 ± 4.05 mm proximal and 15.37 ± 4.54 mm medial. The round ligament (n= 6) was 14.00 ± 2.75 mm and the spermatic cord (n= 2) was 13.57 ± 3.02 mm directly superficial to the AL footprint. The obturator nerve was 63.98 ± 4.57 mm distal as it crossed the adductor brevis muscle laterally. The location of the external pudendal artery was variable but was found to have a mean distance of 37.01 ± 17.97 mm distal and immediately deep to the AL. When repairing AL tendon injuries, the genitofemoral nerve is the structure anatomically nearest the footprint of the tendon, and this structure is most at risk for iatrogenic injury. This study investigates the structures at risk during AL repair and seeks to define their location relative to the footprint. These findings will assist surgeons in identifying the crucial anatomic structures at risk to safely perform an anatomic repair of the tendon and avoid iatrogenic complications.

HERNIA MESH EXPLANTATION FOR MESH INGUINODYNIA AND ALLODYNIA. WHY IS HERNIA MESH SO PAINFUL?

Abstract Introduction Chronic pain after mesh repair for abdominal wall hernia is an indication for the removal of mesh and reconstruction by a non-mesh technique. Materials and Methods In a consecutive series over 19 years, 128 patients had mesh removed to relieve chronic pain. This open method of mesh removal relies on confirming normal anatomical landmarks. The superior and inferior leaf of the External oblique aponeurosis are raised, the spermatic cord is identified and retracted. The mesh is gently dissected off the Internal oblique from lateral to medial, taking care in preserving the vas, and accompanying vessels. Adherent ilio-inguinal, iliohypogastric and genitofemoral nerves are removed with the mesh. The resultant recurrent hernia is repaired by Moloney darn, a tension-free tissue repair. Results 128 consecutive patients have been treated by mesh explantation and immediate reconstruction on average 6 years after implantation. Resolution of symptoms was experienced very shortly after the mesh removed. Preperitoneal mesh particularly Kugel patch has been the most difficult to remove. Meshes have been submitted for histological examination and the findings are usually chronic granulomatous foreign body reaction. Few complications have been encountered with a follow-up period ranging from 6 months to 15 years, the most common being the failure of explantation to alleviate inguinal pain in the long-term. Conclusion All hernia patients should be afforded informed consent including discussing the potential long-term consequences of chronic groin and abdominal pain.

Anatomical study of the relationship between the lumbar intervertebral disc, nerves, and psoas major.

Cadaveric study; To describe the characteristics of the nerve and its relationship with the lumbar intervertebral disc and psoas major muscle. Nerve injury is an understudied complication of extreme lateral interbody fusion. A detailed description of the nerve anatomy would be helpful for surgeons to minimize the risk of this complication. The lumbar plexus and lumbar sympathetic nerve of 10 embalmed male cadavers were dissected, and the distribution, number, and spatial orientation of the nerves on the L1/2 to L4/5 intervertebral discs were examined. Metal wires were applied along nerve paths through the psoas major muscle. The position of the nerves was examined on CT. In zone III at L1/2 and L4/5, no nerves were found. In zone II and zone III at L2/3, no lumbar plexus was found, and only the ramus communicans passed through. At the L1-L5 level, the density of nerves in the posterior half of the psoas major muscle was greater than that in the anterior half. The lumbar plexus was found in all of zone IV. The genitofemoral nerve emerges superficially and anteriorly from the medial border of the psoas major at the L3-4 level, but at the L1/2 level, the sympathetic trunk is located in zone II. The remaining disc-level sympathetic trunks appear in zone I. No nerves were found in zone III of the L1/2 or L4/5 disc. In zones II and III of L2/3, the lumbar plexus appears safe. The genitofemoral nerve travels through zones II and III of L3/4. The distribution density of nerves in the posterior half of the psoas major muscle was greater than that in the anterior half of that muscle at the L1-L5 level.

