Pelvic Splanchnic Nerves Research Articles

Applied anatomy study and preliminary clinical application of hyper selective neurectomy of triceps branches combined with partial neurotomy of S 2 nerve root to relieve spastic equinus foot

To observe the possibility of hyper selective neurectomy (HSN) of triceps branches combined with partial neurotomy of S 2 nerve root for relieving spastic equinus foot. Anatomical studies were performed on 12 adult cadaveric specimens. The S 2 nerve root and its branches were exposed through the posterior approach. Located the site where S 2 joined the sciatic nerve and measured the distance to the median line and the vertical distance to the posterior superior iliac spine plane, and the S 2 nerve root here was confirmed to have given off branches of the pelvic splanchnic nerve, the pudendal nerve, and the posterior femoral cutaneous nerve. Between February 2023 and November 2023, 4 patients with spastic equinus foot were treated with HSN of muscle branches of soleus, gastrocnemius medial head and lateral head, and cut the branch where S 2 joined the sciatic nerve. There were 3 males and 1 female, the age ranged from 5 to 46 years, with a median of 26 years. The causes included traumatic brain injury in 2 cases, cerebral hemorrhage in 1 case, and cerebral palsy in 1 case. The disease duration ranged from 15 to 84 months, with a median of 40 months. The triceps muscle tone measured by modified Ashworth scale (MAC) before operation was grade 3 in 2 cases and grade 4 in 2 cases. The muscle strength measured by Daniels-Worthingham manual muscle test (MMT) was grade 2 in 1 case, grade 3 in 1 case, and 2 cases could not be accurately measured due to grade 4 muscle tone. The Holden walking function grading was used to evaluate lower limb function and all 4 patients were grade 2. After operation, triceps muscle tone, muscle strength, and lower limb function were evaluated by the above grading. The distance between the location where S 2 joined the sciatic nerve and median line was (5.71±0.53) cm and the vertical distance between the location and posterior superior iliac spine plane was (6.66±0.86) cm. Before joining the sciatic nerve, the S 2 nerve root had given off branches of the pelvic splanchnic nerve, the pudendal nerve, and the posterior femoral cutaneous nerve. All the 4 patients successfully completed the operation, and the follow-up time was 4-13 months, with a median of 7.5 months. At last follow-up, the muscle tone of the patients decreased by 2-3 grades when compared with that before operation, and the muscle strength did not decrease when compared with that before operation. Holden walking function grading improved by 1-2 grades, and there was no postoperative hypoesthesia in the lower limbs. HSN of triceps branches combined with partial neurotomy of S 2 nerve root can relieve spastic equinus foot without damaging other sacral plexus nerves.

Clinical Anatomy of the Sacral Nerve Roots and Its Relevance to Their Reconstruction After Sacrectomy.

En bloc sacrectomy is associated with sacral root transection causing loss of urinary bladder, rectum, and sexual function. The aim of the study was to determine the position of the pudendal branches (sensorimotor) and pelvic splanchnic nerves (parasympathetic) on the sacral roots relative to the sacrum, and the minimal and maximal defects in the sacral roots that can be reconstructed by grafting after various types of sacrectomy. Five cadaveric pelves were dissected bilaterally. The lengths and widths of the S1-S4 roots and their branches were measured. Then, the minimal and maximal defects between the proximal and distal stumps of the sacrificed roots were measured following 3 models of sacrectomy (below S2, below S1, and total sacrectomy). The mean distance of the splanchnic nerves from the S2 and S3 anterior sacral foramina was 17.7 ± 7.3 and 23.6 ± 11.1 mm, respectively, and the mean distance of the pudendal S2 and S3 branches was 36.8 ± 13.7 and 30.2 ± 10.8 mm, respectively. The mean widths of the S2 and S3 roots were 9.3 ± 1.9 and 5.4 ± 1.2 mm, respectively. The mean maximal defects in S2 and S3 roots after various types of sacrectomies were between 61.8 ± 16.3 and 100.7 ± 14.3 mm and between 62.7 ± 20.2 and 84.7 ± 25.1 mm, respectively. There were no statistically significant differences between sides or sexes for all obtained measurements. The reconstruction of the S2-S3 roots is anatomically feasible after partial or total sacrectomies in which the resection of the soft tissue does not extend further than approximately 1.5 to 2 cm ventrally from the sacrum.

