World Journal of Surgery

, Volume 32, Issue 8, pp 1768–1775 | Cite as

How to Optimize Autonomic Nerve Preservation in Total Mesorectal Excision: Clinical Topography and Morphology of Pelvic Nerves and Fasciae

  • Nicolas ClausenEmail author
  • Tanja Wolloscheck
  • Moritz A. Konerding



Urogenital dysfunction after rectal and pelvic surgery was significantly decreased with the introduction of nerve-preserving dissection and total mesorectal excision (TME). Profound topographic knowledge of the pelvic connective tissue spaces is indispensable for identification and preservation of autonomic pelvic nerves. The purpose of this cadaver study was to highlight the course of important autonomous nerve structures and to identify potential injury sites.


Eleven cadavers were dissected according to TME with subsequent preparation of the pelvic nerves. The pelves of further three cadavers were sliced horizontally and cubed. Specimens were harvested and processed for light microscopy and immunohistochemistry to analyze both fascia and the types of nerves and their localization.


The neurovascular bundle, arising from the inferior pelvic plexus, shows the highest nerve density. At the lateral edge of Denonvilliers’ fascia, it pierces the parietal pelvic fascia. Several fine nerve branches spread into the loose periprostatic tissue up to the prostate or pass the prostate toward the urinary bladder. En route, we consistently find perikarya of autonomic nerves. Within the mesorectum, nerve fibers are distributed heterogeneously with laterally high densities, ventrally and dorsally low densities.


The highest risk for pelvic nerve damage—apart from lesions of the superior hypogastric plexus itself—is anterolaterally of the rectum where the neurovascular bundle releases from the pelvic sidewall. Careful dissection helps to identify and protect these nerve structures. The retroprostatic Denonvilliers’ fascia contains no important nerve structures.