(O-25) SURGICAL TREATMENT FOR CHRONIC TESTICULAR PAIN: A SYSTEMATIC REVIEW

Abstract Introduction and Objetives Chronic testicular pain (CTP) is defined as 3 months of intermittent or constant testicular pain that is significantly bothersome to the patient. There exist a variety of different surgical treatment options for CTP. They are generally kept as second or even third-line option for persistent cases. This study aims to review and elucidate the literature about surgical treatment for chronic testicular pain. Methods We searched Pubmed, Embase and Cochrane for articles evaluating surgical treatments for CTP. Search terms included “orchialgia”, “spermatic cord”, “chronic scrotal pain”, “chronic testicular pain” and “surgery”. Results Microsurgical Denervation of the Spermatic Cord (MDSC) is the surgical standard when a procedure is indicated for idiopathic chronic orchialgia unresponsive to conservative therapies. The positive response to spermatic cord block is a predictor of MDSC response. Pain relief after MDSC ranges from 76% to 100%. Ultrasound-guided targeted cryoablation could be used in persistent CTP after MDSC with 75% success rate. Epididymectomy is better indicated for CTP in structural abnormality such as cyst, granuloma or mass, with pain relief reaching 50% to 92%. In case of post-vasectomy pain syndrome, vasectomy reversal and MDSC has an overall success from 50% to 100% and 71% to 81% respectively. Ilioinguinal and genitofemoral peripheral nerve stimulation could be used in persistant CTP, and spinal cord stimulation as well. Orchiectomy can be considered as a last resort in case patients do not respond to other forms of treatment, but do not delivers a 100% relief a pain. Conclusion Although it’s variables choices, there is not a gold standard surgical treatment for CTP, representing a challenge for clinicians. Large, controlled trials must be performed to establish strong and reliable evidence for the surgical treatment of CTP. Financing No conflict.

Role of Gubernaculum testis inervation during the process of testicular migration in human fetuses.

The gubernaculum seems to be the most important anatomical structure in the testicular migration process. The objective of this paper is to review current literature regarding the role of gubernaculum testis nerves in testicular migration. We conducted a comprehensive literature review about the gubernaculum testis innervation. A PubMed database search was performed in April 2024, focusing on gubernaculum testis and cryptorchidism and genitofemoral nerve (GFN) and calcitonin gene-related peptide (CGRP) gene. The gubernaculum has its own nerve supply, the GFN, descending on the anteromedial surface of the psoas muscle from L1-L2 segments. The second phase of testicular descent is regulated by androgens and CGRP, released from the sensory nucleus of the GFN. The GFN doesn't directly play a role in testicular migration but there is a theory that shows a regulatory function of this nerve in hormonal action during this process. The gubernaculum testis has important structural alterations during the testicular migration and the genitofemoral nerve and CGRP gene are of great importance in this process. The genitofemoral nerve provides motor innervation to the cremaster muscle and gubernaculum, which helps regulate the position of the testes within the scrotum.

Novel lumbar plexus block versus femoral nerve block for analgesia and motor recovery after total knee arthroplasty.

This study aimed to compare the postoperative analgesic efficacy and motor recovery of a novel lumbar plexus block (LPB) with that of a femoral nerve block (FNB) after total knee arthroplasty (TKA). Forty patients who underwent TKA were randomised equally into an lumbar plexus and sciatic nerve (LS) group (receiving novel LPB) and an femoral and sciatic nerves (FS) group (receiving FNB). The assessed variables were the onset time of pain, time to the first analgesic request, pain scores, motor block at 6, 12, and 24 h after TKA, and the number of patients receiving successful blockade for each branch of the lumbar plexus. In the LS group, the femoral, lateral femoral cutaneous, genitofemoral, iliohypogastric, ilioinguinal, and obturator nerves were blocked in 18, 20, 16, 18, 15, and 19 patients. Compared to the FS group, the LS group had a significantly shorter onset time of pain and time to the first analgesic request, a significantly larger total postoperative dose of sufentanil, significantly higher numeric rating scale scores for both rest and dynamic pain at 6, 12, and 24 h, and faster motor recovery. Novel ultrasound-guided LPB has a high blocking success rate and provides inferior postoperative analgesia, but faster motor recovery after TKA than FNB.

Rational use of Ga-68 PSMA PET-CT according to nomograms and risk groups for the detection of lymph node metastasis in prostate cancer

