Identification des sites anatomiques à risque de lésion nerveuse lors de chirurgie pour endométriose pelvienne profonde

The anatomy of the pelvic plexus in female cadavers: implications for retroperitoneal nerve-sparing surgery

Background

The inferior hypogastric plexus (IHP) is a crucial structure for female continence and sexual function. A nerve-sparing approach should be pursued to reduce the risk of pelvic plexus damage during retroperitoneal pelvic surgery.

Objectives

To analyse the relationship between the female IHP and several pelvic anatomical landmarks.

Materials and Methods

Standardised cadaveric dissection was performed on 5 nulliparous female cadavers. The relationships of the IHP and the mid-cervical plane (MCP), the mid-sagittal plane (MSP), and the uterosacral ligament (USL) were investigated.

Main outcome measures

Distance between IHP and MCP, MSP, and USL.

Results

Distances between the right IHP and the right MSP (mean distance: 16.3 mm; range: 10.0-22.5 mm) and the right USL (mean distance: 4.8 mm; range: 0-15.0 mm) were shorter than those between the left IHP and ipsilateral landmarks (left MSP distance: 23.5 mm; range 18.0-30.0 mm; left USL distance: 5.0 mm; range: 0-20.0 mm). Although the MCP was 3.3 mm (range: 2.5-4.0 mm) left and lateral to the midsagittal line, the right IHP was closer to the MCP (mean distance: 19.6 mm; range: 13.0-25.0 mm) than the left one (mean distance: 20.2 mm; range: 15.0-26.0 mm).

Conclusions

Distances between the right IHP and the MSP, MCP, and ipsilateral USL, are shorter compared to these associated to the left IHP.

What is new?

Right autonomic pelvic plexus is closer to the midline planes and the ipsilateral USL. These anatomical relationships may be greatly helpful for pelvic surgeon while facing retroperitoneal pelvic surgery and looking for a nerve-sparing approach.

Advanced Insights into Human Uterine Innervation: Implications for Endometriosis and Pelvic Pain

(1) Background: Understanding uterine innervation, an essential aspect of female reproductive biology, has often been overlooked. Nevertheless, the complex architecture of uterine innervation plays a significant role in conditions such as endometriosis. Recently, advances in histological techniques have provided unprecedented details about uterine innervation, highlighting its intricate structure, distribution, and density. The intricate nature of uterine innervation and its influence on pathologies such as endometriosis has garnered increasing attention. (2) Objectives: This review aims to compile, analyze, and summarize the existing research on uterine innervation, and investigate its implications for the pathogenesis of endometriosis and associated pain. (3) Methods: A systematic review was conducted in line with PRISMA guidelines. Using the PubMed database, we searched relevant keywords such as "uterine innervation", "endometriosis", and "pain association". (4) Results: The initial literature search yielded a total of 3300 potential studies. Of these, 45 studies met our inclusion criteria and were included in the final review. The analyzed studies consistently demonstrated that the majority of studies focused on macroscopic dissection of uterine innervation for surgical purposes. Fewer studies focused on micro-innervation for uterine innervation. For endometriosis, few studies focused on neural pain pathways whereas many studies underlined an increase in nerve fiber density within ectopic endometrial tissue. This heightened innervation is suggested as a key contributor to the chronic pain experienced by endometriosis patients. (5) Conclusions: The understanding of uterine innervation, and its alterations in endometriosis, offer promising avenues for research and potential treatment.

A reappraisal of the deep uterine vein: a multimodal exploration with implications for pelvic surgery

PURPOSE

Pelvic gynecological surgeries, whether for malignant or benign conditions, frequently result in functional complications due to injuries to the autonomic nervous system. Recognizing the deep uterine vein (DUV) as an essential anatomical reference can aid in preserving these structures. Despite its significance, the DUV is infrequently studied and lacks comprehensive documentation in Terminologia Anatomica. This research endeavors to elucidate a detailed characterization of the DUV.

METHODS

We undertook a systematic literature review aligning with the "PRISMA" guidelines, sourcing from PUBMED and EMBASE. Our comprehensive anatomical examination encompassed cadaveric dissections and radio-anatomical evaluations utilizing the Anatomage® Table.

RESULTS

The literary exploration revealed a consensus on the DUV's description based on both anatomical and surgical observations. It arises from the merger of cervical, vesical, and vaginal veins, coursing through the paracervix in a descending and rearward direction before culminating in the internal iliac vein. The hands-on anatomical study further delineated the DUV's associations throughout its course, highlighting its role in bifurcating the uterus's lateral aspect into two distinct zones: a superior vascular zone housing the uterine artery and ureter and an inferior nervous segment below the DUV representing the autonomic nerve pathway.

