Systematization of the vesical and uterovaginal efferences of the female inferior hypogastric plexus (pelvic): applications to pelvic surgery on women patients |
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Authors: | B Mauroy B Bizet J L Bonnal T Crombet T Duburcq C Hurt |
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Institution: | (1) Anatomy Laboratory, Faculty of Medicine Research Center, Institute of Anatomy, 1, Place de Verdun, 59045 Lille Cedex, France;(2) Department of Urology, C.H. Saint-Philibert, Lomme, France |
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Abstract: | Objective To locate and describe the various efferences of the plexus in order to make it easier to avoid nerve lesions during pelvic
surgery on women patients through a better anatomical knowledge of the inferior hypogastric plexus (IHP).
Materials and methods We dissected 27 formalin embalmed female anatomical subjects, none of which bore any stigmata of subumbilical surgery. The
dissection was always performed using the same technique: identification of the inferior hypogastric plexus, whose posterior
superior angle follows on from the hypogastric nerve and whose top, which is anterior and inferior, is located exactly at
the ureter’s point of entry into the base of the parametrium, underneath the posterior layer of the broad ligament.
Results The IHP is located at the level of the posterior floor of the pelvis, opposite to the sacral concavity. Its top, which is
anterior inferior, is at the point of contact with the ureter at its entry into the posterior layer of the broad ligament.
The uterovaginal, vesical and rectal efferences originate in the paracervix. Three efferent nerves branch, two of them from
its top and the third from its inferior edge: (1) A vaginal nerve, medial to the ureter, follows the uterine artery and divides
into two groups: anterior thin, heading for the vagina and the uterus; posterior, voluminous, heading in a superior rectal
direction (=superior rectal nerve). (2) A vesical nerve, lateral to the ureter, divides into two groups, lateral and medial.
(3) The inferior rectal nerve emerges from the inferior edge of the IHP, between the fourth sacral root and the ureter’s point
of entry into the base of the parametrium.
Conclusion The ureter is the crucial point of reference for the IHP and its efferences and acts as a real guide for identifying the anterior
inferior angle or top of the IHP, the origin of the vaginal nerve, the level of the ureterovesical junction and the division
of the vesical nerve into its two medial and lateral branches. Dissecting underneath and inside the ureter and the uterine
artery involves a risk of lesion of the vaginal nerve and its uterovaginal branches. Further forward, between the intersection
and the ureterovesical junction, dissecting and/or coagulating under the ureter involves a risk of lesions to the vesical
nerve, which are likely to explain the phenomena of denervation of the anterior floor encountered after certain hysterectomies
and/or surgical treatments of vesicoureteral reflux. |
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Keywords: | Urinary incontinence Vesical innervation Pelvic autonomous innervation Hysterectomy Inferior hypogastric plexus Vesicorenal reflux Autonomous nervous system |
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