3D MR neurography with gadolinium contrast to improve the visualization of pelvic nerves and the branches

ObjectiveTo evaluate the effectiveness of 3D NerveVIEW sequence with gadolinium contrast on the visualization of pelvic nerves and their branches compared to that without contrast.MethodsParticipants were scanned twice using 3D NerveVIEW sequence with and without gadolinium contrast to acquire pelvic nerve images. The signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR) and contrast ratio of the nerves were calculated and compared to determine the quality of images. To subjectively assess, using a 3-point scale, branch nerves critical to therapeutic decision-making, including the pelvic splanchnic nerve and pelvic plexus, the superior gluteal nerve, and the pudendal nerve.ResultsIn the 32 eligible participants after using contrast, the CNRs of the images of nerve-to-bone and nerve-to-vessel significantly increased (p < 0.05). The CR of the images with contrast of all nerve-to-surrounding tissues (i.e., bone, muscle, blood vessels, and fat) were also found significantly higher (p < 0.05). The assessment of observers also shows higher scores for images with contrast compared to images without contrast.ConclusionThe 3D NerveVIEW sequence combined with gadolinium contrast improved vascular suppression, increased the contrast between pelvic nerves and surrounding tissue, and enhanced the visualization of nerves and their branches. This study may be helpful for the technically challenging preoperative planning of pelvic diseases surgery.

Pelvic Neuro-Visualization: An Anatomical Illustration of the Autonomic Pelvic Nervous Network in Gynecologic Surgery

ObjectiveDuring radical pelvic surgeries fibers of the autonomic pelvic nervous network can be accidentally damaged leading to significant visceral sequelae, which dramatically affect women's quality of life because of urinary, anorectal, and sexual postoperative dysfunctions.1,2 Direct visualization is one way to preserve hypogastric nerves (HNs), pelvic splanchnic nerves (PSNs), and the bladder branches from the inferior hypogastric plexus (IHP). However, the literature lacks critical photos and/or illustrations that are necessary to understand the precise anatomy needed to preserve the pelvic autonomic fibers. DesignNarrated laparoscopic video footage for identifying, dissecting, and preserving the autonomic nerve bundles during pelvic surgery. SettingTertiary level hospital—“IRCCS Istituto Nazionale dei Tumori”, Milano, Italy. InterventionsVisceral pelvic innervation is established by the superior hypogastric plexus(SHP) located anteriorly to the aortic bifurcation and the median sacral vessels and carries mostly sympathetic fibers. SHP divides in front of the sacrum into the right and left HN. At the level of the paracervix, the HNs join the parasympathetic PSNs coming out from sacral root S2, S3, S4 to form the IHP.2–5 Here, we performed laparoscopic surgery, before “Laparoscopic Approach to Cervical Cancer” trial (LACC) era, identifying key anatomic landmarks useful to highlight the path of the most commonly encountered autonomic pelvic nerves in gynecologic radical surgery: during the narration we describe and illustrate the procedure to identify all autonomic pelvic nerves, the sympathetic fibers, the PSNs, and the bladder branch emerging from the IHP in order to preserve their anatomic and functional integrity. This technique is anatomically and surgically indicated for adequate removal of the parametrical issues and vagina while preserving the total pelvic nervous system. ConclusionNerve-sparing surgery reduces bowel-, bladder- and sexual­ dysfunction without decreasing surgical efficacy.1,2 To accomplish safe and effective surgery, comprehension of the 3 dimensional structure of the vascular and nerve anatomy in the pelvis is essential. This video provides a great resource to educate surgeons, especially the youngest ones, about the retroperitoneal nervous networking: we identified the autonomic nerve pathway from adjacent tissues along the pathway consisting of cardinal, sacro-uterine, rectouterine/vaginal, and vesico-uterine ligaments.

