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Relationships between pelvic nerves and levator ani muscle for posterior sacrocolpopexy: an anatomic study

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Abstract

Background

The placement of posterior mesh during pelvic organ prolapse laparoscopic surgery has been incriminated as responsible for postoperative adverse outcomes such as digestive symptoms, chronic pelvic pain, and sexual dysfunction. These complications may be related to neural injuries that occur during the fixation of the posterior mesh on the levator ani muscle.

Objectives

The aim of our study was to describe the course of the autonomic nerves of the pararectal space and their anatomical relationship with the posterior mesh fixation zone on the levator ani muscle.

Study design

Twenty hemi-pelvis specimens from 10 fresh female cadavers were dissected. We measured the distance between the posterior mesh fixation zone on the levator ani, and the nearest point of adjacent structures: the hypogastric nerve, inferior hypogastric plexus, uterosacral ligament, uterine artery, and ureter. Measurements were repeated starting from the inferior hypogastric plexus.

Results

Nerve fibers of the inferior hypogastric plexus spread out systematically above the superior aspect of the levator ani muscle. Median distance from the posterior mesh fixation zone and the inferior hypogastric plexus was around 2.8 (range 2.1–3.5) cm.

Conclusions

The inferior hypogastric plexus lies above the superior aspect of the levator ani muscle. A short distance between the posterior mesh fixation zone on the levator ani muscle and inferior hypogastric plexus could explain in part postoperative digestive symptoms. These observations support the development of nerve-sparing procedures for posterior mesh placement in the context of pelvic organ prolapse repair and suggest that postoperative complications could be improved by changing the fixation zone.

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Authors and Affiliations

  1. Assistance Publique des Hôpitaux de Paris (AP-HP), Department of Gynecological and Breast Surgery and Oncology, Pitié-Salpêtrière University Hospital, 75013, Paris, France

    Grégoire Rocher, Henri Azaïs, Amélia Favier, Catherine Uzan & Geoffroy Canlorbe

  2. Ecole de Chirurgie, Assistance-Publique Hôpitaux de Paris, 7, rue du Fer à Moulin, 75005, Paris, France

    Grégoire Rocher, Henri Azaïs, Amélia Favier, Catherine Uzan & Geoffroy Canlorbe

  3. Sorbonne University, INSERM UMR_S_938, Cancer Biology and Therapeutics, Centre de Recherche Saint-Antoine (CRSA), 75020, Paris, France

    Catherine Uzan & Geoffroy Canlorbe

  4. Institut Universitaire de Cancérologie (IUC), 75020, Paris, France

    Catherine Uzan & Geoffroy Canlorbe

  5. Scarcell Therapeutics, 101 rue de Sèvres, 75006, Paris, France

    Mathieu Castela

  6. Gynecology Department, The George Washington University School of Medicine and Health Science, Washington, DC, USA

    Gaby Moawad

  7. Department of Obstetrics and Gynecology Gynecology, Rennes Hospital, Rennes University 1, Rennes, France; Université de Rennes 1, Rennes, France

    Vincent Lavoué & Krystel Nyangoh Timoh

  8. Université de Rennes 1 : 2 avenue de Professeur Léon Bernard, 35000, Rennes, France; SAFE CIC 1414 Thematic Team, University Hospital Rennes, Rennes, France

    Vincent Lavoué & Krystel Nyangoh Timoh

  9. Department of Neurosurgery, Rennes University Hospital, Pontchaillou University Hospital, CHU Pontchaillou, 2 rue Henri Le Guilloux, 35033, Rennes Cedex 9, France

    Xavier Morandi

  10. Anatomy Laboratory, Faculty of medicine of Rennes, 2 Avenue du Professeur Léon Bernard, 35043, Rennes, France

    Xavier Morandi & Krystel Nyangoh Timoh

  11. INSERM, UMR 1099, Rennes, F-35000, France; Université de Rennes 1, LTSI, F-35000, Rennes, France

    Xavier Morandi & Krystel Nyangoh Timoh

Authors
  1. Grégoire Rocher
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  2. Henri Azaïs
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  3. Amélia Favier
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  4. Catherine Uzan
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  5. Mathieu Castela
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  6. Gaby Moawad
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  7. Vincent Lavoué
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  8. Xavier Morandi
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  9. Krystel Nyangoh Timoh
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  10. Geoffroy Canlorbe
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Contributions

Manuscript writing: RG, CG. Revisions: AH, UC, CM, MG, LV, MX, NTK, CG. Dissections work: RG, AH, FA, TK, CG. Figure 3: CM. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Geoffroy Canlorbe.

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Conflict of interests

Pr Geoffroy Canlorbe, Pr Vincent Lavoué and Dr Gaby Moawad: Proctor for Intuitive Surgical.

Condensation

We studied relationships between the inferior hypogastric plexus and the mesh fixation zone on the Levator ani muscle used for posterior sacrocolpopexy.

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Appendix

Appendix

See Table 1.

Table 1 Distance between posterior mesh fixation zone, inferior hypogastric plexus and key anatomic structures
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Rocher, G., Azaïs, H., Favier, A. et al. Relationships between pelvic nerves and levator ani muscle for posterior sacrocolpopexy: an anatomic study. Surg Radiol Anat 44, 891–898 (2022). https://doi.org/10.1007/s00276-022-02955-2

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