Robot-assisted Nerve Plane–sparing Eradication of Deep Endometriosis with Double-bipolar Method

ObjectiveTo demonstrate anatomic and technical highlights of a robot-assisted nerve plane–sparing eradication of deep endometriosis (DE).DesignStepwise demonstration of the technique with narrated video footage.SettingAn urban general hospital.InterventionsLaparoscopic nerve-sparing techniques as represented by the Negrar method reportedly result in lower rates of postoperative bladder, rectal, and sexual dysfunctions than classical approaches [1]. In addition, robotic surgery has become available, and 2 meta-analyses have confirmed that robotic surgery is safe and feasible for the treatment of endometriosis, especially in advanced cases [2,3]. However, few papers have shown the surgical techniques for a nerve-sparing procedure using a robotic approach.The patient was a 45-year-old woman who presented with severe chronic pelvic pain and dysmenorrhea resistant to medication therapy. She had no nerve-specific complaints such as pain in the pudendal distribution or a voiding dysfunction. Magnetic resonance imaging revealed multiple uterine fibromas and adenomyosis with DE, involving the uterosacral ligament and surface of the rectum, with cul-de-sac obliteration. The parametrium was not involved in the DE. Robot-assisted nerve plane–sparing excision of DE with a double-bipolar method was performed using the following 8 steps: step 1, adhesiolysis and adnexal surgery; step 2, checking the ureteral course; step 3, separation of the nerve plane (step 3.1, dissection of the avascular layer below the hypogastric nerve, between the prehypogastric nerve fascia and presacral fascia; and step 3.2, dissection of the avascular layer above the hypogastric nerve, between the prehypogastric nerve fascia and fascia propria of the rectum) [4,5]; step 4, reopening of the pouch of Douglas; step 5, complete removal of DE lesions while avoiding injury to the nerve plane; step 6, hysterectomy (if the patient desires non–fertility-sparing surgery); step 7, checking for rectal injury using an air leakage test; and step 8, barrier agents for adhesion prevention.With regard to step 3, as a result of sharp dissection between avascular layers both above and below the hypogastric nerve, autonomic nerves in the pelvis were separated like a sheet with the surrounding fascia (the nerve plane). We then performed steps 4 to 6 in a step-by-step manner while avoiding injury to the nerve plane. The urinary catheter was removed within 24 hours after the surgery, and no residual urine was seen. The patient developed no perioperative complications; in particular, no postoperative bladder or rectal dysfunctions. The precise sharp dissection of the right embryo-anatomic planes on the basis of the detailed mesoanatomy seems important for improving functional outcomes in nerve-sparing surgery [5].ConclusionRobot-assisted nerve plane–sparing eradication of DE is as technically feasible as the conventional laparoscopic approach. The step-by-step technique should help surgeons perform each part of the surgery in a logical sequence, making the procedure easier and safer to complete. However, the latent benefits of robot-assisted nerve-sparing surgery in the treatment of DE remain uncertain.     

Nerve-sparing Surgery for Deep Infiltrating Endometriosis: Laparoscopic Eradication of Deep Infiltrating Endometriosis with Rectal and Parametrial Resection According to the Negrar Method

ObjectiveTo show technical highlights of a nerve-sparing laparoscopic eradication of deep infiltrating endometriosis with rectal and parametrial resection according to the Negrar method.DesignStepwise demonstration of the technique with narrated video footage.SettingTertiary care endometriosis unit. Bowel endometriosis accounts for about 12% of the total cases of endometriosis. Most frequently, rectal infiltration also means parametrial infiltration from the widespread infiltrating disease. Its removal with inadequate anatomical surgical knowledge may lead to severe damage to visceral pelvic innervation, causing bladder, rectal, and sexual function impairments and lasting lifelong. Nerve-sparing techniques, which are the heritage of onco-gynecologic surgery, have been described to have lower post-operative bladder, rectal, and sexual dysfunctions than classical approaches.InterventionsLaparoscopic excision of deep infiltrating endometriosis was performed by following the nerve-sparing Negrar technique in 6 steps: step 0—adhesiolysis, ovarian surgery, and removal of the involved peritoneal tissues; step 1—opening of pre-sacral space, development of avascular spaces, and identification and preservation of pelvic sympathetic fibers of the inferior mesenteric plexus, superior hypogastric plexus, upper hypogastric nerves, and lumbosacral sympathetic trunk and ganglia; step 2—dissection of parametrial planes, isolation of ureteral course, lateral parametrectomy, and preservation of sympathetic fibers of postero-lateral parametrium and lower mesorectum (the lower hypogastric nerves and proximal part of the inferior hypogastric plexus or pelvic plexus); step 3—posterior parametrectomy, deep uterine vein identification, and preservation of the parasympathetic pelvic splanchnic nerves and the cranial and middle part of the mixed inferior hypogastric plexus in caudad posterior parametrium and lower mesorectal planes; step 4—preserving the caudad part of the inferior hypogastric plexus in postero-lateral parametrial ligaments; step 5—preserving the caudad part of the inferior hypogastric plexus in paravaginal planes; and step 6—rectal resection and colorectal anastomosis.ConclusionAs shown in this case, the laparoscopic nerve-sparing complete excision of endometriosis is a feasible and reproducible technique in expert hands and, as reported in the literature, offers good results in terms of bladder morbidity reduction with higher satisfaction than the classical technique.     