Applied anatomy of female pelvic plexus for nerve-sparing radical hysterectomy(NSRH)

BackgroundNerve-sparing radical hysterectomy(NSRH)has the advantage of reducing postoperative complications and improving postoperative quality of life. The separation and protection of the pelvic plexus in NSRH is extremely important and challenging.Methods24 female cadaveric hemipelves were dissected. Morphologic patterns and compositions of pelvic plexus as well as relationship of pelvic plexus to the surrounding structures were observed and documented.ResultsTwo patterns of superior hypogastric plexus were observed, including fenestrated and cord-like shape. The origin of bilateral hypogastric nerves were inferiorly to upper margin of promontory about 1.6 ± 0.1 cm and parallel to the ureter in front of the sacrum. Pelvic splanchnic nerves(PSN)from the second sacral nerve, the third sacral nerve and the forth sacral nerve were observed combing with the hypogastric nerves within the lateral rectal ligament. The sacral sympathetic trunk can be identified anteriorly or medially to the anterior sacral foramen. We identified the boundaries of pelvic plexus as following: the upper margin is formed by the PSNs from the third sacral nerve, posterior margin by inferior rectal artery, and anteriorly by vesical venous plexus. The uterine branches from pelvic plexus were observed accompanying with uterine artery, while other branches were inferiorly to the artery. The PSNs were located beneath the deep uterine veins within the cardinal ligament. The upper margin of pelvic plexus was observed directly approach to urinary bladder within the vesico-vaginal ligament as a single trunk accompanying with ureter, between the middle and inferior vesical veins.ConclusionsOur study clarified the intricate arrangement, distribution and relationship of female pelvic plexus and the related structures to provide reference index for NSRH application. The innervation patterns of bladder and uterine were clarified, and by tracing these visceral branches of pelvic plexus, we suggest several new important land markers for NSRH.

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

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. 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. 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. 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.

Anatomical location of the surgically identifiable bladder branch of the inferior hypogastric plexus for nerve-sparing radical hysterectomy

ObjectiveWe aimed to demonstrate the entire structure of the inferior hypogastric plexus in the female pelvis focusing on surgically identifiable nerve bundles to the urinary bladder. MethodsSurgical videos of transabdominal nerve-sparing radical hysterectomy for 10 patients with cervical cancer at International Federation of Gynecology and Obstetrics (FIGO 2009) stage IB1–IIB were retrospectively analyzed. The paracervical tissue dorsal to the ureter was separated into the lateral component (dorsal layer of the vesicouterine ligament) and medial component (paracolpium) using Okabayashi’s technique. Any bundle-like structures in the paracervical area were isolated and divided using cold scissors, and each cut edge was inspected to determine whether the bundle was a blood vessel or a nerve. ResultsIn all cases, the surgically identifiable nerve bundle of the bladder branch was identified on the rectovaginal ligament running parallel and dorsal to the vaginal vein of the paracolpium. The bladder branch was revealed only after complete division of the vesical veins in the dorsal layer of the vesicouterine ligament where no definitive nerve bundles were observed. The bladder branch was derived laterally from the pelvic splanchnic nerve and medially from the inferior hypogastric plexus. ConclusionsThe surgical identification of the nerve bundle of the bladder branch is essential for a safe and secure nerve-sparing radical hysterectomy. The preservation of the surgically identifiable bladder branch from the pelvic splanchnic nerve as well as from the inferior hypogastric plexus can provide satisfactory postoperative voiding function.

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.

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

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. 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. 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. 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.

