Lecture delivered at CNCI, May, 2015

1. Pelvic Nerve Plexus and
its surgical importance
Dr Sujoy Dasgupta

2. Anatomy of Pelvic Nerves
• Sympathetic fibres-
Thoracolumbar
Noradrenergic
Relays in sympathetic
trunk/ ganglion
• Parasympathetic fibres-
Craniosacral
Cholinergic
Relays in peripheral
ganglion near the organ

4. Sympathetic fibres (T10-L2)
↓
Pre-ganglionic fibres
↓
Sympathetic trunk
↓
Relays in aorticorenal ganglion
(At L1)
↓
Sacral splachnic nerves (Sup hypo)
↓
Sup hypogastric plexus over
bifurcation of aorta (at L4-5)
↓
Rt and Lt (Inf) Hypogastric nerves
Parasympathetic fibres (S2-S4)
↓
Accompany somatic S2-S4
nerves up to sacral foramina
↓
Pre-ganglionic fibres
↓
Unite to form Pelvic splachnic
nerves (Nervi erigentes)
Pelvic Plexus/
Inf hypogastric
Plexus/
(Frankenhauser)
In side wall of rectum

5. Pelvic Plexus
Sympathetic fibres Parasympathetic fibres
Motor Sensory and motor
Along blood vessels (Int Iliac) .
Directly to viscera 1. Relays in pelvic plexus
Then plexus near the organs
Rt colon, Rt 1/3 of Tr colon Sigmoid, Rectum, upper Anal canal
Uterus, clitoros Ut, Cx, tubes, Clitoris
Bladder, ureter, urethra Bladder, ureter, urethra
2. Relays near organ
Lt 2/3 of tr colon
Lt colon

6. Nerve supply of Bladder
Sympathetic (T10-L2)
Sp cord → Aorticorenal
ganglion (relay) → Sup
hypogastric plexus →
Hypogastric nerves →
Pelvic Plexus → Along
vesical artery →
Bladder
• Relaxes detrussor (β3)
• Contracts urethral
sphincter (α1)
• Nerve of filling
Parasympathetic (S2-S4))
Sp cord → Pelvic Splachnic
nerves → Pelvic Plexus
(relay) → Along vesical
artery → Vesical
Plexus(on wall of
bladder)→ Bladder
• Contracts detrussor (M3)
• Carries sensation from
stretching
• Nerve of voiding
• Under higher control
• Upper hand

8. Difficulty
• The classical anatomical
description- difficult to
understand
• Insufficient for the surgeon
because of 3-D distribution of
these nerves in the posterior
part of the pelvis
• Difficulty in seeing the nerves in
open surgery
• Better visualization with
magnification of laparoscope

9. Surgical anatomy
The hypogastric
nerves start
above sacral
promontary
↓
cross the USL from
medial aspect to
the lateral
converging with
the ureter

10. Surgical anatomy (Contd.)
Pelvic splachnic nerves join hypogastric
nerves at the lat part of USL, anterior and
lateral to rectum
↓
Forms Inf hypo plexus- “triangularly shaped
plexus, placed in a sagittal plane”, of 4 x 3 x
0.5 cm
USL is related to the upper part of the plexus
↓
Runs lateral to the vagina (in parametrium &
paracolpium) to the base of the bladder

12. Surgical anatomy (Contd.)
• Hypogastric
nerves join
from Sup
Ventral side
• Pelvic
Splachnic
nerves join
from Lat
dorsal side

13. Surgical anatomy (Contd.)
• Thus USL
has
• a fibrous
part
medially
and
a nervous part
laterally

15. In parametrium
1. Upper part of para-
• Pars nervosa
• Most of the fibers of
the plexus run in this
part
• between the medial
rectal artery above
and LA below
• Showing a straight
course to the bladder
2. Lower part of para-
• Some of the fibres are
placed here
• Enters bladder almost
vertically
• Responsible for the
vesical contraction
after radical
hysterectomy, if this
part has been
conserved

18. “The anatomy and distribution of the pelvic
plexus have not been fully described. If
anatomical details of the pelvic nerve
plexus and the vesical branches could be
elucidated, various types of nerve-
sparing laparoscopic radical
hysterectomies would be achievable,
with procedures adaptable to the level of
cervical carcinoma risk”