Anatomical basis for nerve-sparing radical hysterectomy: immunohistochemical study of the pelvic autonomic nerves

BACKGROUND: Autonomic nerve damage plays a crucial role in the etiology of bladder dysfunction, sexual dysfunction, and colorectal motility disorders that occur after radical hysterectomy. We investigated the extent and nature of nerve damage in conventional and nerve-sparing radical hysterectomy. METHODS: Macroscopical disruption of nerves was assessed through anatomical dissection after conventional and nerve-sparing surgery on five fixed and one fresh cadaver. Immunohistochemical analysis of surgical margins was performed to confirm nerve damage using a general nerve marker (S100) and a sympathetic nerve marker (anti-tyrosine hydroxylase) within sections of biopsies. RESULTS: Macroscopical dissection showed that in the conventional procedure, transsection of the uterosacral ligaments resulted in disruption of the major part of the hypogastric nerve. After nerve-sparing surgery, only the medial branches of the hypogastric nerve appeared disrupted. Division of the cardinal ligaments in the conventional procedure identified the inferior hypogastric plexus running into the most posterior border of the surgical margin. The anterior part of the plexus was disrupted. Dissection of the nerves after the nerve-sparing procedure showed that this anterior part of the plexus was not involved in the surgical dissection line. Dissection of the vesicouterine ligament disrupted only small nerves on the medial border of the inferior hypogastric plexus in both techniques. Microscopical evaluation of the surgical margins confirmed the macroscopical findings. CONCLUSION: Conventional radical hysterectomy results in disruption of a substantial part of the pelvic autonomic nerves. The nerve-sparing modification leads to macroscopic reduction in nerve disruption which is substantiated by microscopical evaluation of surgical margins.     

Keep Your Landmarks Close and the Hypogastric Nerve Closer: An Approach to Nerve-sparing Endometriosis Surgery

ObjectiveExcisional techniques used to surgically treat deep infiltrating endometriosis (DIE) can result in inadvertent damage to the autonomic nervous system of the pelvis, leading to urinary, anorectal, and sexual dysfunction 1, 2, 3, 4. This educational video illustrates the autonomic neuroanatomy of the pelvis, identifying the predictable location of the hypogastric nerve in relation to other pelvic landmarks, and demonstrates a surgical technique for sparing the hypogastric nerve and inferior hypogastric plexus.DesignUsing didactic schematics and medical drawings, we discuss and illustrate the autonomic neuroanatomy of the pelvis. With annotated laparoscopic footage, we demonstrate a stepwise approach for identifying, dissecting, and preserving the hypogastric nerve during pelvic surgery.SettingTertiary care academic hospitals: Mount Sinai Hospital in Toronto, Ontario, Canada, and S. Orsola Hospital in Bologna, Italy.InterventionsRadical excision of DIE with adequate identification and sparing of the hypogastric nerve and inferior hypogastric plexus bilaterally was performed, following an overview of pelvic neuroanatomy. The superior hypogastric plexus was described and the hypogastric nerve, the most superficial and readily identifiable component of the inferior hypogastric plexus, was identified and used as a landmark to preserve autonomic bundles in the pelvis. The following steps, illustrated with laparoscopic footage, describe a surgical technique developed to identify and preserve the hypogastric nerve and the deeper inferior hypogastric plexus without the need for more extensive pelvic dissection to the level of the sacral nerve roots: (1) transperitoneal identification of the hypogastric nerve, with a pulling maneuver for confirmation; (2) opening of the retroperitoneum at the level of the pelvic brim and retroperitoneal identification of the ureter; (3) medial dissection and identification of the hypogastric nerve; and (4) lateralization of the hypogastric nerve, allowing for safe resection of DIE.ConclusionThe hypogastric nerve follows a predictable course and can be identified, dissected, and spared during pelvic surgery, making it an important landmark for the preservation of pelvic autonomic innervation.     

