“Pelvic neuro-visualization: an anatomical illustration of the autonomic pelvic nervous network in gynecologic surgery”

Objective During 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 Oncologic effectiveness of nerve-sparing radical hysterectomy in cervical cancer. Ditto A, Bogani G, Leone Roberti Maggiore U, et al. J Gynecol Oncol. 2018 May;29(3):e41. PMID: 29533024 Google Scholar ,2 Ceccaroni M Clarizia R Roviglione G Ruffo G. Neuro-anatomy of the posterior parametrium and surgical considerations for a nerve-sparing approach in radical pelvic surgery. Surg Endosc. 2013; 27 (NovPMID: 23783554): 4386-4394 Crossref PubMed Scopus (52) Google Scholar 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. Design Narrated laparoscopic video footage for identifying, dissecting, and preserving the autonomic nerve bundles during pelvic surgery. Setting Tertiary level hospital - "IRCCS Istituto Nazionale dei Tumori", Milano, Italy. Interventions Visceral 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 Ceccaroni M Clarizia R Roviglione G Ruffo G. Neuro-anatomy of the posterior parametrium and surgical considerations for a nerve-sparing approach in radical pelvic surgery. Surg Endosc. 2013; 27 (NovPMID: 23783554): 4386-4394 Crossref PubMed Scopus (52) Google Scholar , 3 Querleu D Cibula D Abu-Rustum NR. Update on the Querleu-Morrow Classification of Radical Hysterectomy. Ann Surg Oncol. 2017; 24 (2017 OctPMID: 28785898): 3406-3412 Crossref PubMed Scopus (0) Google Scholar , 4 Fujii S Takakura K Matsumura N et al. Anatomic identification and functional outcomes of the nerve sparing Okabayashi radical hysterectomy. Gynecol Oncol. 2007; 107 (OctPMID: 17905140): 4-13 Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar , 5 Seracchioli R Mabrouk M Mastronardi M et al. Anatomic Cartography of the Hypogastric Nerves and Surgical Insights for Autonomic Preservation during Radical Pelvic Procedures. J Minim Invasive Gynecol. 2019; (Nov-Dec;26PMID: 30708116): 1340-1345 Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar 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 parametrial issues and vagina while preserving the total pelvic nervous system. Conclusion Nerve-sparing surgery reduces bowel-, bladder- and sexual­ dysfunction without decreasing surgical efficacy.1,2 To accomplish safe and effective surgery, comprehension of the three 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. During 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 Oncologic effectiveness of nerve-sparing radical hysterectomy in cervical cancer. Ditto A, Bogani G, Leone Roberti Maggiore U, et al. J Gynecol Oncol. 2018 May;29(3):e41. PMID: 29533024 Google Scholar ,2 Ceccaroni M Clarizia R Roviglione G Ruffo G. Neuro-anatomy of the posterior parametrium and surgical considerations for a nerve-sparing approach in radical pelvic surgery. Surg Endosc. 2013; 27 (NovPMID: 23783554): 4386-4394 Crossref PubMed Scopus (52) Google Scholar 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. Narrated laparoscopic video footage for identifying, dissecting, and preserving the autonomic nerve bundles during pelvic surgery. Tertiary level hospital - "IRCCS Istituto Nazionale dei Tumori", Milano, Italy. Visceral 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 Ceccaroni M Clarizia R Roviglione G Ruffo G. Neuro-anatomy of the posterior parametrium and surgical considerations for a nerve-sparing approach in radical pelvic surgery. Surg Endosc. 2013; 27 (NovPMID: 23783554): 4386-4394 Crossref PubMed Scopus (52) Google Scholar , 3 Querleu D Cibula D Abu-Rustum NR. Update on the Querleu-Morrow Classification of Radical Hysterectomy. Ann Surg Oncol. 2017; 24 (2017 OctPMID: 28785898): 3406-3412 Crossref PubMed Scopus (0) Google Scholar , 4 Fujii S Takakura K Matsumura N et al. Anatomic identification and functional outcomes of the nerve sparing Okabayashi radical hysterectomy. Gynecol Oncol. 2007; 107 (OctPMID: 17905140): 4-13 Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar , 5 Seracchioli R Mabrouk M Mastronardi M et al. Anatomic Cartography of the Hypogastric Nerves and Surgical Insights for Autonomic Preservation during Radical Pelvic Procedures. J Minim Invasive Gynecol. 2019; (Nov-Dec;26PMID: 30708116): 1340-1345 Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar 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 parametrial issues and vagina while preserving the total pelvic nervous system. Nerve-sparing surgery reduces bowel-, bladder- and sexual­ dysfunction without decreasing surgical efficacy.1,2 To accomplish safe and effective surgery, comprehension of the three 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.