19. Materials and methods
• Sample size- 53 patients
• Study duration- April 2009 and April 2011
• Inclusion criteria- who underwent total
laparoscopic radical hysterectomies (A, B, C)
because of cervical carcinomas
• Exclusion criteria-
- mixed pelvic nerve system-sparing status
- Receiving adjuvant RT

20. Classification
Group A
Conventional Nerve-
sparing Technique
•Hypogastric nerves B/L
preserved completely
•Pelvic splachnic nerves
B/L preserved
completely
•Pelvic plexus B/L
preserved completely
Group B
Radical Nerve-sparing
Technique
• Hypogastric nerves
B/L sacrificed
• Pelvic splanchnic
nerves B/L partially
preserved
• Pelvic plexus B/L
partially preserved
Group C
Non Nerve-sparing
Technique
• Hypogastric
nerves B/L
sacrificed
• Pelvic splanchnic
nerves B/L
sacrificed
• Pelvic plexus B/L
completely
sacrificed

21. Indications of these types
Group A
Conventional Nerve-
sparing Technique
•Tx <3 cm in size
• H/P not indicative of a
neuroendocrine type
•Lymph node swelling
and parametrial
invasion not suspected
before surgery
Group B
Radical Nerve-sparing
Technique
• Tx 3-4 cm in size
• H/P all types
including a
neuroendocrine
• No obvious
evidence of lymph
node metastasis or
parametrial
invasion
Group C
Non Nerve-sparing
Technique
• All other high risk
Ca Cx

23. Clinical background of the patients
A B C
N 27 13 13
Stage IA2 3
IB1 23 12 3
IB2 6
2A 1 1
2B 3
3A 1
H/P SCC 20 11 9
Adeno 5 1 2
AdenoSq 2 1
Small 1 1
Adjuvant chemo - All All but one
Death of disease - 1 1
Alive with disease - 1 -

24. Surgical technique
To prevent thermal injury to preserved nerve
systems
• ultrasonic dissection device (Harmonic ACE,
Ethicon Endo-Surgery, Tokyo, Japan)
• vessel sealing device (LigaSure, Covidien,
Tokyo, Japan)
-around the pelvic nerve network

25. Cadaveric study
Rectum resected
↓
pararectal and presacral spaces developed
widely
↓
Sacral nerves (S1- S4) were exposed at the
anterior sacral foramina (site of origin of the
pelvic splanchnic nerves)
↓
the pelvic plexus is approximately 3 cm wide

27. Hypogastric nerves observed easily along the lateral sides of the
mesorectum
↓
LN tissue around the internal iliac region removed completely
↓
S2-S3 roots are identifiable beneath the fascia of the piriform
muscle (pelvic floor)
↓
LN tissue around the cardinal ligament is meticulously removed
↓
The pelvic splanchnic nerves are completely visible as visceral
branches originating from S2-S3 roots
↓
vessel part of the cardinal ligament transected
↓
pelvic plexus can be exposed

29. Adipose tissue around the posterior part of the
vesicouterine ligament removed completely
↓
vesical branches from the pelvic nerve plexus can
be exposed as fibrous tissue connecting the
pelvic plexus with the bladder
↓
USL and paracolpium are transected

30. Control of radicality
Group A
Conventional Nerve-
sparing Technique
•The USL and the
paracolpium tissue are
transected above
the hypogastric nerves
•Exposure of the pelvic
splanchnic nerves is not
necessary
Group B
Radical Nerve-sparing
Technique
• Between the
hypogastric nerves
and pelvic
splanchnic nerves
• Denudation of the
pelvic splanchnic
nerves is necessary
Group C
Non Nerve-sparing
Technique
• Below the
pelvic splanchnic
nerves

32. Bladder function
• Residual volume- not sufficient
• In a study*- only 15% of patients after RH had
a residual urine volume >30% of their bladder
capacity
- 76% of patients developed bladder
dysfunction during the 12 months after
surgery
*Benedetti-Panici P, Zullo MA, Plotti F, Manci N, Muzii L, Angioli R. Long-term bladder function
in patients with locally advanced cervical carcinoma treated with neoadjuvant chemotherapy
and type 3-4 radical hysterectomy. Cancer 2004;100:2110-7.