Laparoscopic Dissection and Anatomy of Sacral Nerve Roots and Pelvic Splanchnic Nerves

Study ObjectiveTo demonstrate the technique of laparoscopic dissection for identification of sacral nerve roots and pelvic splanchnic nerves.DesignCase report (Canadian Task Force classification III).SettingPrivate practice hospital in São Paulo, Brazil.PatientA 31-year-old woman with suspected iatrogenic and/or compression of sacral nerve roots. She reported debilitating pelvic, gluteal, and perineal unilateral left-sided pain (score 8 on a pain scale of 0–10), and had primary infertility with 1 previous failed attempt at in vitro fertilization. Surgical history included laparoscopic excision of endometriosis 10 months before the procedure and left oophoroplasty during adolescence because of a benign neoplasm.InterventionsStandard 4-puncture laparoscopy was performed. The peritoneum of the left pelvic sidewall was resected to preclude eventual residual endometriosis. This also enabled identification of uterine vessels including the deep uterine vein, which is the limit between the pars vascularis superiorly and the pars nervosa inferiorly in the uterine broad ligament. Surgery was using the laparoscopic neuro-navigation (LANN) technique, previously described by one of us (M. P.). For identification of the sacral roots, dissection was begun medial to the ureter and lateral to the uterosacral ligament. The Okabayashi pararectal space was entered as deep as possible via blunt dissection in avascular spaces. Hemostasis was performed using 5-mm bipolar forceps, and harmonic energy was not used. The hypogastric fascia was entered from medial to lateral, and the piriformis muscle was identified. The sacral nerve root S1 was identified lying over it. Dissection then proceeded caudally, and sacral roots S2 and S3 were sequentially identified. Small and delicate fibers forming the pelvic splanchnic nerves were isolated emerging from sacral roots S2 and S3. Other nerve fibers were identified caudally, probably representing pelvic splanchnic nerves emerging from S4.Measurements and Main ResultsThe surgical operative time was 70 minutes, and bleeding was minimal. No suspected compression or iatrogenic injury was identified. The patient was discharged on the day after the procedure. At 8-month follow-up, she had partial resolution of pain (score 5, pain scale 0–10), and another failed attempt at in vitro fertilization was attributed to unsatisfactory quality of the embryos. There were no symptoms or dysfunctions attributable to manipulation of the nerves.ConclusionLaparoscopy is a useful tool for identification of sacral roots and pelvic splanchnic nerves in suspected diseases. Its application in the field of neuropelveology can be expanded with proper knowledge and training.     

Nerve-sparing in Gynecology

ObjectiveTo demonstrate identification and dissection of the pelvic autonomic nerves in gynecologic surgery.DesignIdentification on the right and left pelvic pelvises, dissection and preservation of the inferior hypogastric plexus in deep endometriosis, and dissection and preservation of the pelvic autonomic nerves in radical hysterectomy.SettingAcademic center.InterventionsRobotic excision of the pelvic peritoneum, excision of deep endometriosis in the uterosacral ligaments, and radical hysterectomy.ConclusionPelvic autonomic nerves are easy to identify with the magnification provided with an endoscopic camera. They should be dissected and preserved whenever possible because of their important function.     

Rapport anatomique du ligament utérosacré et du nerf hypogastrique pour la chirurgie des lésions d’endométriose profonde

Endometriosis is a concern for 10 to 15% of women of childbearing age. The uterosacral ligament is the most frequent localization of deep infiltrating endometriosis. Laparoscopic excision of endometriotic nodules may lead to functional consequences due to potential hypogastric nerve lesion. Our aim is to study the anatomical relationship between the hypogastric nerve and the uterosacral ligament in order to reduce the occurrence of such nerve lesions during pelvic surgeries. We based our study on an anatomical and surgical literature review and on the anatomical dissection of a 56-year-old fresh female subject. The hypogastric nerves cross the uterosacral ligament approximately 30 mm from the torus. They go through the pararectal space, 20 mm below the ureter and join the inferior hypogastric plexus at the level of the intersection between the ureter and the posterior wall of the uterine artery, at approximately 20 mm from the torus. No anatomical variation has been described to date in the path of the nerve, but in its presentation which may be polymorphous. Laparoscopy and robot-assisted laparoscopic surgery facilitate the pelvic nerves visualization and are the best approach for uterosacral endometriotic nodule nerve-sparing excision. Precise knowledge by the surgeon of the anatomical relationship between the hypogastric nerve and the uterosacral ligament is essential in order to decrease the risk of complication and postoperative morbidity for patient surgically treated for deep infiltrating endometriosis involving uterosacral ligament.     