Laparoscopic Nerve-Sparing Radical Parametrectomy for Deep Lateral Parametrial Endometriosis

<h3>Study Objective</h3> To demonstrate the anatomical and technical highlights of nerve-sparing radical parametrectomy for deep lateral parametrial endometriosis (LPE). <h3>Design</h3> Stepwise demonstration of this method with narrated video footage. <h3>Setting</h3> An urban general hospital. LPE may involves ureter, internal iliac vessels, inferior hypogastric plexus, pelvic splanchnic nerves, or sometimes sacral nerve roots. Although LPE is not overly rare, isolation of the autonomic nerves from LPE cannot always be guaranteed. In cases where endometriosis lesions are embedded in the deep parametrium, nerve-sparing techniques are no longer considered feasible, except in cases with unilateral involvement. However, even one-sided radical parametrectomy may actually lead to pelvic organ dysfunctions, which seriously affects quality of life. <h3>Patients or Participants</h3> A 38-year-old woman, para 1, presented with a five-year history of severe chronic pelvic and gluteal pain, all of which were resistant to pharmacotherapy. MRI revealed right ovarian endometrioma with LPE reaching the lateral pelvic wall. <h3>Interventions</h3> Laparoscopic surgery. <h3>Measurements and Main Results</h3> Main outcome measures were releasing from severe pain, avoidance of postoperative morbidity and preservation of fertility. The procedure was performed using 8 steps, as follows: Step 1, adhesiolysis and adnexal surgery; Step 2, complete ureterolysis; Step 3, identification and dissection of the hypogastric nerve and inferior hypogastric plexus with development of the pararectal space; Step 4, dissection of internal iliac vessels; Step 5, identification and dissection of sacral roots S2-S4 and pelvic splanchnic nerves; Step 6, complete removal of LPE; Step 7, hemostasis and assessment of tissue perfusion using ICG; and Step 8, application of barrier agents to prevent adhesion. The patient developed no perioperative complications, including postoperative bladder, rectal or sexual dysfunctions. Pain was completely resolved after surgery. <h3>Conclusion</h3> Laparoscopic nerve-sparing radical parametrectomy is technically safe and feasible for selected patients with LPE. Suitably tailored treatment should be provided for each individual, based on both the latest scientific evidence and life planning for the patient.

Nerve-sparing surgery for deep lateral parametrial endometriosis

Although dLPE is not overly rare, isolation of the autonomic nerves from dLPE cannot always be guaranteed. In patients with endometriosis lesions that are embedded in the deep parametrium, nerve-sparing techniques are no longer considered feasible, except for those with unilateral involvement. However, even one-sided radical parametrectomy may actually lead to bladder dysfunction, which seriously affects the quality of life. Therefore, the objective is to demonstrate the anatomical and technical highlights of nerve-sparing laparoscopic surgery for deep lateral parametrial endometriosis (dLPE). Stepwise demonstration of this method with a narrated video footage. An urban general hospital. A 38-year-old woman, para 1, presented with a 5-year history of severe chronic pelvic and gluteal pain, all of which were resistant to pharmacotherapy. The patient showed no neurological disorders, such as bladder dysfunction. Magnetic resonance imaging revealed right ovarian endometrioma and hydrosalpinx with dLPE reaching the lateral pelvic wall. Based on the dermatome involved, we suspected that the main lesion causing gluteal pain was located around the second and third sacral roots. Laparoscopic excision of dLPE with a pelvic autonomic nerve-sparing technique, decompression of somatic nerves and preservation of all branches of the internal iliac vessels. Assessment of preserved tissue perfusion using indocyanine green. The procedure was performed using 8 steps, as follows: step 1, adhesiolysis and adnexal surgery; step 2, complete ureterolysis; step 3, identification and dissection of the hypogastric nerve and inferior hypogastric plexus with development of the pararectal space; step 4, dissection of the internal iliac vessels; step 5, identification and dissection of the sacral roots S2-S4 and the pelvic splanchnic nerves; step 6, complete removal of dLPE; step 7, hemostasis and assessment of tissue perfusion using indocyanine green; and step 8, application of barrier agents to prevent adhesion. Dissection of the pelvic nerves before dLPE excision revealed the relationship between the lesions and pelvic innervation, thereby reducing the risk of nerve injury, whether by minimizing the risk of neuropraxia or by allowing as many nerve fibers as possible to be spared in patients with some invasion of the pelvic nerve system. We considered even partial preservation of these nerves as beneficial to the resumption of pelvic organ functions. The step-by-step technique should help perform each stage of the surgery in a logical sequence, ensuring easy and safe completion of the procedure. Relief from severe pain, avoidance of postoperative morbidity (including intermittent self-catheterization). The patient developed no perioperative complications, including postoperative bladder, rectal, or sexual dysfunctions. Pain was completely resolved. Nerve-sparing surgery is technically safe and feasible for selected patients with dLPE. Suitably tailored treatment should be provided for each individual based on both latest scientific evidence and life planning for the patient.