33. Evaluation of bladder function
Urodynamic study
• Before Sx
• After Sx- 1,3,6, 12 months
• Not to take any medicines for nurogenic bladder- (cholinergic, α1
blocker) during follow up
Parameters-
1. First desire to void (FDV)
- the capacity of the bladder
when the patient feels the
first sensation to void
- to evaluate sensory
function
2. PdetQmax- the detrusor
contraction pressure at
maximum flow
-to evaluate motor function
1. Function ratio (FDV)=
FDV preoperative/
FDV postoperative
2. Function ratio (PdetQmax)=
PdetQmax postoperative/
PdetQmax preoperative

34. Results
The recovery of sensory
function
• Groups A- visible within
12 months after surgery
• sensory function at 6 and
12 months was
statistically higher than
that at 1 month after
surgery.

35. Results (Contd.)
The recovery of sensory
function
• Group B- visible within
12 months after surgery
• sensory function at 6 and
12 months was
statistically higher than
that at 1 month after
surgery.

36. Results (Contd.)
The recovery of sensory
function
• Group C- not at all visible
• FDV ratio (Preop/ postop)
= zero

37. Results (Contd.)
Recovery of motor function
• Group A - visible within
12 months after surgery
• motor function at 6 and
12 months was
statistically higher than
that at 1 month after
surgery

38. Results (Contd.)
The recovery of motor
function
• Group B- significant
recovery of motor
function was not visible
within 12 months after
surgery

39. Results (Contd.)
The recovery of motor
function
• Group C- not at all visible.
• PdetQmax ratio (postop/
preop) = zero

40. Results (Contd.)
For sensory function
• FDV ratio of groups A
and B were
significantly higher
than those of group C
• no significant
difference between
groups A and B

41. Results (Contd.)
For motor function
• PdetQmax ratio of
group A was
significantly higher
than that in groups B
and C
• However, no
significant difference
between groups B and
C

42. Discussion
• Bladder function quite good after
conventional total laparoscopic nerve-sparing
RH (group A)
• Expected to be limited to early stage Ca Cx
• Greater radicality necessary for intermediate
stage or advanced stage Ca Cx
• Nerve-sparing techniques have never been
applied there

43. • In some intermediate-risk Ca Cx, non-nerve-
sparing RH (group C) tends to be
overtreatment
• Radical nerve sparing Sx (group B) is an
promising option there
• Innovative radical technique requires the
complete exposure of the pelvic nerve plexus

44. Bladder function measurement
• Functional ratio of UDS was used
• The preserved nerve function (the sensory
function of groups A and B, and the motor
function of group A) can be improved within
12 months after surgery*
*Ralph G, Tamussino K, Lichtenegger W. Urological
complications after radical abdominal hysterectomy for
cervical cancer. Baillieres Clin Obstet Gynaecol 1988;2:943-52.

45. Anatomical confirmation
• The sensory nerve is
distributed
predominantly at the
lower (dorsal) half of the
pelvic nerve networks
• The sensory functions of
groups A and B are
statistically equivalent
• The sensory function of
group C is significantly
lower
• The motor nerve is
distributed
predominantly at the
upper (ventral) half of
the pelvic nerve networks
• The motor function of
group A is significantly
more preserved
• The motor functions of
groups B and C are
damaged similarly

46. Conclusion
• “…results of this study show that the various
types of total laparoscopic nerve-sparing
radical hysterectomies are technically feasible,
and that they can be tailored to the risk of
cervical cancer.”

47. Strength of the study
• Adequate number of sample size
• Detailed description of the clinical profiles
• RT recipients excluded
• Well defined classification of surgical procedure
• Fresh cadaveric dissection (laparoscopically)
• Full elucidation of the surgical procedures in details-
especially group B
• Nerve sparing without compromising oncological clearance
• UDS- FDV and PdetQmax and the ratios
• Statistical analysis
• Review of literature

48. Weakness of the study
• Blinded ???
• Not randomized
• Sample population different in different
groups
• Group C- “All other high risk ca Cx”
• Details of UDS results