CONCLUSION

A profound understanding of the subperitoneal space anatomy is paramount for pelvic surgeons to mitigate postoperative complications. The DUV's intricate neurovascular interplays underscore its significance as an indispensable surgical guide for safeguarding nerves and the ureter.

Multicenter External Validation of the Deep Pelvic Endometriosis Index Magnetic Resonance Imaging Score

Importance

Preoperative mapping of deep pelvic endometriosis (DPE) is crucial as surgery can be complex and the quality of preoperative information is key.

Objective

To evaluate the Deep Pelvic Endometriosis Index (dPEI) magnetic resonance imaging (MRI) score in a multicenter cohort.

Design, Setting, and Participants

In this cohort study, the surgical databases of 7 French referral centers were retrospectively queried for women who underwent surgery and preoperative MRI for DPE between January 1, 2019, and December 31, 2020. Data were analyzed in October 2022.

Intervention

Magnetic resonance imaging scans were reviewed using a dedicated lexicon and classified according to the dPEI score.

Main outcomes and measures

Operating time, hospital stay, Clavien-Dindo-graded postoperative complications, and presence of de novo voiding dysfunction.

Results

The final cohort consisted of 605 women (mean age, 33.3; 95% CI, 32.7-33.8 years). A mild dPEI score was reported in 61.2% (370) of the women, moderate in 25.8% (156), and severe in 13.1% (79). Central endometriosis was described in 93.2% (564) of the women and lateral endometriosis in 31.2% (189). Lateral endometriosis was more frequent in severe (98.7%) vs moderate (48.7%) disease and in moderate vs mild (6.7%) disease according to the dPEI (P < .001). Median operating time (211 minutes) and hospital stay (6 days) were longer in severe DPE than in moderate DPE (operating time, 150 minutes; hospital stay 4 days; P < .001), and in moderate than in mild DPE (operating time; 110 minutes; hospital stay, 3 days; P < .001). Patients with severe disease were 3.6 times more likely to experience severe complications than patients with mild or moderate disease (odds ratio [OR], 3.6; 95% CI, 1.4-8.9; P = .004). They were also more likely to experience postoperative voiding dysfunction (OR, 3.5; 95% CI, 1.6-7.6; P = .001). Interobserver agreement between senior and junior readers was good (κ = 0.76; 95% CI, 0.65-0.86).

Conclusions and Relevance

The findings of this study suggest the ability of the dPEI to predict operating time, hospital stay, postoperative complications, and de novo postoperative voiding dysfunction in a multicenter cohort. The dPEI may help clinicians to better anticipate the extent of DPE and improve clinical management and patient counseling.

Relationship between uterine veins, ureter and hypogastric nerves for uterine transplantation: an anatomic study

BACKGROUND

Uterine transplantation is on the rise worldwide. In contrast to its arterial anatomy, venous drainage of the uterus is poorly defined in the literature. Our aim was to provide a standardized description of uterine veins through a multimodal approach to establish anatomical landmarks for the uterine transplantation surgeon.

METHODS

Data were obtained from: (1) an anatomical study of eight fresh female cadavers (16 hemipelves) studied separately by an extrafascial dissection from the iliac bifurcation to the uterine pedicle, with analysis of the urinary tract and nerve structures; and (2) a virtual anatomical study from the Anatomage® Table comprising a high-fidelity virtual reconstruction of two deceased female subjects by imaging and anatomical methods.

RESULTS

An inconstant duality of uterine veins was identified: a deep uterine vein of larger caliber, and a superficial uterine vein observed in 25% of cases. A close relationship of the ureter passing posterior to the superficial uterine vein and anterior to the deep uterine vein was evident in the parametrium. The inferior hypogastric plexus was identified in all cases immediately behind the deep uterine vein. The data obtained from the fresh female cadavers were validated by the Anatomage® Table.

CONCLUSIONS

We describe the close relationship of the uterine veins with the ureter and the inferior hypogastric plexus. This knowledge represents a surgical landmark to support the success of uterine transplantation by respecting both the graft and the safety of the living donor by limiting the risk of injuries during uterus procurement. This article is protected by copyright. All rights reserved.