A nerve-sparing radical hysterectomy: Guidelines and feasibility in Western patients

Abstract. Trimbos JB, Maas CP, DeRuiter MC, Peters AAW, Kenter GG. A nerve-sparing radical hysterectomy: Guidelines and feasibility in Western patients.
Surgical damage to the pelvic autonomic nerves during radical hysterectomy is thought to be responsible for considerable morbidity, i.e., impaired bladder function, defecation problems, and sexual dysfunction. Previous anatomical studies and detailed study of surgical techniques in various Japanese oncology centers demonstrated that the anatomy of the pelvic autonomic nerve plexus permits a systematic surgical approach to preserve these nerves during radical hysterectomy without compromising radicality. We introduced elements of the Japanese nerve-preserving techniques and carried out a feasibility study in ten consecutive Dutch patients. The technique involved three steps: first, the identification and preservation of the hypogastric nerve in a loose tissue sheath underneath the ureter and lateral to the sacro-uterine ligaments; second, the inferior hypogastric plexus in the parametrium is lateralized and avoided during parametrial transsection; third, the most distal part of the inferior hypogastric plexus is preserved during the dissection of the posterior part of the vesico-uterine ligament. The clinical study showed that the procedure is feasible and safe, except possibly when used with very obese patients and patients with broad, bulky tumors. Surgical preservation of the pelvic autonomic nerves in radical hysterectomy deserves consideration in the quest to improve both cure and quality of life in cervical cancer patients.     

Total Laparoscopic Excision of an Altman Type IV Sacrococcygeal Teratoma with the Assistance of Intraoperative Transrectal Sonography

ObjectiveTo present the case of a young patient with an Altman type IV sacrococcygeal teratoma (Fig 1) managed exclusively with laparoscopy.DesignA step-by-step demonstration of the technique.SettingA 24-year-old patient complaining of dysmenorrhea, deep dyspareunia, chronic constipation, dyschezia, and bladder atony was diagnosed with a 5-cm cystic tumor compressing the low rectum and overlying the left levator ani muscle.InterventionsLaparoscopic excision of the tumor.At laparoscopy, significant bilateral pelvic venous congestion was found.The left medial and lateral pararectal fossa and the rectovaginal space were developed to the level of the pelvic floor.Several branches of the left internal artery and vein were dissected.The left hypogastric nerve and deep hypogastric plexus were dissected in an effort to preserve ipsilateral autonomic nerve supply to the rectum.Owing to the tumor's soft consistency and dense adherence to the surrounding structures, transrectal sonography facilitated dissection, which was performed medially to the mesorectal fascia and anteriorly to the presacral fascia.The middle sacral artery and peripheral branches of the internal iliac vasculature supplying the tumor were ligated.Part of the left levator ani had to be excised. The rectum was injured during the effort to detach the tumor from its lateral wall. The injury was repaired laparoscopically.The cut edge of the levator ani was used as a flap to reinforce the repair.ConclusionSacrococcygeal teratomas lying entirely in the pelvis (Altman type IV) are extremely rare 1, 2. Complete laparoscopic excision is challenging and potentially dangerous 3, 4, 5, but it is feasible with careful dissection.     

