Nerve-Sparing Routes in Radical Pelvic Surgery

  • Nucelio L. B. M. Lemos
  • Reitan Ribeiro
  • Gustavo Leme Fernandes
  • Mauricio S. Abrão
  • Renato Moretti-Marques


Wertheim’s, Okabayashi’s, and Meig’s work, already in the early 1900s, progressively increased the radicality of hysterectomy for early-stage cervical cancer, mainly by increasing the extent of parametrial excision, correspondingly increasing survival rates [1]. Increased survival, however, charged its price by adding functional morbidity to cancer survivors—prevalence of urinary retention, constipation, and sexual dysfunction rose almost proportionally to survival rates [2, 3]. Those dysfunctions derive from the damage inflicted to the pelvic sympathetic and parasympathetic neural pathways—superior hypogastric plexus, hypogastric nerves, pelvic splanchnic nerves, and the inferior hypogastric (pelvic) plexus. Therefore, the objective of this chapter is to review the anatomy of the autonomic nerves of the pelvis and describe the steps of the LANN technique to expose and preserve the autonomic nerves, as well as the anatomical landmarks to preserve those nerves without the need of previously exposing them.


  1. 1.
    Kraima AC, Derks M, Smit NN, van de Velde CJ, Kenter GG, DeRuiter MC. Careful dissection of the distal ureter is highly important in nerve-sparing radical pelvic surgery: a 3D reconstruction and immunohistochemical characterization of the vesical plexus. Int J Gynecol Cancer. 2016;26(5):959–66. Scholar
  2. 2.
    Seski JC, Diokno AC. Bladder dysfunction after radical abdominal hysterectomy. Am J Obstet Gynecol. 1977;128(6):643–51.PubMedCrossRefGoogle Scholar
  3. 3.
    Fishman IJ, Shabsigh R, Kaplan AL. Lower urinary tract dysfunction after radical hysterectomy for carcinoma of cervix. Urology. 1986;28(6):462–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Nezhat C, Nezhat F, Pennington E, Nezhat CH, Ambroze W. Laparoscopic disk excision and primary repair of the anterior rectal wall for the treatment of full-thickness bowel endometriosis. Surg Endosc. 1994;8:682–5.PubMedCrossRefGoogle Scholar
  5. 5.
    Redwine DB, Wright JT. Laparoscopic treatment of complete obliteration of the cul-de-sac associated with endometriosis: long-term follow-up of en bloc resection. Fertil Steril. 2001;76(2):358–65.PubMedCrossRefGoogle Scholar
  6. 6.
    Gabriel B, Nassif J, Trompoukis P, Lima AM, Barata S, Lang-Avérous G, Wattiez A. Prevalence and outcome of urinary retention after laparoscopic surgery for severe endometriosis--does histology provide answers? Int Urogynecol J. 2012;23(1):111–6. Scholar
  7. 7.
    Fanfani F, Fagotti A, Gagliardi ML, Ruffo G, Ceccaroni M, Scambia G, et al. Discoid or segmental rectosigmoid resection for deep infiltrating endometriosis: a case-control study. Fertil Steril. 2010;94:444–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Ballester M, Chereau E, Dubernard G, Coutant C, Bazot M, Daraï E. Urinary dysfunction after colorectal resection for endometriosis: results of a prospective randomized trial comparing laparoscopy to open surgery. Am J Obstet Gynecol. 2011;204(4):303.e1–6. Scholar
  9. 9.
    Dubernard G, Piketty M, Rouzier R, Houry S, Bazot M, Darai E. Quality of life after laparoscopic colorectal resection for endometriosis. Hum Reprod. 2006;21(5):1243–7.PubMedCrossRefGoogle Scholar
  10. 10.
    Fujiwara T. Surgery for cervical cancer (in Japanese). Tokyo: Igakutoshyosyuppan; 1984.Google Scholar
  11. 11.
    Possover M, Stöber S, Plaul K, Schneider A. Identification and preservation of the motoric innervation of the bladder in radical hysterectomy type III. Gynecol Oncol. 2000;79(2):154–7.PubMedCrossRefGoogle Scholar
  12. 12.
    Höckel M, Konerding MA, Heussel CP. Liposuction-assisted nerve-sparing extended radical hysterectomy: oncologic rationale, surgical anatomy, and feasibility study. Am J Obstet Gynecol. 1998;178(5):971–6.PubMedCrossRefGoogle Scholar
  13. 13.