The Pelvic and Sacral Splanchnic Nerves – Identification by Dissection, Trajectory

The modern principles in pelvic surgery imply the preservation of the nervous structures that are involved in the physiological functioning of the pelvic and genital organs. The main pelvic nervous element is represented by the inferior hypogastric plexus. This plexus receives sympathetic afferent fibres from the hypogastric nerve, parasympathetic afferent fibres from the pelvic splanchnic nerves and also sympathetic afferent fibres coming from the sympathetic sacral chain via the sacral splanchnic nerves. We aimed to demonstrate the anatomy of these structures through dissection and we exposed the origins, pathway and manner of distribution of the splanchnic nerves of the pelvis. We managed to clarify the main anatomical relations of these nerves, among which we highlighted the relation to the branches of the internal iliac artery. The parasympathetic fibres reach the pelvis by running through the anterior rami of the spinal nerves, which are the origin of the sacral plexus. We managed to exhibit the way in which the parasympathetic fibres emerge from the sacral nerves and form the pelvic splanchnic nerves. Pelvic surgery nowadays is focused on nerve-sparing, which essentially means the conservation of the integrity of splanchnic nerves, hypogastric nerves and inferior hypogastric plexuses in order to maintain the normal functioning of the anatomical sphincters and genital organs. In this respect, it is crucial for the surgeon who performs pelvic procedures to be more than well-acquainted to the anatomy of the pelvic splanchnic nerves, which are considered to be the erectile nerves, and to that of the sacral splanchnic nerves.

Postsurgical urodynamic study of total laparoscopic nerve-sparing radical hysterectomy for uterine cervical cancer.

To evaluate the impact on urodynamic results between the laparoscopic nerve-sparing radical hysterectomy (LRH) following a step-by-step procedure and abdominal nerve-sparing radical hysterectomy (ARH) for patients with uterine cervical cancer. This retrospective study enrolled 76 patients with cervical cancer: 35 in the LRH group and 41 in the ARH group. We analyzed their postoperative bladder function in a urodynamics study and examined the volume of resected pelvic nerves contained in parametrial sections using S-100 antibody staining. Estimated blood loss and hospital stay after operation for the LRH group were significantly better than those in the ARH group (p < 0.0001). As well, the number of harvested lymph nodes was significantly higher in the LRH group (p=0.044). There was no difference in perioperative complications between the two groups in this study. The 5-year disease-free survival rates and overall survival rates were 91.2% and 94.0% in the LRH group and 87.8% and 95.1% in the ARH group, both respectively. Although the median residual urine volume were no statistical differences between the LRH group and the ARH group, the recovery of postoperative bladder function (uroflowmetry) in the LRH group rapidly reached presurgery levels at 1month, and the LRH group had a smaller number of s-100 antibody stained nerves contained the parametrial sections. We demonstrated that LRH following a step-by-step procedure could achieve a higher level of prevention of damage to the bladder branch of the pelvic splanchnic nerve plexus and thus restore bladder function more rapidly.