Excision of Deep Endometriosis Nodules of the Sciatic Nerve in 10 Steps

Study ObjectiveTo present 10 standardized and reproducible surgical steps allowing for complete excision of deep endometriosis nodules involving the sciatic nerve.DesignSurgical education video. The local institutional review board confirmed that the video met the ethical criteria required for publication. Patient consent was obtained.SettingTertiary referral center.InterventionsThe excision of deep endometriosis involving the sciatic nerve may be performed following 10 steps: (1) Longitudinal incision of the peritoneum covering the external iliac artery, from the hypogastric vessels to the round ligament and the identification of the genitofemoral nerve. (2) Dissection of the iliolumbar space identified laterally by the psoas muscle and medially by the external iliac artery and vein 1, 2, 3, 4, 5. (3) Identification of the obturator nerve. The dissection is performed on contact with the psoas muscle; when the nerve is surrounded by the nodule, its releasing is progressively carried out. (4) Identification of the obturator vessels, which cross the obturator nerve beneath and follow a lateral direction. (5) Opening of the lumbosacral space, below the level of the obturator nerve, and the identification of the sciatic nerve, resulting from the confluence of L4 to S3 roots. During this step, the deep endometriosis nodule is identified on contact with the greater sciatic foramen. (6) Opening of the broad ligament, between the external iliac vessels and the umbilical artery, and identification of the obturator nerve, as it is usually performed in pelvic lymphadenectomy. The surgeon may either perform a separate incision of the posterior leaf of the broad ligament and medial to the infundibulo-pelvic ligament or prolong medially the incision made at step 1. (7) Identification of the sciatic nerve, which is seen below and medially from the obturator nerve and obturator vessels. During this step, the posterior limit of the nodule is identified. (8) Identification of sacral roots S1, S2, and S3 [6]. The pudendal nerve and the posterior femoral cutaneous nerve may be identified below the S3 and medially from the sciatic nerve and before their exit through the greater sciatic foramen. The posterior and medial limit of the nodule is progressively released [7]. (9) The dissection is continued laterally, on contact with the ischium, down to the ischial spine and the coccygeus muscle. The lateral limit of the nodule is identified and released. (10) The anterior limit of the nodule is identified and, when required, is separated from the bladder. The latter 3 steps are less standardized, and the surgeon may alternate lateral, medial, posterior, and anterior dissection of the nodule, depending on the intraoperative circumstances. In most cases, the nerves are compressed but not infiltrated inside the epineurium, and their complete releasing is followed by significant or complete relief of pain and motor problems [6]. When the nodule infiltrates the nerves inside the epineurium, the excision may be performed into the nerve.ConclusionLaparoscopic excision of deep endometriosis nodules involving the sciatic nerve is a challenging procedure, requiring good anatomic knowledge, surgical skills, preliminary specific training, and multidisciplinary postoperative care. Teaching such a complex procedure is a mandatory but delicate task. By following 10 sequential steps, the surgeon may reduce the risk of hemorrhage originating from the external iliac, obturator, and pudendal vessels; preserve somatic nerves; and successfully excise deep endometriosis nodules. Although the 10 steps attempt to standardize the surgical approach in a challenging localization of deep endometriosis, they are not mandatory and should be adapted to the patient.     

Robot-assisted Exploration of Somatic Nerves in the Pelvis and Transection of the Sacrospinous Ligament for Alcock Canal Syndrome

Study ObjectiveSome articles have reported the surgical management of Alcock canal syndrome (ACS) using the transperineal [1], transgluteal [2], or conventional laparoscopic approach [3,4]. In 2015, Rey and Oderda [5] reported the first robotic neurolysis of the pudendum, providing the advantages of robot-assisted surgery: magnified and 3-dimensional vision and greater precision of movements. However, to our knowledge, there have been no reports on the use of a robotic platform for the treatment of ACS in the field of gynecology. Therefore, the objective of this video is to describe the anatomic and technical highlights of robotic exploration of the somatic nerves in the pelvis and transection of the sacrospinous ligament (nerve decompression) for ACS.DesignStepwise demonstration of the technique with narrated video footage.SettingAn urban general hospital. A 48-year-old woman who had no previous surgical history was referred for severe pain when sitting, cyclic pelvic pain, and gluteal and perineal pain, all of which were resistant to medication therapy. Her pain radiated to the posterior aspect of the thigh. Before coming to our hospital, she visited an orthopedic surgeon a few years earlier and was diagnosed with sciatic neuralgia. Magnetic resonance imaging revealed adenomyosis with neither deep endometriosis nor vascular entrapment. On the basis of neuropelveologic evaluation, the patient was suspected to be suffering from ACS owing to compression of the pudendal nerve and the posterior cutaneous nerve of the thigh by the sacrospinous ligament.InterventionsThe procedure was performed using the following 9 steps while referencing the laparoscopic neuronavigation technique [6]: step 1, opening the peritoneum along the external iliac artery; step 2, exposure of the external iliac artery; step 3, development of the lumbosacral space; step 4, identification of the lumbosacral trunk; step 5, identification of the superior gluteal nerve; step 6, identification of the sciatic nerve; step 7, identification of the inferior gluteal nerve; step 8, identification of the pudendal nerve; and step 9, transection of the sacrospinous ligament. The surgery was completed successfully without any complications, and the postoperative course was uneventful. We considered that there was no relationship between the ACS and endometriosis. The patient reported that her pain decreased gradually at postoperative month 1 and month 3, and finally the neuralgia was completely resolved at month 6. Neuropelveologic evaluation still continues every 6 months.ConclusionRobot-assisted transection of the sacrospinous ligament is a feasible, safe technique for selected patients with ACS. Exploration of the pelvic nerves should be performed for further diagnosis and therapy before prematurely labeling the patient as refractory to the treatment [7].     

