The anatomy of the male inferior hypogastric plexus: What should we know for nerve sparing surgery

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

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Identification and injury to the inferior hypogastric plexus in nerve-sparing radical hysterectomy

Scientific Reports ◽

10.1038/s41598-019-49856-w ◽

2019 ◽

Vol 9 (1) ◽

Author(s):

Lei Li ◽

Yalan Bi ◽

Leiming Wang ◽

Xinxin Mao ◽

Bernhard Kraemer ◽

...

Keyword(s):

Radical Hysterectomy ◽

Immunohistochemical Staining ◽

Lower Percentage ◽

Controlled Study ◽

Control Group ◽

Nerve Sparing ◽

Inferior Hypogastric Plexus ◽

Hypogastric Plexus ◽

Neural Tissues ◽

Waterjet Dissection

Abstract Waterjet dissection of the inferior hypogastric plexus (IHP) resulted in a more rapid return of normal urodynamics than blunt dissection (control group) in patients who received laparoscopic nerve-sparing radical hysterectomy (NSRH) in a randomized controlled study. However, the definite reasons for these results were unknown. This subgroup analysis compared the neural areas and impairment in the IHP uterine branches harvested during NSRH as an alternative to the IHP vesical branches between the waterjet and control groups. This study included samples from 30 eligible patients in each group of the trial NCT03020238. At least one specimen from each side of the IHP uterine branches was resected. The tissues were scanned, images were captured, and the neural component areas were calculated using the image segmentation method. Immunohistochemical staining was used to evaluate neural impairment. The control and waterjet groups had similar areas of whole tissues sent for evaluation. However, the control group had significantly fewer areas (median 272158 versus 200439 μm2, p = 0.044) and a lower percentage (median 4.9% versus 3.0%, p = 0.011) of neural tissues. No significant changes in immunohistochemical staining were found between the two groups. For patients with residual urine ≤100 and >100 ml at 14 days after NSRH (42 and 18 patients, respectively), there were significantly different percentages of neural tissues in the resected samples (p < 0.001). Hence, Due to the accurate identification of IHP during NSRH, the waterjet dissection technique achieved better urodynamic results.

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Le basi anatomiche della prevenzione dei danni neurogeni in corso di chirurgia radicale pelvica nella donna

Urologia Journal ◽

10.1177/039156039406101s48 ◽

1994 ◽

Vol 61 (1_suppl) ◽

pp. 160-161

Author(s):

B. Frea ◽

E. Kocjancic ◽

R. Musci ◽

T. Meroni

Keyword(s):

Adult Female ◽

Pelvic Surgery ◽

Nerve Sparing ◽

Pelvic Cavity ◽

Pelvic Plexus ◽

Inferior Hypogastric Plexus ◽

Hypogastric Plexus

Radical pelvic surgery in women is considerably handicapped by serious neurogenic complications, commonly due to lesions in the inferior hypogastric plexus or its branches, which cannot be easily identified in the female pelvic cavity. The pelvic cavities of 42 adult female cadavers were studied and the relations between the nervous structures and the cardinal and utero-sacral ligaments were analysed. The possibility of identifying and recognising in vivo anatomical findings of the pelvic plexus is the fulcrum of nerve sparing pelvic surgery.

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

Annals of Surgical Oncology ◽

10.1245/s10434-019-07228-8 ◽

2019 ◽

Vol 26 (5) ◽

pp. 1560-1568 ◽

Cited By ~ 5

Author(s):

Lei Li ◽

Shuiqing Ma ◽

Xianjie Tan ◽

Sen Zhong ◽

Ming Wu

Keyword(s):

Radical Hysterectomy ◽

Randomized Controlled Study ◽

Controlled Study ◽

Survival Outcomes ◽

Nerve Sparing ◽

Inferior Hypogastric Plexus ◽

Randomized Controlled ◽

Hypogastric Plexus ◽

Type C

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Nerve-sparing radical hysterectomy in patients with infiltrative cervical cancer

HEALTH OF WOMAN ◽

10.15574/hw.2016.112.46 ◽

2016 ◽

pp. 46-51

Author(s):

T. Dermenzhy ◽

◽

V. Svintitskiy ◽

S. Nespryadko ◽

L. Legerda ◽

...