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

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

\u201cNear-TME\u201d: proposed standardisation of the technique for proctectomy in male patients with ulcerative colitis

BackgroundThe aim of the present study was to describe in detail an approach to proctectomy in ulcerative colitis (UC), which can be standardized; near-total mesorectal excision (near-TME), to prevent injuries to autonomic pelvic nerves and subsequent sexual dysfunction.MethodsWe demonstrate the technique ex vivo on a cadaver from a male patient in lithotomy position and on a sagittal section of a male pelvis. We also demonstrate the technique in vivo in two male patients diagnosed with UC, with no history of sexual dysfunction or bowel neoplasia. The study was performed at the Human Embryology and Anatomy Department. University of Valencia, Spain.ResultsThe posterolateral dissection during a near-TME is similar to that of an oncologic TME, whereas the anterolateral is similar to that of a close rectal dissection. The near-TME technique preserves the superior hypogastric plexus, the hypogastric nerves, the nervi erigentes, the inferior hypogastric plexus, the pelvic plexus and the cavernous nerves.ConclusionThe near-TME technique is the standardisation of the technique for proctectomy in male patients with ulcerative colitis. Near-TME requires experience in pelvic surgery and an exhaustive knowledge of the embryological development and of the surgical anatomy of the pelvis.

The Effect of Cigarette Smoking on Penile Vasculature and Cardiodynamics among Young Saudi Population

Erectile and cardiovascular dysfunctions in cigarette smokers are important signs resulting probably due to pelvic autonomic neuropathy with damage to the parasympathetic nervi erigentes. Evidence related to neuropathic etiology comes from studies that show structural changes in autonomic nerve fibers supplying the corpora cavernosa. The objective of this study was to evaluate the effect of cigarette smoking on penile mid shaft circumference and length, penile pulse amplitude, both systolic and diastolic blood pressures, and heart rate in response to erotic stimulation in young Saudi men living in Western region of Saudi Arabia (Makkah). In this free-living population study data was collected from100 men each (mild, moderate and heavy cigarette smokers) ages between 20 and 35 years with a mean age of 26.42 ± 10.69 years along with 100 age matched healthy non smokers who served as controls. Heavy cigarette smoker group showed a significant decrease (p&lt;0.0005) in mid shaft penile circumference and length and penile pulse amplitude where as both systolic and diastolic blood pressures and heart rate exhibited a significant increase (P&lt;0.025, P&lt;0.0005 and P&lt;0.005 respectively. However this difference was found to be non significant in mild smoker group when compared with non smoker controls. We hypothesized that heavy cigarette smoking seems to be associated with sub-fertility in these males with significant alteration in the penile vasculature and cardiodynamics in a dose-dependent manner.

Pelvic Neuroanatomy Learning from Fresh Frozen Cadaveric Dissections: Overview of Commonly Encountered Pelvic Nerves in Neuropelveology

<h3>Study Objective</h3> To describe commonly encountered pelvic nerves and anatomical landmarks in neuropelveologic surgery. <h3>Design</h3> A narrated video explanation of the autonomic nerves and the somatic nerves in the pelvis, their origin, sensory and motor function. <h3>Setting</h3> An anatomic theater for cadaveric dissections and an urban general hospital for in vivo laparoscopy. <h3>Patients or Participants</h3> N/A. <h3>Interventions</h3> Neuropelveology is new groundbreaking discipline in medicine established by Prof. Marc Possover. Neuropelveology is concerned with the diagnosis of injuries and dysfunctions of the pelvic nerves and with the treatment of the symptoms and diseases caused by them. Sparing the pelvic nerves during surgery requires surgical expertise and an immense understanding of pelvic neuroanatomy. In this video, we educationally reviewed with laparoscopic viewpoint pictures of the superior and inferior hypogastric plexus, hypogastric nerves, pelvic splanchnic nerves, sacral splanchnic nerves, femoral nerve, genitofemoral nerve, obturator nerve, lumbosacral trunk, sacral nerve roots (plexus), pudendal nerve (plexus), sciatic nerve, posterior cutaneous nerve of the thigh. Considering the anatomical relationships between these nerves and adjacent structures, we identified the external and iliac vessels, gluteal vessels, internal pudendal vessels, uterine artery, middle rectal artery, ureter, levator ani muscles, coccygeal muscle, piriform muscle, obturator internus muscle, sacrospinous ligament, sacrotuberous ligament, Alcock's canal, ischial rectal (anal) fossa, lesser sciatic foramen, greater sciatic notch, as well as other anatomical structures in the region of those mentioned. <h3>Measurements and Main Results</h3> Cadaveric laparoscopic dissection provided excellent visual information on essential pelvic neural pathways. <h3>Conclusion</h3> The fresh frozen cadaveric dissections are essential tool for acquiring the knowledge of pelvic anatomy, especially the nerve system. The most important nerves groups are the hypogastric plexus and the sympathetic trunk for the autonomic nerve system, and the sacral and the lumbar plexuses for the somatic nerve system. Preservation of the pelvic neural pathways is necessary to deliver the best patient outcomes while minimizing unwanted surgical complications.

