Abstract
Background
Pelvic surgery carries an inherent risk of autonomic nerve injury leading to genitourinary and bowel dysfunction due to the close proximity of the superior hypogastric plexus (SHP). The aim of this study was to define the detailed anatomy of SHP and identify its relationship with the vascular landmarks and ureters for pelvic autonomic nerve-preserving surgery.
Methods
A cadaveric study on the detailed anatomy of the SHP was conducted in our surgical anatomy research unit. Between 02/2019 and 10/2019, macroscopic anatomical dissections were performed on 45 fresh adult cadavers (39 male, 6 female). Distances between the SHP, major vascular structures, and other anatomical landmarks were measured.
Results
Three types of SHP morphology were observed: mesh (64.8%), single nerve (24.4%), and fiber (10.8%). SHP bifurcation was located inferior to the aortic bifurcation in all cases; however, it was observed cranial to the promontory in 80% of the cases, whereas 18% were caudally and 2% were over the promontory. The closest vessels to the left and right of the SHP bifurcation were the left common iliac vein (LCIV) (86.2%, the mean distance was 8.49 ± 7.97 mm) and the right internal iliac artery (RIIA) (48.2%, mean distance was 13.4 ± 9.79 mm), respectively. At SHP bifurcation level, the lateral edge of the SHP was detected on the LCIV in 22 cases and on the RIIA in 10 cases for the left and right side of the plexus, respectively. The distance between the SHP bifurcation and the ureter was 27.9 mm on the right and 24.2 mm on the left. The width of the left (LHN) and right hypogastric nerves (RHN) were 4.35 mm and 4.62 mm at 2 cm below the SHP bifurcation, respectively. LHN was on the vascular structures in 13 cases, whereas RHN in only 1 case, 2 cm below the SHP bifurcation.
Conclusions
Understanding the location of the SHP, including its relationship with important anatomical landmarks, might prevent iatrogenic injury and reduce postoperative morbidity in the pelvic surgery setting.
Similar content being viewed by others
References
Kim NK, Kim YW, Cho MS (2015) Total mesorectal excision for rectal cancer with emphasis on pelvic autonomic nerve preservation: expert technical tips for robotic surgery. Surg Oncol 24(3):172–180
Akbari RP, Read TE (2006) Laparoscopic rectal surgery: rectal cancer, pelvic pouch surgery, and rectal prolapse. Surg Clin North Am 86(4):899–914
Chew MH, Yeh YT, Lim E, Seow-Choen F (2016) Pelvic autonomic nerve preservation in radical rectal cancer surgery: changes in the past 3 decades. Gastroenterol Rep (Oxf) 4(3):173–185
Hendren SK, O’Connor BI, Liu M, Asano T, Cohen Z, Swallow CJ et al (2005) Prevalence of male and female sexual dysfunction is high following surgery for rectal cancer. Ann Surg 242(2):212–223
Açar HI, Kuzu MA (2012) Important points for protection of the autonomic nerves during total mesorectal excision. Dis Colon Rectum 55(8):907–912
Eveno C, Lamblin A, Mariette C, Pocard M (2010) Sexual and urinary dysfunction after proctectomy for rectal cancer. J Visc Surg 147(1):e21-30
Baader B, Herrmann M (2003) Topography of the pelvic autonomic nervous system and its potential impact on surgical intervention in the pelvis. Clin Anat 16(2):119–130
Selçuk İ, Ersak B, Tatar İ, Güngör T, Huri E (2018) Basic clinical retroperitoneal anatomy for pelvic surgeons. Turk J Obstet Gynecol 15(4):259–269
Correia JAP, De-Ary-Pires B, Pires-Neto MA, De Ary-Pires R (2010) The developmental anatomy of the human superior hypogastric plexus: a morphometrical investigation with clinical and surgical correlations. Clin Anat 23(8):962–970
Paraskevas G, Tsitsopoulos P, Papaziogas B, Natsis K, Martoglou S, Stoltidou A et al (2008) Variability in superior hypogastric plexus morphology and its clinical applications: a cadaveric study. Surg Radiol Anat 30(6):481–488
Brown RA, Ellis CN (2014) The role of synthetic and biologic materials in the treatment of pelvic organ prolapse. Clin Colon Rectal Surg 27:182–190
Joubert K, Laryea JA (2017) Abdominal approaches to rectal prolapse. Clin Colon Rectal Surg 30:57–62
Poylin VY, Irani JL, Rahbar R, Kapadia MR (2019) Rectal- prolapse repair in men is safe, but outcomes are not well understood. Gastroenterol Rep 7(4):279–282
Bozkırlı BO, Aytaç E, Esen E, Özben V, Baca B, Hamzaoğlu İ, Karahasanoğlu T (2019) Robotic ventral mesh rectopexy: where do we stand? Turk J Colorectal Dis 29(1):6–11
Ripperda CM, Jackson LA, Phelan JN, Carrick KS, Corton MM (2017) Anatomic relationships of the pelvic autonomic nervous system in female cadavers: clinical applications to pelvic surgery. Am J Obstet Gynecol 216(4):388
He JH, Wang Q, Cai QP, Dang RS, Jiang EP, Huang HL et al (2010) Quantitative anatomical study of male pelvic autonomic plexus and its clinical potential in rectal resection. Surg Radiol Anat 32(8):783–790
Author information
Authors and Affiliations
Contributions
Substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data: BK, MAG, CA, YG, CB, MO, HIA, MAK. Drafting of the article for important intellectual content: BK, MAG, CA, YG, CB, MO, HIA, MAK. Critical manuscript revision and final approval of the submitted version: BK, MAG, CA, YG, CB, MO, HIA, MAK.
Corresponding author
Ethics declarations
Conflict of interest
The authors have no conflicts of interest including relevant financial interests, activities, relationships, and affiliations.
Ethical approval
The current descriptive anatomic study was conducted after receiving the approval of the scientific and ethics committees from both the Ankara University (ethics committee decision No. 19-42) and the Institute for Forensic Medicine (scientific committee decision No.21589509/2018/411).
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Kutlu, B., Guner, M.A., Akyol, C. et al. Comprehensive anatomy of the superior hypogastric plexus and its relationship with pelvic surgery landmarks: defining the safe zone around the promontory. Tech Coloproctol 26, 655–664 (2022). https://doi.org/10.1007/s10151-022-02622-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10151-022-02622-z