Total Mesorectal Excision Autonomic Nerve Pudendal Nerve Neurovascular Bundle Lateral Ligament 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Heald RJ, Moran BJ, Ryall RDH, Sexton R, MacFarlane JK (1998) Rectal cancer. The Basingstoke experience of total mesorectal excision, 1978–1997. Arch Surg 133:894–899PubMedCrossRefGoogle Scholar
  2. 2.
    Junginger T, Hossfeld DK, Sauer R, Hermanek P (1998) Adjuvante und neoadjuvante Therapie bei Kolon- und Rektumkarzimon. Dtsch Ärztebl 96:698–700Google Scholar
  3. 3.
    Camilleri-Brennan J, Steele RJ (1998) Quality of life after treatment for rectal cancer. Rev Br J Surg 85:1036–1043CrossRefGoogle Scholar
  4. 4.
    Kneist W, Heintz A, Wolf HK, Junginger T (2003) Totale Mesorektumexzision bei Karzinom des mittleren und unteren Rektumdrittels. Onkologische und funktionelle Ergebnisse. Chirurg 74:125–131PubMedCrossRefGoogle Scholar
  5. 5.
    Matsuoka N, Moriya Y, Akasu T, Fujita S (2001) Long-term outcome of urinary function after extended lymphadenectomy in patients with distal rectal cancer. Eur J Surg Oncol 27:165–169PubMedCrossRefGoogle Scholar
  6. 6.
    Shah EF, Huddy SP (2001) A prospective study of genito-urinary dysfunction after surgery for colorectal cancer. Colorectal Dis 3:122–125PubMedCrossRefGoogle Scholar
  7. 7.
    Maeda K, Maruta M, Utsumi T, Sato H, Toyama K, Matsuoka H (2003) Bladder and male sexual functions ofter autonomic nerve-sparing TME with or without lateral node dissection for rectal cancer. Tech Coloproctol 7:29–33PubMedCrossRefGoogle Scholar
  8. 8.
    Sugihara K, Moriya Y, Akasu T, Fujita S (1996) Pelvic autonomic nerve preservation for patients with rectal carcinoma. Oncologic and functional outcome. Cancer 78:1871–1879PubMedCrossRefGoogle Scholar
  9. 9.
    Kourambas J, Angus DG, Hosking P, Chou ST (1998) A histological study of Denonvilliers’ fascia and its relationship to the neurovascular bundle. Br J Urol 82:408–410PubMedGoogle Scholar
  10. 10.
    Benoit G, Droupy S, Quillard J, Paradis V, Giuliano F (1999) Supra and infralevator neurovascular pathways to the penile corpora cavernosa. J Anat 195:606–615CrossRefGoogle Scholar
  11. 11.
    Weihe E, Eiden LE (2000) Chemical neuroanatomy of the vesicular amine transporters. FASEB J 14:2435–2449PubMedCrossRefGoogle Scholar
  12. 12.
    Eiden LE (2000) The vesicular neurotransmitter transporters: current perspectives an future prospects. FASEB J 14:2396–2400PubMedCrossRefGoogle Scholar
  13. 13.
    Butler-Martin SA, Buttery LD, A’Hern RP, Polak JM, Barton DP (2002) Pelvic nerve plexus trauma at radical and simple hysterectomy: a quantitative study of nerve types in the uterine supporting ligaments. J Soc Gynecol Invest 9:47–56CrossRefGoogle Scholar
  14. 14.
    Wanigasekara Y, Kepper ME, Keast JR (2003) Immunohistochemical characterization of pelvic autonomic ganglia in male mice. Cell Tissue Res 311:175–185PubMedGoogle Scholar
  15. 15.
    Arvidsson U, Riedl M, Elde R, Meister B (1997) Vesicular acetylcholine transporter (VAChT) protein: a novel an unique marker for cholinergic neurons in the central an peripheral nervous systems. J Comp Neurol 378:454–467PubMedCrossRefGoogle Scholar
  16. 16.
    Kaleczyc J, Timmerman JP, Majewski M, Lakomy M, Scheuermann DW (1997) Immunohistochemical characteristics of nerve fibres supplying the procine vas deferens. A colocalization study. Histochem Cell Biol 107:229–241PubMedCrossRefGoogle Scholar
  17. 17.
    Höckel M, Konerding MA, Heussel CP (1998) Liposuction-assisted nerve-sparing extended radical hysterectomy: oncologic rationale, surgical anatomy, and feasibility study. Am J Obstet Gynecol 178:971–976PubMedCrossRefGoogle Scholar
  18. 18.
    Lindsey I, Guy RJ, Warren BF, Mortensen NJ (2000) Anatomy of Denonvilliers’ fascia and pelvic nerves, impotence, and implications for the colorectal surgeon. Br J Surg 87:1288–1299PubMedCrossRefGoogle Scholar
  19. 19.
    Konerding MA, Heintz A, Huhn P, Junginger TH (1999) Rektumkarzinom. Optimierung durch Kenntnis der Anatomie unter besonderer Berücksichtigung des Mesorektums. Zentralbl Chir 124:413–417PubMedGoogle Scholar
  20. 20.
    Fritsch H, Kühnel W (1992) Development and distribution of adipose tissue in the pelvis. Early Hum Dev 28:79–88PubMedCrossRefGoogle Scholar
  21. 21.
    Nano M, Dal Corso HM, Lanfranco G, Ferronato M, Hornung JP (2000) Contribution to the surgical anatomy of the ligaments of the rectum. Dis Colon Rectum 43:1592–1598PubMedCrossRefGoogle Scholar
  22. 22.
    Sato K, Sato T (1991) The vascular and neuronal composition of the lateral ligament of the rectum and the rectosacral fascia. Surg Radiol Anat 13:17–22PubMedCrossRefGoogle Scholar
  23. 23.
    Jones OM, Smeulders N, Wiseman O, Miller R (1999) Lateral ligaments of the rectum: an anatomical study. Br J Surg 86:487–489PubMedCrossRefGoogle Scholar
  24. 24.
    Maas CP, Moriya Y, Steup WH, Kiebert GM, Kranenbarg WM, von de Velde CJ (1996) Male sexual function after autonomic nerve-preserving surgery for rectal cancer in the Netherlands: a prospective study on morbidity and functional outcome. Br J Surg 85:92–97CrossRefGoogle Scholar
  25. 25.
    Maas CP, Moriya Y, Steup WH, Klein Kranenbarg E, van de Velde CJ (1998) Radical and nerve-preserving surgery for rectal cancer in the Netherlands: a prospective study on morbidity and functional outcome. Br J Surg 85:92–97PubMedCrossRefGoogle Scholar
  26. 26.
    Maas CP, Moriya Y, Steup WH, Klein Kranenbarg E, van de Velde CJ (2000) A prospective study on radical and nerve-preserving surgery for rectal cancer in the Netherlands. Eur J Surg Oncol 26:751–757PubMedCrossRefGoogle Scholar
  27. 27.
    Höer J, Roegels A, Prescher A, Klosterhalfen B, Töns C, Schumpelick V (2000) Schonung autonomer Nerven in der Rectumchirurgie. Ergebnisser der Präparation an Leichen und fixierten Beckenpräparaten. Chirurg 71:1222–1229PubMedCrossRefGoogle Scholar
  28. 28.
    Lepor H, Gregerman M, Crosby R, Mostofi FK, Walsh PC (1985) Precise localization of the autonomic nerves from the pelvic plexus to the corpora cavernosa: a detailed anatomical study of the adult male pelvis. J Urol 133:207–212PubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2008

Authors and Affiliations

  • Nicolas Clausen
    • 1
    Email author
  • Tanja Wolloscheck
    • 2
  • Moritz A. Konerding
    • 2
  1. 1.Department of General and Visceral SurgeryKetteler-HospitalOffenbachGermany
  2. 2.Department of AnatomyJohannes Gutenberg-University of MainzMainzGermany

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