Nerve-Sparing Radical Hysterectomy: Kobayashi's Method.

After Prof. S. Okabayashi introduced Okabayashi Operation in 1921, several surgeons introduced numerous improvements in Japan. One of them is so-called the Tokyo Method which was improved and revised by Dr. Kyusaku Ogino (1950), Prof. Takashi Kobayashi, University of Tokyo (1961, 1970), and Prof. Shoichi Sakamoto, University of Tokyo (1981). The nerve-sparing radical hysterectomy without sacrificing radicality was introduced in 1961 1 and improved in 1970 by Prof. Kobayashi. 2 The autonomic nerve pathway including hypogastric nerve (sympathetic nerve), pelvic splanchnic nerve (parasympathetic nerve), and pelvic nerve plexus as a junction of the two nerves and the branch of the plexus to the bladder (vesical nerve branch) are preserved except in advanced cases. He divided the process of nerve-sparing surgery into four steps for separating the autonomic nerve pathway from adjacent tissues along the pathway consisting of cardinal, sacrouterine, rectouterine/vaginal, and vesicouterine ligaments. The first step is separation of the cardinal ligament (deep uterine vessels) from the pelvic splanchnic nerve. The second step is separation of the medial side of severed cardinal ligament from the pelvic nerve plexus. The first and second steps are performed in the lateral side of the autonomic nerve system. The third step is separation of sacrouterine and rectouterine/vaginal ligaments from hypogastric nerve and pelvic nerve plexus. The third step is necessary for achieving high radicality, namely, for severing the sacrouterine and rectouterine/vaginal ligaments near the rectum without damage to the pelvic nerve plexus. The fourth step is separation of paravaginal tissues and posterior (deep) layer of the vesicouterine ligament from the vesical nerve branches of the plexus. The third and fourth steps are performed in the medial side of the autonomic nerve system.

Rectal mobilization for laparoscopic pelvic lymphadenectomy of the lower paracervical pathway in patients with uterine cancer.

ObjectiveThe pelvic lymphatic drainage system comprises the upper and lower paracervical pathways (LPPs). Lymph node dissection of the LPP, including the cardinal ligament, internal iliac, internal common iliac, and presacral lymph nodes, requires higher surgical skills because of the anatomical limitations of the pelvic cavity and the dissection of vessels while preserving the nerves in the pelvic floor. In this video, we demonstrate rectal mobilization for laparoscopic complete pelvic lymph node dissection of the LPP in patients with uterine cancer.MethodsRectal mobilization was performed before complete pelvic lymph node dissection of the LPP. The pararectal space was opened widely and the connective tissue between the presacral fascia and prehypogastric nerve fascia was dissected bilaterally, allowing the rectum to be pulled.ResultsThis procedure created a wide-open space in the pelvic floor, allowing clear visualization of the nerves and lymph nodes of the LPP. Laparoscopic complete lymph node dissection of the LPP was performed in the open space while preserving the hypogastric and pelvic splanchnic nerves and isolating the extensive network of blood vessels in the pelvic cavity.ConclusionRectal mobilization enabled the safe execution of laparoscopic complete pelvic lymph node dissection of the LPP in patients with uterine cancer.