    Höckel M, Horn LC, Hentschel B, Höckel S, Naumann G. Total mesometrial resection: high resolution nerve-sparing radical hysterectomy based on developmentally defined surgical anatomy. Int J Gynecol Cancer. 2003;13(6):791–803.PubMedCrossRefGoogle Scholar
  14. 14.
    Trimbos JB, Maas CP, Deruiter MC, Peters AA, Kenter GG. A nerve-sparing radical hysterectomy: guidelines and feasibility in western patients. Int J Gynecol Cancer. 2001;11(3):180–6.PubMedCrossRefGoogle Scholar
  15. 15.
    Possover M, Chiantera V, Baekelandt J. Anatomy of the sacral roots and the pelvic splanchnic nerves in women using the LANN technique. Surg Laparosc Endosc Percutan Tech. 2007;17(6):508–10.PubMedCrossRefGoogle Scholar
  16. 16.
    Possover M, Rhiem K, Chiantera V. The “Laparoscopic Neuro- Navigation” - LANN: from a functional cartography of the pelvic autonomous neurosystem to a new field of laparoscopic surgery. Min Invas Ther Allied Technol. 2004;13:362–7.CrossRefGoogle Scholar
  17. 17.
    Kavallaris A, Banz C, Chalvatzas N, Hornemann A, Luedders D, Diedrich K, Bohlmann M. Laparoscopic nerve-sparing surgery of deep infiltrating endometriosis: description of the technique and patients’ outcome. Arch Gynecol Obstet. 2011;284(1):131–5. Scholar
  18. 18.
    Ceccaroni M, Clarizia R, Alboni C, Ruffo G, Bruni F, Roviglione G, Scioscia M, Peters I, De Placido G, Minelli L. Laparoscopic nerve-sparing transperitoneal approach for endometriosis infiltrating the pelvic wall and somatic nerves: anatomical considerations and surgical technique. Surg Radiol Anat. 2010;32(6):601–4. Scholar
  19. 19.
    Ceccaroni M, Clarizia R, Bruni F, D’Urso E, Gagliardi ML, Roviglione G, Minelli L, Ruffo G. Nerve-sparing laparoscopic eradication of deep endometriosis with segmental rectal and parametrial resection: the Negrar method. A single-center, prospective, clinical trial. Surg Endosc. 2012;26(7):2029–45. Scholar
  20. 20.
    Spagnolo E, Zannoni L, Raimondo D, Ferrini G, Mabrouk M, Benfenati A, Villa G, Bertoldo V, Seracchioli R. Urodynamic evaluation and anorectal manometry pre- and post-operative bowel shaving surgical procedure for posterior deep infiltrating endometriosis: a pilot study. J Minim Invasive Gynecol. 2014;21(6):1080–5. Scholar
  21. 21.
    Mangler M, Herbstleb J, Mechsner S, Bartley J, Schneider A, Köhler C. Long-term follow-up and recurrence rate after mesorectum-sparing bowel resection among women with rectovaginal endometriosis. Int J Gynaecol Obstet. 2014;125(3):266–9. Scholar
  22. 22.
    Che X, Huang X, Zhang J, Xu H, Zhang X. Is nerve-sparing surgery suitable for deeply infiltrating endometriosis? Eur J Obstet Gynecol Reprod Biol. 2014;175:87–91. Scholar
  23. 23.
    Volpi E, Ferrero A, Sismondi P. Laparoscopic identification of pelvic nerves in patients with deep infiltrating endometriosis. Surg Endosc. 2004;18(7):1109–12.PubMedCrossRefGoogle Scholar
  24. 24.
    Lemos N, Souza C, Marques RM, Kamergorodsky G, Schor E, Girão MJ. Laparoscopic anatomy of the autonomic nerves of the pelvis and the concept of nerve-sparing surgery by direct visualization of autonomic nerve bundles. Fertil Steril. 2015. pii: S0015-0282(15)01649-0.
  25. 25.
    DeGroat WC, Yoshimura N. Anatomy and physiology of the lower urinary tract, Handbook of clinical neurology, 3rd series. Oxford: Elsevier; 2015.Google Scholar
  26. 26.
    Mauroy B, Demondion X, Bizet B, Claret A, Mestdagh P, Hurt C. The female inferior hypogastric (= pelvic) plexus: anatomical and radiological description of the plexus and its afferences--applications to pelvic surgery. Surg Radiol Anat. 2007;29(1):55–66.PubMedCrossRefGoogle Scholar
  27. 27.