Surgical Neuropelviology: Combined Sacral Plexus Neurolysis and Laparoscopic Laterally Extended Endopelvic Resection in Deep Lateral Pelvic Endometriosis

ObjectiveSurgical demonstration of combined sacral plexus neurolysis and laparoscopic laterally extended endopelvic resection for deep lateral infiltrating endometriosis.DesignVideo showing principles of neurolysis and laparoscopic laterally extended endopelvic resection applied to endometriotic surgery.SettingUniversity tertiary referral center. Deep infiltrating endometriosis is an underestimated disease with real medical and clinical issues, recently classified as central pelvic endometriosis and lateral pelvic endometriosis further divided into superficial and deep according to the structures’ involvement [1]. The surgical removal of endometriotic foci remains the standard treatment. A wide knowledge of neuroanatomy and high skills in minimally invasive surgery are required to manage this challenging surgical scenario [2].InterventionsNew surgical approach for deep lateral infiltrating endometriosis based on the principles of lateral extended endopelvic resection and neuropelviologic surgery [3,4]. The patient was a 35-year-old woman, para 1, with neuropathic pain radiating to the left leg and a cyclic menstrual disorder. A laparoscopically assisted neuronavigation and subsequent neurolysis allowed the identification of the lateral nodule without damage to the autonomic pelvic innervation [1]. Then, a complete resection of the internal vascular compartment was required to obtain a radical endometriotic eradication. Shaving and bladder resection were also performed to complete removal of the endometriotic foci.ConclusionThe association of neuroanatomic knowledge and surgical oncologic principles applied to minimally invasive surgery should be considered to ensure an adequate surgical radicality and clinical benefit in patients with deep infiltrating endometriosis.     

A systematic nerve-sparing radical hysterectomy technique in invasive cervical cancer for preserving postsurgical bladder function

The objective of this study is to describe a technique for preserving the autonomic nerve systematically, including the hypogastric nerves, pelvic splanchnic nerves, and pelvic plexus and its vesical branches, based on anatomic considerations for the autonomic nerves innervating the urinary bladder, in radical hysterectomies and to assess postsurgical bladder function. A nerve-sparing radical hysterectomy was carried out on 27 consecutive patients with uterine cervical cancer treated between 2000 and 2002. The FIGO stages of the disease consisted of 10 stage Ib1, 6 stage Ib2, 3 stage IIa, and 8 stage IIb. The nerve-sparing procedure was successfully completed in 22 of the 27 patients (81.5%) in the study. At 1 year after the operation, bladder symptoms were significantly improved in the nerve-sparing group compared to the non-nerve-sparing group. Urinary incontinence and abnormal (diminished) bladder sensation were observed in three of the five patients (two patients had both symptoms), for whom the nerve-sparing procedure could not be performed, but none of the 22 patients for whom the nerve-sparing procedure was performed had incontinence, and only two patients had abnormal (increased) bladder sensation (P= 0.0034 for incontinence and P= 0.030 for abnormal bladder sensation). The patients' survival was not adversely affected by the nerve-sparing procedure. Although it is still preliminary, the surgical technique described in this report is thought to be effective for preserving bladder function, and thus, the quality of life could be improved for patients with cervical cancer who are treated with a radical hysterectomy. For further evaluation of the efficacy of nerve-sparing radical hysterectomy, a prospective randomized trial needs to be performed.     

Possible Role of the Posterior Compartment Peritonectomy,as a Part of the Complex Surgery,Regarding Recurrence Rate,Improvement of Symptoms and Fertility Rate in Patients with Endometriosis,Long-Term Follow-Up