ObjectivesThe aim was to ensure efficient utilization of PSMA PET-CT by examining the correlation of pathological lymph node metastasis with nomogram scores and risk classifications. Methods and materialsRobot-assisted radical prostatectomy and bilateral pelvic lymph node dissections for pelvic lymph nodes were performed using the same template. Bilaterally pelvic lymph nodes were removed within the boundaries of genitofemoral nerves, psoas muscle and lateral pelvic wall laterally, ureteric crossing of the iliac vessels superiorly, lateral bladder wall medially, Cooper ligaments distally, and endopelvic fascia, neurovascular bundles and internal iliac arteries posteriorly. Clinical nomograms were used to calculate the probability of lymph node metastasis preoperatively. Using receiver operating characteristics analysis, discriminatory cut-offs were calculated. The diagnostic performance of PSMA PET-CT was determined for detecting lymph node metastasis. ResultsFor 81 patients, the median age was 64 years. The median PSA was 6.8 ng/ml. Most patients were in the D'Amico intermediate (56.8%) and high (37%) risk groups. Median Briganti 2017, MSKCC, and Partin scores were 35 (4–99), 37 (8–90), and 12 (2–38), respectively, in pN1 patients. The area under the curve for Briganti 2017, MSKCC, Partin nomograms and PSMA PET-CT scans were 0.852, 0.871, 0.862, and 0.588. Sensitivity, specificity, positive predictive value and negative predictive value for Ga-68 PSMA PET-CT for lymph node metastasis detection were 21.4%, 94%, 42.9%, and 85.1%, respectively, for the whole group. By using higher threshold values for clinical nomograms (Briganti 2017 >32, MSKCC >12, Partin >5), PSMA PET-CT had higher sensitivity (42.9, 30, 27.2) in detecting lymph node metastasis. ConclusionsPatients in the D'Amico high-risk group and those with high nomogram scores are the best candidates who will benefit from preoperative PSMA PET-CT staging to estimate lymph node metastasis.

A rare case of perineal neuralgia treated with ultrasound‐guided nerve block combined with water separation

AbstractA middle‐aged man experienced intermittent acupuncture‐like pain in the skin of the right scrotum and medial thigh 1 month after undergoing laparoscopic high ligation of the right hernial sac for a right indirect inguinal hernia in November 2020, and the pain persisted for 6 months. Under ultrasound guidance, ilioinguinal and genitofemoral nerve block and local adhesion water separation were performed with a mixture of 0.25% lidocaine (6 mL) plus prednisolone acetate (10 mg), and the same drugs and methods were repeated five times once a week. After five treatments, the visual analogue scale (VAS) score was reduced from 7 before treatment to 1. During the follow‐up period, at 3 months after the end of treatment, the VAS score remained at 0, and this score was sustained at 0 even at the 6‐month follow‐up. These outcomes indicate that ultrasound‐guided nerve block combined with water separation technology can effectively alleviate neuralgia caused by surgical adhesion, which holds important clinical significance in managing such conditions.

Nerve identification during open inguinal hernia repair: a systematic review and meta-analyses

PurposeInguinal hernia repair is one of the most common operations worldwide and despite this, the incidence of chronic pain remains high after inguinal hernia repair. The optimal nerve handling strategy is controversial and the rate at which nerves are identified remains uncertain. This study aimed to determine the identification rates of the ilioinguinal, iliohypogastric, and genitofemoral nerves as well as nerve handling strategies.MethodsThis review was registered on PROSPERO (CRD 42023416576). PubMed, Embase, and Cochrane Central were systematically searched. Studies with more than 10 patients were included if they reported an identification rate for at least one of the nerves during elective open inguinal hernia repair in adults. Studies requiring nerve identification in their study design were excluded. Bias was assessed with the JBI critical appraisal tool and Cochrane’s RoB-2 tool. The overall estimate of the prevalence was analysed with prevalence meta-analyses.ResultsA total of 22 studies were included. The meta-analyses included 18 studies, which resulted in an identification rate of 82% (95% CI: 76–87%) for the ilioinguinal nerve, 62% (95% CI: 54–71%) for the iliohypogastric nerve, and 41% (95% CI: 27–55%) for the genitofemoral nerve. Nerves were spared in 82% of all repairs.ConclusionThe ilioinguinal, iliohypogastric, and genitofemoral nerves were identified in 82%, 62%, and 41% of surgeries, respectively. Most studies used a nerve-preserving strategy. The role of nerve identification in the development of chronic pain remains uncertain, as well as the optimal nerve handling strategy.