Keyword(s):

Cervical Cancer ◽

Radical Hysterectomy ◽

Contractile Function ◽

Major Elements ◽

Control Group ◽

Nerve Sparing ◽

Group I ◽

Hypogastric Plexus ◽

Prognostic Indexes

The objective: to improve an effectiveness of therapy and quality of life of patients with infiltrative cervical cancer using radical hysterectomy accomplished with nerve-sparing methodology. Patients and Methods: Ninety patients with histologically verified infiltrative cervical cancer were cured with radical hysterectomy (RHE) in the Department of Oncogynecology of National Cancer Institute (Kyiv, Ukraine) in 2012-2016. The age of the patients was from 26 to 65 years (an average age of 42.61±1.06). The patients were distributed in 2 groups: group I treated with nerve-sparing radical hysterectomy (NSRHE), 45 patients, the main group; group II treated with radical hysterectomy (RHE III), the control group, 45 patients. The prognostic indexes in the groups were similar. Results. NSRHE that included the dissection of cardinal ligament, separation of dorsal and anterior layers of uterovesical ligament allowed separate uterine branch of inferior hypogastric plexus, preserve an innervation of urinary bladder and prevent the malfunction of its contractile function at postoperative period. Conclusion. The data of the urodynamic study using cystomanometry performed at pre- and early operative periods have shown that surgical treatment of patients with infiltrative cervical cancer with preservation of the major elements of pelvic autonomic plexuses allows significantly decrease the rate of postoperative urogenical malfunctions. Key words: nerve-sparing radical hysterectomy, cervical cancer, cystomanometry.

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Clinical Management of Chronic Pelvic Pain in Endometriosis Unresponsive to Conventional Therapy

Journal of Personalized Medicine ◽

10.3390/jpm12010101 ◽

2022 ◽

Vol 12 (1) ◽

pp. 101

Author(s):

Augusto Pereira ◽

Manuel Herrero-Trujillano ◽

Gema Vaquero ◽

Lucia Fuentes ◽

Sofia Gonzalez ◽

...

Keyword(s):

Pelvic Pain ◽

Conventional Therapy ◽

Chronic Pelvic Pain ◽

Myofascial Pain ◽

Visceral Pain ◽

University Hospital ◽

Common Symptom ◽

Rectal Pain ◽

Inferior Hypogastric Plexus ◽

Hypogastric Plexus

Background: Although several treatments are currently available for chronic pelvic pain, 30–60% of patients do not respond to them. Therefore, these therapeutic options require a better understanding of the mechanisms underlying endometriosis-induced pain. This study focuses on pain management after failure of conventional therapy. Methods: We reviewed clinical data from 46 patients with endometriosis and chronic pelvic pain unresponsive to conventional therapies at Puerta de Hierro University Hospital Madrid, Spain from 2018 to 2021. Demographic data, clinical and exploratory findings, treatment received, and outcomes were collected. Results: Median age was 41.5 years, and median pain intensity was VAS: 7.8/10. Nociceptive pain and neuropathic pain were identified in 98% and 70% of patients, respectively. The most common symptom was abdominal pain (78.2%) followed by pain with sexual intercourse (65.2%), rectal pain (52.1%), and urologic pain (36.9%). A total of 43% of patients responded to treatment with neuromodulators. Combined therapies for myofascial pain syndrome, as well as treatment of visceral pain with inferior or superior hypogastric plexus blocks, proved to be very beneficial. S3 pulsed radiofrequency (PRF) plus inferior hypogastric plexus block or botulinum toxin enabled us to prolong response time by more than 3.5 months. Conclusion: Treatment of the unresponsive patient should be interdisciplinary. Depending on the history and exploratory findings, therapy should preferably be combined with neuromodulators, myofascial pain therapies, and S3 PRF plus inferior hypogastric plexus blockade.

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