Study ObjectiveBeside the pain, there are 2 further problems in the management of endometriosis: the high recurrence rate (10% per year) and the high rate of impaired fertility. The objective of this study was to investigate the pathogenesis of these 2 factors.DesignThis is a retrospective cohort study, and the aim is to evaluate the complete excision of endometriotic lesions, including the posterior compartment of the peritoneum, with regard to postoperative outcome, focusing on relieving pain, increasing fertility rate, and decreasing recurrence rate.SettingCharité-University Clinic, Department of Gynaecology, Endometriosis research Centre.PatientsFifty-four patients were enrolled in this study, with severe deep infiltrating endometriosis (scored by ENZIAN) and superficial endometriosis, as well as endometriomas (revised American Society for Reproductive Medicine [rASRM] I = 3; II = 15; III = 10; and IV = 26).InterventionsPosterior compartment peritonectomy (visible endometriotic lesions and inflamed altered peritoneum) was performed in all patients as part of a complex surgery: complete excision of endometriosis.Measurements and Main ResultsPostoperative outcomes were evaluated, based on the postoperative follow-up (up to 5 years) of 54 investigated patients. In 36 women (66%) preoperative complaints were eliminated. Furthermore, of 28 women seeking improved fertility, pregnancy was reported in 13 cases (46%). In 7 (54%) cases pregnancy occurred spontaneously, and in the remainder with assisted fertilization. In addition, long-term follow-up demonstrated a recurrence rate in 1.8% of patients.ConclusionOverall, the number of complaints was significantly reduced. Only in the case of reproductive-aged women with ongoing postoperative complaints was it important to preserve the uterus. Although this pilot study on systematic posterior peritonectomy showed improvement in recurrence and fertility rate, the main question remains: will this surgical technique achieve better results and outcomes in the future? This has to be addressed in a prospective randomized study.     

子宫次广泛/广泛切除手术保留盆腔植物神经对膀胱功能恢复保护作用的初步观察

目的:初步探讨子宫次广泛/广泛切除手术主韧带切除时保留腹下神经和盆腔内脏神经对术后膀胱功能保护作用技术上的可行性。方法:2006年7月3日至2006年8月11日,复旦大学附属肿瘤医院收治子宫颈癌和子宫内膜癌,切除主韧带保留腹下和盆腔内脏神经的病例12例。结果:子宫内膜癌子宫次广泛手术4例,术后3~4天拔除尿管,拔除后即刻自行排尿,无残余尿。6例Ⅰb1~Ⅱa期子宫颈癌患者中5例术后7天拔除尿管;1例患者1周拔除尿管失败,情绪紧张,复置尿管时出尿400ml,1周后成功拔除。2例Ⅱb期子宫颈癌患侧贴盆壁切除主韧带,健康侧保留神经者,分别于术后10天和14天成功拔除尿管。结论:保留盆腔植物神经的子宫主韧带切除手术在子宫次广泛切除手术中易于推广;在广泛性子宫切除术中需要进一步探索;对于Ⅱb期子宫颈癌不主张保留神经。     

Pelvic Neuroanatomy: An Overview of Commonly Encountered Pelvic Nerves in Gynecologic Surgery

ObjectiveThis video tutorial identifies key anatomic landmarks useful in identifying the path of the most commonly encountered pelvic nerves in benign gynecologic surgery.DesignThis is a narrated overview of commonly encountered pelvic nerves during benign gynecology, their origin, sensory, and motor function, as well as sequelae related to injury.SettingThe unintended injury of pelvic neural connections can be a complication of any pelvic surgery, however, surgery for malignancy or endometriosis may increase the likelihood of encountering these nerves. The majority of focus surrounding surgical nerve injury, however, relates to patient positioning [1]. Injury to the pelvic nerves can lead to lifelong sexual, bladder, and defecatory dysfunction [2].InterventionsWe review the Genitofemoral, Lateral Femoral Cutaneous, Ilioinguinal, Obturator, Superior and Inferior Hypogastric nerves, Pelvic Splanchnic nerves, and the Sacral nerves. Surgical illustrations are used (Fig. 1) alongside real-time narrated video to help viewers recognize the normal course of commonly encountered pelvic nerves at the time of gynecologic surgery (Figs2–3).ConclusionThe surgical management of complex pelvic disease can unfortunately carry significant patient morbidity [3]. The neural pathways traveling through the pelvis via the hypogastric nerves are responsible for proprioception, vaginal lubrication, and proper functioning or the urethral and anal sphincters [4]. Sparing these nerves during pelvic surgery, and especially when anatomic planes are distorted by pelvic disease, requires surgical expertise and an immense understanding of pelvic neuroanatomy [4,5]. Preservation of the pelvic neural pathways is necessary to deliver the best patient outcomes while minimizing unwanted surgical complications. This video tutorial also highlights the origin of these nerves, their anatomic location, procedures in which these nerves may be encountered, and what sequelae occur from their unintended injury.     