Ultrasound Guided Fascia Iliaca Compartment Block versus Three in One Block for Post Operative Analgesia in Patients Undergoing Hip and Knee Replacement Surgeries

Abstract Background Patients undergoing total hip and knee arthroplasty experience substantial and sustained postoperative pain. Inadequate analgesia may impede physical therapy and rehabilitative efforts and delay hospital dismissal. Peripheral nerve blockade of the lumbosacral plexus has emerged as an analgesic approach. In several studies, unilateral peripheral block provided quality of analgesia and functional outcomes similar to those of continuous epidural analgesia and superior to those of systemic analgesia, but with fewer side effects because of their opioid-sparing properties. Peripheral nerve block techniques may be the optimal analgesic method following total joint arthroplasty. Aim of the Work To compare postoperative analgesia between ultrasound-guided FICB and three in one nerve block. Study design a prospective randomized double-blinded study. Patients and Methods The study was conducted on 80 randomly chosen patients from 21 to 65 years old in Ain Shams University Hospitals after approval of the medical ethical committee. Patients were divided randomly into two groups, each group consisted of 40 patients group I and group II. After preoperative assessment and obtaining baseline vital data, all patients received spinal anesthesia. Patients in the group I received FICB (35-40 ml of 0.25% bupivacaine). Patients in group II received three in one bock (35-40 mL of bupivacaine 0.25%). Results Both FICB and three in one block provided good quality of postoperative analgesia and patient satisfaction as evidenced by low VAS and low postoperative rescue analgesic requirements. Both techniques provided equal sensory blockage of femoral nerve, obturator nerve, and genitofemoral nerve, but sensory blockage of LFC nerve was demonstrated in 92.5% patients in FICB and 62.5% of patients in three in one block, which was significantly lower (p-value <0.001 HS). VAS at 12 hours after surgery during movement of 3.68 ± 2.77 in the FICB group and 4.90 ±0.18 in the 3 in 1 group were statistically significant (P value = 0.007). Conclusion The FICB provides a high degree of sensory blockade of the LFC nerve and improves analgesia when continuous passive motion is initiated in the early postoperative period; also, it is easy to perform, reliable and does not threaten any vital organ. Thus, FICB can be recommended as an alternative to three in one block for the treatment of pain after hip and knee arthroplasty.

Robotic management of isolated endometriosis of sciatic nerve: a reproducible approach that can guide through the labyrinth of pelvic neuroanatomy

To present the robotic, standardized, and reproducible surgical technique we routinely use in our center to manage isolated endometriosis of the sciatic nerve. Surgical video article. Tertiary referral center. A 36-year-old woman suffering from left-sided sciatica pain was diagnosed with an isolated endometriotic nodule of the left sciatic nerve at preoperative assessment. The patient included in this video gave consent for publication of the video and posting of the video online, including on social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, and Scopus), and other applicable sites. Complete removal of the isolated endometriotic nodule of the sciatic nerve may be performed through a stepwise robotic approach. The surgery starts laterally with the opening of the iliolumbar space between the external iliac vessels and the psoas muscle, as well as the identification of the genitofemoral and obturator nerves. The lumbosacral trunk and emergence of the sciatic nerve were then identified medially and caudally to the obturator nerve. The surgery moves medially with the anterograde dissection of both the internal iliac artery and vein, which allows a safe approach to the posterior and medial limits of the nodule. Ligation of branches of internal iliac vessels directed toward the nodule may be necessary during this step. Isolation and ligation of obturator vessels are frequently required to obtain a bloodless dissection of the lateral limit of the nodule from the lateral pelvic wall. The complete removal of the nodule was then achieved using an alternating approach to all limits of the nodule previously identified, with subsequent release of the sciatic nerve. Description of the relevant pelvic neuroanatomy and the evaluation of robotic routes in the field of pelvic neurosurgery. The use of standardized techniques together with the advantages of a robotic route can make the radical excision of isolated endometriosis of the sciatic nerve reproducible, feasible, and safe. Because of the complexity of neuroanatomy and the risk of severe complications, this surgery remains challenging, and patients affected by deep infiltrating endometriosis involving retroperitoneal neural structures should be referred to multidisciplinary management in expert centers.

Cadaveric Analysis of Key Anatomic Structures of Athletic Pubalgia.