[Sacral neuromodulation as treatment of non-neurological vesical emptying disorders]

GOAL

The goal was to evaluate the results of sacral neuromodulation (SNM) in non-neurological vesical emptying disorders.

PATIENTS AND METHODS

From February 2010 to October 2017, 28 patients presenting voiding symptoms or a non-obstructive chronic urine retention without neurological cause have been operated for an SNM (test phase). The test was positive in case of decreased number of proper intermittent self-catheterization (SC) or post-voiding residual urine (PVR) of at least 50 %. A 100 % positive result meant the return to a spontaneous voiding without SC with a non-significative PVR (<100ml).

RESULTS

The median follow-up was of 53.2±21.2 months. Twenty-four (85.7%) tests were positive, from which twenty-two (78.6%) were 100% positive. 16 (84.2%) out of 19 patients with SC had spontaneous voiding without PVR. The number of daily SC decreased from 4.6±1.5 to 0.4±1.2 in post-operative (P<0.001). The PVR was of 287.1±170.4ml vs. 30.4±48.6ml in post-operative (P<0.001). Fourteen patients (58.3%) underwent at least one chirurgical revision or a removal of material ; mainly for loss of efficiency, end of battery, electrode migration and pain on material. At the end of the follow-up, 70.8% of the responding patients had their device still efficient.

CONCLUSION

Results showed that SNM appears to be an efficient treatment of non-neurological emptying vesical troubles. Nevertheless, the re-operation rate was still significant.

LEVEL OF EVIDENCE

3.

Endometriosis of the vesico-vaginal septum: a rare and unusual localization (case report)

BACKGROUND

We report a rare and unusual case of endometriosis in the vesico-vaginal septum. The location of this disease at this site is so uncommon that the literature about is very rare.

CASE PRESENTATION

A 41-year-old female was presented with urinary symptoms. There was history of caesarean section. Physical examination revealed an anterior vaginal wall mass. Pelvic MRI showed an inter vesico-vaginal mass, suggesting a leiomyoma. Surgical excision was performed by the vaginal route. There were no postoperative complications. Histopathology examination showed focal endometriosis.

CONCLUSION

Endometriosis of the anterior compartment remains relatively rare; its localization to the vesico-vaginal septum (VVS) is very rare. With the occurrence of nonspecific cyclic urinary signs in women during periods of genital activity, endometriosis should be mentioned, especially in the presence of an antecedent of pelvic surgery.

[Anatomic reports of vegetative nerves within para rectal fossa, to the rectal endometriosis surgery application]

OBJECTIVES

The objective of the study was to describe the inferior hypogastric plexus and nerves constituting the para-rectal fossa in order to study the importance of anatomical knowledge in rectal endometriosis surgery.

METHODS

In order to discover the complete anatomy of the study area, we carried out a review of the literature and relied on dissection of a female cadaver and operative dissections in patients treated for rectal endometriosis.

RESULTS

The inferior hypogastric plexus, the hypogastric nerve and the pelvic splanchnic nerves are the nervous elements component the para-rectal fossa. These nerves were important urinary, digestive and sexual functions. The dissection of the Okabayashi and the Latzko spaces within the para-rectal fossa and sparing nerve within this zone is more important for the prevention of traumatic nervous sequelae during rectal endometriosis surgery. The pelvic anatomy can be by attraction and sheathing nerve structures by endometriosis lesions which can complicate preservation techniques.

CONCLUSION

Lesions of pelvic vegetative nerves running through the para-rectal fossa can be responsible for urinary, digestive and sexual disorders that can affect patients quality of life. There is currently only one standardized "nerve sparing" technique in pelvic endometriosis surgery. Knowledge of the anatomy of the nerves making up the para-rectal fossa helps to orient the operative dissection and prevent postoperative nerve complications after surgery for rectal endometriosis.

Standardization of laparoscopic extrafascial hysterectomy: anatomic considerations to protect the ureter

PURPOSE

To describe the procedure of laparoscopic extrafascial hysterectomy to avoid ureter injury.

METHODS

Data were obtained from: (1) anatomic study of ten fresh female cadavers to measure the distance between the point where the ureter and uterine artery cross and the level of section of the ascending branch of the uterine artery during extrafascial dissection of the uterine pedicle and uterosacral ligament (Paris School of Surgery). The Wilcoxon test was used to compare measurements within each subject. P < 0.05 was considered to denote significance; (2) prospectively collected clinical data from women undergoing laparoscopic extrafascial hysterectomy from July 2006 to March 2014 at Poissy University Hospital, to describe the laparoscopic extrafascial hysterectomy technique with analysis of surgical complications using the Clavien-Dindo classification.