    Wallner C, Maas CP, Dabhoiwala NF, Lamers WH, DeRuiter MC. Innervation of the pelvic floor muscles: a reappraisal for the levator ani nerve. Obstet Gynecol. 2006;108(3 Pt 1):529–34.PubMedCrossRefGoogle Scholar
  28. 28.
    Grigorescu BA, Lazarou G, Olson TR, Downie SA, Powers K, Greston WM, Mikhail MS. Innervation of the levator ani muscles: description of the nerve branches to the pubococcygeus, iliococcygeus, and puborectalis muscles. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(1):107–16.PubMedPubMedCentralCrossRefGoogle Scholar
  29. 29.
    Petros PE, Ulmsten U. An integral theory of female urinary incontinence. Acta Obstet Gynecol Scand. 1990;69(Suppl 153):1–79.Google Scholar
  30. 30.
    Petros PE, Ulmsten UI. An integral theory and its method for the diagnosis and management of female urinary incontinence. Scand J Urol Nephrol Suppl. 1993;153:1–93.PubMedGoogle Scholar
  31. 31.
    Chung EA, Emmanuel AV. Gastrointestinal symptoms related to autonomic dysfunction following spinal cord injury. Prog Brain Res. 2006;152:317–33.PubMedCrossRefGoogle Scholar
  32. 32.
    Kinugasa Y, Arakawa T, Murakami G, Fujimiya M, Sugihara K. Nerve supply to the internal anal sphincter differs from that to the distal rectum: an immunohistochemical study of cadavers. Int J Color Dis. 2014;29(4):429–36. Scholar
  33. 33.
    Moszkowicz D, Peschaud F, Bessede T, Benoit G, Alsaid B. Internal anal sphincter parasympathetic-nitrergic and sympathetic-adrenergic innervation: a 3-dimensional morphological and functional analysis. Dis Colon Rectum. 2012;55(4):473–81. Scholar
  34. 34.
    Cook TA, Brading AF, Mortensen NJ. The pharmacology of the internal anal sphincter and new treatments of ano-rectal disorders. Aliment Pharmacol Ther. 2001;15(7):887–98.PubMedCrossRefGoogle Scholar
  35. 35.
    Feng B, Brumovsky PR, Gebhart GF. Differential roles of stretch-sensitive pelvic nerve afferents innervating mouse distal colon and rectum. Am J Physiol Gastrointest Liver Physiol. 2010;298(3):G402–9. Scholar
  36. 36.
    Petros PE, Swash M. The musculo-elastic theory of anorectal function and dysfunction. Pelviperineology. 2008;27:89–93. http://www.pelviperineology.orgGoogle Scholar
  37. 37.
    Ercoli A, Delmas V, Fanfani F, Gadonneix P, Ceccaroni M, Fagotti A, Mancuso S, Scambia G. Terminologia Anatomica versus unofficial descriptions and nomenclature of the fasciae and ligaments of the female pelvis: a dissection-based comparative study. Am J Obstet Gynecol. 2005;193(4):1565–73.PubMedCrossRefGoogle Scholar
  38. 38.
    Bonneau C, Cortez A, Lis R, Mirshahi M, Fauconnier A, Ballester M, Daraï E, Touboul C. Lymphatic and nerve distribution throughout the parametrium. Gynecol Oncol. 2013;131(3):708–13.PubMedCrossRefGoogle Scholar
  39. 39.
    Querleu D, Morrow CP. Classification of radical hysterectomy. Lancet Oncol. 2008;9(3):297–303.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Possover M, Quakernack J, Chiantera V. The LANN technique to reduce postoperative functional morbidity in laparoscopic radical pelvic surgery. J Am Coll Surg. 2005;201(6):913–7.PubMedCrossRefGoogle Scholar
  41. 41.
    Lemos N, Souza C, Marques RM, Kamergorodsky G, Schor E, Girão MJ. Laparoscopic anatomy of the autonomic nerves of the pelvis and the concept of nerve-sparing surgery by direct visualization of autonomic nerve bundles. Fertil Steril. 2015;104(5):e11–2. Scholar
  42. 42.
    Possover M, Schneider T, Henle KP. Laparoscopic therapy for endometriosis and vascular entrapment of sacral plexus. Fertil Steril. 2011;95(2):756–8. PubMed PMID: 20869701PubMedCrossRefGoogle Scholar
  43. 43.