This study proposes to establish in-depth inspection of the anatomic structures involved with the pathology of athletic pubalgia in a cadaver model. Eight male fresh frozen cadavers were dissected in a layered fashion. The rectus abdominis (RA) and adductor longus (AL) tendon insertions were isolated to quantify the size of the anatomic footprint and distance from the surrounding anatomy. The RA insertional footprint was 1.65 cm (SD, 0.18) in width by 1.02 cm (SD, 0.26) in length, and the AL insertional footprint on the underside of the pubis was 1.95 cm (SD, 0.28) in length by 1.23 cm (SD, 0.33) in width. The ilioinguinal nerve was 2.49 cm (SD, 0.36) lateral to the center of the RA footprint and 2.01 cm (SD, 0.37) lateral to the center of the AL footprint. The spermatic cord and the genitofemoral nerve were just lateral to the ilioinguinal nerve and were 2.76 cm (SD, 0.44) and 2.66 cm (SD, 0.46) from the rectus and AL footprints, respectively. Surgeons should be cognizant of these anatomic relations during both initial dissection and tendon repair to optimize repair and avoid iatrogenic injury to critical structures in the anterior pelvis.

ID: 205005 Dorsal Root Ganglion Stimulation at L1 & L2 for Post- Ilioinguinal, Iliohypogastric, and Genitofemoral Neurectomy

We present a case report of a 36-year-old female that underwent neurectomy of ilioinguinal, iliohypogastric and genitofemoral nerves at an outside hospital and presented with severe left-sided groin pain. Patient developed chronic pain, post-cesarean section and the subsequent neurectomies worsened the symptoms. Dorsal root ganglion stimulation (DRGS) has emerged as novel treatment option for refractory chronic pelvic pain (CPP). DRGS delivers targeted target to focal areas and is able to reliably capture body parts like the pelvis making it an ideal modality for the treatment of CPP. We present successful resolution of symptoms once DRGS leads were placed at L1, and L2 neuroforamen.

Old but Gold: The Surgeon’s Affair to Manage Inguinal Hernia

Purpose: Inguinal hernia repair is a common surgical procedure. It was widely reported worldwide during the COVID-19 pandemic. To manage the lack of anesthesiologists, we have introduced a new protocol to manage inguinal hernia repair. Methods: This protocol is the result of a strong collaboration between surgeons and anesthesiologists. It was based on EHS recommendations and the well-described percutaneous ilioinguinal–iliohypogastric and genitofemoral nerves block. Results: More than 400 patients have been treated at our institution. The application of the protocol has led to a sensible reduction in initially planned spinal anesthesia. The complications traditionally related to spinal anesthesia have not been reported in 80% of the patients. Only three patients required the infusion of atropine or flumazenil without the need to involve anesthesiologist. Conclusion: The application of our protocol seems promising. Preliminary results have shown the safety and efficacy of percutaneous ilioinguinal–iliohypogastric and genitofemoral nerves block. The combination of this kind of anesthesia with wound protector and adequate postoperative pain control can lead to a reproducible system avoiding the not strictly necessary presence of an anesthesiologist. The changes that have occurred in the healthcare system in recent years should be new opportunities for the improvement of resources and results.

P-086 NERVE IDENTIFICATION DURING OPEN MESH HERNIOPLASTY: A DESCRIPTIVE CROSS-SECTIONAL STUDY

Abstract Background It is recommended to identify nerves in the surgical field during open inguinal hernioplasty. This ensures proper dissection and reduces the incidence of post-operative inguinodynia. From limited surgical studies, it appears that identifying nerves may not be possible in all cases. Little is known about the factors that affect their identification. Materials and methods We conducted a cross-sectional study on thirty-six male patients with primary inguinal hernia. We looked for the nerves during Lichtenstein hernioplasty. We collected data on the identification & preservation of nerves for calculating the nerve identification rates. We observed the course of the nerves and evaluated the effect of BMI, height, anaesthesia type, surgical experience, ASA, type of hernia and sac contents on nerve identification. Results Ilioinguinal nerve (IIN), Iliohypogastric Nerve (IHN), and Genital branch of genitofemoral nerve (GBN) were identified in 86.1%, 75%, and 50% of the groin dissections. It was easier to identify the IIN when the omentum was the content of the sac. The IHN was easily identified in patients with BMI ≤ 25 kg/m2. Conclusion Nerve identification can be challenging during surgery. The GBN and IHN are more prone to dissection-related injuries. Identification of IHN and IIN is difficult in overweight individuals and cases where hernia contains bowel.