Systematic Nerve Sparing during Surgery for Deep-infiltrating Posterior Endometriosis Improves Immediate Postoperative Urinary Outcomes

Study ObjectiveEvaluate the feasibility and risk–benefit ratio of systematic nerve sparing by complete dissection of the inferior hypogastric nerves and afferent pelvic splanchnic nerves during surgery for deep-infiltrating endometriosis (DIE) on the basis of complication rates and postoperative bladder morbidity.DesignObservational before (2012–2014)–and–after (2015–2017) study based on a prospectively completed database of all patients treated medically or surgically for endometriosis.SettingUnicentric study at the Centre Hospitalier Intercommunal de Poissy-St-Germain-en-Laye.PatientsThis study included patients undergoing laparoscopic surgery for DIE (pouch of Douglas resection with or without colpectomy or bilateral uterosacral ligament resection), with complete excision of all identifiable endometriotic lesions, with or without an associated digestive procedure, between 2012 and 2017. The exclusion criteria included prior history of surgery for DIE or colorectal DIE excision, unilateral uterosacral ligament resection, and bladder endometriotic lesions.InterventionsFor the patients in group 1 (2012–2014, n = 56), partial dissection of the pelvic nerves was carried out only if they were macroscopically caught in endometriotic lesions, without dissection of the pelvic splanchnic nerves. The patients in group 2 (2015–2017, n = 65) systematically underwent nerve sparing during DIE surgery, with dissection of the inferior hypogastric nerves and pelvic splanchnic nerves.Measurements and Main ResultsBoth groups were comparable in terms of patient age, parity, body mass index, and previous abdominal surgery. The operating times were similar in both groups (228 ± 105 minutes in group 2 vs 219 ± 71 minutes in group 1), as were intra- and postoperative complication rates. Time to voiding was significantly longer in the patients in group 1 (p <.01), with 7 (12.9%) patients requiring self-catheterization in this group compared with no patients (0%) in group 2. The duration of self-catheterization for the 7 patients in group 1 was 28, 21, 3, 60, 21, 1 (stopped by the patient), and 28 days, respectively. Uroflowmetry on postoperative day 10 was abnormal in 5/25 patients in group 1 compared with 1/33 in group 2 (p = .031).ConclusionSystematic and complete nerve sparing, including pelvic splanchnic nerve dissection, during surgery for posterior DIE improves immediate postoperative urinary outcomes, reducing the need for self-catheterization without increasing operating time or complication rates.     

Sacro-lumbar intersegmental spinal reflex in autonomic pathways mediating female sexual function

IntroductionAutonomic neurons in paracervical ganglia mediating vasodilation in the female reproductive tract receive inputs from both midlumbar and sacral spinal levels. However, it is not known how the lumbar pathways are activated.AimThis study tested whether stimulation of pudendal sensory nerve could activate lumbar spinal outflows to paracervical ganglia via a spinal reflex pathway.MethodsIsolated spinal cords with attached peripheral nerves were removed from urethane‐anesthetized female guinea pigs and perfused via the aorta with physiological salt solution. Spinal pathways to midlumbar preganglionic neurons were tested by recording extracellular compound action potentials (CAPs) in lumbar splanchnic or distal hypogastric nerves after electrical stimulation of thoracic spinal cord or the pudendal nerve. CAPs also were recorded from pelvic nerves after pudendal nerve stimulation. Sensory neurons were retrogradely traced from the pudendal nerve and characterized immunohistochemically.Main Outcome MeasuresActivation of preganglionic neurons projecting from midlumbar spinal cord to paracervical ganglia following stimulation of pudendal sensory nerves in isolated preparations.ResultsThoracic spinal cord stimulation produced CAPs in hypogastric nerves that were abolished by transection of L3 lumbar splanchnic nerves. Pudendal nerve stimulation produced CAPs in L3 lumbar splanchnic, hypogastric, and pelvic nerves, demonstrating an ascending intersegmental spinal circuit to midlumbar levels in addition to the sacral spinal circuit. These CAPs in hypogastric nerves were enhanced by bicuculline (10 µM), blocked by tetrodotoxin (1 µM) but were not affected by hexamethonium (200 µM). Retrograde axonal tracing revealed four groups of sensory neurons in S3 dorsal root ganglia that were distinguished immunohistochemically.ConclusionMidlumbar preganglionic neurons projecting to paracervical ganglia regulating blood flow and motility in the female reproductive tract can be activated by an ascending intersegmental spinal pathway from pudendal sacral inputs, which is inhibited by local spinal circuits. This pathway will help understand pathological conditions affecting reproductive function. Yuan SY, Gibbins IL, Zagorodnyuk VP, and Morris JL. Sacro‐lumbar intersegmental spinal reflex in autonomic pathways mediating female sexual function. J Sex Med 2011;8:1931-1942.