“Nerve-sparing” laparoscopic treatment of parametrial ectopic pregnancy

To demonstrate laparoscopic surgical management of parametrial ectopic pregnancy. Video presentation of laparoscopic nerve-sparing treatment of parametrial pregnancy. Tertiary university center. A 33-year-old patient, nullipara at 8 weeks of gestation, with no comorbidity and no previous surgery, was admitted to a spoke hospital for acute abdominal pain. During hospitalization, a transvaginal gynecologic ultrasound revealed pregnancy with ectopic localization. Free pelvic fluid was detected, and a subsequent diagnostic laparoscopy was performed because of worsening symptoms. During the procedure, hemoperitoneum drainage was instituted and American Society of Reproductive Medicine stage III pelvic endometriosis was diagnosed. A round formation approximately 3 cm in diameter was found at the left posterior parametrium (Fig.1). Due to the pregnancy position and β-human chorionic gonadotropic (β-hCG; 820 mUI /mL) values, conservative treatment was chosen. Thus, methotrexate at 50 mg/m2 body surface area was administered. A second dose of methotrexate was administered seven days after the first one, and the β-hCG increased to 1068 mUI. On day 14 after treatment, the β-hCG was 1053 mUI/mL. Therefore, surgical treatment was chosen, and the patient was transferred to our center. An ultrasound assessment confirmed the ectopic pregnancy with a live fetus in the left posterior parametrium. The patient underwent operative laparoscopy to remove the ectopic pregnancy. Surgery was performed using a 3-dimensional optical system (TIPCAM 1, S D3-LINK; Karl Storz SE & Co., Tuttlingen, Germany). After drainage of the hemoperitoneum, the gestational sac was identified in the left posterior parametrium. The uterus, tubes, and ovaries showed normal morphology. Pelvic endometriosis was confirmed. After accessing the left pelvic retroperitoneum with the medial and lateral pararectal spaces' opening and development, ipsilateral ureterolysis was necessary to isolate the parametrial pregnancy in close contact with it. Coagulation and sectioning of the deep uterine veins were essential to control hemostasis. Identification of the left hypogastric nerve, which was partially infiltrated by the chorionic villi, and the pelvic splanchnic nerves, was required to safeguard them (Fig.2). Subsequently, the surgeon decided to place a ureteral stent to prevent urologic complications. The laparoscopic approach proved to be safe and feasible to manage parametrial pregnancy. The pregnancy was removed entirely. The patient was discharged 72 hours after the procedure with an uneventful postoperative course. The histologic report confirmed the diagnosis of parametrial pregnancy on decidualized endometriotic tissue. The β-hCG serum level became negative in 20 days. Extrauterine pregnancies represent one of the leading causes of maternal death in the first trimester and constitute approximately 1%-2% of total pregnancies. Of these percentages, only 5%-8.3% are nontubal. Cases of abdominal pregnancy are even rarer, estimated at <1%, and among these, according to a recent review, only 20 cases of retroperitoneal pregnancy were described in the literature. The intraoperative finding of multiple endometriotic implants on the parietal peritoneum above the retroperitoneal pregnancy, together with the decidualized endometriosis result of the histologic examination have been considered to explain the pathogenesis of the condition. It is plausible to suppose that endometriosis has represented the access route for the fertilized ovum, which implanted on endometriotic superficial tissue and then moved toward the retroperitoneal vascularized structures. The diagnosis and treatment are challenging for the gynecologist. Medical treatment is a valid approach to uninterrupted early ectopic pregnancies; however, symptomatic patients' medical therapy failure is one indication for a surgical procedure. The laparoscopic method is optimal, especially in cases like the reported one, in which minimally-invasive techniques allowed complete removal of the pregnancy, respecting the anatomic structures of the retroperitoneum using nerve-sparing techniques. Furthermore, it ensured a safe ureteral stent placement without imaging. The laparoscopic surgical approach can be a safe and feasible option. It allows an early discharge, with a minimum risk of dysfunctional complications, and improves life quality compared to more destructive interventions. In conclusion, to control vascular, nervous, and urinary tract structures, surgical treatment should be based on anatomic knowledge of retroperitoneal anatomy to guarantee the best surgical outcome.