Genitourinary vascularized composite allotransplantation for gender affirmation in trans men: An anatomical feasibility study

Gender affirmation in trans men requires multiple staged procedures. The final masculinizing step involves phalloplasty or metoidioplasty and further incorporation of penile and testicular prostheses. However, these are functionally suboptimal and associated with high complication rates. Therefore, we sought to investigate the anatomical feasibility of one-stage genitourinary vascularized composite allotransplantation (GUVCA) for such gender-affirming surgeries. Twenty fresh cadaveric dissections were performed to delineate the neurovascular anatomy of the proposed GUVCA. Specifically, in donors (n=14), besides the penis and scrotum, the GUVCA included an inferior bladder patch with the urinary sphincter, prostate, seminal vesicles, as well as a strip of the pubic bone. In trans men recipients, osteotomies of the pubic bone to match that of the donor GUVCA were required. Five cadaveric GUVCA transplants were then performed to simulate one-stage gender affirmation surgery. The GUVCA required (1) vascular anastomoses between the recipient's deep inferior epigastric, external pudendal, and superficial circumflex iliac (or superficial inferior epigastric) vessels to the donor's internal pudendal, external pudendal and genitofemoral vessels respectively; (2) neurosynthesis between the recipient pudendal and dorsal clitoral nerves to the donor pudendal and genitofemoral nerves; and (3) urinary bladder anastomosis at the bladder neck, upstream of the urinary sphincter. Average donor measurements (length (cm), diameter (mm)) were: external pudendal artery (2.5, 2.0) and vein (2.0, 3.5), internal pudendal artery (15.0, 4.0), pudendal (15.0, 3.0) and genitofemoral nerves (8.0, 2.0). We have described the anatomical basis for a one-stage GUVCA in trans masculine genitourinary reconstruction.

Position of lumbar plexus nerves in the psoas major: Application to transpsoas approaches to the lumbar spine.

Far lateral interbody fusion is a minimally invasive operating technique. However, the incidence of postoperative neurological complications is high, and some scholars question its safety. This study describes the neuroanatomical features and spatial orientation within the psoas major. Ten embalmed male cadavers were selected and the left psoas major was dissected. Subsequently, the area between the anterior and the posterior edges of the vertebral body was divided into three equal zones. The nerves' distribution, number, and spatial orientation of the L1/2 to L4/5 intervertebral discs were examined. A caliper was used to measure the diameter of the nerve. The safety zone of the L1/2 intervertebral disc level is located in zone I and II, the relative safe zones of the L2/3 and L4/5 intervertebral discs are located in zone II, and the safety zone of the L3/4 intervertebral disc level is located in the caudal side of zone II. The genitofemoral nerve exits the psoas major in a co-trunk or two-branch pattern, and its exit point was distributed between the L3 and L4 vertebral bodies, mainly at the L3/4 intervertebral disc level. The sympathetic ganglia in the psoas major appeared only in zone I at the L2/3 intervertebral disc level. This is a systematic anatomical study that describes the nerves of the psoas major. Spine surgeons can use this study-which consists of important clinical implications-for preoperative planning, and thus, reduce the risk of nerve injury during surgery.

Are Nerves Left In Situ Associated With Less Chronic Pain Than Manipulation During Inguinal Hernia Repair?

IntroductionNerve damage has been implicated in chronic groin pain, particularly iliohypogastric, ilioinguinal, and genital branches of genitofemoral nerves. We investigated whether three nerve identification (3N) and preservation is associated with decreased pain 6 mo after hernia repair compared to two common strategies of nerve management: ilioinguinal nerve identification (1N) and two nerve identification (2N). MethodsWe identified adult inguinal hernia patients within the Abdominal Core Health Quality Collaborative national database. Six-month postoperative pain was defined using the EuraHS Quality of Life tool. A proportional odds model was used to estimate odds ratios (ORs) and expected mean differences in 6-month pain for nerve management while adjusting for confounders identified a priori. ResultsFour thousand four hundred fifty one participants were analyzed; 358 (3N), 1731 (1N), and 2362 (2N) consisting mostly of White males (84%) over the age of 60 y old. Academic centers identified all three nerves more often than ilioinguinal or two nerve identification methods. Median 6-month postoperative pain scores were 0 [interquartile range 0-2] for all nerve management groups (P = 0.51 3N versus 1N and 3N versus 2N). There was no evidence of a difference in the odds of higher 6-month pain score in nerve management methods after adjustment (3N versus 1N OR: 0.95; 95% confidence interval 0.36-1.95, 3N versus 2N OR: 1.00; 95% confidence interval 0.50-1.85). ConclusionsAlthough guidelines emphasize three nerve preservation, the management strategies evaluated were not associated with statistically significant differences in pain 6 mo after operation. These findings suggest that nerve manipulation may not contribute as a significant role in chronic groin pain after open inguinal hernia repair.

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.