    Possover M, Baekelandt J, Flaskamp C, Li D, Chiantera V. Laparoscopic neurolysis of the sacral plexus and the sciatic nerve for extensive endometriosis of the pelvic wall. Minim Invasive Neurosurg. 2007;50(1):33–6. PubMed PMID: 17546541PubMedCrossRefGoogle Scholar
  44. 44.
    Lemos N, D'Amico N, Marques R, Kamergorodsky G, Schor E, Girão MJ. Recognition and treatment of endometriosis involving the sacral nerve roots. Int Urogynecol J. 2015.
  45. 45.
    Abrão MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C. Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before management. Hum Reprod Update. 2015;21(3):329–39. Scholar
  46. 46.
    Remorgida V, Ragni N, Ferrero S, Anserini P, Torelli P, Fulcheri E. How complete is full thickness disc resection of bowel endometriotic lesions? A prospective surgical and histological study. Hum Reprod. 2005;20:2317–20.PubMedCrossRefGoogle Scholar
  47. 47.
    Abrao MS, Podgaec S, Dias JA Jr, Averbach M, Silva LF, Marino de Carvalho F. Endometriosis lesions that compromise the rectum deeper than the inner muscularis layer have more than 40% of the circumference of the rectum affected by the disease. J Minim Invasive Gynecol. 2008;15:280–5.PubMedCrossRefGoogle Scholar
  48. 48.
    De Cicco C, Schonman R, Craessaerts M, Cl V, Ussia A, Koninckx PR. Laparoscopic management of ureteral lesions in gynecology. Fertil Steril. 2009;92:1424–7.PubMedCrossRefGoogle Scholar
  49. 49.
    Dubernard G, Rouzier R, David-Montefiore E, Bazot M, Daraï E. Urinary complications after surgery for posterior deep infiltrating endometriosis are related to the extent of dissection and to uterosacral ligaments resection. J Minim Invasive Gynecol. 2008;15(2):235–40. PubMed PMID: 18313000PubMedCrossRefGoogle Scholar
  50. 50.
    Armengol-Debeir L, Savoye G, Leroi AM, Gourcerol G, Savoye-Collet C, Tuech JJ, Vassilieff M, Roman H. Pathophysiological approach to bowel dysfunction after segmental colorectal resection for deep endometriosis infiltrating the rectum: a preliminary study. Hum Reprod. 2011;26(9):2330–5.PubMedCrossRefGoogle Scholar
  51. 51.
    Koninckx PR, Ussia A, Adamyan L, Wattiez A, Donnez J. Deep endometriosis: definition, diagnosis, and treatment. Fertil Steril. 2012;98(3):564–71.PubMedCrossRefGoogle Scholar
  52. 52.
    Kamergorodsky G, Lemos N, Rodrigues FC, Asanuma FY, D’Amora P, Schor E, Girão MJ. Evaluation of pre- and post-operative symptoms in patients submitted to linear stapler nodulectomy due to anterior rectal wall endometriosis. Surg Endosc. 2015;29(8):2389–93. Scholar
  53. 53.
    Kavallaris A, Zygouris D, Dafopoulos A, Kalogiannidis I, Terzakis E. Nerve-sparing radical hysterectomy in early stage cervical cancer. Latest developments and review of the literature. Eur J Gynaecol Oncol. 2015;36(1):5–9.PubMedGoogle Scholar
  54. 54.
    Yabuki Y, Asamoto A, Hoshiba T, Nishimoto H, Nishikawa Y, Nakajima T. Radical hysterectomy: an anatomic evaluation of parametrial dissection. Gynecol Oncol. 2000;77:155–63.PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Nucelio L. B. M. Lemos
    • 1
  • Reitan Ribeiro
    • 2
  • Gustavo Leme Fernandes
    • 3
  • Mauricio S. Abrão
    • 4
  • Renato Moretti-Marques
    • 5
  1. 1.Department of Obstetrics and GynecologyUniversity of Toronto, Women’s College HospitalTorontoCanada
  2. 2.Gynecologic Oncology DepartmentErasto Gaertner, Instituto de Oncologia do Paraná, and Hospital Marcelino ChampagnatCuritibaBrazil
  3. 3.Gynecology Oncology Division, Department of Obstetrics and GynecologyCentral Hospital of Irmandade da Santa Casa de Misericórdia de São PauloSão PauloBrazil
  4. 4.Ob/Gyn DepartmentSao Paulo UniversitySao PauloBrazil
  5. 5.Oncology DepartmentHospital Israelita Albert EinsteinSão PauloBrazil

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