RESULTS

Anatomic study: The mean (SD) distance between the point where the ureter and uterine artery cross and the level of the section of the ascending branch of the uterine artery were: 11.6 mm (5.2) in neutral position and 25 mm (7.5) after pulling the uterus laterally; and 25mm (8.9) after sectioning the ascending portion of the uterine pedicle and 38.6 mm (4.5) after complete uterine artery pedicle dissection through the uterosacral ligaments. After release of the ureter, the curve in front of the uterine artery disappeared. Clinical laparoscopic study: Sixty-eight patients underwent laparoscopic extrafascial hysterectomy. No ureteral complications occurred.

CONCLUSION

Laparoscopic extrafascial hysterectomy is a safe and feasible procedure. Combined lateralization and elevation of the uterus, section of the ascending branch of the uterine artery, and its extrafascial dissection along the uterosacral ligament contribute to protecting the ureter during the procedure.

[Nerve sparing techniques in deep endometriosis surgery to prevent urinary or digestive functional disorders: Techniques and results: CNGOF-HAS Endometriosis Guidelines]

OBJECTIVES

To evaluate the feasibility and functional urinary and digestive results of nerve sparing techniques in endometriosis surgery.

METHODS

A research on the medline/pubmed database using specific keywords (nerve sparing, endometriosis, pelvic nerves) identified 7 publications among about 50 whose purpose was to describe the feasibility, the techniques and the functional results of nerve preservation in this indication. Among them there are: 2 uncontrolled retrospective studies, 3 prospective non-randomized studies, a meta-analysis and a review of the literature.

RESULTS

Nerve preservation requires a perfect knowledge of the anatomy of the pelvic autonomic system. The laparoscopic approach is preferred by the different authors due to its anatomical advantage. The feasibility of this technique seems to be demonstrated despite certain limitations in the different studies and depending of the retroperitoneal extension of the lesions. When feasible, it is likely to significantly improve postoperative urinary function (urinary retention) compared to a conventional technique. It is observed no difference regarding digestive function.

CONCLUSIONS

Nerve sparing in this indication is a technique the feasibility of which has been demonstrated and is subject to the topography and extent of the disease. In the absence of invasion or entrapment of pelvic autonomic nerves by endometriosis, this technique improves postoperative voiding function (NP3). During pelvic surgery for endometriosis, it is recommended to identify and preserve autonomic pelvic nerves whenever possible (GradeC).

A step towards stereotactic navigation during pelvic surgery: 3D nerve topography

Background

Long-term morbidity after multimodal treatment for rectal cancer is suggested to be mainly made up by nerve-injury-related dysfunctions. Stereotactic navigation for rectal surgery was shown to be feasible and will be facilitated by highlighting structures at risk of iatrogenic damage. The aim of this study was to investigate the ability to make a 3D map of the pelvic nerves with magnetic resonance imaging (MRI).

Methods

A systematic review was performed to identify a main positional reference for each pelvic nerve and plexus. The nerves were manually delineated in 20 volunteers who were scanned with a 3-T MRI. The nerve identifiability rate and the likelihood of nerve identification correctness were determined.

Results

The analysis included 61 studies on pelvic nerve anatomy. A main positional reference was defined for each nerve. On MRI, the sacral nerves, the lumbosacral plexus, and the obturator nerve could be identified bilaterally in all volunteers. The sympathetic trunk could be identified in 19 of 20 volunteers bilaterally (95%). The superior hypogastric plexus, the hypogastric nerve, and the inferior hypogastric plexus could be identified bilaterally in 14 (70%), 16 (80%), and 14 (70%) of the 20 volunteers, respectively. The pudendal nerve could be identified in 17 (85%) volunteers on the right side and in 13 (65%) volunteers on the left side. The levator ani nerve could be identified in only a few volunteers. Except for the levator ani nerve, the radiologist and the anatomist agreed that the delineated nerve depicted the correct nerve in 100% of the cases.

Conclusion

Pelvic nerves at risk of injury are usually visible on high-resolution MRI with dedicated scanning protocols. A specific knowledge of their course and its application in stereotactic navigation is suggested to improve quality of life by decreasing the likelihood of nerve injury.

Electronic supplementary material

The online version of this article (10.1007/s00464-018-6086-3) contains supplementary material, which is available to authorized users.