Systematization of the vesical and uterovaginal efferences of the female inferior hypogastric plexus (pelvic): applications to pelvic surgery on women patients
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To locate and describe the various efferences of the plexus in order to make it easier to avoid nerve lesions during pelvic surgery on women patients through a better anatomical knowledge of the inferior hypogastric plexus (IHP).
Materials and methods
We dissected 27 formalin embalmed female anatomical subjects, none of which bore any stigmata of subumbilical surgery. The dissection was always performed using the same technique: identification of the inferior hypogastric plexus, whose posterior superior angle follows on from the hypogastric nerve and whose top, which is anterior and inferior, is located exactly at the ureter’s point of entry into the base of the parametrium, underneath the posterior layer of the broad ligament.
The IHP is located at the level of the posterior floor of the pelvis, opposite to the sacral concavity. Its top, which is anterior inferior, is at the point of contact with the ureter at its entry into the posterior layer of the broad ligament. The uterovaginal, vesical and rectal efferences originate in the paracervix. Three efferent nerves branch, two of them from its top and the third from its inferior edge: (1) A vaginal nerve, medial to the ureter, follows the uterine artery and divides into two groups: anterior thin, heading for the vagina and the uterus; posterior, voluminous, heading in a superior rectal direction (=superior rectal nerve). (2) A vesical nerve, lateral to the ureter, divides into two groups, lateral and medial. (3) The inferior rectal nerve emerges from the inferior edge of the IHP, between the fourth sacral root and the ureter’s point of entry into the base of the parametrium.
The ureter is the crucial point of reference for the IHP and its efferences and acts as a real guide for identifying the anterior inferior angle or top of the IHP, the origin of the vaginal nerve, the level of the ureterovesical junction and the division of the vesical nerve into its two medial and lateral branches. Dissecting underneath and inside the ureter and the uterine artery involves a risk of lesion of the vaginal nerve and its uterovaginal branches. Further forward, between the intersection and the ureterovesical junction, dissecting and/or coagulating under the ureter involves a risk of lesions to the vesical nerve, which are likely to explain the phenomena of denervation of the anterior floor encountered after certain hysterectomies and/or surgical treatments of vesicoureteral reflux.
KeywordsUrinary incontinence Vesical innervation Pelvic autonomous innervation Hysterectomy Inferior hypogastric plexus Vesicorenal reflux Autonomous nervous system
- 8.Kamina P, Demondion X, Richer JP, Scepi M AND Faure JP (2003) Anatomie clinique de l’appareil génital féminin. Encycl. Méd Chir. (Editions Scientifiques et Médicales Elsevier SAS, Paris), Gynécologie, 10 A10, 28pGoogle Scholar
- 13.Maas CP, TerKuile MM, Laan E, Tuijnman CC, Weijenborg PTM, Trimbos JB, Kenter GG (2004) Objective assessment of sexual in women with a history of hysterectomy. Br J Obstet Gynaecol 11:456–462Google Scholar
- 21.Van der Vaart CH, Van der BoM JG, DeLeeuw JR, Roovers JP, Heintz APM (2002) The contribution of hysterectomy to the occurrence of urge and stress urinary incontinence symptoms. Br J Obstet Gynaecol 109:149–154Google Scholar